Background and objective Golf is a popular recreational activity among older adults, many of whom develop shoulder pathology requiring surgical intervention. Despite increasing interest in return-to-sport outcomes, comparative data on return to golf following shoulder arthroscopy versus shoulder arthroplasty remain limited. This study aims to compare return-to-golf outcomes, patient satisfaction, and functional recovery between patients undergoing shoulder arthroscopy and those undergoing shoulder arthroplasty. This is a retrospective cohort study and represents level III evidence. Methods A retrospective comparative study was performed on 71 recreational golfers, including 46 (64.8%) who underwent arthroscopy and 25 (35.2%) who underwent arthroplasty. Pre- and postoperative assessments included range of motion (ROM) and patient-reported outcome measures (PROMs). The PROMs included the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), and subjective shoulder value (SSV). Golf-specific outcomes included return timelines, satisfaction, and performance. Paired t-tests assessed within-group changes, and independent t-tests evaluated between-group differences. Results Both groups demonstrated significant improvements in ASES, VAS, and SSV scores (all p < 0.001). Forward flexion and external rotation improved more in the arthroplasty group (p = 0.001 and p = 0.030), while internal rotation did not significantly improve in either group. The mean time to resume putting, chipping, and driving was 5.8 ± 3.1 months, 6.2 ± 3.0 months, and 7.4 ± 2.9 months, respectively, with no significant differences between groups (putting, p = 0.890; chipping, p = 0.894; driving, p = 0.990). At 12 months, 57 of 71 patients (80.3%) had returned to golf (p = 0.970), and 65 of 71 patients (91.5%) reported being satisfied or very satisfied. Conclusion Recreational golfers undergoing either shoulder arthroscopy or arthroplasty experience significant functional improvements and high return-to-golf rates. Surgical technique was not associated with differences in return timelines, satisfaction, or golf-specific performance. These findings may guide patient expectations and support shared decision-making in surgical planning.
The incidence of periprosthetic distal femur fractures after total knee arthroplasty (TKA) is increasing in parallel with the increasing number of primary TKA procedures being performed. This number will continue to rise going forward. Treatment decisions depend on patient factors, fracture characteristics, and implant stability. It is important to have a thorough understanding of the available modalities for treatment, including their indications, advantages, and disadvantages, to effectively manage these injuries and optimize outcomes. Nonoperative treatment is indicated in select cases but is generally associated with inferior outcomes, including higher rates of nonunion, malunion, and medical complications secondary to prolonged immobility. Operative management is the gold standard, and options include open reduction internal fixation (ORIF) with plates and screws, intramedullary nailing (IMN), nail/plate combination constructs, and revision arthroplasty with distal femoral replacement (DFR). Locking plate fixation can be useful for comminuted or more complex fractures and poor bone stock, while IMN is less invasive, preserving biology and allowing for earlier mobilization in some cases, especially when combined with plating. DFR is indicated for cases of implant loosening or severe bone loss and has been associated with more reliable early weight-bearing at the expense of increased risks for infection and revision arthroplasty. Overall, each of the treatment modalities discussed is a viable option for the management of these complex injuries. Management should ultimately be tailored to the individual patient. The surgeon should consider patient factors, fracture characteristics, implant stability, and their own level of expertise when deciding on treatment.
There is increasing use of preoperative biomarker assessment in patients undergoing total knee arthroplasty. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are the commonly used measures of ongoing inflammation. The impact of discordance between these values on postoperative outcomes remains poorly understood. Three cohorts were identified: one with a mildly elevated ESR and normal CRP, the other with a mildly elevated CRP and normal ESR, and the third with a mildly elevated ESR and CRP, with laboratory values obtained within 1 month of primary total knee arthroplasty. Groups were compared to patients with normal markers. At 90 days postoperatively, patients with mildly elevated CRP and ESR had a significantly higher odds of periprosthetic joint infection (PJI) compared to patients with normal inflammatory markers (odds ratio [OR]: 3.90; 95% confidence interval [CI]: 2.28-6.68; P < .001). At 3 years postoperatively, patients with mildly elevated inflammatory markers had significantly higher odds of PJI (OR: 3.80; 95% CI: 2.41-6.00; P < .001), complications (OR: 1.34, 95% CI: 1.00-1.79; P = .047), and revision knee arthroplasty (OR: 3.34; 95% CI: 1.68-6.64; P < .001). At 90 days, patients with mildly elevated preoperative CRP (5.1-15 mg/L) and normal ESR demonstrated significantly increased odds of PJI compared to patients with normal markers (OR: 2.00, 95% CI: 1.37-2.87; P < .001). Mildly elevated CRP and ESR were significantly associated with an increased risk of PJI, revision arthroplasty, and composite complications. Elevated ESR with normal CRP was associated with a higher risk of composite complications at 3 years postoperatively.
