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Risk Factors for Nonunion Following Lateral Locked Plating of Distal Femoral Fractures: A Bayesian Analysis of 560 Patients

JBJS -

J Bone Joint Surg Am. 2026 Feb 4;108(3):235-243. doi: 10.2106/JBJS.25.00498. Epub 2025 Nov 18.

ABSTRACT

BACKGROUND: Lateral locked plating remains an important treatment strategy for distal femoral fractures but has been associated with nonunion rates ranging from 6% to 20%. The objective of this study was to identify factors associated with nonunion following lateral locked plating of distal femoral fractures with use of a Bayesian analysis.

METHODS: All consecutive patients ≥18 years of age who were treated with lateral locked plating for a distal femoral fracture at 2 Level-I trauma centers between 2006 and 2024 and who had ≥3 months of follow-up were included. Multivariable Bayesian logistic regression analysis was performed to identify factors associated with nonunion, which was defined as a reoperation to promote healing, and the results are reported as odds ratios (ORs) with 95% credible intervals (CrIs). Probabilities of >95% were considered very strong evidence of an association with nonunion, and probabilities of 90% to 95% were considered strong evidence.

RESULTS: A total of 560 patients (median age, 68 years; 29% male; 90% White; 97% non-Hispanic; 41% with distal periprosthetic fractures) were included. Fifty-four patients (9.6%) underwent reoperation to promote healing. There was very strong evidence that multifragmentary comminution of the metaphysis (versus simple fracture: OR, 2.60; 95% CrI, 0.91 to 8.06), medial cortical comminution of >0 to 25 mm (versus 0 mm: OR, 3.11; 95% CrI, 1.35 to 7.48), and varus (lateral distal femoral angle [LDFA] of ≥84°: OR, 3.04; 95% CrI, 1.46 to 6.51) or valgus (LDFA of ≤78°: OR, 2.42; 95% CrI, 0.96 to 5.99) malalignment increased the odds of nonunion. A screw density of ≤0.60 proximal to the working length reduced the odds of nonunion (versus ≥0.81: OR, 0.40; 95% CrI, 0.16 to 0.95), although the size and certainty of this effect varied in the sensitivity analysis that utilized alternative thresholds. There was strong evidence that obesity increased the odds of nonunion (OR, 1.64; 95% CrI, 0.86 to 3.13) and that intact wedge fractures reduced the odds of nonunion (versus simple fracture: OR, 0.35; 95% CrI, 0.05 to 1.74).

CONCLUSIONS: One in 10 patients developed nonunion and underwent reoperation to promote healing. Surgeons should restore coronal plane alignment and may consider augmenting fixation in the presence of multifragmentary comminution. Constructs in which all screw holes proximal to the working length are filled should be avoided, although the optimal configuration remains unclear and depends on other construct characteristics influencing biomechanics. Overall, the small to moderate effect sizes highlight the multifactorial etiology of nonunion following lateral locked plating of distal femoral fractures.

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

PMID:41636737 | PMC:PMC12834285 | DOI:10.2106/JBJS.25.00498

The Ultrasound-Assisted Patellar Glide Test: A Novel Examination Method for Quantifying Patellar Instability

JBJS -

J Bone Joint Surg Am. 2026 Feb 4;108(3):227-234. doi: 10.2106/JBJS.25.00707. Epub 2025 Nov 24.

ABSTRACT

BACKGROUND: Patellofemoral instability is a difficult problem to assess because of its dynamic nature, which is not easily quantified using physical examination techniques. This study aimed to describe and evaluate a novel examination method using stress ultrasonography to quantify patellar instability. The secondary aim was to assess the relationship of stress ultrasonography measurements with clinical and morphologic risk factors for patellar instability.

METHODS: Knees with symptomatic patellar instability underwent the ultrasound-assisted patellar glide test. In this test, the patella was translated laterally from its resting position during ultrasound visualization until an endpoint was reached. The medial patellofemoral distance (MPFD) was used to quantify the gap between the medial boundary of the patella and the trochlea, and the difference in MPFD between the resting (unloaded) and loaded conditions was defined as the delta MPFD. Measurements were compared with those in asymptomatic contralateral knees of patients with unilateral instability, asymptomatic knees after patellar stabilization surgery, and control knees. Regression analyses assessed for relationships of MPFD with morphological and clinical risk factors. Receiver operating characteristic (ROC) curve analysis assessed the ability of stress ultrasonography measurements to discriminate between knees with and without symptomatic patellar instability.

