J Bone Joint Surg Am. 2025 Jan 15;107(2):174-183. doi: 10.2106/JBJS.24.00390. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: Although the majority of intertrochanteric femoral fractures in the United States are now treated with cephalomedullary nailing, it remains uncertain whether differences in clinical performance by nail type exist. The purpose of this study was to compare the aseptic revision rates associated with the 3 most commonly utilized cephalomedullary nails in the United States today: the Gamma nail (Stryker), the INTERTAN (Smith+Nephew), and the Trochanteric Fixation Nail/Trochanteric Fixation Nail Advanced (TFN/TFNA; DePuy Synthes).

METHODS: Using an integrated health-care system's hip fracture registry, patients ≥60 years of age who were treated with 1 of these 3 commonly used cephalomedullary nail devices were identified. Potential confounders were identified and controlled for, including age, gender, race or ethnicity, body mass index, smoking status, American Society of Anesthesiologists classification, anesthesia type, Elixhauser comorbidities, and the operating surgeon. Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) by cephalomedullary nail type, with mortality and revisions unrelated to the index fracture considered as competing events.

RESULTS: There were 19,215 patients included in the study sample (71.4% female, 77.0% White), including 4,421 in the Gamma nail group, 2,350 in the INTERTAN nail group, and 12,444 in the TFN/TFNA nail group. In the multivariable analysis involving nails of all lengths, the INTERTAN group was found to have a higher risk of aseptic revision compared with the TFN/TFNA group (8-year crude revision rate, 2.9% compared with 1.8%; hazard ratio [HR], 1.62 [95% confidence interval (CI), 1.15 to 2.27]; p = 0.006). The increased risk associated with the INTERTAN nail was primarily seen among the long nails (HR, 1.83 [95% CI, 1.16 to 2.87]; p = 0.009) rather than the short nails (HR, 1.36 [95% CI, 0.87 to 2.11]; p = 0.18). There were no differences in aseptic revision observed between the Gamma group and the TFN/TFNA group.

CONCLUSIONS: In this study of 19,215 patients with a hip fracture treated with cephalomedullary nailing, the INTERTAN nail was found to have a significantly higher risk of aseptic revision. Further research is required to determine whether these results could be related to the unique design of this implant.

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

PMID:39812725 | DOI:10.2106/JBJS.24.00390

J Bone Joint Surg Am. 2025 Jan 15;107(2):163-173. doi: 10.2106/JBJS.24.00184. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

METHODS: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

RESULTS: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

CONCLUSIONS: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

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

PMID:39812724 | DOI:10.2106/JBJS.24.00184

J Bone Joint Surg Am. 2025 Jan 15;107(2):144-151. doi: 10.2106/JBJS.24.00245. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: In the setting of cervical open-door laminoplasty, the question of whether or not every opened laminar level should be instrumented has not been sufficiently investigated. We postulated that the surgical outcomes of open-door laminoplasty with instrumentation of every second opened level (skip-fixation) might not be inferior to those of laminoplasty with instrumentation of every opened level (all-fixation). The purpose of the present study was to test the noninferiority of laminoplasty with skip-fixation in improving myelopathy at 2 years postoperatively compared with all-fixation. Additionally, we compared radiographic and surgical outcomes between the 2 types of procedures.

METHODS: This prospective, multicenter, unblinded randomized controlled trial included patients ≥60 years of age who underwent C3 to C6 open-door cervical laminoplasty for the treatment of degenerative cervical myelopathy. Patients were allocated to the skip-fixation group (n = 80) or the all-fixation group (n = 75) using a permuted block method. The primary outcome was the between-group difference in the Japanese Orthopaedic Association (JOA) score at 2 years postoperatively. Secondary outcomes included surgical data, complications, 2-year change in the JOA score, Neck Disability Index (NDI), EQ-5D-5L (EuroQol 5-dimension 5-level instrument) score, visual analog scale (VAS) score for neck pain, and radiographic outcomes.

RESULTS: One hundred and thirty patients (including 66 in the skip-fixation group and 64 in the all-fixation group) completed the trial at 2 years (follow-up rate, 83.9%). The difference in the JOA score at 2 years was 0.0298 (95% confidence interval [CI], -0.706 to 0.766), which was within the noninferiority margin (p < 0.0001; noninferiority test). In the secondary analyses, laminoplasty with skip-fixation demonstrated a significantly shorter surgical time (p = 0.010; Mann-Whitney U test) and greater improvement in the VAS score for neck pain, NDI, and EQ-5D-5L score (p = 0.006, p = 0.047, p = 0.037, respectively; mixed-effect model) compared with all-fixation. There were no significant between-group differences in radiographic outcomes, including the hinge union rate.

CONCLUSIONS: Skip-fixation may be sufficient to achieve noninferior 2-year postoperative improvement in myelopathy. Additionally, laminoplasty with skip-fixation potentially can lead to improvements in terms of neck pain, neck disability, and quality of life compared with all-fixation.