Surgical treatment for forefoot deformities in patients with rheumatoid arthritis (RA) has recently shifted toward joint-preserving procedures for all toes. In contrast, resection arthroplasty was previously commonly performed for lesser toes. Advances in drug therapy have improved life expectancy, resulting in an increased number of long-term survivors who previously underwent resection arthroplasty. With increased activity levels, recurrence of plantar callosities in the forefoot has become more frequent, often leading to gait disturbance. In general, revision surgery for such cases often involves additional bone resection; however, this approach may result in further shortening of the metatarsals and increase the risk of further recurrence. Therefore, we applied metatarsal shortening offset osteotomy, which we typically perform as a primary procedure, as a salvage procedure to reduce the risk of recurrence. We report three cases treated using this strategy. In all cases, the second to fifth metatarsal heads had been resected, but the resection stumps were covered with pseudo-cartilaginous tissue. This allowed metatarsal shortening offset osteotomy to be performed as a procedure similar to that used in primary surgery, achieving the planned correction. Consequently, both radiographic and clinical improvements were observed. These findings suggest that metatarsal shortening offset osteotomy may be a possible salvage option after primary resection arthroplasty for forefoot deformity in patients with RA.
 Prospectively registering the primary trial outcome is important to reduce selective outcome reporting and increase the trustworthiness of findings, which guide clinical practice. The objectives of our systematic review were to explore and compare the reporting characteristics of prospectively and non-prospectively registered trials investigating exercise therapy following total knee arthroplasty.  Randomized trials comparing effects of exercise therapy after total knee arthroplasty for osteoarthritis were identified in 4 databases from 2000 to August 12, 2024. One primary outcome per trial was extracted, using a pre-specified hierarchical algorithm, irrespective of outcome domain. Pooled standardized mean differences (SMDs) were calculated on pre-specified outcome domains, and risk-of-bias assessed using the Cochrane Risk-of-Bias tool v2.  94 trials, comprising 9,396 participants, were included, of which 13 were prospectively registered, 33 retrospectively registered, and 48 unregistered. A single primary outcome was defined in 44% of the 94 trials, and 4 trials reported a primary outcome consistent with a prospective registration. The pooled SMD of primary outcomes was 0.06 (95% confidence interval [CI] -0.03 to 0.16) for prospectively registered trials, 0.67 (CI 0.22-1.11) for retrospectively registered trials, and 0.59 (CI 0.32-0.86) for unregistered trials. Lower risk-of-bias ratings and higher proportions of intention-to-treat adherence, dropout reporting, and adverse event reporting were observed among prospectively registered trials.  Among prospectively registered trials we showed smaller effect size estimates between interventions with lower risk-of-bias ratings, and higher proportions of intention-to-treat adherence, dropout reporting, and adverse event reporting in contrast to trials without prospective registration; furthermore, clear specification of a single primary outcome was uncommon among trials evaluating exercise therapy after total knee arthroplasty.
Preoperative planning software has gained traction in shoulder arthroplasty, enabling surgeons to better visualize patient's anatomy and optimize implant positioning. Widespread adoption of such tools depends not only on their efficacy but also on surgeon satisfaction and perceived utility in day-to-day practice. However, data on surgeons' satisfaction and perceived utility of such software remain limited. This survey aimed to evaluate surgeons' overall satisfaction, perception and the willingness to recommend the software as a training tool for fellows. A retrospective observational survey was conducted to evaluate overall satisfaction and usage patterns among orthopedic surgeons using pre-operative 3D planning software (Blueprint®). All surgeons were contacted via email with a web-based questionnaire. Reponses were analyzed with descriptive statistics to assess overall surgeon satisfaction, level of agreement with predefined statements, likelihood of future use and willingness to recommend the software to others. The web-based questionnaire was distributed to 1100 orthopedic surgeons between September 30, 2024, and November 11, 2024. 312 responses were received, of which 273 were evaluable responses. Most respondents were low-volume or medium-volume surgeons, and high-volume surgeons were underrepresented (<7.7%). 270 responses were collected from surgeons evaluating their overall satisfaction, with 97% of the feedback being positive. 96% of surgeons said the planning software boosted their confidence in their preoperative plan and 33% during surgery, and 86% reported lower stress compared to performing the procedure without it. This survey suggests that pre-operative 3D planning software (Blueprint®) is a well-received digital solution in shoulder arthroplasty, with perceived benefits regarding surgical planning, surgeon's stress level, confidence and training.
