搜索结果：Arthroplasty

Debridement, antibiotics, and implant retention (DAIR) are the recommended surgical treatments for acute periprosthetic joint infections (PJI). The success of DAIR has been variable due to the patient heterogeneity. This multinational study evaluated the success rate and risk factors of failure of a DAIR procedure after primary arthroplasty and was separated for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients diagnosed with acute postoperative PJI between 1999 and 2017 and treated with DAIR after primary THA or TKA were included. In total, 643 patients from five European centers and one in the United States were analyzed. Acute postoperative PJI was defined as infections occurring within three months after primary arthroplasty. Treatment failure was defined as any subsequent surgical intervention to control the infection, including a repeated DAIR procedure, and death related to infection within one year. The success rate for DAIR after primary THA was 66.4% (253 of 381). Stepwise logistic regression identified significant independent risk factors for DAIR failure in THA: preoperative C-reactive protein levels (CRP) over 71 mg/L (odds ratio (OR) 2.48, P = 0.004), men (OR 2.17, P < 0.013), and an indication for arthroplasty other than osteoarthritis (OR 4.23, P <0.001). The overall success rate for DAIR after primary TKA was 68.7% (180 of 262). Significant independent risk factors for failure were chronic renal failure (OR 4.02, P = 0.034), preoperative serum CRP levels over 116 (OR 5.39, P <0.001), and polymicrobial infections (OR 2.22, P <0.043). Polyethylene exchange was an independent success factor in this population (OR 0.39, P = 0.018). The DAIR failure rates in acute postoperative PJI were similar for primary TKA and THA, but risk factors differed; high preoperative CRP was the only shared independent predictor. Host factors for DAIR failure differ between hips and knees.

Revision total elbow arthroplasty is technically demanding and carries a substantial risk of postoperative neurological complications because of scarring, altered anatomy, implant removal, and repeated humeral and ulnar exposure. The incidence, nerve distribution, and recovery profile of nerve injury after revision total elbow arthroplasty remain incompletely defined. This study aimed to systematically review the literature to define the incidence, recovery profile, and risk factors for nerve injury after revision TEA. A systematic review of the literature was performed in accordance with PRISMA guidance. Thirteen retrospective case series were included, comprising 282 revision total elbow arthroplasties in 271 patients. Random-effects meta-analysis of proportions was undertaken where the data permitted. The primary outcome was postoperative nerve injury following revision total elbow arthroplasty. Secondary outcomes included nerve type, recovery, secondary nerve-related procedures, infection, triceps insufficiency, metallosis, periprosthetic fracture, and re-revision. The pooled incidence of postoperative nerve injury was 22.3% (95% CI 16.3 to 29.6; I2 = 34.6%). The crude incidence was 60 of 282 revisions (21.3%, 95% CI 16.6 to 26.5). The ulnar nerve was involved in 66.7% of all nerve injuries, the radial nerve in 31.7%, and the median nerve in 1.7%. No significant difference in pooled nerve-injury incidence was identified between studies published before 2010 and those published from 2010 onwards (22.9% vs 21.4%, p = 0.837). Recovery reporting was heterogeneous; among injuries with numerically extractable outcomes, 85.4% improved partially or completely (95% CI 72.2 to 93.9). Secondary nerve-related procedures were reported in seven studies. Pooled complication estimates were 10.2% for infection, 13.6% for triceps insufficiency, 25.5% for metallosis, 15.9% for periprosthetic fracture, and 14.0% for re-revision. Postoperative nerve injury is a common and clinically important complication of revision total elbow arthroplasty, affecting approximately one in five cases. The ulnar nerve is most frequently involved, although radial nerve injury accounts for a substantial proportion of cases. Many neuropathies improve during follow-up, but persistent deficits and the need for secondary nerve-related procedures are not uncommon. Future studies should adopt standardised neurological definitions and reporting to improve comparability and guide preventive surgical strategies.

