J Bone Joint Surg Am. 2025 Jun 26. doi: 10.2106/JBJS.24.01081. Online ahead of print.

ABSTRACT

BACKGROUND: AAOS Clinical Practice Guidelines recommend spica casting for the treatment of most femoral fractures in children 6 months to 5 years of age. The purpose of the present study was to compare the outcomes of treatment with prefabricated braces with those of spica casting.

METHODS: We performed a randomized prospective study of patients 6 months to 5 years of age who were managed with functional bracing or spica casting for the treatment of diaphyseal femoral fractures at 2 pediatric trauma centers. Patients with polytrauma, medical comorbidities impacting fracture-healing, or <6 weeks of follow-up were excluded. Spica casts were placed in the operating room with the patient under anesthesia. Functional braces were placed at bedside.

RESULTS: Eighty patients (40 in the spica casting group and 40 in the functional bracing group) met the inclusion criteria and were analyzed. The mean age was 2.0 years in the casting group and 2.3 years in the bracing group (p = 0.15). Radiographs demonstrated similar shortening (9.0 ± 7.6 mm in the casting group and 6.8 ± 8.2 mm in the bracing group; p = 0.21), varus angulation (9.0º ± 11.9º in the casting group and 5.6º ± 9.4º in the bracing group; p = 0.19), and procurvatum (9.4º ± 12.9º in the casting group and 6.7º ± 8.4º in the bracing group; p = 0.31). At 6 weeks, there were no differences in shortening (13.1 ± 9.4 mm in the casting group and 11.0 ± 10.0 mm in the bracing group; p = 0.35), varus angulation (2.4º ± 7.3º in the casting group and 5.3º ± 6.3º in the bracing group, p = 0.06), or procurvatum (12.3º ± 9.8º in the casting group and 9.1º ± 8.1º in the bracing group; p = 0.11). Fifty-one patients (24 in the casting group and 27 in the bracing group) had 1 year of follow-up. There were no differences between the groups in terms of shortening (4.9 ± 5.4 mm in the casting group and 3.0 ± 6.9 mm in the bracing group; p = 0.23) or varus angulation (1.8º ± 3.5º in the casting group and 1.2º ± 4.1º in the bracing group; p = 0.56), but there was a slight difference in procurvatum (11.7º ± 8.3º in the casting group and 5.1º ± 5.8º in the bracing group; p < 0.01). More superficial skin issues were observed in the bracing group than in the casting group (9 compared with 1; p = 0.02), but all skin issues resolved with local wound care. Patients in the casting group had more difficulty moving independently (median score, 8 of 10 in the casting group and 5 of 10 in the bracing group; p = 0.05). Patients in the bracing group were more likely to fit into their car seat (40% in the casting group versus 86% in the bracing group; p < 0.01).

CONCLUSIONS: In this prospective randomized trial, patients who were treated with functional bracing had equivalent outcomes to those who were treated with spica casting. Prefabricated functional braces provided a viable alternative, avoiding the cost and anesthesia associated with cast placement.

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

PMID:40570075 | DOI:10.2106/JBJS.24.01081

J Bone Joint Surg Am. 2025 Jun 26. doi: 10.2106/JBJS.24.01554. Online ahead of print.

ABSTRACT

Leadership selection in the field of orthopaedic surgery takes place in many settings, including national, regional, and local associations; academic departments; and private practice groups. In general, there is neither a consistent method of competency-based leadership selection nor a codified set of criteria by which to identify a successful leader in national organizations. This can potentially lead to leadership based on personality rather than process. Polling results among the orthopaedic leaders who were present at the 2024 American Orthopaedic Association (AOA) Annual Meeting Symposium revealed that 80% think that the selection process for board leadership for national orthopaedic organizations needs to improve, and 75% think that the selection process for academic department chairs also needs to improve. This summary of the 2024 AOA Symposium provides a strategy for consistent, competency-based leadership selection in orthopaedic organizations, identifies potential key selection criteria that are necessary to identify talent, and enumerates steps that can be used by nominating or search committees. Although the focus of this work is directed toward the process that is used to identify leaders for national orthopaedic organizations, features of academic medical leadership and corporate talent selection will be highlighted for consideration and translation to the orthopaedic community.

PMID:40570068 | DOI:10.2106/JBJS.24.01554

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01489. Online ahead of print.

ABSTRACT

BACKGROUND: The Roussouly classification is a popular system for the categorization of spinal alignment, although the categorization of continuous measures may compromise efforts toward a precision-medicine approach to sagittal alignment in spine surgery. Vertebral-pelvic angles provide continuous measures of sagittal alignment without the risk of misclassification.

