Int Orthop. 2025 Aug 7. doi: 10.1007/s00264-025-06632-y. Online ahead of print.

ABSTRACT

BACKGROUND: Ehlers-Danlos Syndrome (EDS) is a connective tissue disorder characterized by joint hypermobility, ligamentous laxity, and frequent joint injuries. These features could increase the risk of anterior cruciate ligament (ACL) tears, typically managed through ACL reconstruction (ACLR). Surgical intervention in EDS is challenging due to potential complications such as poor wound healing and tissue fragility. Limited evidence exists regarding the outcomes of ACLR in EDS patients; therefore, in this study we aimed to evaluate survival rates of primary and revision ACLR and examine associated demographic and anatomic risk factors for failure after ACLR.

METHODS: A retrospective review of 21 EDS patients (25 knees) who underwent ACLR between 1993 and 2023 was conducted. Patients with vascular EDS were excluded. Demographic and surgical data, including graft type, cause of injury, concomitant procedures such as meniscus repair and anatomical measurements (posterior tibial slope, intercondylar notch width, lateral femoral condyle morphology, tibiofemoral rotation and tibial tubercle- trochlear groove distance), were collected. Survival analysis was performed using Kaplan-Meier curves, with endpoints defined as ACLR failure or conversion to total knee arthroplasty (TKA). A multivariable survival analysis was used to identify predictors of outcomes. In addition, the influence of demographic and anatomical factors on the development of concomitant injuries and concomitant procedures were assessed. Anatomical factors were then compared with non-EDS patients from the existing literature.

RESULTS: The overall survival rate was 85.7% at mean follow-up of 50 months. Primary ACLR showed significantly higher survival rates 93.8% compared to revision ACLR 62.5% at 50 months (p = 0.03). Sports injuries, particularly skiing, were the leading cause of ACL tears (62%). Anatomical differences, such as increased lateral femoral condyle ratio (LFCR) and tibiofemoral rotation (TFR), were observed compared to non-EDS, ACL-intact patients from the literature (p < 0.01). However, these factors did not predict failure or influence concomitant injuries.

CONCLUSION: This study demonstrates that ACLR in EDS patients achieves good survival rates. Anatomical risk factors differed significantly from non-EDS, ACL-intact patients, but were not predictive of failure, highlighting ligamentous laxity as the primary challenge.

PMID:40775375 | DOI:10.1007/s00264-025-06632-y

Int Orthop. 2025 Aug 7. doi: 10.1007/s00264-025-06630-0. Online ahead of print.

ABSTRACT

PURPOSE: Shoulder deformities and impaired function in individuals with birth brachial plexus injury (BBPI) are often caused by internal rotator (IR) contractures and abductor weakness, which may progress to glenohumeral dysplasia. Although subscapularis-complex release and tendon transfer is a time-tested procedure, there are controversies regarding the appropriate management of shoulder contractures, especially in preschool children. Therefore, this study examines the efficiency of arthroscopically done progressive controlled release of IR contracture combined with tendon transfer.

METHODS: This study included 12 children who presented with shoulder soft tissue contractures and functional impairments, specifically, loss of shoulder abduction and external rotation, but with good deltoid function. They underwent a surgical intervention involving arthroscopy-assisted subscapularis-complex release and conjoint muscle transfer onto the infraspinatus footprint on the humeral head. The evaluation of shoulder function was conducted using the Mallet score system, and the range of motion was measured at preoperative and six month postoperative intervals. Statistical analyses were performed to determine the significance of the outcomes.

RESULTS: The average age of participants was 4.83 ± 2.1 years. Preoperatively, the mean Mallet score was 14.08 ± 1.4, which improved to 23.83 ± 1.2 postoperatively. The average gain in shoulder abduction was 66.4 ± 5.6°, and external rotation improved by 85.4 ± 16.6° at 18 months final follow-up. All patients exhibited improvements in shoulder function, with a significant correlation (p value = 0.037) between Naraka grading, and clinical outcomes.

CONCLUSION: The combined surgical approach of arthroscopic subscapularis-complex release with conjoint tendon transfer effectively enhances the shoulder function in the studied cohort. Further research and extended follow-up are needed to evaluate the long-term benefits.

LEVEL OF EVIDENCE: Level IV (Therapeutic case series).

PMID:40772960 | DOI:10.1007/s00264-025-06630-0

Injury. 2025 Jul 28;56(10):112624. doi: 10.1016/j.injury.2025.112624. Online ahead of print.

ABSTRACT

INTRODUCTION: The purpose of this study was to utilize a large national database to evaluate short- and long-term outcomes of acute management of proximal humerus fractures (PHF) with reverse total shoulder arthroplasty (RSA) compared to open reduction internal fixation (ORIF).

