Int Orthop. 2025 Mar 22. doi: 10.1007/s00264-025-06500-9. Online ahead of print.

ABSTRACT

PURPOSE: Cutibacterium species, formerly known as Propionibacterium, are gram-positive, anaerobic bacilli increasingly recognized as a cause of periprosthetic joint infection (PJI) following total hip arthroplasty (THA). This study aimed to compare the incidence of Cutibacterium-associated PJI among different surgical approaches for THA.

METHODS: A retrospective review was conducted on patients treated for Cutibacterium-associated PJI following THA between 2011 and 2021. Patients were categorized based on the surgical approach: direct anterior (DAA), lateral, or posterior. A total of 211 patients met inclusion criteria, comprising 153 men (72.5%) and 58 women (27.5%).

RESULTS: Among the 211 cases of Cutibacterium-associated PJI, 102 (48.3%) underwent THA via DAA, 63 (29.9%) via a lateral approach, and 46 (21.8%) via a posterior approach. There were no significant differences between groups in age, sex, laterality, BMI or fistula formation. The incidence of Cutibacterium PJI was significantly higher with DAA compared to the lateral (P < 0.001) and posterior approaches (P < 0.001), while no significant difference was observed between lateral and posterior approaches (P = 0.059). The rate of Cutibacterium-associated PJI has increased since 2016.

CONCLUSION: Nearly half of all Cutibacterium PJIs were associated with the DAA. Surgeons should be aware of this increased risk and implement appropriate preventive measures when performing THA via DAA.

PMID:40119900 | DOI:10.1007/s00264-025-06500-9

J Bone Joint Surg Am. 2025 Mar 22. doi: 10.2106/JBJS.24.00311. Online ahead of print.

ABSTRACT

BACKGROUND: Delayed bone healing is common in orthopaedic clinical care. Agents that alter cell function to enhance healing would change treatment paradigms. 4-aminopyridine (4-AP) is a U.S. Food and Drug Administration (FDA)-approved drug shown to improve walking in patients with chronic neurological disorders. We recently showed 4-AP's positive effects in the setting of nerve, wound, and even combined multi-tissue limb injury. Here, we directly investigated the effects of 4-AP on bone fracture healing, where differentiation of mesenchymal stem cells into osteoblasts is crucial.

METHODS: All animal experiments conformed to the protocols approved by the Institutional Animal Care and Use Committee at the University of Arizona and Pennsylvania State University. Ten-week-old C57BL/6J male mice (22 to 28 g), following midshaft tibial fracture, were assigned to 4-AP (1.6 mg/kg/day, intraperitoneal [IP]) and saline solution (0.1 mL/mouse/day, IP) treatment groups. Tibiae were harvested on day 21 for micro-computed tomography (CT), 3-point bending tests, and histomorphological analyses. 4-AP's effect on human bone marrow mesenchymal stem cell (hBMSC) and human osteoblast (hOB) cell viability, migration, and proliferation; collagen deposition; matrix mineralization; and bone-forming gene/protein expression analyses was assessed.

RESULTS: 4-AP significantly upregulated BMP2 gene and protein expression and gene expression of RUNX2, OSX, BSP, OCN, and OPN in hBMSCs and hOBs. 4-AP significantly enhanced osteoblast migration and proliferation, collagen deposition, and matrix mineralization. Radiographic and micro-CT imaging confirmed 4-AP's benefit versus saline solution treatment in mouse tibial fracture healing (bone mineral density, 687.12 versus 488.29 mg hydroxyapatite/cm3 [p ≤ 0.0021]; bone volume/tissue volume, 0.87 versus 0.72 [p ≤ 0.05]; trabecular number, 7.50 versus 5.78/mm [p ≤ 0.05]; and trabecular thickness, 0.08 versus 0.06 mm [p ≤ 0.05]). Three-point bending tests demonstrated 4-AP's improvement of tibial fracture biomechanical properties versus saline solution (stiffness, 27.93 versus 14.30 N/mm; p ≤ 0.05). 4-AP also increased endogenous BMP2 expression and matrix components in healing callus.

CONCLUSIONS: 4-AP increased the healing rate, biomechanical properties, and endogenous BMP2 expression of tibiae following fracture.

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

PMID:40120116 | DOI:10.2106/JBJS.24.00311

Injury. 2025 Mar 16;56(4):112272. doi: 10.1016/j.injury.2025.112272. Online ahead of print.

