A 2-stage approach is most commonly used to treat periprosthetic joint infection (PJI). Some successful studies of the 1-stage approach were underpowered, lacked a 2-stage comparative group, and excluded patients with draining sinuses, comorbidities, and/or antibiotic-resistant organisms. Given the morbidity and expense associated with 2-stage treatment, we conducted a prospective, multicenter, randomized trial to compare the results of 1- and 2-stage PJI treatment, specifically including patients with draining sinuses, comorbidities, and resistant organisms. Patients presenting for surgical treatment of a chronic PJI with a known organism following primary total hip or knee arthroplasty were included (with infection defined by Musculoskeletal Infection Society [MSIS] criteria). Patients with prior revision, culture-negative infection, or fungal infection, or who were immunosuppressed or had soft-tissue involvement precluding wound closure, were excluded. Patients were classified according to the McPherson host staging system. Clinical success was defined as (1) no clinical failure or reinfection with the same or new organism; (2) no reoperation for PJI; and (3) no PJI-related death. A double-instrument setup was used for all patients, as were similar irrigation and antibiotic protocols. A total of 323 patients (166 one-stage; 157 two-stage) were randomized. Groups were similar with respect to demographics and host classification. After excluding patients who died or were lost to follow-up, 258 of the 323 patients had 2-year follow-up (135 one-stage and 123 two-stage). The rate of patient loss to follow-up was similar between the treatment groups. Sixteen patients in the 1-stage group and 9 patients in the 2-stage group died prior to 2-year follow-up. Overall, the 2-year success rate of 1-stage treatment was 97% (131 of 135), while the success of 2-stage treatment was 91% (112 of 123) (p = 0.04). Compared with the 2-stage group, the 1-stage group had 3-times the odds of overall success in a regression analysis (unadjusted odds ratio = 3.22 [95% confidence interval = 1.0 to 10.38]). After adjusting for specific variables (McPherson host grade, resistant organism, and draining sinuses), 1-stage treatment also had 3-times the odds of success. The results of this prospective randomized trial indicated that 1-stage treatment (97% success) was statistically noninferior to 2-stage treatment (91% success) when treating chronic PJI following primary total hip or knee arthroplasty, provided the protocols described here are explicitly followed. Extrapolation to other patient cohorts and clinical situations should be avoided. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Lower surgeon case-volume has been associated with a greater risk of postoperative complications such as dislocation following total hip arthroplasty (THA). However, robotic assistance and computer navigation may mitigate the volume-dependent risk of instability. This study sought to compare dislocation rates between lower-volume surgeons performing technology-assisted (TA) THAs and higher-volume surgeons utilizing conventional instrumentation (CI). The Premier Healthcare Database was queried to identify adult patients who underwent primary elective THA from 2016 to 2023. Surgeons with <10% technology use formed the CI group, and surgeons with ≥90% technology use formed the TA group. These groups were further subdivided into higher-volume (HV) and lower-volume (LV) on the basis of surgeon annual case-volume, using a previously validated threshold of 109 cases/year. Mixed-effects modeling was used to compare the 90-day risk of dislocation between patients treated by low-volume surgeons using TA (LV-TA group) and high-volume surgeons using CI (HV-CI group). A total of 669,098 patients undergoing THA were identified. Of these, 5,447 patients were treated by LV-TA surgeons and 190,550, by HV-CI surgeons. Notably, LV-TA surgeons achieved a similar rate of dislocation compared with HV-CI surgeons (0.48% versus 0.42%, p = 0.510). After controlling for confounding factors, the risk of dislocation remained comparable between LV-TA and HV-CI surgeons (adjusted odds ratio: 1.062, 95% confidence interval: 0.677 to 1.668, p = 0.793). Surgeons with a lower case-volume who used technology assistance achieved a rate of dislocation similar to that of surgeons with a higher case-volume who used conventional instrumentation. These findings demonstrate that technology assistance, including computer navigation and robotic assistance, may attenuate the association between surgeon case-volume and dislocation risk following primary THA. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Nontraumatic osteonecrosis of the femoral head (ONFH) can lead to major disability in patients of all ages. It presents at various levels of severity and can be either symptomatic or asymptomatic. There is a vast array of management strategies. Treatment is often subject to physician bias. Clinical practice guidelines that are broad-based, internationally developed, consensus-driven, and strictly evidence-based are needed. The aim of this guideline by the Association Research Circulation Osseous (ARCO) was to develop international evidence-based recommendations to assist physicians and patients in managing ONFH. ARCO convened an international, multidisciplinary guideline panel that was balanced to minimize potential bias from conflicts of interest. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was utilized, including GRADE Evidence-to-Decision frameworks. The panel prioritized clinical questions, defined criteria for the systematic review of evidence, evaluated the statistical analysis, and, by consensus, approved recommendation statements, which were then subject to external review by content experts and stakeholders (a health policy-maker and a patient). The panel agreed on 12 recommendations for the diagnosis, evaluation, and management of ONFH. Key recommendations of these guidelines require accurately staging ONFH and determining when pain may be due to ONFH. They establish principles for optimal decision-making by assessing the quality of evidence backing various treatments and identifying numerous areas for additional investigation. This international evidence-based guideline provides standardized recommendations for the diagnosis and management of nontraumatic ONFH. It synthesizes all available evidence using GRADE methodology and offers practical, consensus-supported guidance for accurate staging, imaging selection, treatment decision-making, and the identification of patients who would benefit from joint-preserving interventions. The guideline supports clinicians in reducing practice variation, improving diagnostic accuracy, and optimizing treatment pathways for patients with ONFH.