The aim of this study was to investigate the impact of musculoskeletal (MSK) health literacy on clinical outcomes and patient satisfaction following total shoulder arthroplasty (TSA). We hypothesized that low MSK health literacy score would be associated with inferior clinical outcomes and lower patient satisfaction rates. A retrospective cohort study was conducted at a tertiary care center. Patients between 6 months and 9 years post-operative following shoulder arthroplasty, both anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty were included. All patients were treated by one of 2 sports fellowship-trained surgeons. Patients were emailed a questionnaire that included basic demographics, American Shoulder and Elbow Surgeons (ASES) shoulder score, TSA satisfaction, and the Literacy in Musculoskeletal Problems survey. Patients were categorized as having low health literacy (LHL) if they answered fewer than 6 out of 9 questions correctly on the Literacy in Musculoskeletal Problems survey and as having normal health literacy (NHL) if they answered 6 or more questions correctly. Statistical analysis was performed to determine associations between LHL, patient characteristics, and outcomes of interest. This included multivariate logistic and linear regression models that assessed the relationship between MSK health literacy and ASES. Of 734 patients emailed the survey, 310 responded, and 230 met inclusion criteria and were included in the final analysis. One hundred and seventy-seven patients (77%) had NHL and 53 individuals (23%) had LHL. The mean ASES score was 74.2 &#xb1; 19.8 in the NHL group and 62.9 &#xb1; 23.9 in the LHL group. Patients with LHL had significantly lower ASES scores than those with NHL (P = .0007). Patient satisfaction rate (90.3% vs. 82.7%, P = .2101) and willingness to undergo surgery again (89.8% vs. 84.9%, P = .334) were similar between the NHL and LHL groups, respectively. Multivariate analysis showed that NHL was independently predictive of a significantly higher ASES score (P = .009, odds ratio: 1.025). Approximately one-quarter of patients undergoing TSA at our institution had LHL. Patients with LHL were found to have significantly lower patient-reported outcome scores, although rates of patient satisfaction and willingness to undergo surgery again were comparable to those with NHL. These findings highlight an association between health literacy and post-operative recovery that likely reflects the influence of broader educational and socioeconomic determinants of health. These findings should be interpreted as associative and hypothesis-generating.

Shoulder arthroplasty has emerged as a reliable treatment for end-stage glenohumeral arthritis. However, as the volume of total shoulder arthroplasty (TSA) increases nationwide, revision procedures are expected to rise in parallel. These surgeries are already known to be technically challenging and associated with higher complication rates, longer recovery, and increased costs. Despite this growing demand, limited large-scale data exist to identify which patient factors predict early failure and adverse outcomes. This study aimed to evaluate predictors of revision and postoperative complications following TSA using a national health system database to guide preoperative optimization and surgical planning. A retrospective cohort study was performed using the Hospital Corporation of America (HCA) Healthcare database to identify adults (&#x2265;18 years) who underwent primary or revision TSA between 2016 and 2022. Variables included patient demographics (age, sex, race, BMI), and Elixhauser Comorbidity Index (ECI). The primary outcomes were revision within 2 years and incidence of postoperative complications (including infections, cardiac events, thromboembolic events, and prosthetic complications). Secondary outcomes included time to revision and length of hospital stay. Multivariable logistic regression was used to assess predictors of revision and complications, while linear regression evaluated associations with timing of revision. Among 44,952 TSA cases, 579 patients (1.3%) underwent revision within two years. Male sex (OR 1.77; 95% CI 1.50-2.10; p<0.001) and higher ECI (OR 1.09, 95% CI 1.03-1.14, p=0.001) were significantly associated with increased revision risk. Increasing age was associated with a 2% decrease in odds per additional year of age (OR 0.98; 95% CI 0.97-0.99; p<0.001). Postoperative complications occurred in 1,413 patients (3.1%) and were more common among younger patients (OR 0.98 per year; p<0.001), males (OR 1.52; p<0.001), and those with higher comorbidity burden (OR 1.12 per unit; p<0.001). Race and BMI were not significantly associated with revision or postoperative complications. Among patients who underwent revision, the mean time to revision was 205 days, and no patient-level variables were significantly associated with time to revision on multivariable analysis. This large-scale analysis identifies male sex, younger age, and higher comorbidity burden as independent factors associated with revision surgery and postoperative complications following total shoulder arthroplasty. These findings highlight the need for risk-informed patient selection, counseling, and perioperative optimization. As the volume of total shoulder arthroplasty continues to grow, these results support the development of targeted care pathways aimed at minimizing revision rates and improving outcomes across diverse patient populations.