ABSTRACT

INTRODUCTION: Fracture-related infection (FRI) poses a substantial challenge in orthopaedic trauma surgery, potentially leading to permanent functional impairment or necessitating amputation in patients who are expected to recover fully. Data on the incidence, pathogen detection rates, outcomes, and optimal management strategies for patellar FRI are limited. Therefore, this study aimed to identify the most common pathogens associated with patellar fixation-related infections, evaluate the functional outcome associated with FRI of the patella, and develop a management algorithm for addressing these severe complications.

METHODS: This retrospective review analyzed a prospectively maintained database to identify all patients with FRI of the patella treated at our institution between January 2015 and August 2023. Data on demographics, fracture characteristics, surgical details, and outcomes were collected. Descriptive statistical analyses were performed using SPSS software.

RESULTS: Over the 9-year period, 32 cases of patellar fractures complicated by infection following surgical treatment were identified, with complete follow-up data available (mean age, 56.5 ± 15.8 years). Infection occurred in 13 patients within 2 weeks of fixation and in 19 patients between 2 and 10 weeks postoperatively. Following debridement, nine patients retained their original fixation, eight underwent hardware removal, and 15 underwent hardware replacement. Seven patients developed septic arthritis and were managed with arthroscopic knee lavage. Metagenomic next-generation sequencing demonstrated a sensitivity of 93.8 % (30/32), which was significantly higher than that of traditional microbiological culture (53.1 %; P < 0.01). All surgical incisions achieved primary healing within 2 weeks post-closure with no recurrence of infection, skin necrosis, osteomyelitis, or nonunion. At the final follow-up, all fractures had united, with the Böstman patellar fracture functional scores ranging from 24 to 29, resulting in a 100 % excellent/good rate.

CONCLUSIONS: Comprehensive and multidisciplinary management approaches can achieve successful bone union and favourable long-term outcomes in patients with patellar FRI. However, further validation through large-scale studies is necessary to confirm these findings.

PMID:40117911 | DOI:10.1016/j.injury.2025.112272

Int Orthop. 2025 Mar 21. doi: 10.1007/s00264-025-06495-3. Online ahead of print.

ABSTRACT

PURPOSE: To evaluate the efficacy of tibiotalocalcaneal arthrodesis using retrograde nailing (TTCAN) in post-traumatic conditions with high septic risk. We hypothesized that this minimally invasive technique would achieve bone union and satisfactory functional recovery without increasing septic risk.

METHODS: A prospective single-centre observational study included 20 patients who underwent TTCAN between January 2020 and December 2023. The primary outcome was the complete joint fusion rate at six months. Secondary outcomes included pain assessment, complications, functional evaluation using the modified AOFAS score, and quality of life assessment using the SF-12 questionnaire.

RESULTS: Complete tibiotalocalcaneal fusion was achieved in 55% of patients at six months. Diabetes was significantly associated with fusion failure (p = 0.026). For nonunion cases (n = 14), the consolidation rate reached 78.6% at six months and 92.9% at final follow-up. The mean modified AOFAS score was 48.4 ± 17.5 at six months, improving to 51.2 ± 19.3 at final follow-up (mean 15.6 months). Quality of life assessment showed greater impact on physical (PCS-12: 32.0 ± 6.9) than mental (MCS-12: 47.0 ± 12.7) components. Complications included delayed healing (25%) and one superficial infection.

CONCLUSION: TTCAN proves to be a reliable salvage solution for complex ankle and hindfoot trauma in high-risk septic contexts, enabling limb preservation with acceptable functional outcomes and minimal complications.

PMID:40116881 | DOI:10.1007/s00264-025-06495-3

Int Orthop. 2025 Mar 21. doi: 10.1007/s00264-025-06456-w. Online ahead of print.

ABSTRACT

PURPOSE: Early onset scoliosis (EOS) surgery with growth rods has complications. While casting is an alternative, special frames and training are often unavailable. Our study evaluates a simple, reproducible casting technique for EOS using universally available equipment without a special casting table.

METHODS: 27 children with EOS underwent serial casting with a simple technique using two standing stools, a Cervical Sayre traction kit, and a metal plate. Casts were changed every three to four months. Pre, post, and follow-up Cobb angles and complications were recorded. Patients were grouped into congenital (CS) and non-congenital (NCS) EOS and compared.

RESULTS: 27 children (mean age 4.15 years) with EOS underwent 116 casting procedures (mean 4.29 casts/patient). Significant curve correction (63.85° to 33.8°) was noted (p < 0.05). NCS had better correction than CS post-first cast (p < 0.05). Complications included three dermatitis and one mild respiratory distress.