Understanding drivers of supply and labor cost variation in orthopaedic surgery is crucial to provide value-based care. Time-driven activity-based costing (TDABC) is a more accurate methodology for capturing costs of care than traditional methods. Anterior cruciate ligament reconstruction (ACLR) is one of the most performed outpatient procedures within orthopaedic surgery. The purpose of this study was to characterize the cost composition of ACLR and identify factors that drive cost variation. Cost data for supplies and time-based personnel usage were extracted from electronic health records and were used to calculate costs using TDABC. TDABC methodology was applied to calculate the cost of personnel usage by multiplying the duration and associated cost per minute. Descriptive statistics and mixed-effects modeling were used to determine cost drivers. This study included 861 patients who underwent ACLR at 8 hospitals. The mean patient age (and standard deviation) was 31.1 ± 11.6 years. Of the 861 patients, 350 were male and 511 were female; 85.6% of patients were White, 8.1% were Asian, and 3.4% were Black. There was 3.2-fold variation in supply costs ($2,950) and 1.6-fold variation in labor costs ($940) between the 10th and 90th percentiles. Overall, supply costs accounted for 58.2% of total costs, whereas labor costs comprised the remaining 41.8%. The intraoperative phase was the greatest generator of total cost (89.7%). After adjusting for surgeon and hospital variability, variation in total cost was most effectively explained by graft type, primary surgery status, and meniscal repair (conditional R2 = 0.84; marginal R2 = 0.27). On subanalysis, patients undergoing allograft ACLR had significantly higher total costs, implant costs, and age compared with those undergoing ACLR with any autograft type (all p < 0.01). The most notable drivers of labor and supply cost variation were graft type, surgeon, surgery center, primary surgery status, and concomitant meniscal repair. Understanding modifiable cost drivers may aid health systems in designing value-based pathways, implant formularies, and surgeon education programs. Future studies may integrate cost with outcome measures for a more holistic view of value. Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
➢ Open fractures are a critical global health challenge that disproportionately affect individuals in low- and middle-income countries (LMICs), primarily due to road traffic collisions. Surgical management of open fractures is 1 of the 3 essential bellwether procedures identified by The Lancet Commission on Global Surgery.➢ We developed and evaluated a novel hybrid course on open fracture management for surgical trainees and practicing surgeons in Rwanda, combining a self-directed, virtual, pre-course curriculum with a live, in-person workshop in Kigali in June 2025 that was simultaneously live-streamed for virtual attendees. Prerecorded multilingual lectures (English and French) and curated peer-reviewed articles provided foundational knowledge in advance and prepared learners for in-person didactics, case discussions, and skills training.➢ The in-person workshop included didactic sessions and discussions of local clinical cases from Rwanda related to open fracture management and other orthopaedic emergencies, along with hands-on practice in fracture external fixation and negative pressure wound therapy using affordable devices designed for resource-constrained practice.➢ The workshop engaged 160 active learners (37 in-person, 123 virtual) and demonstrated high overall satisfaction among 84 survey respondents, with an average rating of 4.6 out of 5.➢ Self-reported confidence in managing open fractures increased substantially following the course, from a mean rating of 3.83 to 4.69 on a 5-point scale (p < 0.001). Most survey respondents reported that the course moderately or significantly improved their knowledge (96.4%) and would change their clinical practice (96.5%).➢ Participant feedback highlighted opportunities for improvement, including extending the workshop duration to increase hands-on time, expanding the content on complex soft-tissue management, and improving the engagement of remote learners through mechanisms such as the provision of low-cost external fixation models for at-home practice.➢ Future directions include integrating the course into medical student and general practitioner education in Rwanda, adapting it for major surgical conferences regionally and internationally, and continuing to prioritize hands-on training modules. Iterative refinement of the course is planned on the basis of participant feedback.