METHODS: The TriNetX platform was utilized to perform a retrospective review of patients who sustained PHFs treated within three weeks of injury. Patients were identified using Current Procedural Terminology codes and the International Classification of Disease diagnosis codes. The cohorts were 1:1 propensity matched. Patients who received RSA were propensity matched to patients who underwent ORIF. Short-term and long-term outcomes were compared across the cohorts across various post operative periods. Kaplan Meier survival analysis was used to analyze implant survival rate and Cox hazard ratio was used to identify risk factors of re-operation.

RESULTS: Following propensity matching, each cohort included 2733 patients with an average age of 71±9.5. Patients treated with ORIF were more likely to have a re-operation or hospital admission than patients who underwent RSA at both 1 and 2 year follow up (5.5 % vs 2.1 %; p < 0.001; 6.9 % vs 2.6 %, p < 0.001 and 13.7 % vs 11.3 %, p = 0.01; 19.6 % vs 16.4 %, p = 0.003). At two year follow up, 173 patients treated with ORIF had a re-operation of which 60 (35 %) were converted to arthroplasty. On Kaplan Meier survival analysis for re-operation, both implants had satisfactory survival rates at both one and two year time point with survival rates over 90 %. However, there was a difference between survival rates at both one and two years between the ORIF and RSA groups (94 % vs 98 %, p < 0.0001; 91 % vs 97 %, p < 0.0001). For ORIF, patients with four part PHF and osteoporosis had a 39 % and 19 % increased risk of re-operation (p < 0.001; p = 0.03).

CONCLUSION: While both ORIF and RSA have been shown to be acceptable techniques for managing PHFs in the elderly, ORIF had a significantly higher re-operation and hospital readmission rate at mid- and long-term follow up. Additionally, a large portion of patients undergoing re-operation following ORIF were converted to shoulder arthroplasty although acute RSA has superior outcomes compared to delayed RSA. Therefore, for operative elderly candidates we advocate for the use of RSA in three- and four-part PHFs.

PMID:40763431 | DOI:10.1016/j.injury.2025.112624

J Bone Joint Surg Am. 2025 Aug 5. doi: 10.2106/JBJS.24.01511. Online ahead of print.

ABSTRACT

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce blood loss during total knee arthroplasty (TKA) and total hip arthroplasty (THA), but the most effective administration method has yet to be determined. This systematic review and meta-analysis aimed to compare topical and systemic TXA administration to reduce operative blood loss.

METHODS: MEDLINE, Embase, and Cochrane CENTRAL were screened for randomized controlled trials comparing topical and systemic TXA for patients who underwent elective TKA and THA. The primary outcome was the total volume of operative blood loss, and the secondary outcomes were postoperative transfusion requirements, hemoglobin drop, hospital length of stay, and the frequencies of the main adverse events (infections and thromboembolic events). Data pooling was performed using RStudio. Subgroup analyses compared outcomes between TKA and THA.

RESULTS: Fifty-nine randomized controlled trials with a total of 6,791 patients were included in this review. Data analysis showed no significant difference between topical and systemic TXA application in terms of total blood loss (Hedges g = 0.11; 95% confidence interval [CI], -0.04 to 0.26; I2 = 82.4%). There was also no significant difference between the 2 groups in hemoglobin drop, hospital length of stay, and transfusion requirements. Subgroup analysis showed that patients undergoing TKA who received topical TXA had a significant reduction in total blood loss (g = 0.19; 95% CI, 0.00 to 0.38; I2 = 85%; p = 0.046) compared with those who received systemic TXA.

CONCLUSIONS: Topical and systemic TXA were equally effective in reducing blood loss in the analysis in which THA and TKA were combined. However, in TKA, topical application significantly reduced blood loss compared with systemic administration, while the reverse was true in THA. Further research is still necessary to find the optimal TXA dosage and administration route.

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

PMID:40763214 | DOI:10.2106/JBJS.24.01511

J Bone Joint Surg Am. 2025 Aug 5. doi: 10.2106/JBJS.24.01436. Online ahead of print.

ABSTRACT

BACKGROUND: Accurate debridement of poorly perfused bone and soft tissue is critical to reduce the risk of infection in open fracture or of recurrent fracture-related infection (FRI). However, accurate delineation of viable and nonviable tissue is difficult with current technology. The aim of this pilot study was to develop and evaluate an indocyanine green (ICG)-based dynamic contrast-enhanced fluorescence imaging (DCE-FI) strategy to provide intraoperative, objective, real-time information on bone perfusion using an osteotomy model in patients undergoing lower-extremity amputation.