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

PMID:39812723 | DOI:10.2106/JBJS.24.00245

J Bone Joint Surg Am. 2025 Jan 15;107(2):134-143. doi: 10.2106/JBJS.24.00309. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Early knee effusion is a common phenomenon after total knee arthroplasty (TKA), with potential clinical implications. Unlike traditional alloy knee prostheses, the polyetheretherketone (PEEK) knee system has radiographic transparency on magnetic resonance (MR) scans, which allows analysis of prosthetic knee effusion. We aimed to identify the distribution and volume of knee effusion after TKA with the PEEK prosthesis with use of MR imaging and to analyze whether dynamic changes in effusion were correlated with serum inflammatory marker changes and knee function recovery.

METHODS: Nine patients with osteoarthritis who were 59 to 74 years old underwent unilateral TKA with the PEEK prosthesis between June 2021 and August 2021. Dynamic early postoperative changes in the volume and distribution of knee effusion were evaluated with use of 3D MR stereoscopic images. Serum inflammatory markers were measured via blood tests, and joint function was evaluated with use of the subjective functional score of the Knee Society Score (KSS) and knee range of motion (ROM). Linear regression analyses were performed to assess for correlations between knee effusion volume and inflammatory markers and between knee effusion volume and joint function.

RESULTS: The mean serum inflammatory marker levels increased significantly at 1 week after TKA with the PEEK prosthesis and then gradually decreased with time from 1 to 6 months. The mean total knee effusion volume gradually decreased over time. Concurrently, the mean KSS subjective functional score and mean knee ROM improved with time. Total knee effusion volume was positively correlated with C-reactive protein level (R2 = 0.16; p = 0.007) and negatively correlated with the change in KSS score between the preoperative and postoperative time points (R2 = 0.19; p = 0.003). Using the 1-week total knee effusion volume as a reference, a positive correlation was observed between the reduction in total knee effusion volume and the actual value of the ROM (R2 = 0.36; p = 0.0001) from 3 to 24 months postoperatively.

CONCLUSIONS: Through 3D MR imaging, the precise distribution and volume of, and dynamic changes in, knee effusion after TKA with the PEEK prosthesis were confirmed and were found to be correlated with inflammation and joint function in the early postoperative period. The results demonstrate the potential clinical benefit of the PEEK-based knee system for future use.

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

PMID:39812722 | PMC:PMC11717431 | DOI:10.2106/JBJS.24.00309

J Bone Joint Surg Am. 2025 Jan 15;107(2):127-133. doi: 10.2106/JBJS.23.01118. Epub 2024 Nov 22.

ABSTRACT

BACKGROUND: Antiseptic solutions are commonly utilized during total joint arthroplasty (TJA) to prevent and treat periprosthetic joint infection (PJI). The purpose of this study was to investigate which antiseptic solution is most effective against methicillin-sensitive Staphylococcus aureus (MSSA) and Escherichia coli biofilms established in vitro on orthopaedic surfaces commonly utilized in total knee arthroplasty: cobalt-chromium (CC), oxidized zirconium (OxZr), and polymethylmethacrylate (PMMA).

METHODS: MSSA and E. coli biofilms were grown on CC, OxZr, and PMMA discs for 24 and 72 hours. Biofilm-coated discs were treated with control or various antiseptic solutions for 3 minutes. Solutions included 10% povidone-iodine, a 1:1 mixture of 10% povidone-iodine plus 3% hydrogen peroxide, diluted povidone-iodine, 0.05% chlorhexidine gluconate, and a surfactant-based formulation of ethanol, acetic acid, sodium acetate, benzalkonium chloride, and water. Following treatment, discs were sonicated to quantify adherent bacteria or underwent imaging with scanning electron microscopy to identify biofilm. Antiseptic solutions were considered efficacious if they produced a 3-log (1,000-fold) reduction in colony-forming units compared with controls.

RESULTS: On both OxZr and CC, 10% povidone-iodine with hydrogen peroxide eradicated all MSSA, and it achieved clinical efficacy on PMMA at both 24-hour MSSA biofilm (p < 0.0002) and 72-hour MSSA biofilm (p = 0.002). On 72-hour MSSA biofilm, 10% povidone-iodine eradicated all bacteria on OxZr and CC, and it achieved clinical efficacy on PMMA (p = 0.04). On 24-hour MSSA biofilm, 10% povidone-iodine achieved efficacy on all surfaces (all p < 0.01). The surfactant-based formulation only achieved clinical efficacy on 72-hour MSSA biofilms on CC (p = 0.04) and OxZr (p = 0.07). On 72-hour E. coli biofilm, 10% povidone-iodine with or without hydrogen peroxide achieved clinical efficacy on all surfaces. No other solution achieved clinical efficacy on either MSSA or E. coli.

CONCLUSIONS: Antiseptic solutions vary considerably in efficacy against bacterial biofilm. The 10% povidone-iodine solution with or without hydrogen peroxide consistently removed MSSA and E. coli biofilms on multiple orthopaedic surfaces and should be considered for clinical use.