Proximal humeral fractures (PHF) are common in the elderly population, and the use of reverse total shoulder arthroplasty (rTSA) as treatment has risen substantially in recent years. As opposed to statistical significance, clinical value has increasingly been utilized to evaluate outcomes, thus this study aims to define patient acceptable symptom state (PASS) thresholds, minimal clinically important differences (MCID), and substantial clinical benefit (SCB) values for American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score (CMS), and Shoulder Arthroplasty Smart (SAS) score in patients undergoing rTSA for PHFs. A prospectively collected multicenter database inclusive of 43 clinical sites using Advita Ortho implant system was queried for patients receiving who underwent reverse total shoulder arthroplasty for proximal humeral fracture with a minimum of 2 years follow-up between 2007 and 2024. Patients were divided into Early (no prior ORIF, malunion, or nonunion) and Late (history of ORIF, malunion, or nonunion) treatment groups. Prospectively, outcome metrics including preoperative and postoperative CMS, ASES score, SAS score, active range of motion, visual analog scale (VAS) pain scores, self-reported shoulder function score, and patient satisfaction rate were collected from the electronic medical record. Receiver operating characteristic (ROC) curve analysis was used to determine the PASS thresholds while MCID and SCB values were determined via anchor-based methods and distribution-based methods, respectively. PASS thresholds were numerically higher in the Late group across all measures. Postoperative ASES, CMS, and SAS scores all showed good discriminative ability for identifying patients who achieved PASS. Optimal PASS thresholds were 58 (AUC = 0.73) and 60 (AUC = 0.80) for ASES, 62 (AUC = 0.65) and 66 (AUC = 0.77) for CMS, and 61 (AUC = 0.74) and 67. (AUC = 0.85) for SAS in the Early and Late groups, respectively. Anchor-based MCID values were slightly lower in the Late group, suggesting that a smaller score change was needed for perceived improvement by patients (ASES: 10.84 and 10.31; CMS: 9.59 and 8.54; SAS: 10.75 and 7.60). Distribution-based SCB thresholds were observed to have higher values in the Early group, indicating that patients treated earlier required greater functional improvement to perceive substantial benefit (ASES: 17.35 and 16.49; CMS: 15.35 and 13.67; SAS: 17.19 and 12.16). In patients undergoing reverse total shoulder arthroplasty for proximal humeral fracture, PASS thresholds for ASES, CMS, and SAS demonstrate good discriminative ability for identifying clinically meaningful improvement. Thresholds are reported separately for Early and Late treatment cohorts and should be interpreted as descriptive benchmarks.

Periprosthetic joint infection (PJI) remains a devastating complication following total joint arthroplasty, leading to substantial morbidity and increased healthcare costs. Cefazolin is the standard agent for perioperative antibiotic prophylaxis. However, the rising prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has prompted the use of dual prophylaxis with vancomycin and cefazolin. The efficacy and safety of this combined strategy remain controversial. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered on the international prospective register of systematic reviews (ID CRD420251077695). A comprehensive search of PubMed, Web of Science, Embase, and the Cochrane Library was performed. Randomized controlled trials and observational studies directly comparing cefazolin alone with combined vancomycin and cefazolin as intravenous prophylaxis in patients undergoing total joint arthroplasty were included. The primary outcome measures were PJI and SSI (surgical site infection), and secondary outcome measures were AKI (acute kidney injury). Eight studies including 1,041,058 patients met the inclusion criteria. Dual prophylaxis was associated with a higher risk of SSI (odds ratio [OR] =1.39; 95% confidence interval [CI] = 1.23 to 1.58), but a lower risk of PJI (OR = 0.64; 95% CI = 0.46 to 0.91). There was no significant difference in risk of AKI between regimens (OR = 1.30; 95% CI = 0.76 to 2.20), although substantial heterogeneity was observed among studies reporting renal outcomes. Routine addition of vancomycin to cefazolin does not reduce overall SSI rates and may increase superficial infections. However, it may decrease PJI risk without significantly increasing AKI. These findings support a selective, risk-stratified prophylactic strategy rather than universal dual antibiotic therapy in total joint arthroplasty.

Metal implant hypersensitivity remains a subject of ongoing debate in the orthopaedic community. With the global rise in total knee arthroplasty (TKA) procedures per annum and an increasing prevalence of reported metal allergies in the general population, understanding the clinical relevance of metal implant hypersensitivity in knee arthroplasty patients is essential. This systematic review evaluates the relationship between metal hypersensitivity, diagnostic testing, and postoperative outcomes following TKA. A literature search was conducted using the Ovid, MEDLINE, and Embase databases for studies published between 1990 and December 2024. Studies assessing diagnosis, management, or outcomes of metal hypersensitivity in TKA were included. Both prospective and retrospective studies were considered. The search yielded 554 records, with an additional 25 studies identified through manual reference screening. Following full-text assessment of 58 articles and application of predefined inclusion and exclusion criteria, 24 studies were included. Data extraction focused on study design, patient demographics, implicated metals, diagnostic methods, interventions, and outcomes. Patient Reporting Items for Systematic Reviews & Meta Analysis (PRISMA) guidelines were followed. A pooled cohort of 5615 knee arthroplasty cases was analyzed, with a mean patient age of 65.35 years and a female predominance (60.55%). Among these, 1165 patients had a documented history of metal hypersensitivity. Twenty studies reported follow-up durations, with a mean follow-up of 27.59 months. Patient symptoms, diagnostic test results, patient-reported outcome measures, and revision rates were evaluated. The available literature demonstrates significant heterogeneity and limited comparability across studies. Current evidence suggests that self-reported metal allergy or positive skin patch/lymphocyte transformation tests do not reliably predict poorer pain or functional outcomes following TKA. The clinical significance of metal hypersensitivity remains uncertain, highlighting the need for standardized diagnostic criteria and further high-quality research.