CONCLUSION: The technique yielded results similar to those of traditional casting tables/frames and is ideal for resource-limited settings.

PMID:40116880 | DOI:10.1007/s00264-025-06456-w

Int Orthop. 2025 Mar 21. doi: 10.1007/s00264-025-06502-7. Online ahead of print.

ABSTRACT

PURPOSE: Rotator cuff (RC) tears are common in older adults, often leading to muscle atrophy. Standard arthroscopic repair has high re-tear rates, prompting the use of biological patches for augmentation. This study assessed differences in range of motion, strength, and tendon healing using ultrasound in primary and revision RC repairs using acellular dermal allograft augmentation.

METHODS: Forty-eight patients undergoing arthroscopic RC repair with dermal allograft augmentation were assessed, with 42 completing a median follow-up of 32.4 months. Twenty patients had primary repairs and 22 had revision procedures. A control group of 26 patients, matched for age, sex, BMI, and RC injury type, underwent RC repair without patch augmentation. Active range of motion, Constant-Murley socre (CS), Simple Shoulder Test (SST), Subjective Shoulder value (SSV) and isometric strength were measured. Tendon healing was assessed via dynamic US.

RESULTS: Both primary and revision groups showed significant improvements in clinical scores and shoulder mobility. However, the primary group had significantly higher postoperative CS, SST and SSV scores. Strength tests indicated lower values in the revision group compared to primary and control groups. Ultrasound outcomes showed reduced tendon thickness in 23 patients, with similar repair integrity across groups. Five cases of RC re-tears were noted, with higher but not significantly different re-tear rates in the revision group.

CONCLUSION: Dermal allograft augmentation in RC repair leads to significant clinical improvement in both primary and revision cases, but strength recovery is less pronounced in revision repairs. Long-term follow-up is necessary to validate these findings and assess the durability of tendon healing.

LEVEL OF EVIDENCE: Level III, Retrospective cohort design, Treatment study.

PMID:40116879 | DOI:10.1007/s00264-025-06502-7

SICOT J. 2025;11:19. doi: 10.1051/sicotj/2025013. Epub 2025 Mar 20.

ABSTRACT

INTRODUCTION: The two-stage management of hip Prosthetic Joint Infection (PJI) is faced with a high rate of dislocation. Dual mobility (DM) cups have proved effective in reducing the risk of dislocation, but few data are available on the two-stage management of hip PJI. The objectives of this retrospective cohort study were to analyze the rate of dislocation, and the rate of recurrent dislocation and to identify risk factors for dislocation. Our hypothesis was that the use of a DM cup during a two-stage replacement had a low instability rate.

METHODS: Data from 70 two-stage changes with DM cup reimplantation performed in our centre between 2011 and 2020 were retrospectively collated. The mean age was 69 years [18-93], with a mean follow-up of 3.4 years [1.5-9.6]. Dislocation rates and risk factors for prosthetic instability were collected. Univariate and multivariate analyses were performed to identify risk factors favouring prosthetic instability.

RESULTS: The rate of dislocation at the last follow-up was 8.6% (6/70), including 4.3% (3/70) in patients with no infection recurrence. The rate of recurrent dislocation was 0% when infection was controlled. The occurrence of spacer dislocation, the presence of immunosuppressive and antiaggregant medication, the local grade of the McPherson score and infection treatment failure were associated with the occurrence of a dislocation. No risk factors were identified in the multivariate analysis.

DISCUSSION: Compared with the rates reported in the literature, the use of a DM cup seems indicated in this context in order to lower the risk of recurrent dislocation. Preventing spacer dislocation and infection recurrence seems to be essential to avoid the risk of instability of the future prosthetic hip.

PMID:40111057 | PMC:PMC11924924 | DOI:10.1051/sicotj/2025013

Injury. 2025 Mar 7:112257. doi: 10.1016/j.injury.2025.112257. Online ahead of print.

ABSTRACT

BACKGROUND: Burden of pediatric burn (PB) varies globally, attributable to a spectrum of countries, medical condition, and Socio-demographic Index (SDI). We determined the trends and changes in the global burden of PB among children using Global Burden of Disease (GBD) data.

METHODS: Data were extracted from the GBD, offering an exhaustive overview of the age-standardized incidence, Disability-Adjusted Life Years (DALYs), and mortality rates of PBs from 2009-2019. We assess the data of the PB burden across 204 nations and territories, as well as to investigate the interplay between the SDI and a spectrum of burn-related sequelae, encompassing amputations and inhalation injuries.