For patients with periacetabular metastases, protrusio acetabuli is a severely painful and mobility-impairing complication that requires subsequent open joint surgery. We aimed to identify specific structural changes that are associated with progression to protrusio acetabuli and to create a scoring system to guide risk stratification. In this single-institution cohort study, we identified all patients who underwent primary surgical stabilization for periacetabular metastases with osteolytic or mixed osteolytic-osteoblastic characteristics from October 2017 through January 2025. Cases of protrusio acetabuli prior to surgical intervention were identified. Pain and ambulatory functional scores and treatment history were recorded. Locations of bone destruction were evaluated using coronal-cut computed tomography (CT) scans obtained within 3 months before clinical presentation (and earlier, as available). Trabecular and subchondral cortical bone mass of the periacetabular weight-bearing portions were indirectly assessed via Hounsfield unit ratio comparisons across scans. Univariable analysis of each feature was performed. The highest-scoring features were used to create a scoring system and analyzed using a receiver operating characteristic (ROC) curve. Finite element analysis was performed for biomechanical validation. Eighty-seven patients (67 non-protrusio [mean age of 65.5 ± 13.0 years; 37 female]; 20 protrusio [mean age of 72.9 ± 10.1 years; 11 female]) were included. Locationally, bone defects, thinning, or linear fractures in the middle-third (apex) alongside contiguous involvement of either the medial- or lateral-third of the weight-bearing dome were highly predictive of protrusio. A >50% cortical bone-mass decrease of the acetabular weight-bearing dome was associated with protrusio (p < 0.05). A radiographic risk scoring system was then constructed using a grading system from low- to high-risk features. ROC analysis showed a score of ≥3.0 as 95.0% sensitive and 91.0% specific for progression to protrusio. Finite element analysis further showed that cortical bone loss of the middle-third (apex) of the weight-bearing dome was critical. We propose the use of clinical and radiographic risk predictors to stratify patients with periacetabular metastases on the basis of the risk of protrusio. Anatomically, surgical stabilization of the middle-third (apex) of the weight-bearing dome is critical to preventing or delaying progression to protrusio. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Major anxiety symptoms are commonly observed in patients undergoing total hip arthroplasty (THA); these symptoms exacerbate pain and compromise hip recovery. Olanzapine demonstrates clinically meaningful efficacy in reducing anxiety; thus, we investigated its anxiolytic effect and benefits for enhancing recovery in these high-risk patients. We prospectively enrolled 135 patients who were scheduled for primary THA at our institution between April 2024 and March 2025 and who scored at least 40 points on the State-Trait Anxiety Inventory-State (STAI-S) before surgery. Patients randomly received oral olanzapine (2.5 mg), alprazolam (0.4 mg), or a placebo once nightly for 5 days beginning on the day of admission. The 3 groups (45 patients in the olanzapine group, 45 in the alprazolam group, and 44 in the placebo group after 1 patient was lost to follow-up) were compared postoperatively in terms of the STAI-S score, Pittsburgh Sleep Quality Index (PSQI), visual analog scale (VAS) pain score, opioid consumption, and functional recovery of the hip. Adverse events related to drugs and surgery were recorded. Compared with placebo and alprazolam, olanzapine was associated with significantly lower STAI-S scores on postoperative days (PODs) 1 and 3, significantly lower resting VAS pain scores on PODs 1 to 3, and significantly lower incidence of postoperative nausea and vomiting. The olanzapine group and the alprazolam group demonstrated significantly better sleep quality based on the PSQI on POD 3 compared with the placebo group. Moreover, the olanzapine group had lower opioid consumption on PODs 1 to 3 than the placebo group. Patients in the olanzapine group exhibited better Harris hip scores and Hip Disability and Osteoarthritis Outcome Scores. The 3 groups did not significantly differ in terms of adverse events. Perioperative low-dose olanzapine may be an effective option for reducing anxiety levels, sleep disorders, and postoperative nausea and vomiting, mitigating postoperative pain and enhancing hip recovery among patients with anxiety symptoms undergoing THA. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