Outpatient total shoulder arthroplasty (TSA) is increasingly performed as perioperative pathways and value-based care models expand. However, a subset of patients scheduled for outpatient TSA require unexpected inpatient admission, which may indicate higher perioperative risk and increased resource use. We hypothesized that older age, greater comorbidity burden, and longer operative time would be associated with conversion from planned outpatient TSA to inpatient admission, and that conversion would be associated with worse short-term outcomes. Planned outpatient TSA cases were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2021. Revision arthroplasty, hemiarthroplasty, procedures for infection or malignancy, fracture-related cases, emergency or other nonelective cases, records with missing length of stay (LOS), and extreme LOS outliers were excluded. All included cases were planned outpatient procedures; patients with LOS 0-1 day comprised the Outpatient cohort, and those with LOS &#x2265;2 days comprised the Conversion-to-Inpatient cohort. Demographics, comorbidities, operative time, and 30-day outcomes were compared between groups, and multivariable logistic regression identified independent predictors of conversion and associations with adverse events. A total of 6,755 planned outpatient TSA cases met inclusion criteria, including 6,302 (93.3%) Outpatient and 453 (7.2%) Conversion-to-Inpatient cases. Compared with Outpatient patients, the Conversion-to-Inpatient cohort was older (70.3 &#xb1; 9.6 vs 68.0 &#xb1; 9.5 years), more often female, and more frequently Hispanic, with higher BMI and a greater proportion of American Society of Anesthesiologists class &#x2265;3 and comorbidities (all P < .05). Mean operative time was longer among converted patients (127.9 &#xb1; 59.3 vs 104.7 &#xb1; 40.8 minutes, P < .001). On multivariable analysis, older age, female sex, Hispanic ethnicity, ASA &#x2265;3, diabetes, COPD, and longer operative time were independent predictors of conversion. Conversion-to-Inpatient status was associated with higher odds of 30-day reoperation, overall morbidity, bleeding transfusion, and non-home discharge, while adjusted 30-day readmission did not differ significantly between cohorts. Unplanned conversion from outpatient to inpatient status occurs in approximately 7% of planned outpatient TSAs and is associated with identifiable demographic, comorbidity, and operative risk factors, as well as higher morbidity, transfusion requirements, and non-home discharge. These findings may help inform patient counseling and perioperative planning for outpatient TSA pathways.

The utility and optimal threshold for serum laboratory tests taken prior to revision shoulder arthroplasty are unknown. We performed a multi-institutional study of consecutive revision shoulder arthroplasties to define the optimal thresholds of serum laboratory samples to predict bacterial presence in intraoperative cultures with and without Definite Periprosthetic Joint Infection (PJI). Multicenter data was collected on 579 revision shoulder arthroplasties. Preoperative serum erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), complete blood count differentials, and ratios were reported. Analysis was stratified based on International Consensus Meeting (ICM) Definite and Non-Definite PJI and two different thresholds of culture positivity (&#x2265;2 or &#x2265;3). Receiver operating characteristic (ROC) curves were constructed, and area under the curve (AUC), optimal thresholds, and diagnostic utility for each test were calculated. Eighty-three patients (14%) had Definite PJI per ICM criteria while 496 (86%) had Non-Definite PJI. Cutibacterium was the most common bacteria recovered in both Definite PJI and Non-Definite PJI. For Definite PJI using a threshold of &#x2265;3 positive cultures, AUC values were 0.543 for ESR and 0.659 for CRP. Optimal thresholds based on ROC curves were 50.5 mm/hr for ESR and 5.9 mg/L for CRP. Sensitivity and specificity were 0.422 and 0.714, respectively, for ESR and 0.818 and 0.536, respectively, for CRP. For Non-Definite PJI, the AUC value was below 0.5 for ESR indicating the test was worse than chance. AUC values for CRP were 0.533 and 0.540 using thresholds of &#x2265;2 and &#x2265;3 positive cultures, respectively. Optimal threshold based on ROC curves were 9.1. This is the first large-scale, multicenter study of consecutive revision shoulder arthroplasties analyzing the utility of preoperative serum laboratory values in predicting positive intraoperative cultures. Overall diagnostic utility of these tests in predicting bacterial presence is low in the setting of both Definite and Non-Definite PJI, particularly serum ESR. In approaching patients with more obvious clinical symptoms (Definite PJI), optimal cutoff values are 50 mm/hr for ESR and 10 mg/L for CRP. When approaching workup of a patient without obvious signs of infection (Non-Definite PJI), serum ESR and CRP have limited value in predicting presence of bacteria at the time of revision arthroplasty.