Postoperative resilience varies widely among older adults, yet the biological drivers of recovery remain unclear. We evaluated whether preoperative immune profiles-measured in plasma and through ex vivo whole-blood stimulation-predict resilience to the acute stress of total knee arthroplasty. A total of 152 adults (≥60 years) in the PRIME-KNEE cohort underwent elective total knee arthroplasty and had available blood samples for measurement of 45 immune biomarkers, quantified in plasma and in whole blood stimulated ex vivo for 24 hours with lipopolysaccharide (LPS) or influenza antigen (FLU). Resilience was assessed using Expected Recovery Differential (ERD) and Resilience Trajectory (RT) across pain severity, pain interference, lower-extremity physical activities of daily living (LE-PADLs), and step counts. An exploratory stability-selection framework using LASSO identified biomarker predictors of postoperative outcomes. Plasma and stimulated biomarkers showed broadly similar predictive performance. A shared set of biomarkers-including LBP, leptin, TNFR1, CD30, and LIF-was consistently selected across models. Immune predictors explained ∼12-24% of the variance in resilience outcomes. Distinct immune signatures emerged for pain versus functional recovery: pain-related predictors mapped to local inflammatory and neuroimmune pathways, whereas function-related predictors reflected systemic inflammatory load and cytokine signaling. Preoperative immune biomarkers, whether measured in plasma or after ex vivo stimulation, capture meaningful variance in postoperative resilience. The divergence between pain-related and function-related immune signatures highlights biologically distinct pathways underlying different dimensions of recovery and supports further development of immune-based perioperative risk assessment. In this study, we explored why recovery after knee replacement surgery varies so widely among older adults. While many people regain mobility and experience pain relief, others continue to struggle with discomfort and limited function. We asked whether differences in the immune system before surgery might help explain these outcomes. To do this, we measured a wide range of immune signals in blood samples collected before surgery and then followed participants over several months, tracking their pain, daily activities, and physical movement. We found that patterns in these immune signals were linked to how well people recovered. Importantly, some of the signals that predicted pain recovery were different from those linked to improvements in physical function, suggesting that these aspects of recovery are driven by distinct biological processes. Our findings place the immune system at the center of recovery from major surgery and highlight its potential as a tool for identifying who may need more support. In the future, this knowledge could help guide more personalized approaches to care and improve recovery for older adults undergoing surgery.
Although os acromiale is often noted on preoperative imaging in patients undergoing reverse total shoulder arthroplasty (rTSA), its clinical significance is ill-defined. The purpose of this study was to compare the clinical outcomes in shoulders with an os acromiale undergoing rTSA with a matched control group. We conducted a retrospective review of a prospectively collected shoulder arthroplasty database for patients who underwent primary rTSA with a minimum 2-year clinical follow-up. Preoperative imaging studies taken within 6 months of surgery were assessed for an os acromiale. Sixty-four shoulders with os acromiale were identified and were matched in a ratio of 1:5 to a control group (n = 320) based on age (within 3 years), sex (exact), preoperative diagnosis, preoperative forward elevation (within 5°) and American Shoulder and Elbow Surgeons score (within five points). Clinical outcome scores, shoulder strength, and active range of motion assessed preoperatively and at latest follow-up as well as the incidence of complications were compared between cohorts. Outcomes of meso- and meta-acromion were grouped and compared with preacromion shoulders. The incidence of os acromiale was 9.7% (64/663) in our institution. Of these, 55% (n = 34) were preacromion, 38% (n = 24) were mesoacromion, and 8% (n = 5) were meta-acromion. No statistically significant differences were found in any outcome score, shoulder strength, or range of motion measures between shoulders with os acromiale and matched controls. Similar proportions of each cohort achieved a clinically significant benefit (minimal clinically important difference/substantial clinical benefit) for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, constant score, abduction, forward flexion, external rotation, and internal rotation. Shoulders with os acromiale had a similar overall complication rate compared with matched controls (14% vs. 12%; P = 0.658). No statistical difference in outcomes were observed between the pre- and meso-/meta-acromion shoulders. Patients with os acromiale undergoing rTSA have similar postoperative functional outcomes and pain relief compared with matched controls. Ⅲ, Retrospective Matched Cohort Study.