METHODS: Fifteen patients who were ≥18 years of age and were undergoing lower-extremity amputation were included in this study. Perfusion-related kinetic parameters derived from DCE-FI, including maximum fluorescence intensity, ingress slope, and blood flow, were compared among 3 conditions reflecting sequentially increasing osseous damage: baseline, osteotomy (disruption of endosteal blood flow), and osteotomy plus periosteal stripping (disruption of endosteal and periosteal blood flow).

RESULTS: There were significant decreases in median values from baseline to after osteotomy alone for maximum intensity (96.2 to 58.9 relative fluorescence units [RFUs]), ingress slope (3.2 to 2.0 RFU/second), and blood flow (6.7 to 4.9 mL/min/100 g). Following osteotomy plus periosteal stripping, there were also significant decreases in median values for maximum intensity (12.0 RFU), ingress slope (0.2 RFU/s), and blood flow (0.8 mL/min/100 g). The Mann-Whitney U test confirmed a significant perfusion reduction (p < 0.001) in the tibial diaphysis due to these injuries. The areas under the curve (AUC) in the receiver operating characteristic (ROC) analysis for identifying periosteal stripping (compared with only osteotomy or no osseous damage) were 0.89 to 0.90, which were higher than the AUCs for identifying any osseous damage (osteotomy with or without periosteal stripping) compared with no damage, 0.75 to 0.82.

CONCLUSIONS: This clinical study utilizing DCE-FI for intraoperative bone perfusion assessment in orthopaedic surgery demonstrated that kinetic variables derived from DCE-FI can effectively characterize and classify degradation of bone perfusion due to osteotomy and osteotomy plus periosteal stripping.

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

PMID:40763212 | DOI:10.2106/JBJS.24.01436

J Bone Joint Surg Am. 2025 Aug 5. doi: 10.2106/JBJS.24.00920. Online ahead of print.

ABSTRACT

BACKGROUND: Vancouver Type-B1 and C periprosthetic hip fractures have traditionally been treated using single- or double-plate fixation constructs. Concern exists regarding screws within the cement mantle due to the theoretical risk of cement fracture and eventual prosthetic loosening. The aim of this study was to assess femoral stem survivorship in patients with Vancouver Type-B1 or C fractures around a well-fixed cemented femoral component who were treated with a plate construct and screws into the cement mantle. The hypothesis was that screw fixation into the cement mantle would not compromise stem fixation.

METHODS: A retrospective review was performed of patients who were consecutively, surgically treated for a periprosthetic fracture around a femoral stem by 3 surgeons, as identified through a search of records from January 1, 2007, to January 1, 2023. A total of 112 consecutive patients with Vancouver Type-B1 or C periprosthetic femoral fractures treated at our institutions were reviewed. Patients who underwent fixation using plate constructs with ≥1 screw within the cement mantle around the stem were included. Patients were followed until union, revision due to plate construct failure, or stem revision. Other complications, including alignment loss, cemented stem subsidence, radiographic stem loosening, and new cement-mantle fractures, were assessed.

RESULTS: Twenty-eight patients (19 female; 27 White or Caucasian; 3 Hispanic or Latino; mean age, 81.4 ± 8.7 years) met the inclusion criteria. Radiographic union was achieved in 26 patients (92.9%). The study included 8 (28.6%) interprosthetic fractures between a total hip arthroplasty prosthesis and a total knee arthroplasty prosthesis. The mean union time was 8.0 ± 4.6 months (range, 2.2 to 25.6 weeks). The mean follow-up duration following the index procedure was 33.3 ± 24.0 months (range, 6.1 to 86.2 months). Two nonunions occurred (7.1%), both involving plate failure. Both patients required revision of the femoral prosthesis, which was not loose at the time of reoperation. No stem subsidence or cement mantle fractures occurred during follow-up, and no revisions were performed for stem loosening.

CONCLUSIONS: Screw fixation into cement around a well-fixed stem did not contribute to stem loosening at short-term follow-up. There were no isolated femoral component revisions for cement mantle issues.

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

PMID:40763211 | DOI:10.2106/JBJS.24.00920

J Bone Joint Surg Am. 2025 Aug 5. doi: 10.2106/JBJS.25.00031. Online ahead of print.

ABSTRACT

➢ The growing prevalence and complexity of spinal pathologies have prompted hospital systems to establish dedicated spine centers to provide personalized, high-quality patient care.➢ The Joint Commission offers Advanced Certification in Spine Surgery to recognize programs that meet rigorous, evidence-based standards of care to their patient population.➢ Designing and implementing a spine center of excellence require the identification of key stakeholders, the development of a strategic plan, the generation of evidence-based clinical protocols, and routine evaluation of program metrics.➢ Spine centers of excellence offer standardized clinical pathways involving comprehensive preoperative optimization and coordinated postoperative care, thus leading to reduced complications and improved patient satisfaction with outcomes.➢ With recent advancements in minimally invasive techniques, robotic surgery, and value-based care models, a dedicated spine program should routinely evaluate the current best clinical practices to ensure compliance with the latest evidence-based care.