RESULTS: The age-standardized incidence, DALYs, and mortality rates for PBs were calculated at 135.25 (95 % UI: 205.27-89.44), 1.01 (95 % UI: 1.37-0.72), and 93.16 (95 % UI: 67.42-124.21), respectively. A slight predominance in the PB burden was observed among females relative to males. An inverse correlation between SDI and burn incidence was observed for SDI values below 0.4, which shifted to a positive correlation for mortality and DALY rates within the 0.4-0.6 range, followed by a plateau. Above an SDI of 0.4, a negative correlation with mortality and DALY was discerned. The highest global incidence was reported in Latin America, whereas Oceania (excluding Australia and New Zealand) exhibited the highest mortality and DALY rates. Severe burns were linked to the most substantial burden, succeeded by inhalation injuries and amputations.

CONCLUSION: The PB burden, as indicated by age-standardized incidence, DALYs, and mortality rates, is modulated by SDI and gender, with pronounced disparities in epidemiological patterns between Oceania and Australasia, despite their similar socio-economic categorization. There is an imperative to intensify burn prevention strategies in middle- and high-income countries and to augment treatment capabilities in low- and middle-income nations. Emphasis on the management of severe burns is paramount for diminishing the overall PB burden, with a subsequent imperative to address inhalation injuries and amputations. Heightened vigilance in burn care and prevention is imperative, particularly in Latin America, Africa, and Oceania, to ameliorate the impact of these injuries on vulnerable pediatric cohorts.

PMID:40113549 | DOI:10.1016/j.injury.2025.112257

Injury. 2025 Mar 13;56(4):112270. doi: 10.1016/j.injury.2025.112270. Online ahead of print.

NO ABSTRACT

PMID:40112614 | DOI:10.1016/j.injury.2025.112270

J Bone Joint Surg Am. 2025 Mar 20. doi: 10.2106/JBJS.24.00160. Online ahead of print.

ABSTRACT

BACKGROUND: Magnetic intramedullary lengthening nails (MILNs) have become an increasingly popular method for long-bone distraction osteogenesis as a means of overcoming the limitations of bone lengthening with an external fixator. While factors such as nail diameter, alignment, and other mechanical characteristics have been associated with an increased risk of nail breakage, the relationship between the percentage of maximum lengthening utilized and nail breakage remains unexplored. We specifically assessed overall complications, with and without the inclusion of contractures, based on the amount of distraction (25% to 60%, 61% to 90%, and 91% to 100% of maximum).

METHODS: We retrospectively reviewed the records for 176 pediatric patients and 109 adult patients who had undergone limb lengthening and had ≥24 months of follow-up. The cohort was further stratified by the amount of distraction: 25% to 60% (n = 75 children and 30 adults), 61% to 90% (n = 72 children and 29 adults), and 91% to 100% (n = 29 children and 50 adults). The mean ages were 14.53, 13.53, and 12.49 years, respectively, in the pediatric cohorts and 27.1, 34.3, and 23.8 years, respectively, in the adult cohorts. The percentages of males and females were 48% vs. 52%, 54.2% vs. 45.8%, and 48.3% vs 51.7%, respectively, in the pediatric cohorts and 56.7% vs. 43.3%, 51.8% vs. 48.2%, and 58% vs. 42% in the adult cohorts. Complications included contractures, loss of length, bone fracture, axial deviation, nail failure, failure to lengthen, nail fracture/failure, and screw failure. Analysis of variance (ANOVA) was conducted to compare mean complications across the 3 distraction categories, and Tukey pairwise t tests were performed to compare mean complications between individual distraction categories.

RESULTS: Without contractures, complication rates were similar between the pediatric cohorts (p = 0.09): 4.0% (25% to 60% distraction), 13.9% (61% to 90% distraction), and 6.9% (91% to 100% distraction). With contractures included, complication rates were greatest in the 61% to 90% pediatric cohort (38.9%), followed by the 91% to 100% cohort (27.6%) and the 25% to 60% cohort (13.3%) (p = 0.002). Similarly, the adult population had a homogeneous rate of complications without the inclusion of contractures (p = 0.13). Likewise, we observed a similarly variable distribution with contractures considered, with the greatest frequency in the 91% to 100% group (36%), followed by the 61% to 90% group (31%) and the 25% to 60% group (10%) (p = 0.04).

CONCLUSIONS: This is the first study to explore the relationship between the percentage of nail lengthening and nail complications. The speculation that full extension of the nail could lead to increased nail bending or breakage was not consistent with our findings. This finding was consistent whether contractures were included or not.