 Stiffness after total knee arthroplasty (TKA) is a common early complication and multiple risk factors are recognized. We aimed to investigate the risk factors for manipulation under anesthesia after primary TKA and for the subsequent revision TKA in patients requiring manipulation using national healthcare registers.  We used the comprehensive register data of the PERFECT project that included data from the Finnish arthroplasty register (FAR) and the Care Register of Health Care (CRHC). We excluded patients under 40 years old. The Aalen-Johansen estimator and Cox proportional hazards regression model were used in the risk assessment.  154,883 patients had primary TKA in Finland in 1999-2020 , of which 3,861 patients required manipulation within 1 year of primary TKA. The 1-year cumulative incidence of manipulation was 2.5%. In the multivariable analysis, female sex (hazard ratio [HR] 1.53, CI 1.42-1.64), diabetes mellitus (HR 1.19, CI 1.08-1.31), coronary artery disease (HR 1.25, CI 1.12-1.39), and hypercholesterolemia (HR 1.16, CI 1.06-1.28) were associated with an increased risk of manipulation. Increasing age was associated with a decreased risk of manipulation (multivariable HR 0.94 per year, CI 0.94-0.94). Patients requiring manipulation within 1 year of primary TKA had a significantly increased risk of revision TKA (HR 2.26, CI 2.05-2.50). The 10-year cumulative risk of revision TKA after manipulation was 15% (CI 14-16).  Manipulation was more likely to be performed for females, relatively younger patients, and patients with diabetes mellitus, coronary artery disease, or hypercholesterolemia. Patients who had manipulation within 1 year of primary TKA had an increased risk of revision with a 10-year cumulative risk of revision of 15%.
Short-stem total hip arthroplasty (THA) aims to preserve proximal femoral bone stock and promote physiological load transfer compared to conventional cementless stems. This design is particularly relevant for younger, active patients, in whom long-term implant survival and bone preservation are critical. To systematically review and meta-analyse the functional and radiological outcomes of short-stem THA in young patients. A systematic search of Medline, Embase, PubMed, and the Cochrane Library was conducted to May 2025 following PRISMA guidelines. Eligible studies included patients with mean age <55 years and ⩾4.5 years mean follow-up. Primary outcome was Harris Hip Score (HHS) or modified Harris Hip score (mHHS); secondary outcomes were complications, survivorship, and radiological findings. 32 studies involving 4082 hips (mean age 46.7 years, mean follow-up 8.6 years) were included. Mean HHS improved from 45.3 to 93.8. Complications were infrequent, including intraoperative fracture (1.6%), dislocation (0.6%), and infection (0.4%). Radiological changes, including osteolysis (1.3%), heterotopic ossification (1.9%), and stem subsidence ⩾2 mm (0.7%), were uncommon. Stem survivorship free from aseptic loosening was 99.7%. The overall revision rate was 1.6%. Subgroup analyses indicated better outcomes and lower revision rates with posterolateral approaches and ceramic-on-ceramic bearings. Short-stem total hip arthroplasty in patients younger than 55 years appears to be associated with excellent mid- to long-term functional outcomes, low complication rates, and high implant survivorship. While these findings suggest that short stems are a safe and durable option for young, active patients, substantial heterogeneity across studies and the limited randomised evidence warrant cautious interpretation. These findings are hypothesis-generating and warrant confirmation in adequately powered prospective studies.PROSPERO registration:No: CRD420251046310.