PMID:40763208 | DOI:10.2106/JBJS.25.00031

J Bone Joint Surg Am. 2025 Aug 5. doi: 10.2106/JBJS.24.01269. Online ahead of print.

ABSTRACT

BACKGROUND: The smallest worthwhile effect (SWE) enables patients to evaluate the expected value of a treatment by weighing its benefits, risks, and costs. It has emerged as an alternative to the minimal clinically important difference (MCID) for interpreting patient-reported outcome measures (PROMs). The purposes of this study were to determine the SWE estimates and MCID thresholds in patients undergoing surgery for adult idiopathic scoliosis (AdIS) and to verify whether meeting or exceeding the SWE estimates correlates with satisfaction at a minimum of 2 years postoperatively.

METHODS: Patients with postoperative satisfaction measured at a minimum of 2 years were prospectively recruited between July 2017 and August 2022. The Scoliosis Research Society-22 revised (SRS-22r) questionnaire was preoperatively administered to estimate the SWE thresholds using the benefit-harm trade-off method. The baseline SRS-22r and the SRS-30 at a minimum of 2 years postoperatively were recorded to determine the MCID estimates using the anchor-based approach, with questions 24 to 30 of the SRS-30 used as anchors. A construct validity assessment was performed to evaluate the association between meeting or exceeding the 50th percentile of the SWE (SWE50) threshold and postoperative satisfaction (defined as a score of ≥4 on both SRS-22r satisfaction questions). Race and ethnicity data were collected from the medical records.

RESULTS: A total of 119 Asian participants (19 male and 100 female) with a mean age of 26.5 ± 7.2 years were included. The absolute SWE50 estimates for the SRS-22r were 0.8 (interquartile range [IQR], 0.6 to 1.2) for self-image, 0.0 (IQR, 0.0 to 0.2) for function, 0.0 (IQR, 0.0 to 0.6) for pain, 0.4 (IQR, 0.0 to 0.6) for mental health, and 0.4 (IQR, 0.2 to 0.6) for the total score. The MCID thresholds for the corresponding domains or total score were 0.7, 0.1, 0.1, 0.3, and 0.3, respectively. Achieving or exceeding the absolute SWE50 threshold for the total score (p < 0.001) or the self-image (chi-square, 11.3; p < 0.001), function (chi-square, 6.3; p = 0.012), or pain (chi-square, 5.7; p = 0.017) domain was significantly correlated with postoperative satisfaction at a minimum of 2 years.

CONCLUSIONS: The SWE could serve as an effective alternative to the MCID for interpreting PROMs at a minimum of 2 years postoperatively in patients with AdIS.

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

PMID:40763206 | DOI:10.2106/JBJS.24.01269

Int Orthop. 2025 Aug 5. doi: 10.1007/s00264-025-06617-x. Online ahead of print.

ABSTRACT

INTRODUCTION: Debridement, antibiotics, and implant retention (DAIR) is a commonly employed strategy for managing acute postoperative prosthetic joint infections (PJI) while preserving the prosthesis. However, the clinical value of an unplanned second DAIR - performed due to inadequate infection control - remains controversial and is often considered a potential treatment failure. This study aimed to compare the two year clinical outcomes of patients undergoing a single DAIR versus those requiring an unplanned second DAIR for acute postoperative PJI of the hip or knee.

METHODS: We retrospectively reviewed electronic medical records of patients treated with DAIR for acute postoperative PJI between January 1999 and December 2020. Patients were categorized into two groups: those managed with a single DAIR (DAIR-1 group) and those requiring an unplanned second DAIR within 12 weeks (DAIR-2 group). Treatment failure was defined as any of the following: further debridement beyond 12 weeks, revision surgery with prosthesis removal, initiation of long-term suppressive antibiotic therapy, or PJI-related mortality. Patients lost to follow-up before two years were excluded.

RESULTS: A total of 318 patients were included, with 292 in the DAIR-1 group and 26 in the DAIR-2 group. Mean follow-up was 89.4 months. At two years, revision surgery was required in 19.2% (56/292) of DAIR-1 patients and 42.3% (11/26) of DAIR-2 patients (p = 0.005). Overall failure-free survival at two years was observed in 75.3% (220/292) of DAIR-1 patients compared to 46.2% (12/26) of those in the DAIR-2 group (p = 0.001).