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

PMID:40112087 | DOI:10.2106/JBJS.24.00160

Int Orthop. 2025 Mar 20. doi: 10.1007/s00264-025-06498-0. Online ahead of print.

ABSTRACT

Nerve injury primarily leads to neuropathic pain but may also have overlapping elements of nociplastic pain or ongoing nociceptive pain. Electrical stimulation is particularly effective in the treatment of neuropathic pain and may be effective for nociplastic and nociceptive pain. While multiple mechanisms contribute to the analgesic effect of electrical stimulation, the most widely accepted theory for the predominant effect is that of Melzack and Wall's gate control theory. According to this theory, non-painful sensory input carried by low-threshold large-diameter Aβ fibres disrupt the transmission of pain signals in small pain fibers (Aδ and C fibres). This occurs through the activation of inhibitory interneurons in the dorsal horn, which ultimately blocks pain signal transmission.This theory has been employed for different forms of stimulation, including transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS), and peripheral nerve stimulation (PNS). Each of these methods offers a different approach to localized stimulation and neuromodulation for the treatment of pain. TENS is a non-invasive technique, that delivers electrical currents via surface electrodes placed on the skin. PENS, in contrast, is a minimally invasive method that applies electrical currents through small needles inserted near a target muscle or neural structure. PNS involves the implantation of temporary or permanent electrodes to deliver electrical stimulation directly to peripheral nerves. These modalities are widely used to manage various pain conditions including non-malignant, chronic musculoskeletal and neuropathic pain, such as chronic low back pain, neck pain, neuropathic pain, myofascial pain, and post-operative pain. TENS is particularly notable as a non-invasive device that is affordable, over-the-counter, self-administered, and nonpharmacological option that does not pose the risk of toxicity or overdose. PENS stands out for its ability to integrate electrical stimulation therapy with electroacupuncture through a minimally invasive technique. PNS, on the other hand, is unique in its capacity to precisely target specific nerves and provide a range of stimulation options for extended treatment durations.This article provides a narrative overview of TENS, PENS and PNS with a particular focus on their application for neuropathic pain management and for athletes. We will review mechanisms of action, indications, diagnostic and treatment algorithms, as well as complications and limitations. The overview concludes with a complex case study demonstrating the use of various electrical stimulation therapies, ultimately to successful pain resolution for the patient.

PMID:40111452 | DOI:10.1007/s00264-025-06498-0

J Bone Joint Surg Am. 2025 Mar 20. doi: 10.2106/JBJS.24.00266. Online ahead of print.

ABSTRACT

BACKGROUND: Total knee arthroplasty (TKA) is one of the most commonly performed elective procedures in North America. While advancements have been made in patient optimization, surgical technique, and implant design, tourniquet use remains a contentious issue as it relates to patient outcomes and postoperative experience.

METHODS: As part of the PEPPER trial, we identified 5,684 patients who underwent primary TKA, of whom 4,866 (85.6%) underwent surgery with a tourniquet (the YT group) and 818 (14.4%) underwent surgery without a tourniquet (the NT group). The cohort was predominantly female (60.8%), White (77%), and of an ethnicity other than Hispanic or Latino (96.8%). The mean age of the patients was 64.6 ± 9.2 years. The primary outcomes were the Knee injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS JR); Patient-Reported Outcomes Measurement Information System Physical Health Summary (PROMIS-PH10); and numeric pain rating scale (NPRS), which were captured preoperatively and at 1, 3, and 6 months postoperatively. The secondary outcomes were length of stay, discharge disposition, analgesic consumption, and postoperative complications. Multivariable analysis was performed to assess the associations between tourniquet use and patient-reported outcome measures (PROMs) following TKA.

RESULTS: The percentages of patients achieving the minimal clinically important difference (MCID) for the KOOS JR were significantly different at 1 month only (YT, 55.4%; NT, 47.9%). This difference disappeared at 3 and 6 months. There was no difference between the YT and NT groups in terms of the percentage of patients achieving the MCID for the PROMIS-PH10 or NPRS at any time point. There were no differences between the YT and NT groups at any time point with respect to the KOOS JR, PROMIS-PH10, and NPRS. There were no differences in opioid consumption, operative time, length of stay, wound-related complications, or readmissions postoperatively.