To investigate the biomechanical characteristics of the proximal tibia (including cortical bone, cancellous bone, and bone cement) after lateral unicompartmental knee arthroplasty (L-UKA) under conditions of normal bone mass, osteopenia, and osteoporosis through finite element analysis of the tibial plateau, and to evaluate the impact of osteoporosis on the risk of postoperative tibial fracture from a biomechanical perspective, focusing on stress, strain, and deformation distribution patterns. Based on CT data of the tibia from a healthy adult male volunteer, a three-dimensional finite element model of L-UKA was established, including the femoral component, tibial component, ultra-high molecular weight polyethylene insert, bone cement, medial tibial cartilage, and tibia (comprising cortical and cancellous bone). Three groups of bone density parameters were defined: normal bone mass (T-score ≥-1.0SD), osteopenia (T-score -2.5SD--1.0SD), and osteoporosis (T-score ≤-2.5SD). Different bone conditions were simulated by adjusting the elastic modulus of cortical and cancellous bone. Boundary conditions included complete constraint of the distal tibia, application of a 600 N vertical load on the femoral component, and a 400 N vertical load on the medial tibial cartilage to simulate single-leg stance during slow walking. The maximum stress, maximum strain, and maximum deformation of key structures were measured. As bone mass decreased, the biomechanical responses of bone and bone cement changed significantly. Specifically, the maximum stress, maximum strain, and maximum deformation of cortical bone and the bone cement layer increased markedly. For cancellous bone, the maximum stress decreased, while the maximum strain and maximum deformation increased. The maximum stress of the insert were similar across the three groups, with minimal variation (<1%); the peak stress was located at the contact area between the insert and the femoral component. The biomechanical risk of tibial fracture after L-UKA significantly increases in patients with osteoporosis, particularly for periprosthetic stress or fragility fractures. 通过对膝关节外侧间室人工单髁置换术（lateral unicompartmental knee arthroplasty，L-UKA）后胫骨平台生物力学进行有限元分析，探讨正常骨质、骨量减少及骨质疏松状态下，L-UKA术后胫骨近端（包括皮质骨、松质骨、骨水泥层）的应力、应变及变形分布特征，从生物力学角度评估骨质疏松对术后胫骨骨折风险的影响。. 基于 1 名健康成年男性志愿者胫骨CT数据，构建包含股骨假体、胫骨假体、超高分子量聚乙烯垫片、骨水泥、内侧胫骨软骨及胫骨（包含皮质骨与松质骨）的L-UKA三维有限元模型。设定正常骨质（T值≥−1.0SD）、骨量减少（T值−2.5SD～−1.0SD）和骨质疏松（T值≤−2.5SD）3组骨密度参数，通过调整皮质骨和松质骨弹性模量模拟不同骨质条件。模型边界条件为胫骨远端完全固定，在股骨假体上施加600 N垂直载荷，内侧胫骨软骨上施加400 N垂直载荷，以模拟慢走步态中单腿支撑情况。测量关键结构最大应力、最大应变及最大变形。. 随着骨量减少，骨骼及骨水泥层生物力学响应发生显著变化。其中，皮质骨及骨水泥层最大应力、最大应变、最大变形均明显增加；松质骨最大应力降低，最大应变、最大变形增加。3组模型垫片最大应力接近，变化幅度极小（<1%），峰值应力位于垫片与股骨假体接触区域。. 骨质疏松患者L-UKA术后发生胫骨骨折的生物力学风险显著增高，尤其是假体周围应力性或脆性骨折。.
Dislocation after total hip arthroplasty (THA) is a devastating complication. The hip-spine relationship is a significant contributor to hip instability and dislocation after THA but is predominantly evaluated with static radiographs, limiting its utility. This study evaluated a novel artificial intelligence (AI)-based application for real-time analysis of hip-spine motion prior to THA to dynamically evaluate patients' hip-spine stiffness in real-time prior to THA. Preoperative hip and spine flexibility were assessed using an AI application that recorded patients performing sit-to-stand, forward flexion, and standing posture maneuvers. Minimum and maximum neck, spine, trunk, and knee angles were measured preoperatively. Preoperative radiographs were also evaluated for spinal stiffness indicators. Acetabular component abduction and anteversion angles were measured to confirm adequate positioning. Nineteen patients underwent THA via an anterior-based muscle-sparing approach with a minimum 12-month follow-up. The mean preoperative forward flexion trunk angle was 95.7° ± 14.4° (25th percentile: ≤87.2°). During sit-to-stand, mean maximum and minimum spine angles were 38.3° ± 13.3° (25th percentile: ≤27.6°) and 5.1° ± 5.9° (75th percentile: ≥6.2°), respectively. Fifteen patients (78.9%) received 36-mm femoral heads. Mean abduction and anteversion was 43.9° and 26.4°, respectively. No postoperative hip dislocations occurred. This AI-based hip joint assessment tool may serve as a clinic-based tool to evaluate the hip-spine relationship as a dynamic predictor of dislocation risk. It may offer greater accuracy than static radiographs, which cannot comprehensively capture real-time functional movements. This tool may improve surgical planning, particularly in higher-risk patients. Larger studies are needed to validate its predictivity and clinical utility.