CONCLUSION: Unplanned second DAIR procedures are associated with significantly lower success rates at two years. Nonetheless, given that nearly half of these patients remained free of failure, a second DAIR may still be a reasonable therapeutic option in selected cases, provided that the increased risk of a poorer prognosis is taken into account.

PMID:40762855 | DOI:10.1007/s00264-025-06617-x

SICOT J. 2025;11:44. doi: 10.1051/sicotj/2025044. Epub 2025 Aug 4.

ABSTRACT

BACKGROUND: To evaluate whether the use of patient-specific instrumentation (PSI) or conventional instrumentation (CI) is associated with superior implant positioning and knee alignment in total knee arthroplasty (TKA).

METHODS: Clinical data, pre- and post-operative knee X-rays of 95 patients, who underwent TKA with use of either patient-specific instrumentation (group PSI) or conventional intra-/extramedullary cutting guides (group CI) were retrospectively collected. Preoperative measurements of knee alignment were done by assessing the femorotibial axis, the lateral femoral distal angle, and the medial tibial proximal angle. Postoperative measurements of the mechanical TKA alignment were performed by assessing the relative position of components to the femur and tibia and the femorotibial axis angle. Only when all three parameters were within generally accepted limits was the postoperative radiological outcome considered optimal.

RESULTS: Preoperative measurements and demographics were similar among the two groups. No statistically significant differences were found between postoperative radiographic findings in patients operated on with PSI or CI. A restoration of the femorotibial axis was achieved in 87.8% and 87.0% of patients treated with PSI and CI, respectively (p = 0.583). Coronal alignment of the femoral component was within acceptable limits in 97.6% and 94.4% (p = 0.631) of patients of the PSI and CI groups, respectively. The respective percentages for the tibial component were 85.3% and 83.3% (p = 0.510) of patients. An accurate coronal plane radiological outcome was achieved in 82.9% and 77.8% of patients treated with PSI and CI, respectively (p = 0.611) Conclusions: The use of PSI does not increase the accuracy of component positioning and leg axis restoration compared to CI in TKA in patients with mild deformity.

PMID:40758900 | PMC:PMC12321163 | DOI:10.1051/sicotj/2025044

SICOT J. 2025;11:43. doi: 10.1051/sicotj/2025046. Epub 2025 Aug 4.

ABSTRACT

INTRODUCTION: Knee dislocations, particularly high-grade injuries such as Schenck class KDIV, are complex injuries often resulting from high-energy trauma. While magnetic resonance imaging (MRI) is widely used preoperatively to assess ligamentous damage, its diagnostic accuracy remains uncertain.

METHODS: A retrospective review was conducted on 92 patients who underwent surgery for a knee dislocation at a Level I trauma center over 10 years. Patients who had a preoperative MRI report and intraoperative confirmation of a KDIV injury without a tibial plateau fracture were included, which left 31 patients. MRI sensitivity was determined by comparing radiology reports to operative findings with fluoroscopic examination under anesthesia (EUA) for injuries to the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), and posterolateral corner (PLC). Postoperative follow-up documents were reviewed for functional outcomes. A one-way analysis of variance (ANOVA) was performed to evaluate differences in sensitivity across ligament types, followed by a Tukey post hoc test for pairwise comparisons. Mean flexion ROM at final follow-up (≥6 months) was compared between the accurate and inaccurate MRI cohorts using an independent t-test.

RESULTS: Only 35.5% of MRI reports fully matched operative findings. MRI sensitivity was 71.0% for the ACL (22/31), 61.3% for the PCL (19/31), 93.5% for the MCL (29/31), 64.5% for the LCL (20/31), and 51.6% for the PLC (16/31). ANOVA revealed that MCL sensitivity was significantly higher than that of the PLC, PCL, and LCL. The difference in mean flexion ROM at final follow-up between accurate and inaccurate MRI cohorts was not statistically significant (p = 0.56).

DISCUSSION: Preoperative MRI radiology reports demonstrated substantial limitations in accurately identifying ligamentous injuries in KDIV knee dislocations, particularly involving the PLC, PCL, and LCL. These findings highlight a gap between radiologic interpretation and surgical findings. Surgeons should interpret MRI reports with caution and incorporate fluoroscopic EUA at the time of surgery to ensure a comprehensive assessment of ligamentous damage.

PMID:40758899 | PMC:PMC12321162 | DOI:10.1051/sicotj/2025046

EFORT Open Rev. 2025 Aug 4;10(8):589-599. doi: 10.1530/EOR-2024-0105.

ABSTRACT

PURPOSE: The objective of this study was to assess the benefits of the PENG block on pain control and functional recovery.

METHODS: Randomized controlled trials in PubMed, Web of Science, Embase, and the Cochrane Library were selected, and data were meta-analyzed using a random-effects model to estimate mean difference (MD) or standardized mean differences (SMD).