The aim of this systematic review was to evaluate the impact of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on medical complications, implant failure rates, and health-care-related costs in patients undergoing hip or knee arthroplasty. A comprehensive search of electronic databases, including PubMed, Embase, Web of Science, the Cochrane Library, the World Health Organization International Clinical Trials Registry Platform (ICTRP), and the UK Clinical Trials Gateway, was conducted and was limited to studies from database inception to March 31, 2025. Inclusion criteria comprised randomized controlled trials or cohort studies involving adults (≥18 years old) undergoing total joint arthroplasty (TJA) while receiving a GLP-1 RA treatment of any dosage or duration. The risk of bias was assessed using the Cochrane risk-of-bias tool and ROBINS-I (Risk Of Bias In Non-Randomized Studies - of Interventions) assessment. Due to substantial heterogeneity in the study designs, a qualitative synthesis approach was employed. Eight retrospective studies met the inclusion criteria, encompassing 22,611 GLP-1 RA users and 77,810 controls. The mean patient age ranged from 56 to 64 years. Hospital readmission rates showed the most consistently favorable results among GLP-1 RA users, with 3 studies reporting significant reductions of 29% to 47% during the 90-day postoperative period. Five studies demonstrated that GLP-1 RA use was associated with significant reductions, ranging from 30% to 44%, in periprosthetic joint infection (PJI) rates, whereas 3 studies found no significant differences. Hospital resource utilization favored GLP-1 RA therapy, with several studies demonstrating shorter hospital stays and lower 90-day costs. Medical complications yielded variable results: some studies reported increased vascular and pulmonary events among GLP-1 RA users, whereas others observed reduced sepsis and hypoglycemic events in those patients. GLP-1 RA therapy was associated with reduced hospital readmissions and decreased hospital costs within 90 days postoperatively, although its benefits for PJI prevention showed mixed results, with some studies demonstrating significant reductions in PJI while others showed no difference. No consistent clinical advantages were observed at the 2-year follow-up. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
This observational study systematically used magnetic resonance imaging (MRI) to determine the prevalence of concomitant osteomyelitis and its influence on clinical outcomes in cases of pediatric septic arthritis (SA) of the hip. We retrospectively analyzed the demographic, clinical, microbiological, and radiographic data of 58 children treated for SA of the hip who underwent systematic MRI between 2000 and 2025. Patients were categorized into 2 groups: isolated septic arthritis and septic arthritis with concomitant osteomyelitis. The clinical and laboratory parameters, causative pathogens, and treatments were compared between the groups. Concomitant osteomyelitis was identified with MRI in 43% (25) of the 58 patients, while radiographs detected it in only 16%. Demographic, clinical, and inflammatory parameters were statistically similar between the groups. Kingella kingae was the most commonly identified pathogen (37.9%), and Staphylococcus aureus and Streptococcus spp. were more frequently associated with repeat surgery. No significant differences in complication rates, treatment duration, or outcomes were found between the groups. The systematic use of MRI revealed concomitant osteomyelitis in >40% of cases of pediatric SA. However, the presence of osteomyelitis was not associated with worse outcomes, suggesting that factors related to the microorganism profile or virulence must contribute substantially to disease severity. Nonetheless, MRI should be considered early in any diagnostic work-up of pediatric SA of the hip. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Effective pain management following total knee arthroplasty (TKA) is crucial to optimizing patient outcomes and experiences. Multimodal pain management protocols vary between institutions, with some recently proposing the addition of an intraosseous (IO) injection of morphine intraoperatively. The purpose of this study was to investigate whether the addition of an intraoperative, IO injection of morphine during elective primary TKA would lead to improved pain control and decreased narcotic consumption during the postoperative period. In this double-blinded, randomized controlled trial, 100 patients undergoing elective primary TKA were prospectively enrolled. All patients received spinal anesthesia and intravenous sedation combined with an intraoperative, surgeon-administered adductor canal block. The experimental group received an intraoperative, IO injection containing 10 mg of morphine and 500 mg of vancomycin in 110 mL of normal saline solution. The control group received the same injection but without morphine. All patients received 6 daily text-message surveys (3 in the morning and 3 in the evening) for 14 days postoperatively to collect pain scores, morphine milligram equivalent (MME) consumption, and nausea and vomiting events. Data on demographics, operative factors, post-anesthesia care unit (PACU) pain scores, PACU MME consumption, and patient-reported outcomes were also collected. Linear mixed-effects (LME) models were utilized. A total of 88 patients (52.3% [n = 46] female; mean age, 69.1 ± 9.0 years [range, 46 to 89 years]; 89.8% [n = 79] White) were included in the analysis. The LME model demonstrated no differences between the groups with respect to daily pain scores at any time point within 14 days postoperatively (p = 0.969). There were no differences between the groups with respect to daily MME consumption at any time point within 14 days postoperatively (p = 0.377). There were also no differences in total MME consumption or weekly MME consumption postoperatively (p ≥ 0.878). IO morphine did not significantly improve postoperative pain control or decrease narcotic consumption up to 2 weeks postoperatively among patients undergoing elective primary TKA. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Periprosthetic femoral fractures (PFFs) are an increasingly common indication for revision total hip arthroplasty (THA). While patient-related risk factors are well documented, the influence of femoral stem design on PFF risk remains poorly characterized. In this study using nationwide data, we assessed the association between stem design and PFF risk. We analyzed 182,118 primary THAs (performed from 2015 to 2023) from the Swiss National Joint Registry (SIRIS). Cementless stems were categorized according to the Kheir classification, and cemented stems were categorized as double-tapered polished, triple-tapered polished, composite-beam, or custom. A multivariable Cox regression model, including variables such as age, sex, American Society of Anesthesiologists (ASA) class, body mass index (BMI), surgical indication, prior ipsilateral hip surgery, stem design, collar, dual-mobility cup, bearing, and head size, was analyzed. Hazard ratios (HRs) with 95% confidence intervals (CIs) are reported. Among 182,118 THAs (mean patient age, 68.9 ± 11.5 years; female sex in 53.1% of cases), 1,226 (0.7%) were complicated by PFF. The cumulative incidence of PFF reached 0.7% at 5 years and 1.3% at 10 years. Higher PFF risk was associated with an age of 75 to 84 years (HR = 1.68 [95% CI = 1.44 to 1.96]) and ≥85 years (HR = 1.86 [95% CI = 1.47 to 2.35]), ASA class of 3 to 5 (females, HR = 1.70; males, HR = 1.73), BMI of <18.5 kg/m2 (HR = 1.61) or ≥40 kg/m2 (HR = 1.64), prior ipsilateral hip surgery (HR = 1.32), and use of a dual-mobility cup (HR = 1.56). Elective procedures (HR = 0.36) and collared stems (HR = 0.26) were associated with a lower risk. Compared with cementless type-3 stems, cementless type-7 (anatomic) stems showed a higher risk of PFF (HR = 1.88), whereas cementless type-1B (HR = 0.62) and composite-beam cemented stems (HR = 0.45) were protective. In this large nationwide registry study, femoral stem design independently influenced PFF risk after primary THA. Cementless anatomic stems increased the risk, whereas composite-beam cemented stems and the presence of a collar conferred a protective effect. These findings support personalized implant selection, particularly for older patients or those with frailty. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Contemporary rotating-hinge total knee arthroplasties (RH-TKAs) have shown reasonable short-term survivorship in smaller series, but concerns remain regarding risks of aseptic and septic failure. The purpose of this study was to assess outcomes of contemporary RH-TKAs in one of the largest series to date. We retrospectively identified 575 RH-TKAs (60% used for aseptic etiologies and 40% used during reimplantation in 2-stage treatment of periprosthetic joint infection [PJI]) from 2002 to 2021 at a single institution. The mean age was 67 years, 58% were female, and the mean body mass index was 33 kg/m2. Sixty-five percent had Anderson Orthopaedic Research Institute (AORI) type-2B or 3 bone loss. Kaplan-Meier survivorship analyses were performed. The mean follow-up was 6 years (range, 2 to 19 years). Survivorship free from any revision was 76% at 5 years and 64% at 10 years. The most common revision indications were PJI (54%) and aseptic loosening (20%). RH-TKA used in the primary setting showed better survivorship compared with RH-TKA used during reimplantation after PJI (79% versus 60% at 10 years). Survivorship free from revision for aseptic loosening was 96% at 5 years and 90% at 10 years. Survivorship free from revision for PJI was 84% at 5 years and 81% at 10 years. Survivorship free from revision for PJI was even lower for RH-TKAs used during reimplantation, 74% at 5 years and 73% at 10 years. RH-TKA used during reimplantation in the treatment of PJI was associated with an increased risk of any revision (HR = 2, p < 0.001). Radiographic analysis of 425 knees that were not revised and had radiographs available for review showed that 6% of femoral components and 8% of tibial components had evidence of loosening at the time of final follow-up. The mean Knee Society Score improved from 33 to 69 at 2 years (p < 0.001). The 10-year survivorship free from aseptic loosening was 90% in this large series of RH-TKAs. This represents one of the best survivorships free from aseptic loosening published to date. Knees with prior PJI had markedly poorer survivorship than knees treated for aseptic etiologies, with double the risk of revision. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Bone density can impact treatment decisions for orthopaedic conditions. While ad-hoc intraoperative surgeon assessment of bone quality is common, the accuracy of such evaluation remains unknown. The primary purpose of this study was to determine whether orthopaedic surgeons' intraoperative assessment of bone quality closely correlated with validated measures. In this prospective cross-sectional study, we enrolled adult patients undergoing orthopaedic surgery at a Level-I trauma center. Eligibility required an opportunistic computed tomography (CT) scan of the lumbar spine, glenoid, wrist, pelvis/femur, proximal tibia, or calcaneus. Seven surgeons, blinded to objective measures of bone quality, provided intraoperative bone-quality assessments using a 10-point Likert scale and categorized bone quality as normal, osteopenic, or osteoporotic. Hounsfield units (HUs) were measured on CT using a previously published technique. All images were reviewed by a single orthopaedic surgeon, blinded to intraoperative bone-quality assessments. Of the 229 patients enrolled, 215 had available CT data and were included in the study. The average age of these patients was 44 years (range, 18 to 95 years), with 40.5% being female. Over half of the patients (61%) were Black or African American, while a quarter of the patients (25%) were White. The most common surgical sites included the femur (39 patients, 18.1%), ankle (31, 14.4%), and acetabulum (26, 12.1%). A positive linear relationship between HU and surgeon bone-quality assessments was observed (r = 0.66; p < 0.0001), which was consistent across surgical anatomic sites. Abnormal bone quality was correctly identified by surgeon assessment with 84% sensitivity and 97% specificity. This study demonstrated that surgeons can reliably detect abnormal bone quality through intraoperative assessment across numerous surgical sites. Intraoperative assessments may provide actionable and reliable feedback regarding bone density without additional cost or radiation in cases when opportunistic scans are not available. This information can inform intraoperative decision-making and presents opportunities for bone-health interventions. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Coronal plane angular deformity remains under-investigated in the context of pediatric anterior cruciate ligament (ACL) tears. We hypothesized that baseline coronal alignment in pediatric and adolescent patients with a first-time ACL injury would differ from that in a matched healthy comparison population of patients without knee pathology. Patients ≤18 years of age who underwent primary ACL reconstruction and had preoperative lower-extremity hip-to-ankle alignment radiographs (cases) and individuals without lower-extremity conditions that would influence alignment (controls) were matched 1:1 on the basis of age (±1 year) and sex. Coronal plane parameters included the hip-knee-ankle angle (HKA), mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), and medial proximal tibial angle (MPTA). Decision stump analyses were used to identify clinically relevant alignment threshold values. A total of 200 patients were included in the analysis (100 per group). The mean age was 12.7 ± 2.1 years in the ACL group (58% White/Caucasian, 50% female) and 13.1 ± 2.4 years in the control group (49% White/Caucasian, 50% female). Compared with controls, patients with an ACL tear demonstrated increased valgus alignment across all 4 parameters: MAD (-4.1 ± 7.8 versus -0.3 ± 7.6 mm; p < 0.001), HKA (-1.4° ± 2.6° versus -0.5° ± 2.3°; p = 0.006), mLDFA (85.3° ± 1.9° versus 86.1° ± 1.7°; p = 0.004), and MPTA (88.0° ± 1.8° versus 87.2° ± 1.9°; p = 0.004). Conditional logistic regression demonstrated increased odds of an ACL tear associated with each 1-unit increase in valgus alignment, as measured by MAD (inverse odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.02 to 1.10; p = 0.003), HKA (inverse OR: 1.14; 95% CI: 1.02 to 1.27; p = 0.022), mLDFA (inverse OR: 1.27; 95% CI: 1.08 to 1.50; p = 0.005), and MPTA (OR: 1.28; 95% CI: 1.07 to 1.53; p = 0.006). In the decision stump analysis of HKA, a value of -0.5° demonstrated that 60% of participants with ≥0.5° of valgus alignment had an ACL tear compared with 38% of patients with neutral alignment, varus alignment, or <0.5° of valgus alignment. Pediatric and adolescent patients with an ACL tear demonstrated greater valgus alignment than age- and sex-matched controls, with each 1° increase in HKA valgus alignment increasing the odds of an ACL tear by 14%. Routine preoperative assessment is necessary as coronal plane deformity is modifiable through concomitant implant-mediated guided growth in skeletally immature patients. The inclusion of coronal plane alignment parameters in ACL-related investigations is warranted to elucidate their contribution to injury risk and surgical outcomes. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Optimal surgical treatment for recurrence of lumbar disc herniation (LDH) remains controversial, with options ranging from repeat microdiscectomy (MD) to instrumented fusion (IF). This study aimed to guide surgical decision-making by analyzing reoperation rates, clinical and radiographic risk factors for treatment failure, and functional outcomes following MD versus IF. Prospectively collected data from 450 patients in our outcomes database who underwent surgery for recurrent LDH from 2004 through 2023 were retrospectively analyzed. Clinical assessment included predominant symptoms, neurological deficits, and American Society of Anesthesiologists (ASA) grade. Radiographic assessment included disc height, Pfirrmann grade, facet angle, and Modic changes on magnetic resonance imaging, as well as spinopelvic parameters on standing radiographs. Patient-reported outcomes were assessed using the Core Outcome Measures Index (COMI) and achievement of the minimal clinically important change (MCIC) of ≥2.2 points. Propensity-score matching (PSM) was performed to control for confounding factors. Reoperation rates were analyzed with a minimum 5-year follow-up. Of 450 patients with recurrent LDH, 316 (70.2%) underwent MD and 134 (29.8%) underwent IF. In 192 patients after PSM, IF showed nonsignificantly higher MCIC achievement (odds ratio [OR] = 1.20, 95% confidence interval [CI]: 0.66 to 2.17, p = 0.65) and lower COMI scores compared with the MD group (3.34 ± 2.89 versus 4.01 ± 2.95, p = 0.059; derived Oswestry Disability Index [ODI]: 23.8 versus 28.1). IF demonstrated significantly lower reoperation risk compared with MD (15.7% [116/316] versus 36.7% [21/34], p < 0.001). The reoperations following MD were predominantly subsequent IF (73.3%) and repeat MD (23.3%), while the reoperations after IF were predominantly adjacent segment surgery (57.1%) and hardware revision (33.3%). BMI of ≥35 kg/m2 was a significant predictor of reoperation after MD (univariate OR = 3.63, p = 0.039), while disc height of <6 mm (OR = 1.97) and Modic type-1 changes (OR = 1.78) showed trends toward increased reoperation risk (both p < 0.10). Although both procedures achieved clinical improvement, IF demonstrated superior long-term durability as shown by significantly lower reoperation rates over extended follow-up. Our findings support a risk-stratified surgical selection: IF should be strongly considered in patients with BMI of ≥35 kg/m2 and those with progressive disc degeneration, whereas MD remains appropriate for patients without these risk factors. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Female surgeons more commonly delay childbearing and experience higher rates of infertility than women in the general population. More women are entering orthopaedic surgery but face unique challenges in family building. The accessibility of fertility preservation strategies among female orthopaedic surgeons remains underexplored. We aimed to investigate facilitators of and barriers to oocyte cryopreservation, especially during orthopaedic residency. A survey regarding family planning and experiences surrounding oocyte cryopreservation was designed and distributed via residency program directors, regional orthopaedic societies, and the Ruth Jackson Orthopaedic Society. Female orthopaedic surgery residents, fellows, and attending physicians were invited to participate. Of 169 participants, 107 (63%) reported intentionally delaying childbearing and 58 (34%) reported delaying or planning to delay for ≥4 years. Although 91 respondents (54%) had considered oocyte cryopreservation, only 36 (21%) had undergone or planned to undergo at least 1 cycle and 55 (33%) ultimately decided not to undergo it. Inflexible scheduling of work, lack of insurance coverage, and restrictive leave policy were the most important barriers to oocyte cryopreservation during residency. Among current residents and fellows, 30 (38%) would not have been comfortable telling program leadership that they were planning to undergo oocyte cryopreservation and 25 (32%) reported that they would not have been provided adequate scheduling flexibility. When given 5 multiple-choice questions about female fertility and the oocyte cryopreservation process, respondents answered a mean of 1.46 questions correctly. This study revealed a high degree of interest in oocyte cryopreservation among survey respondents but identified persistent barriers of financial burden, inflexible scheduling, institutional stigma, and limited fertility knowledge. Residency programs should prioritize schedule flexibility, proactive leadership support, and privacy-conscious accommodations for fertility-related care as well as structured reproductive health education for trainees. Barriers to fertility preservation during orthopaedic training directly affect physician well-being and the ability to recruit and retain women in this specialty, which, in turn, impact patient access to quality care from a diverse physician workforce.