Long-term data following periprosthetic patellar fractures around primary total knee arthroplasty (TKA) are lacking. The purpose of this study was to describe the classification, management, and outcomes of periprosthetic patellar fractures in, to our knowledge, the largest series to date. We identified 214 (213 cemented and one uncemented) periprosthetic patella fractures (205 patients) around a primary TKA sustained between 1989 and 2020. There were eight intraoperative fractures and 206 postoperative fractures. Postoperative fractures were classified according to the Ortiguera and Berry classification. There were 76% Type I fractures, 12% Type II fractures, 6% Type IIIA fractures, and 6% Type IIIB fractures. The mean patient age was 66 years (range 22 to 90), 56% were men, and their mean body mass index (BMI) was 32 (range, 21 to 54). The mean patient follow-up was seven years (range, two to 19). The incidence of intraoperative patellar fracture was 0.02%, occurring most frequently during exposure, implant preparation, or trialing (75%). The 10-year survivorships free of any revision and any reoperation after intraoperative fractures were both 88%. Among the 206 postoperative fractures, the majority (66%) occurred atraumatically, while 31% occurred after ground level falls. Among postoperative fractures, the 10-year survivorship free of any revision and any reoperation was 71 and 61%, respectively. Revision and reoperation risk after postoperative fracture varied by Ortiguera and Berry classification. The 10-year survivorship free of any revision was highest in Type I (80%) and significantly lower in Type II (60%) fractures. Compared to Type I fractures, survivorship free of revision was decreased in Type II (hazard ratio (HR) 8.4, P < 0.001), Type IIIA (HR 17.0, P < 0.001) and Type IIIB (HR 8.1, P < 0.001) fractures. Mortality following postoperative periprosthetic patellar fractures was 7% at two years and 55% at 10 years. Intraoperative periprosthetic patellar fractures during primary TKA were rare and generally well-tolerated. Ortiguera and Berry Types II and III fractures were associated with the highest risk of revision and reoperation.
Persistent pain after total hip arthroplasty (THA) is a common complication requiring extensive diagnostic effort and is often associated with potentially invasive and morbid treatment options. With THA volume expected to steadily increase there is a similarly growing need for creative and effective diagnostic and therapeutic options for these clinically challenging patients. Hip arthroscopy has emerged as a promising tool in the setting of persistent pain after THA with expanding indications and promising outcomes. The purpose of this article was to provide a review of the current state of literature regarding arthroscopic and endoscopic solutions for common causes of persistent pain after THA with a focus on patient selection, indications, surgical considerations, outcomes, and complications. The most common indication for hip arthroscopy after THA is iliopsoas tendinopathy, showing excellent outcomes with symptom resolution in greater than 90% of patients after arthroscopic iliopsoas release or lengthening. The second most common indication is diagnostic arthroscopy in the setting of otherwise negative extensive work-up, which has shown diagnostic value for occult implant loosening, capsular fibrosis, and metal hypersensitivity. Endoscopic decompression for the treatment of ischiofemoral impingement and sciatic nerve decompression has also shown consistent improvements in pain and function. In addition to these well described indications, future utilization of hip arthroscopy for loose body removal, capsular plication for instability, and management of prosthetic joint infection are potentially emerging indications. Hip arthroscopy after THA is a safe and effective tool for the management of common causes of persistent pain after THA with robust support for iliopsoas pathology and emerging evidence and outcomes for less common indications. Future research will both expand and narrow these indications as diagnostic criteria, patient selection, and surgical techniques are refined.
To evaluate whether preoperative CT-derived three-dimensional bone shape modes are associated with failure to achieve the Knee Society Score Function subscore (KSS-Function) minimal clinically important difference (MCID) after total knee arthroplasty (TKA). This retrospective study included patients with knee osteoarthritis who underwent primary robotic-assisted knee arthroplasty between January 2019 and January 2024. Bone shape modes were extracted from preoperative CT-based segmentations of the distal femur, proximal tibia, and patella using statistical shape modeling. Clinical outcome analysis was restricted to TKA knees with complete 1-year KSS-Function follow-up. MCID non-achievement was defined as failure to achieve a 10-point improvement in KSS-Function. Associations between shape modes and MCID non-achievement were assessed using logistic regression, with adjustment for clinical covariates. Internal discrimination was evaluated using repeated patient-level grouped cross-validation. Among 151 TKA knees, 15.9% did not achieve the KSS-Function MCID. Female sex and higher BMI were associated with greater odds of MCID non-achievement. After adjustment for sex and BMI, five shape modes were associated with MCID non-achievement. These modes reflected less pronounced patellofemoral bony remodeling, patellar median ridge curvature, and localized contour variation near the central tibial plateau. The clinical-only, shape-only, and combined models achieved AUCs of 0.680, 0.696, and 0.754, respectively. The combined model had a 0.074 higher AUC than the clinical-only model, but paired bootstrap analysis was not significant (p = 0.130). CT-derived bone shape modes were associated with MCID non-achievement after TKA, suggesting bone morphology may offer insights, but their incremental value requires confirmation in larger, adequately powered cohorts.