RESULTS: Eleven trials involving 1,135 patients were included. The PENG block was associated with significantly lower total opioid consumption than sham/no block (MD: -25.23, 95% CI: -27.01 to -23.45, I 2 = 0%), as well as better functional recovery. The PENG block was noninferior to the suprainguinal fascia iliaca block regarding postoperative pain scores and functional recovery and had a significant reduction in total opioid consumption (MD: -8.25, 95% CI: -16.48 to -0.02, I 2 = 68%). The PENG block was associated with similar total opioid consumption and functional recovery as the periarticular anesthetic infiltration (PAI), but worse static pain scores at 12 h (SMD: 0.41, 95% CI: 0.08-0.75, I 2 = 51%) and dynamic pain scores at 48 h after surgery (SMD: 0.36, 95% CI: 0.08-0.64, I 2 = 0%).

CONCLUSIONS: While current evidence supports the PENG block as a viable alternative to other types of peripheral analgesia in THA, existing data remain insufficient to conclude that the PENG block outperforms other peripheral analgesia when it comes to pain control or functional recovery. More well-designed randomized controlled trials are needed in the future to thoroughly explore whether the PENG block has superiority over other analgesic techniques.

PMID:40757814 | PMC:PMC12326972 | DOI:10.1530/EOR-2024-0105

EFORT Open Rev. 2025 Aug 4;10(8):574-588. doi: 10.1530/EOR-2024-0049.

ABSTRACT

PURPOSE: Diagnosing osteomyelitis in the foot/ankle region is challenging primarily due to anatomical constraints. While bone biopsy is the gold standard, non-invasive methods such as SPECT (single photon emission computed tomography) and MRI are sensitive but lack specificity. This study aims to evaluate SPECT/CT's potential, integrating functional and structural imaging, to improve osteomyelitis diagnosis in this region.

METHODS: A systematic review following PRISMA guidelines and the Cochrane Handbook was conducted, including comprehensive research across major databases (inception to October 2022). Diagnostic studies using SPECT/CT for suspected foot/ankle bone lesions or inflammation were included. We carried out descriptive analysis, SROC curve generation, and calculated mean sensitivities and specificities. Subgroup analyses were conducted for various tracers, CT resolutions, and evaluation strategies. Sensitivity and heterogeneity analyses, bias risk, and publication bias were assessed.

RESULTS: Eleven diagnostic studies (463 patients) were reviewed, with seven focusing on diabetic patients. Tracers included labeled leukocytes (WBC), antigranulocyte antibodies, phosphonates (BS), and gallium citrate. Clinical follow-up was the primary reference standard. Mean sensitivity of SPECT/CT for osteomyelitis diagnosis was 93.8% (95% CI: 89.7-96.4%), and specificity was 84.6% (95% CI: 65.1-94.2%). WBC SPECT/CT was more specific (79.4%) but less sensitive (89.2%) than BS SPECT/CT (specificity 46.5%, sensitivity 93.1%). Combined tracers yielded the highest mean specificity (96.4%).

CONCLUSION: SPECT/CT shows promising diagnostic performance for osteomyelitis in the foot/ankle region, especially when applying combined tracer methods. It is particularly advantageous in chronic, postoperative, and post-traumatic cases, offering added value compared to MRI.

PMID:40757813 | PMC:PMC12326970 | DOI:10.1530/EOR-2024-0049

EFORT Open Rev. 2025 Aug 4;10(8):623-635. doi: 10.1530/EOR-2024-0120.

ABSTRACT

Total knee arthroplasty is a highly effective intervention for end-stage osteoarthritis, yet nearly 20% of patients report dissatisfaction with clinical outcomes. This dissatisfaction is often linked to intraoperative parameters, particularly whole-leg alignment and component positioning, which might play a role in ensuring both satisfaction and long-term implant survival. Over the past two decades, alignment techniques have progressed from systematic, two-dimensional methods focused on the frontal plane to more personalized, three-dimensional approaches. This evolution has introduced inconsistencies and confusion among surgeons regarding alignment techniques, terminology, and application, underscoring the need for standardized definitions that can be universally adopted. This work provides standardized definitions for six main knee alignment techniques to enhance communication within the scientific community, particularly in clinical research. While not an exhaustive analysis of each method, this effort focuses on the foundational principles of these techniques, organized using a standardized framework to facilitate comparison and improve clarity in the field.

PMID:40757810 | PMC:PMC12326975 | DOI:10.1530/EOR-2024-0120

EFORT Open Rev. 2025 Aug 4;10(8):636-645. doi: 10.1530/EOR-2024-0135.