CLINICAL RELEVANCE: Clinicians should be aware of the differences in the efficacy of antiseptic solutions on different orthopaedic surfaces when treating MSSA or E. coli biofilms.

PMID:39812721 | DOI:10.2106/JBJS.23.01118

J Bone Joint Surg Am. 2025 Jan 15;107(2):113-120. doi: 10.2106/JBJS.24.01130. Epub 2024 Nov 20.

NO ABSTRACT

PMID:39812720 | DOI:10.2106/JBJS.24.01130

J Bone Joint Surg Am. 2024 Sep 19. doi: 10.2106/JBJS.24.00229. Online ahead of print.

ABSTRACT

BACKGROUND: Manual compartment palpation is used as a component of the clinical diagnosis of acute compartment syndrome (ACS), particularly in obtunded patients. However, its utility and accuracy in the upper limb are unknown. The purposes of this study were to assess the accuracy of manual compartment palpation of ACS in the forearm in a cadaveric model and to assess the role of clinician experience in this setting.

METHODS: Reproducible, sustained elevation of intracompartmental pressure was established in 8 fresh upper-limb cadaveric specimens. The 3 forearm compartments (volar, dorsal, and mobile wad) were randomized to pressures of 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (ACS). This was achieved by using fluid infusion and a pressure monitoring system. Orthopaedic clinicians with varying experience (residents, registrars, and consultants) used palpation to assess forearm compartments with known intracompartmental pressures. The examiners were blinded to the compartment pressures and the other examiners' responses. After the examination, the following 3 questions were answered: (1) Was compartment syndrome present? (2) In which compartment(s) was the pressure elevated? (3) What would be the next management step (fasciotomy or observation)?

RESULTS: Manual palpation of compartment pressure had an overall sensitivity of 70%, a specificity of 56%, a positive predictive value of 24%, a negative predictive value of 90%, and a likelihood ratio (LR) of 20.3 (p < 0.001). The sensitivity was similar in detecting ACS in the volar and dorsal compartments (70% and 69%, respectively). The sensitivity and specificity of combined volar and dorsal compartment palpation were 81% and 64% (LR, 16.6; p < 0.001) when performed by residents, 72% and 46% (LR, 4.2; p = 0.040) when performed by registrars, and 58% and 63% (LR, 3.6; p = 0.057) when performed by consultants. All of the compartments that were deemed positive for ACS were recommended for fasciotomy.

CONCLUSIONS: In our study, manual palpation of compartment pressure had a low accuracy in the diagnosis of ACS of the forearm and was not improved by clinician experience.

CLINICAL RELEVANCE: We recommend against the use of manual palpation of compartment pressure in the diagnosis of forearm ACS in an obtunded patient.

PMID:39808584 | DOI:10.2106/JBJS.24.00229

J Bone Joint Surg Am. 2025 Jan 9. doi: 10.2106/JBJS.24.00655. Online ahead of print.

ABSTRACT

BACKGROUND: The financial and resource burden of management of olecranon fractures in the elderly is likely to increase with an aging population. There is limited evidence guiding treatment choice in this cohort. This study aimed to determine whether operative treatment of displaced olecranon fractures in elderly patients provides superior 12-month functional outcomes compared to nonoperative treatment.

METHODS: A multicenter pragmatic randomized controlled trial was conducted across 24 hospitals in Australia and New Zealand. Patients aged ≥75 years presenting with an acute (within 14 days), displaced, closed, isolated olecranon fracture were included. Operative treatment involved reduction and stabilization using tension band wiring or plate fixation. Nonoperative treatment consisted of a sling for comfort and early movement as tolerated. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes were the DASH score at 3 months and pain, quality of life, Mayo Elbow Performance Score (MEPS), active elbow range of motion, and complication rate at 3 and 12 months. Data were analyzed based on an intention-to-treat principle, with sensitivity analyses using as-treated groups.

RESULTS: Sixty participants were randomized, 27 to the operative group (mean age and standard deviation [SD], 83 ± 5.8 years; 22 [81%] females) and 33 to the nonoperative group (mean age, 82 ± 4.5 years; 23 [70%] females), with no significant difference in baseline characteristics. There was no significant difference (mean difference, -6.6; 95% confidence interval [CI] = -14.9 to 1.8; p = 0.12) in the mean DASH scores at 12 months (the primary outcome) between the operative (12.3 ± 14) and nonoperative (18.9 ± 18) groups. Although active elbow extension was significantly superior in the operative group at 12 months, no other secondary outcome differed significantly between groups at 12 months.

CONCLUSIONS: The study found no significant difference in DASH scores at 12 months between the operative and nonoperative groups. This supports nonoperative treatment as a reasonable option for displaced stable olecranon fractures in elderly patients.

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

PMID:39787259 | DOI:10.2106/JBJS.24.00655

J Bone Joint Surg Am. 2025 Jan 7. doi: 10.2106/JBJS.24.01095. Online ahead of print.

NO ABSTRACT

PMID:39774540 | DOI:10.2106/JBJS.24.01095