Tranexamic acid (TXA) reduces blood loss and transfusion requirements in patients who underwent primary total hip arthroplasty (THA). However, the optimal route of TXA administration remains unclear. This randomized controlled trial evaluated whether intraosseous (IO) TXA administration was noninferior to intravenous (IV) or topical administration. In this equal-proportion, noninferior randomized controlled trial, 126 patients undergoing primary THA from October 2024 to April 2025 were randomized to IO (20 mg/kg TXA applied in the cancellous bone of the femur and ilium), IV (20 mg/kg TXA applied five minutes before incision), or topical (20 mg/kg TXA applied before suture) group. The primary outcome was hemoglobin (Hb) reduction on the day of surgery (DOS) and postoperative days one to three (POD one to three). The secondary outcomes included blood loss, transfusion rate, and adverse events. Demographics were similar among the groups. The mean Hb reduction was comparable on the DOS, POD one, POD two, and POD three (P = 0.431, 0.532, 0.479, and 0.443, respectively). Exploratory analyses showed lower mean calculated total blood loss in the IO group on the DOS and POD one than in the other groups (DOS and POD one: P = 0.005 and 0.016, respectively), although the clinical relevance of this finding remains uncertain. Transfusion rates were 2.3, 7.1, and 2.3% in the IO, IV, and topical group, respectively (P = 0.434). There was one patient in the topical group who developed deep vein thrombosis; no pulmonary embolism or infections were reported. The blood-sparing efficacy of IO TXA administration is noninferior to that of IV and topical administration, with potential benefit in early postoperative blood loss control. Further high-quality studies are needed to confirm its superiority and establish its clinical value.
The purpose of this study was to provide 2-year post-operative clinical outcomes and survivorship of a novel, fully 3D-printed humeral prosthesis. This is a prospective case series of 34 patients who underwent anatomic total shoulder arthroplasty (TSA) with a fully 3D-printed humeral prosthesis. Minimum post-operative follow-up was two years. Patient demographics, clinical outcomes, and radiographic outcomes were collected. X-rays were examined for radiolucent lines surrounding the implant. The primary outcome was TSA survivorship. Secondary outcomes were patient-reported outcome measure (PROM) scores and radiographic findings. At a minimum follow-up of 2 years, there were no revisions or reoperations with a prosthetic survivorship of 100%. At final follow-up, patients had significant improvement in American Shoulder and Elbow Surgeons and visual analog scale scores (P < .001), with a mean post-operative American Shoulder and Elbow Surgeons of 93 and visual analog scale of 0.5. The rate of any periprosthetic radiolucent line on X-ray was 2 of 34 (6%). All identified radiolucent lines were <0.5 mm. The results of early clinical follow-up of this fully 3D-printed, off-the-shelf humeral prosthetic are encouraging. Post-operative radiolucent lines appear to be minimal in thickness, infrequent, and of unclear clinical significance given 100% survivorship and reassuring PROMs. Further clinical follow-up of this and other 3D-printed systems is necessary to confirm that additive manufacturing is a mechanically durable and viable method for off-the-shelf TSA manufacturing.
Patient-reported outcome measures (PROMs) are important markers to assess patient improvement after total joint arthroplasty (TJA). PROMs are increasingly relevant because of new PROM-reporting requirements for elective inpatient TJA from the Centers for Medicare & Medicaid Services. Social determinants of health (SDOH) disparities have been associated with various worse outcomes after TJA, but to our knowledge, it is not yet known how PROM completion may be affected by SDOH disparities. Among patients undergoing TJA, (1) are there SDOH disparities (such as insurance, transportation access, and living alone) that are associated with differences in PROM completion? (2) Are there neighborhood metrics, including Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI), that are associated with differences in PROM completion? This study was a retrospective, comparative single-institution study of 12,842 patients who underwent primary, unilateral TJA for osteoarthritis between 2019 and 2022. Study participants had a mean ± SD age of 67 ± 10 years, 45% (5745) were men, and 86% (10,131 of 11,833) were White. Mean ± SD national ADI score was 34 ± 21, and SVI score was 0.4 ± 0.3. PROMs were collected within the first year preoperatively and at 6 months, 1 year, and 2 years postoperatively per institutional protocol. Patient demographic and socioeconomic factors were collected from the institutional medical record. We examined whether PROM noncompletion and completion differed in terms of SDOH, including living alone, transportation access, and insurance type. Race and ethnicity were self-reported by patients. We additionally examined whether PROM noncompletion and completion differed in terms of neighborhood metrics including SVI and ADI scores. For proportions, a clinically important difference was defined by a 15% change. We found no clinically important differences regarding SDOH disparities in terms of PROM noncompletion and completion; specifically, there were no differences in PROM completion based on Black race (preoperative: 13% [312 of 2332] versus 9% [884 of 9501]; p < 0.001; 1 year: 11% [886 of 8015] versus 8% [310 of 3818]; p < 0.001), lack of transportation access (preoperative: 3% [67 of 2002] versus 2% [199 of 8494]; p = 0.01; 1 year: 3% [205 of 7050] versus 2% [61 of 3446]; p = 0.001), living alone (preoperative: 23% [466 of 1988] versus 21% [1750 of 8452]; p = 0.01; 1 year: 23% [1577 of 6999] versus 19% [639 of 3441]; p < 0.001), and commercial insurance preoperatively (62% [1577 of 2563] versus 65% [6675 of 10,279]; p < 0.001). For neighborhood-level metrics, we found no clinically important difference for PROM noncompletion and completion in terms of mean ± SD ADI scores nationally (preoperative: 36 ± 23 versus 34 ± 21; p = 0.004; 1 year: 39 ± 21 versus 33 ± 20; p < 0.001) and SVI scores (preoperative: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.53 to 0.73]; p < 0.001; 1 year: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.61 to 0.80]; p < 0.001). No clinically important difference was found for various SDOH disparities and neighborhood metrics investigated in this study. Considering these findings, lack of transportation access, living alone, race, insurance type, and address-related neighborhood disadvantage may not be strong indicators of PROM completion after TJA. However, SDOH disparities still require further investigation to understand the relationship between other SDOH disparities and different populations outside of our urban institution. Level III, prognostic study.