RESULTS: Four hundred and seventy-seven knees in 277 patients were included in this study; 173 of the knees had patellar instability (patient age, 24 ± 8 years; 72% female). Delta MPFD was 3 times greater in knees with patellar instability (median, 3.3 mm [95% confidence interval, 3.1 to 3.4 mm]) than in the contralateral asymptomatic (1.1 mm [0.9 to 1.3 mm]), postoperative (1.0 mm [0.8 to 1.2 mm]), and control knees (1.4 mm [1.1 to 1.6 mm]). ROC analysis demonstrated an optimal threshold value for delta MPFD of 2.0 mm, which had an area under the curve (AUC) of 0.97 (0.94 to 0.99), demonstrating excellent discrimination in identifying knees with patellar instability. No relationships of clinical or morphologic risk factors with delta MPFD were found.

CONCLUSIONS: A delta MPFD of ≥2 mm on the ultrasound-assisted patellar glide test had an AUC of 0.97 for identifying knees with symptomatic patellar instability, indicating excellent discriminatory ability. Additional studies utilizing this method are recommended to standardize and quantify assessments of patellar instability.

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

PMID:41636736 | DOI:10.2106/JBJS.25.00707

Intimate Partner Violence in a Patient Population with Orthopaedic Trauma: Gender Disparities, Delayed Disclosures, and Poor Clinical Outcomes

JBJS -

J Bone Joint Surg Am. 2026 Feb 4;108(3):212-218. doi: 10.2106/JBJS.25.00407. Epub 2025 Nov 26.

ABSTRACT

BACKGROUND: This prospective cohort study determined the prevalence of intimate partner violence (IPV) across gender groups, investigated timing of disclosures during the standard-of-care follow-up period, and examined if there was an association between IPV and clinical outcomes.

METHODS: This study included 314 patients ≥18 years of age presenting with orthopaedic injuries to the fracture clinics at 2 academic hospitals. Participants were asked about experiences with IPV, return to function, and overall health at each routine clinical follow-up. Cox proportional-hazards regression models were used to explore associations between IPV status and return to work, leisure activities, home responsibilities, and overall functioning.

RESULTS: Of the 528 patients approached, 314 provided consent and completed at least the initial visit. Of these, 184 (58.6%) self-identified as women, 126 (40.1%) identified as men, and 3 (1.0%) self-identified as non-binary. Forty-six percent of women reported lifetime experience of IPV, compared with 35% of men and 100% of gender-diverse participants. A smaller proportion of men who disclosed IPV did so at their first visit compared with women, especially with respect to sexual IPV: 6 men (50.0%) compared with 42 women (79.2%). During follow-up, 16 participants (6.7% of 238 who returned to the clinic at least once), including 8 men, 7 women, and 1 gender-diverse participant, disclosed experiencing IPV during their recovery period. Disclosing IPV at any visit was associated with a 45% lower likelihood of returning to a pre-injury level of function with respect to work (hazard ratio [HR], 0.55 [95% confidence interval (CI), 0.33 to 0.91]; p = 0.021) and a 36% lower likelihood of returning to a pre-injury overall level of functioning (HR, 0.64 [95% CI, 0.46 to 0.90]; p = 0.01).

CONCLUSIONS: Results showed an unacceptably high prevalence of IPV in all genders. Gender differences in timing of disclosure emphasize the need for tailored approaches in clinical settings and repeated opportunities for IPV disclosure. This study emphasizes the hidden nature of IPV among patients with orthopaedic trauma and its effects on their health and recovery.

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

PMID:41636735 | PMC:PMC12834265 | DOI:10.2106/JBJS.25.00407

Acupuncture vs usual care for chronic low back pain: a systematic review and meta-analysis of immediate and intermediate effects

SICOT-J -

SICOT J. 2026;12:7. doi: 10.1051/sicotj/2025061. Epub 2026 Feb 3.

ABSTRACT

INTRODUCTION: Chronic low back pain (CLBP) is a leading global cause of disability. Acupuncture is increasingly integrated into its management, yet its standalone effectiveness compared to usual care remains uncertain. This review aimed to assess the immediate (≤2 weeks) and intermediate (2 weeks-6 months) effects of acupuncture versus usual care on pain and disability in adults with CLBP.

METHODS: A systematic review and meta-analysis of randomized controlled trials was conducted, searching MEDLINE, CENTRAL, Scopus, and PEDro through November 2024. Eligible studies compared acupuncture (body, electroacupuncture, scalp) to usual care (physiotherapy, education, medication, and exercise) in adults with CLBP. Outcomes included pain and disability at immediate and intermediate follow-up. Data were pooled using a random-effects model. Risk of bias was assessed with the PEDro scale, and GRADE was used to evaluate evidence certainty. Sensitivity and subgroup analyses were conducted to explore clinical and methodological heterogeneity and test the reliability of findings.