A 62-year-old man presented with bilateral posterior shoulder dislocations 2 months after sustaining an accidental electric shock while fishing. Imaging confirmed chronic locked posterior dislocations with reverse Hill-Sachs lesions and large humeral head articular defects (approximately 60% on the left and 55% on the right), together with partial-thickness supraspinatus and subscapularis tendon tears. The patient underwent staged reverse total shoulder arthroplasty. At the 12-month follow-up, he was free from pain with a markedly improved active range of motion (forward flexion, 130&#xb0;; abduction, 100&#xb0;) and excellent functional outcomes (constant score: 86, left shoulder; 83, right shoulder; ASES, 90). This case supports reverse shoulder arthroplasty as a viable option for a chronic bilateral posterior shoulder dislocation with substantial humeral head defects.

Social determinants of health influence patient outcomes. In total joint arthroplasty (TJA), factors such as race, marital status, insurance type, and socioeconomic status affect outcomes and discharge disposition. One underexplored factor is patient education level. Although census data associate higher education with improved health outcomes, its impact following TJA has not been examined. This study evaluated differences in outcomes and discharge disposition between patients with higher versus lower education levels after TJA. A retrospective review within an integrated healthcare system identified consecutive patients undergoing primary TJA from 2011 to 2021 using CPT codes 27130 (total hip arthroplasty [THA]) and 27447 (total knee arthroplasty [TKA]). Patients were grouped by education level: greater than high school (GHS) and less than or equal to high school (LHS), as documented in the medical record. Demographics, comorbidities, surgical variables, and 90-day postoperative complications were analyzed. A total of 887 patients met inclusion criteria (451 GHS, 436 LHS) with mean follow-up of 6.7&#xa0;&#xb1;&#xa0;3.0 years. GHS patients were younger (63.8&#xa0;&#xb1;&#xa0;11.1 vs. 65.6&#xa0;&#xb1;&#xa0;12.0 years, p&#xa0;=&#xa0;0.022) and less likely to undergo TKA (59% vs. 68%, p&#xa0;=&#xa0;0.005). Groups were similar in race, body mass index, Charlson comorbidity index, smoking status, and insurance type. A greater proportion of GHS patients were discharged home (86% vs. 77%, p&#xa0;=&#xa0;0.002). Among TKA patients, home discharge remained higher in GHS patients (85% vs. 75%, p&#xa0;=&#xa0;0.019), with a similar trend in THA. There were no differences in length of stay, 90-day emergency department visits, readmissions, reoperations, or mortality. Patients with greater than high school education were more likely to be discharged home following TJA, particularly TKA. Education level may help identify at-risk patients undergoing TJA and anticipate postoperative resource needs.

More than 10 years ago, the German Society for Orthopaedics and Orthopaedic Surgery (DGOOC) implemented the German Arthroplasty Registry (EPRD), as well as the EndoCert certification initiative to maintain highest possible quality standards for patients undergoing joint replacement procedures. In addition to the individual responsibilities assigned to each organization, their collaboration also generates further synergies. For hospitals participating in both programs, a&#xa0;key advantage lies in the combination of the high EndoCert standards (mainly created for perioperative and early postoperative treatment) with the long-term outcome monitoring provided by the EPRD (continuous feedback on implant survival). The integration of various quality assurance items ensures the highest possible level of safety for patients. Moreover, the structures underlying EPRD and EndoCert could also be used to support the further development of German hospital reform activities in the field of arthroplasty care. HINTERGRUND: Mit dem Endoprothesenregister Deutschland (EPRD) und der Zertifizierungsinitiative EndoCert hat die Deutsche Gesellschaft f&#xfc;r Orthop&#xe4;die und Orthop&#xe4;dische Chirurgie (DGOOC) zwei &#xe4;u&#xdf;erst erfolgreiche Initiativen zur Sicherstellung endoprothetischer Versorgungsqualit&#xe4;t geschaffen. Neben den von jeder Organisation wahrzunehmenden Verantwortlichkeiten ergeben sich aus der Zusammenarbeit zus&#xe4;tzliche Synergien. W&#xe4;hrend das Register die mittel- und langfristige Ergebniskontrolle mit Bezug auf Implantat und Einrichtung gew&#xe4;hrleistet, fordert EndoCert erg&#xe4;nzend die Definition reproduzierbarer Prozesse im Rahmen der station&#xe4;ren Behandlung und pr&#xfc;ft deren Einhaltung &#xfc;ber externe j&#xe4;hrliche Audits vor Ort. Die Pflicht zur Vernetzung von Endoprothetikzentren der Grund- und Maximalversorgung gew&#xe4;hrleistet zus&#xe4;tzlich die Verlegungsm&#xf6;glichkeit in Problemf&#xe4;llen. Die aus beiden Verfahren resultierende Kombination von Struktur&#x2011;, Prozess- und Ergebnisqualit&#xe4;t gew&#xe4;hrleistet eine gr&#xf6;&#xdf;tm&#xf6;gliche Sicherheit f&#xfc;r Patientinnen und Patienten. Auch f&#xfc;r die Weiterentwicklung der Krankenhausreform k&#xf6;nnten die dem EPRD und EndoCert zugrundeliegenden Strukturen nutzbar gemacht werden.