 Intraoperative fluoroscopy during primary total hip arthroplasty (THA) can be used to assist in component positioning in order to optimize placement and restore hip kinematics. Whether fluoroscopy leads to superior outcomes is subject to debate. We aimed to examine the use of fluoroscopy in the Netherlands and determine the association between the use of fluoroscopy and short-term revision risk following primary THA via the direct anterior approach (DAA).  We included 49,878 primary THAs, performed via DAA, registered in the LROI from 2022-2024. Competing risk analysis and multivariable Cox-regression analyses were used to assess differences in implant survival between use of fluoroscopy and conventional surgery. Hazard ratios (HR) were adjusted for body mass index, previous surgeries, and fixation, and stratified for age, ASA class, and diagnosis.  Unadjusted cumulative incidence of revision after 6 months, 1, 2, and 2.5 years did not show significant differences: the 2.5-year revision rate was 1.7% (95% confidence interval [CI] 1.5-1.9) for the fluoroscopy group, and 2.0% (CI 1.8-2.3) in the conventional group. Multivariable analysis demonstrated that the use of fluoroscopy was associated with a significantly lower risk of revision than conventional surgery (HR 0.8, CI 0.7-0.9).  The use of intraoperative fluoroscopy in primary THA via DAA in the Netherlands is associated with a significantly lower short-term risk of revision. The data showed no major differences in revision due to malalignment and periprosthetic fractures. Revision rates were low in both groups and clinical differences were only small.
Cementless total knee arthroplasty (TKA) has emerged as an alternative to cemented fixation. We used the American Joint Replacement Registry (AJRR) to assess trends in cementless TKA utilization and associated one-year revision rates. We analyzed primary TKAs recorded in the AJRR from 2012 to 2024 with available fixation data. Annual proportions of cementless fixation were calculated, and trend analyses were performed using Kendall Tau-b tests. The one-year revision risk was evaluated in cases linkable to Centers for Medicare and Medicaid Services (CMS) data among patients aged 65 years and older with at least two years of potential follow-up. A multivariable generalized linear model was used to estimate one-year revision risk, adjusting for patient and hospital characteristics and clustering by institution. A sub-analysis examined specific reasons for revision. Of 1,178,783 primary TKAs from 2012 to 2024, 127,781 (10.8%) were cementless. Use increased from 1.6 to 19.0% across all regions (P < 0.002). In the CMS-linked cohort (n = 685,274), 52,742 (7.7%) were cementless. The one-year revision rates were 1.61% for cementless and 1.53% for cemented TKAs (P = 0.162). After adjustment, cementless fixation was associated with increased revision risk (adjusted odds ratio (aOR) = 1.12; 95% confidence interval (CI): 1.00 to 1.25; P = 0.05). Revision risk was more strongly associated with age greater than 75 years (aOR = 0.76), men (aOR = 1.49), body mass index greater than 40 (aOR = 1.64), Charlson Comorbidity Index greater than 5 (aOR = 2.66), and hospital versus ambulatory surgery center (aOR = 4.78). Sub-analysis revealed higher risk of revision with cementless fixation for aseptic loosening (0.11 versus 0.06%; aOR = 2.37) and instability (0.14 versus 0.09%; aOR = 1.64). Cementless TKA utilization has grown in the AJRR. While associated with a modestly higher one-year revision risk, the absolute difference is small and may not be clinically meaningful.