CONCLUSIONS: Tourniquet use was associated with more patients achieving the MCID for the KOOS JR at 1 month compared with no tourniquet use. This difference disappeared at 3 and 6 months. At 1, 3, and 6 months, there were no differences in opioid consumption, health-care utilization, or complications between patients undergoing TKA with a tourniquet versus without a tourniquet. Tourniquet use did not have a clinically meaningful impact on PROMs in the multivariable analysis. Arthroplasty surgeons may use these data during preoperative discussions with patients regarding tourniquet use as it relates to the surgeon's preference and how it could influence postoperative function.

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

PMID:40112083 | DOI:10.2106/JBJS.24.00266

Int Orthop. 2025 Mar 20. doi: 10.1007/s00264-025-06496-2. Online ahead of print.

NO ABSTRACT

PMID:40111451 | DOI:10.1007/s00264-025-06496-2

Int Orthop. 2025 Mar 20. doi: 10.1007/s00264-025-06481-9. Online ahead of print.

ABSTRACT

PURPOSE: Tendon lengthening is a common lower limb surgical procedure in paediatric orthopaedics and deformity correction. Healing of a lengthened tendon is typically supported by casting and unloading of the operated limb. Although tendon rupture or overcorrection may adversely affect surgical outcomes, few studies have examined surgical means of improving post-operative stability of the tendon. We aim to evaluate a novel method for augmenting Z-Plasty tendon lengthening as a first step to clinical translation.

METHODS: In this experimental ex vivo study, we employed a bovine flexor tendon model (n = 18) to examine a novel mechanical augmentation method after tendon lengthening by Z-plasty. Conventional surgical suturing of the imposed Z-plasty (n = 6) and an experimental group (n = 6), in which additional augmentation was performed by interlocking fibres of a biomaterial scaffold to the underlying tendon using a novel micro-needling technique, were compared to native tendons (n = 6).

RESULTS: The needle interlocked scaffold successfully augmented the suture repair, showing more than doubled ultimate failure force compared to controls (482 ± 107 N vs. 206 ± 37 N, p < 0.01), and more than 1.5-fold repair stiffness (41 ± 7 N/mm vs. 26 ± 9 N/mm, p < 0.01).

CONCLUSION: We conclude that the use of an interpenetrating biomaterial scaffold represents a promising new approach for improving biomechanical tendon properties, which may have an implication on the stability of tendon suture, lengthening and tendon transfer procedures as well as on post-operative management and earlier mobilization.

PMID:40111450 | DOI:10.1007/s00264-025-06481-9

J Bone Joint Surg Am. 2025 Mar 20. doi: 10.2106/JBJS.24.00642. Online ahead of print.

ABSTRACT

BACKGROUND: Fluoroscopy plays a crucial role in various medical procedures, especially in orthopaedic and spinal surgery. However, concerns have arisen regarding ocular radiation exposure given its association with posterior lens opacities and cataracts. Protective measures are essential to mitigate ocular radiation exposure. During spine surgery, loupes are frequently used but often lack lead lining. The purpose of the present study was to assess the effect of surgical loupes, as compared with lead glasses and plastic face shields, on ocular radiation exposure.

METHODS: Dosimeters were positioned anterior (unshielded) and posterior (shielded) to the lens of each type of eyewear: lead glasses, surgical loupes, and plastic face shields. Eyewear/dosimeters were exposed directly to the horizontal beam of a C-arm for 2 minutes of continuous fluoroscopy. This was repeated 20 times for each type of eyewear (40 total/eyewear, 120 times overall). Radiation doses were modeled with use of generalized estimating equations with a Gaussian distribution and identity link function. Separate models were employed for each outcome, including eyewear category (lead glasses, loupes, plastic shield) and dosimeter position (anterior/unshielded versus posterior/shielded).

RESULTS: Radiation dose was significantly lower in posterior compared with anterior dosimeters for lead glasses (0.00 versus 1,689.80 mRem; p < 0.001) and for loupes (20.27 versus 1,705.95 mRem; p < 0.001). The difference for plastic face shields did not reach significance (1,539.75 versus 1,701.45 mRem; p = 0.06). Lead glasses offered the most protection, followed by surgical loupes and then plastic shields, when comparing the shielded dosimeter readings (0.00 versus 20.27 versus 1,539.75; p < 0.001 for all comparisons). There was no significant difference in radiation dose for dosimeters placed anterior to lead glasses, loupes, and plastic face shields (1,689.80 versus 1,705.95 versus 1,701.45 mRem; p = 0.99).

CONCLUSIONS: Lead glasses were most effective (∼100% reduction), followed by surgical loupes (97%), whereas plastic face shields showed no significant reduction in radiation dose. Surgical loupes can substantially reduce ocular radiation exposure.

CLINICAL RELEVANCE: Surgical loupes may offer ocular radiation protection.