Lateralized reverse total shoulder arthroplasty (rTSA) designs aim to restore tension and function of the deltoid and remaining rotator cuff. Although the role of the subscapularis (SSC) is established in the native shoulder and after anatomic total shoulder arthroplasty, its repair after rTSA remains controversial. The teres minor (TM) is considered a principal contributor to external rotation in rTSA, particularly when the infraspinatus (ISP) is insufficient, yet its length-tension behavior across forward elevation has not been characterized. Fifteen preoperative computed tomography scans from patients undergoing rTSA were used to generate three-dimensional shoulder models. rTSA was simulated using 4 lateralized implant configurations differing in glenoid baseplate position and neck-shaft angle (NSA): (1) a Frankle-type configuration with a centrally positioned ("high") glenoid baseplate and a 135&#xb0; NSA; (2) an inferiorly positioned (flush with the lower border of the glenoid) baseplate with a 135&#xb0; NSA; (3) an inferiorly positioned baseplate with a 145&#xb0; NSA; and (4) an inferiorly positioned baseplate with a 155&#xb0; NSA. Forward elevation from 0&#xb0; to 120&#xb0; at 20&#xb0; abduction and 0&#xb0; rotation was analyzed. Muscle-tendon length changes were computed for TM, SSC, ISP, and deltoid. Outcomes included biphasic prevalence, circle angle (the forward-elevation angle at which muscle length transitions from shortening to lengthening), and curvature. SSC consistently lengthened with forward elevation across all 4 lateralized rTSA designs. All TM curves (60/60, 100%) were biphasic, with early shortening followed by lengthening. The median TM circle angle occurred at 50&#xb0; [44-56] and curvature was -0.015 (95% confidence interval -0.016 to -0.015). In comparison, ISP was biphasic in 80% (48/60), SSC in 45% (27/60), and deltoid in 38% (23/60). Median circle angles were 77&#xb0; [71-83] for ISP, 38&#xb0; [25-52] for SSC, and 33&#xb0; [23-45] for deltoid. TM exhibited a significantly earlier circle angle than ISP (-26.9&#xb0;, 95% confidence interval -32.2 to -21.7) and greater curvature than all other muscles. These patterns were preserved across 135&#xb0;, 145&#xb0;, and 155&#xb0; designs. This study confirms SSC lengthening during forward elevation across lateralized rTSA designs and describes a novel biphasic length-tension pattern of the TM circle. These findings provide a biomechanical rationale for SSC repair vulnerability and highlight the functional contribution of the TM to external rotation in elevated positions after rTSA.

Cemented femoral fixation is recommended for arthroplasty in femoral neck fracture (FNF) because of lower periprosthetic fracture risk, but carries cement-related risks, longer operative time, and technical variability. Modern collared cementless stems have emerged as potential alternatives. This study compared a triple-tapered collared cementless stem with a collared composite-beam cemented stem in total hip arthroplasty (THA) for displaced FNF. We asked the following: (1) Is periprosthetic fracture risk different between fixation strategies?; (2) Are revision rates and survivorship different?; (3) Are functional outcomes comparable?; and (4) Are mortality and complications affected by fixation type? We retrospectively reviewed 521 primary THAs for displaced FNF (2017 to 2024) at a tertiary center. Patients received a cemented collared composite-beam stem (n = 105) or a triple-tapered collared cementless stem (n = 416). Primary outcomes were periprosthetic femoral fracture and all-cause revision. The secondary outcomes included intraoperative fracture, wound debridement, aseptic loosening, periprosthetic joint infection, stem subsidence greater than five mm, dislocation, venous thromboembolism, mortality, and Harris Hip Score (HHS). Propensity score overlap-weighting balanced baseline covariates. Survivorship was assessed with Kaplan-Meier and an overlap-weighted Cox model. Outcomes were reanalyzed in the Dorr C subgroup. After overlap-weighting, baseline covariates were well balanced. Weighted periprosthetic fracture (2.74 versus 2.97%) and all-cause revision (2.76 versus 5.36%) were comparable. Revision-free survivorship through 24 months did not differ (hazard ratio 0.896; P = 0.916). There were no dislocations. HHS favored cementless fixation (mean difference 6.50 points; P < 0.0001). Mortality was low and similar between groups. Dorr C subgroup findings were consistent with the cohort. After propensity score overlap-weighting, periprosthetic fracture rates, revision rates, and 24-month revision-free survivorship were comparable between a triple-tapered collared cementless stem and a collared composite-beam cemented stem in displaced FNF THA. The HHS was higher in the cementless group. Modern collared cementless stems may represent a reasonable option in select patients. Larger multicenter prospective studies with longer follow-up are needed to confirm durability and refine patient selection.