RESULTS: A total of 2.956 records were identified, and 8 RCTs (n = 1,123 participants) were included in this study. Acupuncture significantly reduced pain at both immediate (SMD = -0.73, 95% CI -1.04 to -0.42) and intermediate (SMD = -1.13, 95% CI -1.82 to -0.43) timepoints. Disability also improved at both follow-ups (immediate: SMD = -0.49, 95% CI -0.68 to -0.30 and intermediate: SMD = -0.79, 95% CI -1.18 to -0.41). Sensitivity analyses confirmed effect robustness, especially in electroacupuncture subgroups. Certainty of evidence ranged from low to very low due to risk of bias, inconsistency, and suspected publication bias.

DISCUSSION: Acupuncture appears more effective than usual care for reducing pain and disability in adults with CLBP, but the certainty of evidence is low, warranting cautious interpretation.

PMID:41632890 | PMC:PMC12867475 | DOI:10.1051/sicotj/2025061

Factors driving higher opioid use after total hip arthroplasty: Insights from a large-scale, tertiary centre analysis

SICOT-J -

SICOT J. 2026;12:6. doi: 10.1051/sicotj/2025064. Epub 2026 Feb 3.

ABSTRACT

INTRODUCTION: Effective postoperative pain management is imperative in total hip arthroplasty (THA) to enable early mobilization and accelerate recovery pathways. This study investigated the patterns of inpatient opioid consumption following THA and identified the factors associated with increased opioid usage.

METHODS: In this large-scale, single-institution study, we analyzed data from 1,867 primary THAs between April 2019 and July 2023. We collected data on demographics, length of stay (LOS), type of anaesthesia, Post Anaesthesia Care Unit (PACU) admissions, 30-day readmissions, total opioid consumption (MME; morphine milligram equivalents), implant fixation techniques, surgical characteristics and pre- and postoperative haemoglobin (Hb) levels. Factors associated with increased opioid consumption (patients in the ≥ 75th percentile of inpatient opioid consumption; MME ≥ 211.9 mg) were identified through univariate and multivariate logistic regression models.

RESULTS: The cohort included 1150 women (61.6%) and 717 men (38.4%). The median inpatient opioid use was 88 mg (IQR = 39.3-211.9). In the univariate model, significant predictors included age, American Society of Anaesthesiologists (ASA) score, manual THA technique, general anaesthesia, pre- and postoperative Hb levels, need for PACU admission and year of surgery. After adjusting for baseline demographics in the hierarchical multivariate logistic regression model, significant predictors of higher opioid utilization were age (OR 0.989 [95% CI 0.981-0.997], p = 0.01), general anaesthesia (OR 2.386 [95% CI 1.865-3.054], p < 0.001), PACU admission (OR 2.098 [95% CI 1.310-3.358], p = 0.002), ASA score (OR 1.492 [95% CI 1.193-1.866], p < 0.001), postoperative Hb levels (OR 0.981 [95% CI 0.970-0.992], p < 0.001), and year of surgery (OR 0.638 [95% CI 0.579-0.703], p < 0.001) indicating that later years were associated with lower odds of high opioid consumption).

DISCUSSION: Younger age, higher ASA scores, lower postoperative haemoglobin, the need for PACU admission and general anaesthesia were significantly associated with increased opioid consumption following THA. Recognizing these factors can facilitate the development of tailored postoperative pain management protocols, enabling targeted interventions that minimize opioid reliance while enhancing recovery.

PMID:41632889 | PMC:PMC12867471 | DOI:10.1051/sicotj/2025064

Chondrosarcoma arising from long-standing Dysplasia Epiphysealis Hemimelica of the proximal humerus: A case report

SICOT-J -

SICOT J. 2026;12:5. doi: 10.1051/sicotj/2025057. Epub 2026 Feb 3.

ABSTRACT

Dysplasia Epiphysealis Hemimelica (DEH), or Trevor's disease, is a rare, nonhereditary skeletal disorder involving abnormal cartilaginous overgrowth of the epiphysis. To our knowledge, malignant transformation has not been previously documented. We report a unique case of chondrosarcoma arising from a DEH lesion in the proximal humerus nearly 30 years after the initial diagnosis. The patient was treated with wide resection and reconstruction using a proximal humeral replacement with a reverse-constrained total shoulder arthroplasty. This case highlights the need for long-term follow-up in patients with DEH, especially when new symptoms suggest possible malignant transformation.

PMID:41632888 | PMC:PMC12867468 | DOI:10.1051/sicotj/2025057

Comparison of patient demographics and implant complications in patients with multiple sclerosis undergoing total hip arthroplasty versus hemiarthroplasty for femoral neck fractures

Injury -

Injury. 2026 Jan 22;57(3):113055. doi: 10.1016/j.injury.2026.113055. Online ahead of print.