PMID:40112043 | DOI:10.2106/JBJS.24.00642

J Bone Joint Surg Am. 2025 Mar 20. doi: 10.2106/JBJS.24.00838. Online ahead of print.

ABSTRACT

BACKGROUND: Many surgeons recommend weight loss for patients with obesity before total joint arthroplasty (TJA), but few studies have evaluated weight loss interventions. This study compared weight loss using a remote dietitian and a mobile application (app) with weight loss using standard care for patients with severe obesity before TJA.

METHODS: This multicenter randomized controlled trial included 60 subjects with a body mass index (BMI) of 40 to 47 kg/m2 who had been scheduled for primary total hip or knee arthroplasty from September 2019 to January 2023. The mean age was 61 years, 67% were women, and the mean BMI was 44 kg/m2. The control subjects (n = 29) received standard care; the intervention subjects (n = 31) completed video calls with dietitians and used a mobile app for 12 weeks preoperatively. Weights and surveys were collected at baseline and 12 weeks, with 87% follow-up. Weight loss, patient-reported outcomes, complications, revisions, and reoperations were compared. The mean follow-up was 1.8 years.

RESULTS: The intervention subjects lost more weight (-4.1 versus -2.1 kg, p = 0.22) and had larger decreases in BMI (-1.4 versus -0.9 kg/m2, p = 0.36 than the controls, but not significantly so. The intervention subjects had higher odds of achieving a BMI of <40 kg/m2 (odds ratio = 1.9, p = 0.44), but not significantly so. There were no significant differences in the mean change in the Hip disability and Osteoarthritis Outcome Score, the Knee injury and Osteoarthritis Outcome Score, or the Lower Extremity Activity Scale score. At baseline, only 11% had seen a dietitian in the last 3 months. Most subjects (83%) felt that video calls were helpful. There were no differences in complications between the groups; there was a patellar fracture in the control group and a deep venous thromboembolism in the intervention group.

CONCLUSIONS: A preoperative weight loss intervention using a dietitian and a mobile app was feasible and viewed favorably among patients. Remote dietitians and mobile apps may address gaps in access to obesity treatment before TJA. While the intervention subjects lost more weight and were more likely to achieve a BMI of <40 kg/m2, the differences were not significant. More intensive interventions may be needed to achieve enough weight loss for clinically important improvements in TJA.

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

PMID:40112039 | DOI:10.2106/JBJS.24.00838

Int Orthop. 2025 Mar 19. doi: 10.1007/s00264-025-06501-8. Online ahead of print.

ABSTRACT

PURPOSE: This study seeks to explore whether intra-wound vancomycin powder (IVP) is a cost-effective adjunct to standard of care (SOC) in patients undergoing total joint arthroplasty (TJA) from a US payor perspective.

METHODS: A decision-analytic model in the form of a decision tree was developed to compare the cost and outcomes of IVP with those of SOC in preventing periprosthetic joint infections (PJI) in TJA patients. The base case analysis assumes a hypothetical practice with an equal volume (50/50) of THA and TKA procedures in both the IVP + SOC and the SOC arm. Cost and clinical effectiveness data were obtained from published literature. Sensitivity and threshold analyses were used to estimate how changing inputs would impact the cost-effectiveness of IVP.

RESULTS: Deterministic results found that in the base case model, IVP as an adjunct to SOC generates a cost saving of $260.38/patient. In scenario analysis, where THA and TKA procedures were separated, the estimated cost saving was $241.50/patient and $279.27/patient, respectively. Break-even analysis showed that the cost of IVP per patient would need to be $244.82-$282.59, or the PJI relative risk (RR) be approximately 0.99. Probabilistic analysis found IVP + SOC was cost-saving in 99.26% of the 10,000 iterations in the base case model.

CONCLUSION: Applying local vancomycin as an adjunct to SOC in primary TJA is not just cost effective, but cost-saving in reducing PJIs, saving an average of $260.38/patient. Depending on individual institution/practice infection rates and revision surgery costs, local vancomycin administration for primary TJA should be considered.

PMID:40107989 | DOI:10.1007/s00264-025-06501-8

J Bone Joint Surg Am. 2025 Mar 20. doi: 10.2106/JBJS.24.00916. Online ahead of print.

ABSTRACT

BACKGROUND: As the United States health-care system transitions to a value-based model, the minimal clinically important difference (MCID) has become an important metric for assessing perceived benefit in clinical settings. However, there is substantial ambiguity surrounding the MCID value because the calculation method used can lead to substantial changes in the clinical interpretation of surgical success.