ABSTRACT

Hamstring injuries are a significant concern in high-speed running and kicking sports, contributing to a high incidence and recurrence rate among athletes. Anatomical and biomechanical properties of the hamstrings, especially the biceps femoris long head, make them susceptible to strain, contributing to the high injury rate observed in athletes. Key risk factors, including prior injury history, neuromuscular deficiencies, excessive load, and muscle-tendon architecture, have been identified as contributors to injury prevalence. Eccentric strengthening exercises, particularly the Nordic hamstring exercise, are highlighted for their effectiveness in reducing the incidence of hamstring injuries. Stretching protocols, when combined with strengthening exercises, have shown potential in enhancing muscle flexibility and reducing injury risk, although their standalone effectiveness remains a subject of ongoing research.

PMID:40757809 | PMC:PMC12326974 | DOI:10.1530/EOR-2024-0135

EFORT Open Rev. 2025 Aug 4;10(8):611-622. doi: 10.1530/EOR-2024-0119.

ABSTRACT

The main goal of a successful total knee arthroplasty is to relieve pain and restore function. While mechanical alignment provides excellent long-term implant survivorship, clinical and functional outcomes remain less than ideal. As a result, the focus has gradually shifted to a more personalized surgical approach based on the patient's specific characteristics. There is a pressing need for agreement on definitions of key terms to standardize limb alignment measurements and improve understanding and communication within the field. This work aims to clarify the concept of native limb alignment, outline how it is measured, and propose a standardized terminology to describe it.

PMID:40757805 | PMC:PMC12326966 | DOI:10.1530/EOR-2024-0119

EFORT Open Rev. 2025 Aug 4;10(8):600-610. doi: 10.1530/EOR-2024-0128.

ABSTRACT

PURPOSE: Meniscal extrusion (ME) can have detrimental effects. The aim of this study was to analyze the evidence about the reliability, potential of standing and dynamic evaluations, and influencing factors identified by using ultrasound (US) to evaluate knee ME.

METHODS: A systematic review of the literature was performed in February 2024 on PubMed, Scopus, and the Cochrane Library databases to select all articles, dealing with the US evaluation of ME. Relevant data of the involved articles, including study type, number of patients, age, sex, US technique, and data comparison with other radiological examinations, were extracted and collected for the study analysis.

RESULTS: Sixty studies on 4,742 patients were included: 38 cross-sectional, ten longitudinal, two case-control, and ten biomechanical studies. A strong correlation was found between MRI and US, with good US sensitivity (96%) and specificity (82%), and moderate to excellent interrater and intrarater reliability. US examinations in the standing position with weight-bearing or more complex dynamic conditions reported a significant influence of weight-bearing on MME. US was able to identify a relationship between meniscus posterior root tear and MME, as well as between ME and both pain and early osteoarthritis.

CONCLUSIONS: US is a valuable tool for the study of ME and the identification of the association between ME and various conditions. US in dynamic and weight-bearing evaluations is useful to characterize this anatomical abnormality in different pathologies, including OA, meniscal lesions, and in the follow-up of surgical procedures, providing important data to choose the best treatment to address patients affected by ME.

PMID:40757803 | PMC:PMC12326973 | DOI:10.1530/EOR-2024-0128

J Bone Joint Surg Am. 2025 Aug 4. doi: 10.2106/JBJS.24.01619. Online ahead of print.

ABSTRACT

BACKGROUND: Flatfoot, or pes planus, is a common anatomical variation marked by a reduced or absent longitudinal arch. Although it is often considered benign, the condition can progress to progressive collapsing foot deformity (PCFD), a debilitating pathology. This study aimed to identify imaging biomarkers that distinguish asymptomatic flatfoot from PCFD by comparing 3D measurements among normally aligned feet, asymptomatic flatfeet, and feet with PCFD.

METHODS: A prospective, comparative, and controlled study was conducted on 561 feet in 475 subjects: 88 control subjects with 98 normally aligned feet, 66 control subjects with 132 asymptomatic flatfeet, and 321 patients with 331 feet with symptomatic PCFD. Bilateral weight-bearing computed tomography (WBCT) scans were performed, and various 3D measurements were analyzed, focusing on hindfoot valgus (Class A deformity), midfoot and/or forefoot abduction (Class B), arch collapse (Class C), and peritalar subluxation (PTS) (Class D). Statistical analysis, including multivariable nominal regression, was used to identify significant predictors of symptoms.

RESULTS: Progressive increases in Class A, B, and C deformity parameters were observed from normally aligned feet to asymptomatic flatfeet and finally to feet with PCFD. Significant differences in PTS (Class D deformity) were found only in the comparison between the feet with PCFD and the control groups, with reduced joint coverage and increased sinus tarsi coverage, indicating extra-articular impingement. Multivariable analysis identified the minimum sinus tarsi distance as the strongest predictor of symptoms, with a threshold of 1.9 mm best distinguishing symptomatic from asymptomatic feet.