Modular neck prostheses in total hip arthroplasty (THA) offer intraoperative flexibility for adequate femoral anteversion and offset, which is particularly beneficial in anatomically complex cases such as developmental dysplasia of the hip. However, the efficacy of current modular neck options on range of motion in addressing abnormal femoral anteversion is unclear. This study aimed to evaluate the effectiveness of current modular neck configurations with a 32-mm femoral head, in accommodating various femoral anteversion. A prosthetic impingement analyses was conducted by collision detection using computer-aided design models of a dual modular neck femoral stem with four neck configurations: 15&#xb0; anteverted, straight, 15&#xb0; retroverted, and 30&#xb0; retroverted. The cup safe zone, defined as the combination of cup inclination and anteversion that satisfied all the required range of motion criteria without prosthetic impingement, was assessed across stem anteversion angles (-25&#xb0; to 85&#xb0;). The four modular neck configurations collectively provided continuous safe zones for stem anteversion ranging from 0&#xb0; to 75&#xb0;, at a clinically recommended cup inclination of 40&#xb0;. In contrast, the straight neck alone provided it in limited range (10&#xb0;-40&#xb0;), making it inadequate for managing abnormal femoral anteversion. Notably, the constant combined anteversion concept did not hold at extreme anteversion values. A modular neck system offering configurations from 15&#xb0; anteverted to 30&#xb0; retroverted, when combined with 40&#xb0; cup inclination, effectively accommodates various femoral anteversion. These findings support the clinical utility of modularity in THA and underscore the importance of optimizing stem anteversion to address complex anatomical variations.

Distal femoral resection is a determinant of coronal alignment and extension-gap symmetry in total knee arthroplasty (TKA). Conventional intramedullary (IM) alignment relies on a fixed femoral canal-referenced valgus angle, which can be affected by anatomical variability and does not account for extension-gap ligament tension. By contrast, a ligament-tension-guided extramedullary (EM) workflow preserves the femoral canal and uses full-extension tension feedback rather than a preset angle to guide coronal positioning. This single-centre retrospective cohort study analysed 76 unilateral primary TKAs performed by a single senior surgeon between September 2019 and January 2024 (EM, n&#x2009;=&#x2009;37; IM, n&#x2009;=&#x2009;39). In the EM group, coronal guide positioning was based on full-extension tension feedback without a preset valgus angle, whereas the IM group used conventional intramedullary alignment with a fixed 6&#xb0; femoral canal-referenced valgus setting. The primary outcome was coronal precision, defined as the absolute deviation of the mechanical lateral distal femoral angle (mLDFA) from 90&#xb0; on standardised full-length weight-bearing radiographs 6 weeks postoperatively. Prespecified secondary outcomes were mLDFA within &#xb1;&#x2009;3&#xb0; of 90&#xb0;, intraoperative visible blood loss, distal femoral resection-step time, and haemoglobin (Hb) decrease within 24&#xa0;h. Compared with conventional IM alignment, the EM workflow was associated with greater coronal precision, with a smaller absolute deviation of the mLDFA from the 90&#xb0; target (P&#x2009;=&#x2009;0.016) and a higher proportion of knees within &#xb1;&#x2009;3&#xb0; of target (P&#x2009;=&#x2009;0.020). Intraoperative visible blood loss and haemoglobin decrease within 24&#xa0;h were lower in the EM group (both P&#x2009;<&#x2009;0.001), whilst distal femoral resection-step time was comparable (P&#x2009;=&#x2009;0.235). Exploratory early recovery measures were favourable in the EM group and should be interpreted cautiously. At 12 months, KSS and WOMAC scores, complication rates, and revision-free status were comparable, and no revision was required in either group. In primary TKA, ligament-tension-guided EM distal femoral resection was associated with greater coronal precision and a lower perioperative bleeding burden than fixed-angle IM alignment, without clear between-group differences in 12-month clinical outcomes. These findings support prospective evaluation of tension-informed coronal target selection.