METHODS: A total of 1,113 patients who underwent either total knee arthroplasty (TKA) or total hip arthroplasty (THA) between June 2021 and June 2023 and completed their patient-reported outcomes (the KOOS JR [Knee injury and Osteoarthritis Outcome Score for Joint Replacement] or HOOS JR [Hip disability and Osteoarthritis Outcome Score for Joint Replacement]) preoperatively and at 1 year postoperatively were reviewed for this study. The MCID values for the HOOS JR and KOOS JR were determined using 16 statistically appropriate methods, and the resulting MCID values were applied to the study group to assess how differences in methods changed the number of patients who met the MCID at 1 year postoperatively.

RESULTS: The study cohort consisted of 570 patients who underwent TKA and 543 who underwent THA. The overall cohort was 62.2% female, had a mean age of 69.3 ± 8.3 years, and was 92.3% Caucasian, 2.9% African American, and 4.8% other race (i.e., Asian, multiracial, or "other"). The MCID values varied substantially among the methods evaluated. The mean MCID was 11.5 ± 9.2 (range, 0.5 to 36.6) for the KOOS JR and 12.2 ± 8.9 (range, 0.6 to 34.3) for the HOOS JR. Distribution-based methods led to smaller but more variable MCID values, whereas anchor-based methods were noted to have larger but more consistent MCID values.

CONCLUSIONS: Different statistical approaches resulted in substantial variation in the MCID threshold value, which affected the number of patients who reached the MCID. This study demonstrates the ambiguity of the MCID and casts some doubt regarding its utility for assessing the surgical benefit of total joint arthroplasty.

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

PMID:40112037 | DOI:10.2106/JBJS.24.00916

SICOT J. 2025;11:18. doi: 10.1051/sicotj/2025010. Epub 2025 Mar 19.

ABSTRACT

This narrative review evaluates the purpose and functionality of rotating hinged total knee arthroplasty (RHTKA). The main indications for an RHTKA are poor bone stock, soft tissue compromise, gross instability, and periprosthetic fractures. Studies have shown that an RHTKA may be used in both the primary and revision scenarios to improve the range of motion and functional outcomes. Radiostereometric analysis has shown that some RHTKA designs are associated with early femoral component micromotion, but this has not translated to increased failure or revision rates. Implant survivorship with a modern RHTKA is comparable to a condylar-constrained TKA at mid-term follow-up. The most common complications associated with RHTKA are aseptic loosening, periprosthetic joint infection, stiffness and periprosthetic fractures.

PMID:40106746 | PMC:PMC11922500 | DOI:10.1051/sicotj/2025010

Injury. 2025 Mar 10;56(4):112260. doi: 10.1016/j.injury.2025.112260. Online ahead of print.

ABSTRACT

INTRODUCTION: As the ravages of war, road traffic crashes, and interpersonal violence have led society to view injury as a preventable illness, the delivery of trauma care has shifted from the standalone hospital to system-based care. A trauma system is an organized, coordinated, integrated effort that delivers care from the prehospital setting to the facility, and then to rehabilitation, to reduce morbidity and mortality of the injured patient. However, many countries still lack this systematic care. Recognizing this discrepancy, we conducted what appears to be the first multinational, collaborative study of mature trauma systems in order to identify their successes and challenges, so that we may close this gap in care.

METHODS: From January 2022-January 2023, trauma system leaders in Australia, Canada, France, Israel, Italy, New Zealand, the United Kingdom, and the United States of America answered a semi-structured questionnaire. Each expert detailed their system's context for creation, delineated their successes and challenges, and described their plans for future development. From this data we extracted key themes shared by all eight systems.

RESULTS: Our results revealed that these eight mature trauma systems are encompassed by two main processes, which we titled 'development' and 'maturation'. We found that the developmental process relies on a sentinel paper inciting political leadership to build the system. The system then contains six essential elements: governance, trauma network, pre-hospital care, facility-based care, trauma registry/quality improvement, and rehabilitation. The maturation process is the course of operationalizing the system once it is established to produce the intended result. This consists of connectivity and coordination, supporting key stakeholders, and continually subjecting the system to review for improvement.

CONCLUSION: This innovative study describes eight distinct mature trauma systems and identifies commonalities between them. The lessons learned from these eight systems should be used both by countries with an existing trauma system to aid in maturation, and by developing nations looking to construct a trauma system, so that the disparities in trauma care delivery may start to dissipate.

PMID:40107186 | DOI:10.1016/j.injury.2025.112260