CONCLUSIONS: This study demonstrated that although hindfoot valgus, midfoot and/or forefoot abduction, and arch collapse deformities progressively increase from normal alignment to PCFD, significant subtalar joint subluxation and sinus tarsi impingement were unique to symptomatic PCFD. These findings suggest that PTS can serve as a crucial biomarker for diagnosing pathologic flatfoot (PCFD) and differentiating it from asymptomatic flatfoot. Future research should explore the predictive value of PTS biomarkers in identifying flatfoot at high risk for collapse and their impact on clinical management and surgical decision-making.

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

PMID:40758778 | DOI:10.2106/JBJS.24.01619

J Bone Joint Surg Am. 2025 Aug 4. doi: 10.2106/JBJS.24.01404. Online ahead of print.

ABSTRACT

BACKGROUND: This study was performed to determine if the Patient-Reported Outcomes Measurement Information System (PROMIS), the 9-item Oswestry Disability Index (ODI-9), and back pain intensity predict abnormal magnetic resonance imaging (MRI) findings in pediatric patients with back pain.

METHODS: We performed a retrospective review from April 2021 to June 2023 of 300 children (200 girls and 100 boys) aged 5 to 18 years with caregiver-reported back pain who underwent MRI of the spine and had completed the PROMIS Pediatric computerized adaptive testing measures for Pain Interference, Mobility, and Anxiety and the ODI-9, and had rated back pain intensity on a scale ranging from 0 to 5. Patients were excluded if they had neuromuscular or syndromic scoliosis, a history of previous spinal surgeries, or isolated neck pain. MRI findings were grouped as non-spinal and spinal findings, and then categorized into subgroups as incidental, correlative, and causative findings. Incidental findings were considered those in children with normal MRI findings. Patient-reported outcome measures (PROMs) were compared between children with normal and abnormal MRI findings (defined by the presence of correlative and/or causative findings) with use of Mann-Whitney U tests and logistic regression analysis.

RESULTS: Of the 300 children, 126 (42%) had abnormal MRI findings and 174 (58%) had normal MRI findings. Lower PROMIS Mobility scores (39.2 versus 42.8, p = 0.001) and higher ODI-9 percentages (27.4 versus 23.3, p = 0.015) were associated with abnormal MRI findings. A PROMIS Mobility threshold of 40.5 and an ODI percentage threshold of 21.1 were optimal for predicting abnormal MRI findings. We did not find an association between PROMIS Anxiety, PROMIS Pain Interference, or pain intensity with abnormal MRI findings.

CONCLUSIONS: Lower PROMIS Mobility scores and higher ODI-9 scores, which reflect worsening functional disability, were associated with abnormal MRI findings in pediatric patients with back pain. Additionally, the minimum clinically important difference was met for the PROMIS Mobility score between those with normal and abnormal MRI.

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

PMID:40758775 | DOI:10.2106/JBJS.24.01404

Injury. 2025 Jul 27;56(10):112626. doi: 10.1016/j.injury.2025.112626. Online ahead of print.

ABSTRACT

Burn injuries result in profound and enduring consequences that extend well beyond the initial physical trauma. Although survival rates have significantly improved in recent decades, particularly in high-income countries, many survivors continue to experience complex psychological and social challenges that persist long after discharge from hospital care. This review outlines the current understanding of the psychological and social impacts of burn injuries and highlights key strategies to support survivors and their families through each stage of recovery. Common psychological concerns include post-traumatic stress, anxiety, depression, and disruptions to self-perception. These issues frequently emerge early in the recovery process and may endure for several years, influencing daily functioning, interpersonal relationships, and the ability to return to work. Caregivers are also affected, often experiencing emotional fatigue and psychological strain, particularly when access to support services is limited. Reintegration into everyday life is frequently marked by social stigma and exclusion, with children and adolescents being especially vulnerable due to ongoing identity development. Holistic recovery requires more than physical rehabilitation; it requires a coordinated, multidisciplinary approach that incorporates psychological support, social reintegration, and long-term follow-up. Interventions such as cognitive-behavioural therapy, peer and family support programs, and digital health platforms have shown promise in addressing these needs. While some individuals report personal growth following burn trauma, outcomes are influenced by various factors, including mental health history, community context and available support. Psychosocial care must be responsive to cultural and developmental differences and accessible across diverse settings. Innovations such as virtual reality and telehealth are increasingly valuable in bridging service gaps, particularly for individuals in rural or underserved areas.

PMID:40753695 | DOI:10.1016/j.injury.2025.112626