ABSTRACT

INTRODUCTION: Multiple sclerosis (MS) is a chronic neurological condition characterized by muscle spasticity, which may influence the outcomes of hip arthroplasty procedures, particularly in patients undergoing total hip arthroplasty (THA) or hemiarthroplasty for femoral neck fractures. It is unclear whether implant complications and revision rates differ between these two surgical approaches in patients with MS. The aim of this study was to compare patient demographics and 2-year implant complications in patients with MS undergoing THA versus hemiarthroplasty for femoral neck fractures.

METHODS: A retrospective analysis was performed using a nationwide claims database (2010-2022). MS patients who did not have dementia who underwent THA or hemiarthroplasty for femoral neck fractures were identified. Two-year implant complications, including hip dislocations, aseptic loosenings, periprosthetic joint infections (PJIs), periprosthetic fractures, and all-cause revisions, were compared between the two groups using multivariable logistic regressions while controlling for age, sex, comorbidities, and overall Elixhauser Comorbidity Index (ECI).

RESULTS: A total of 2018 patients with MS (604 THA and 1414 hemiarthroplasty) were included. Patients had no difference in overall comorbidity burden (ECI 7.47 vs. 6.93, p = 0.015). At 2 years, THA was associated with significantly higher rates of aseptic loosenings (OR: 4.17, p = 0.001) and all-cause revisions (OR: 3.04, p < 0.0001). Patients undergoing THA also showed trends toward higher rates of hip dislocations (OR: 1.53, p = 0.087) and PJIs (OR: 1.73, p = 0.059) compared to hemiarthroplasty.

CONCLUSIONS: Patients with MS undergoing THA for femoral neck fractures are associated with a higher risk for implant complications, including aseptic loosening and all-cause revisions, compared to those undergoing hemiarthroplasty. Surgeons should consider these outcomes when selecting the appropriate surgical option for patients with MS who do not have dementia with femoral neck fractures.

PMID:41633030 | DOI:10.1016/j.injury.2026.113055

Preoperative malnutrition is associated with increased early complications and higher two-year nonunion risk after Tibial shaft fracture fixation

Injury -

Injury. 2026 Jan 30;57(3):113084. doi: 10.1016/j.injury.2026.113084. Online ahead of print.

ABSTRACT

BACKGROUND: Malnutrition is a potentially modifiable risk factor that may influence perioperative complications and fracture healing. This study evaluated the association between preoperative laboratory-defined malnutrition and short-term complications and 2-year outcomes following operative fixation of tibial shaft fractures.

METHODS: Using the TriNetX Research Network (112 healthcare organizations), adults (≥18 years) undergoing operative management for tibial shaft fracture were identified. Preoperative malnutrition was defined as albumin ≤3.5 g/dL and/or leukocytes ≤1.5 × 10³/µL within 1 year prior to the index event. Cohorts were propensity score matched 1:1 on demographics and comorbidities. Outcomes were assessed from day 1 post-index through 90 days (medical/surgical complications) and 730 days (healing-related and limb outcomes). Risk ratios (RR) and hazard ratios (HR) with 95% confidence intervals (CI) were reported.

RESULTS: After matching, 44,780 patients were included in each cohort (89,560 total), with good balance across covariates (all SMDs <0.10). At 90 days, malnutrition was associated with higher risk of acute respiratory failure/mechanical ventilation (13.9% vs 3.4%; RR 4.10 [95% CI 3.88-4.33].; HR 4.32 [4.09-4.57].), sepsis (5.2% vs 1.2%; RR 4.35 [3.97-4.77].; HR 4.47 [4.07-4.91].), postoperative infection (5.7% vs 1.8%; RR 3.14 [2.90-3.39].; HR 3.23 [2.99-3.50].), acute kidney injury (8.6% vs 3.0%; RR 2.90 [2.73-3.08].; HR 2.99 [2.81-3.18].), and DVT/PE (6.5% vs 2.7%; RR 2.36 [2.21-2.52].; HR 2.42 [2.26-2.59].) (all p < 0.001). At 2 years, malnutrition was associated with increased nonunion (4.4% vs 1.6%; RR 2.69 [2.47-2.92].; HR 2.85 [2.62-3.10].), chronic osteomyelitis (12.5% vs 3.9%; RR 3.19 [3.02-3.36].; HR 3.50 [3.32-3.69].), hardware removal (10.1% vs 6.0%; RR 1.68 [1.61-1.76].; HR 1.83 [1.74-1.92].), and amputation (1.4% vs 0.4%; RR 3.47 [2.95-4.08].; HR 3.59 [3.05-4.23].) (all p < 0.001). Revision fixation did not differ (8.4% vs 8.1%; p = 0.096).

CONCLUSIONS: Preoperative laboratory-defined malnutrition was independently associated with substantially higher 90-day morbidity and increased 2-year nonunion and limb-complication risk following operative tibial shaft fracture management. These findings support preoperative nutritional risk stratification and targeted optimization efforts in this population.

PMID:41633029 | DOI:10.1016/j.injury.2026.113084

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