While osteoarthritis (OA) and rheumatoid arthritis (RA) can necessitate total knee arthroplasty (TKA), the mechanisms and radiographic patterns of joint space narrowing (JSN) differ. Deep learning (DL) enables compartment-specific measurement of minimum joint space width (mJSW). This study compared JSN patterns between patients with RA and OA undergoing TKA and evaluated associations between mJSW and RA disease activity. In this retrospective study, 409 RA patients undergoing TKA (2000-2021) were age- and sex-matched with OA patients. A validated DL model quantified medial and lateral mJSW from AP knee radiographs at two time points: early (>2 years before TKA) and late (&#x2264;2 years before TKA). The rate of JSN was calculated in 302 patients with paired radiographs. Mixed-effects models adjusted for BMI and alignment. RA disease activity, serology, and medications were recorded. RA demonstrated narrower lateral mJSW than OA at the late time point (5.6 vs. 7.0 mm, P<0.01), with comparable medial values. RA exhibited uniform bicompartmental JSN, whereas OA patients showed medial narrowing. RA had a faster mean lateral &#x394;mJSW (0.11 mm/year; P = 0.01), while OA had a faster mean medial &#x394;mJSW (0.21 mm/year; P<0.001). Longer RA duration and higher inflammatory markers were negatively associated with lateral mJSW. Seronegative RA showed faster lateral &#x394;mJSW in the surgical knee than seropositive patients (0.12 vs 0.06 mm/year; P = 0.03). Patients with RA demonstrated diffuse, symmetric cartilage loss contrasting with medialpredominant narrowing in patients with OA. Automated DL-based measurement enables scalable, compartment-specific assessment of compartment-specific patterns of joint degeneration.

The optimal fixation method in total hip arthroplasty (THA) remains under debate. While cemented fixation has been associated with a lower risk of periprosthetic fracture, uncemented fixation predominates in Japan. This study aimed to compare early postoperative complications between cemented and uncemented fixation in elective THA using a nationwide inpatient database. We identified 198,102 patients aged&#x2009;&#x2265;&#x2009;65 years who underwent primary THA for osteoarthritis, osteonecrosis, or rheumatoid arthritis between December 2011 and March 2023 from the Japanese Diagnosis Procedure Combination (DPC) database. After 1:1 propensity score matching for age, sex, body mass index (BMI), and Charlson Comorbidity Index, 36,859 patients were included in each fixation cohort. Surgical and medical complications, and in-hospital mortality were compared using multivariate logistic regression. Cemented fixation was associated with a significantly lower risk of periprosthetic fracture (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.30-0.53; p&#x2009;<&#x2009;0.001), blood transfusion (OR, 0.76; 95% CI, 0.74-0.78; p&#x2009;<&#x2009;0.001), and deep vein thrombosis (OR, 0.79; 95% CI, 0.74-0.84; p&#x2009;<&#x2009;0.001). There were no statistically significant differences based on the predefined threshold (p&#x2009;<&#x2009;0.001) in dislocation, infection, pulmonary embolism, cardiac or cerebrovascular events, or in-hospital mortality between fixation types, although a trend toward higher in-hospital mortality in the cemented group was observed. Cemented THA was associated with reduced rates of periprosthetic fracture, transfusion, and deep vein thrombosis without increasing other perioperative or medical complications. These findings suggest that cemented fixation may be associated with favorable short-term outcomes in selected patients.

Optimizing patient outcomes in reverse total shoulder arthroplasty remains a subject of ongoing research. Newly described radiographic angles allow the determination of the glenoid and humeral component contributions to lateralization and distalization, which might play a role in patient outcomes. Thus, this study aims to explore the effect of radiographically measured glenoid versus humeral lateralization and distalization on patient reported outcomes and reoperation. 217 consecutive patients who underwent rTSA from November 2016 to August 2022 were retrospectively reviewed. Pre-operative and final follow-up subjective shoulder value (SSV), visual analogue scale for pain (VAS), and American Shoulder and Elbow Surgeons Score (ASES), and unplanned reoperations were recorded. Preoperative and postoperative Lateralization Shoulder Angle (LSA) and Distalization Shoulder Angle (DSA) were also recorded. Postoperative Glenoid Lateralization Angle (GLA), Humeral Lateralization Angle (HLA), modified Distalization Shoulder Angle (mDSA), Glenoid Distalization Angle (GDA), and Humeral Distalization Angle (HDA). Correlations between different pairings of radiographic angular measurements were calculated along with correlations between individual radiographic measurements and each patient reported outcome measure. Greater positive change from preoperative to postoperative LSA and smaller postoperative DSA were significantly correlated with improved SSV in both univariable and multivariable analysis. A larger decrease from preoperative to postoperative LSA was associated with higher odds of reporting VAS > 0 on univariable analysis at follow up. Otherwise, there were no associations between radiographic measurements and postoperative outcome scores. The strongest correlation for postoperative lateralization measurements was between LSA and HLA (r = +0.83) and for postoperative distalization measurements was between mDSA and GDA (r = +0.72). Greater postoperative LSA and HLA values had higher odds of reoperation (post LSA OR = 1.11; p = 0.011, post HLA OR = 1.10; p = 0.047). Greater positive change from preoperative to postoperative LSA was associated with improved subjective-shoulder value scores. Lower global distalization was associated with greater subjective-shoulder value scores. While global lateralization may be beneficial in moderation along with limiting global distalization, the independent effects of glenoid or humeral-sided lateralization or distalization measured radiographically may have a lesser impact on patient reported outcomes.