The study compared health-related quality of life and fracture-healing based on the fixation method following isolated open tibial fractures in Latin America. A prospective study was conducted across 18 trauma centers in 8 countries. Adult patients with isolated open tibial diaphyseal fractures were included. The primary outcome measures were Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Health Survey (SF-12), which was administered at baseline and at follow-up at 6, 12, 26, and 52 weeks. The secondary outcome measure was the modified Radiographic Union Scale for Tibial Fractures (mRUST) score. Of 422 patients, 389 had a baseline evaluation, with 352 (83.4% of the 422) completing at least 1 SF-12 follow-up and 309 (73.2%) completing at least 1 SF-12 follow-up and having radiographic follow-up within 1 year postoperatively. Initial definitive intramedullary nailing and external fixation or casting followed by staged intramedullary nailing were the most common fixation strategies. Both fixation methods were performed with similar frequency for Gustilo-Anderson (GA) Type-I and II injuries. The majority of GA Type-IIIA and IIIB/C fractures were treated with staged fixation. The presence of minimal or superficial contamination did not influence whether fractures were treated with initial intramedullary nailing or staged intramedullary nailing, whereas the presence of deep contamination was associated with staged management. For all GA types combined, initial definitive intramedullary nailing was associated with significantly higher PCS and MCS scores at 1 year than staged fixation. The mRUST scores at 1 year for all GA types combined were higher with initial definitive intramedullary nailing than with staged intramedullary nailing. Staged treatment remains common in Latin America, even for less severe injuries. Initial intramedullary nailing was associated with improved PCS and MCS scores and significantly higher mRUST scores relative to staged intramedullary nailing. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Infection remains one of the most catastrophic complications following orthopaedic surgery. Despite substantial advances in molecular diagnostics, biomarker assays, and consensus definitions, accurately diagnosing orthopaedic infection continues to challenge even the most experienced clinicians. There are differences in the diagnosis and treatment of infections that are related to different anatomic regions. The difficulty arises from the inherent biological diversity of infecting organisms and surgical locations, variable host responses, and the absence of a true diagnostic "gold standard." This article summarizes the current diagnostic challenges and emerging solutions, drawing on recent high-impact evidence and consensus frameworks.
Pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR) are powerful techniques for correcting severe spinal deformities. Although PSO has been proposed as a viable alternative to VCR, their comparative efficacies and safety profiles require further elucidation. This single-center retrospective study analyzed 169 patients (mean age, 22 years; 84 male; 169 ethnic Chinese) with severe kyphoscoliosis who underwent primary corrective surgery via PSO (n = 85) or VCR (n = 84). Radiographic parameters, surgical data, intraoperative neuromonitoring (IOM) changes, Scoliosis Research Society (SRS)-22 scores, and complications were compared between groups. Both techniques significantly improved all radiographic parameters and SRS-22 scores (p < 0.001). The VCR group demonstrated superior correction of the major curve (65.5% versus 56.9%, p = 0.003), segmental kyphosis (68.1% versus 61.5%, p = 0.03), and apical vertebral rotation (48.5% versus 34.4%, p = 0.001). At the critical osteotomy stage, 105 (62.1%) of 169 patients experienced IOM signal decline. The neurological complications rate was significantly higher in the VCR group (13 of 84 versus 7 of 85, p = 0.038), as was the overall complication rate (43 of 84 versus 29 of 85, p = 0.008). Each 1° increase in correction achieved with VCR was associated with a 1.6% higher risk of complications (OR = 1.016, p = 0.045). Although both PSO and VCR were highly effective for major deformity correction, VCR provided a greater magnitude of correction in the coronal, sagittal, and axial planes. However, this advantage was counterbalanced by a significantly higher risk of complications, including neurological deficits. Despite the frequent reversibility of IOM signal declines, VCR retained a higher risk profile due to its higher overall complication rate. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Long-term outcomes of femoroacetabular impingement (FAI) surgery, particularly survivorship, are critical to guide treatment decision-making and patient counseling, yet only a limited number of studies have reported mid- to long-term survivorship. The purpose of this study was to report survivorship rates at a mean 10-year follow-up in a large, multicenter FAI surgery cohort and to identify clinical predictors of survivorship. A prospective, multicenter cohort study assessed patients treated for FAI with hip arthroscopy or surgical dislocation from 2008 to 2012. At a minimum of 8 years, 362 hips (80.1%) had follow-up that permitted assessment of total hip arthroplasty (THA)-free survivorship. A Cox proportional-hazards model was developed to identify risk factors for THA. The cohort included 362 hips with a mean patient age of 32.1 years; 53% were in females, and 95.6% were in Caucasian patients. The THA-free survivorship of the cohort was 90.6% at a mean of 10.4 ± 1.6 years postoperatively. Risk factors for THA were older age at surgery (p = 0.01), male sex (p = 0.02), body mass index of ≥30 kg/m2 (p = 0.009), and femoral head chondromalacia (p < 0.001). This study demonstrates that FAI surgery yielded durable 10-year THA-free survivorship of 90.6%. Older age at surgery, obesity, male sex, and femoral head chondromalacia were key predictors of conversion to THA. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.