METHODS: We performed a cross-sectional study of asymptomatic adult volunteers with normal spines (no evidence of disc degeneration or scoliosis). Full-spine radiographs were obtained, and radiographic parameters were collected, including pelvic incidence (PI), sacral slope, lumbar lordosis, the apex of lordosis, the L1-pelvic angle (L1PA), and the T4-pelvic angle (T4PA). All spines were classified as Roussouly Type 1, 2, 3, or 4 on the basis of sacral slope and the apex of lumbar lordosis. Associations between the L1PA and PI, the L1PA and T4PA, and the T4-L1PA mismatch and PI were assessed for the whole cohort and when stratified by Roussouly type. A multinomial logistic regression model was fit to estimate Roussouly type based on PI, the L1PA, and the T4PA. Agreement (weighted κ), accuracy, and area under the receiver operating characteristic curve (1 type versus the rest) were computed. A subanalysis assessed potential variations in the relationships when Roussouly Type-3 spines were further classified as Type 3A (anteverted) versus Type 3.

RESULTS: The 320 included volunteers had a median age of 37 years (interquartile range [IQR], 27 to 47 years), and 193 (60%) were female. By self-reported race or ethnicity, the highest percentage of patients were Caucasian (White, 38%) or East Asian (36%), followed by Arabo-Bèrbère (16%). Spines were classified as Roussouly Type 1 in 18 (6%) of the volunteers, as Type 2 in 63 (20%), as Type 3 in 161 (50%), and as Type 4 in 78 (24%). The L1PA was strongly associated with PI across Roussouly types (weakest in Roussouly Type-1 spines). A multinomial logistic regression model estimating Roussouly type by PI, the L1PA, and the T4PA showed strong agreement (weighted κ, 0.84), excellent discrimination, and overall accuracy of 0.82.

CONCLUSIONS: The T4-L1-Hip axis is conceptually aligned with the description of spinal shapes in the Roussouly classification but with the advantage of utilizing continuous measures of spinal alignment. Goals of surgical realignment incorporating the T4-L1-Hip axis will be comparable with alignment planning using the Roussouly classification but with improved accuracy and precision.

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

PMID:40560977 | DOI:10.2106/JBJS.24.01489

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.00009. Online ahead of print.

ABSTRACT

BACKGROUND: The diagnosis of acute compartment syndrome (ACS) using a single-point pressure measurement device has demonstrated low specificity. Recently, sensors that allow for continuous monitoring of compartment pressure have been introduced, with improved specificity and sensitivity compared with single-point measurement. In this article, we present an economic model used to evaluate the cost-benefits of continuous pressure measurement in patients at risk for ACS.

METHODS: The model used a decision-tree structure to estimate the treatment costs of ACS at 60 days and 1 year after admission and over the patient's lifetime. It assumed systematic use of the diagnostic devices for all tibial shaft and tibial plateau fractures and estimated the cost-effectiveness of continuous pressure measurement compared with noncontinuous pressure measurement by comparing costs, quality-adjusted life-years (QALYs), and length of stay (LOS).

RESULTS: The improved specificity of continuous pressure measurement reduced unnecessary fasciotomies by 94%. The inflation-adjusted cost of an uncomplicated tibial fracture averaged $57,144; the performance of an unnecessary fasciotomy increased that cost by $27,790. The gain in QALYs was 0.004 per patient, with a net health benefit of 0.06 QALYs. Over a 60-day time horizon, the model showed an estimated decrease in LOS of 2.73 days, on average, per patient. The net monetary benefit was $2,789 (range, -$1,246 to $6,151) in favor of the continuous measurement, increasing to $4,085 (range, -$745 to $8,103) over the lifetime of the patient following the most conservative scenario of equal ACS grade distribution.

CONCLUSIONS: Most of the ACS economic burden lies in the lack of specificity of the current diagnostic methods. The low incidence of ACS and the high risk associated with prophylactic treatment indicate that improvement in health and economic outcomes should focus on reducing the rate of unnecessary fasciotomies.

LEVEL OF EVIDENCE: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

PMID:40560966 | DOI:10.2106/JBJS.24.00009

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01419. Online ahead of print.

ABSTRACT

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) has undergone numerous changes to promote care for patients at high social risk. However, the effect of these changes on surgeon MIPS performance and caseload selection remains unclear. Thus, the purpose of this study was to evaluate how orthopaedic surgeon MIPS scores, demographics, practice characteristics, and patient populations varied on the basis of patient social risk in 2017 compared with 2021.

METHODS: CMS data were utilized to examine U.S. orthopaedic surgeons. Surgeons were placed into social-risk quintiles on the basis of the proportion of their patients who were dually eligible for Medicare and Medicaid, with the highest quintile representing the highest social risk. Demographics, practice location characteristics, patient data, and MIPS performance were assessed for the years 2017 and 2021. Differences between social-risk quintiles were assessed utilizing chi-square, Student t, and Wilcoxon signed-rank tests and multivariable logistic regression.

RESULTS: In 2017, surgeons with caseloads at the highest, compared with the lowest, social risk had lower MIPS performance scores (mean [and standard deviation], 66.0 ± 37.6 versus 70.1 ± 33.5; p < 0.001). However, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk had significantly higher MIPS performance scores (mean, 88.7 ± 16.9 versus 81.5 ± 18.3; p < 0.001). In terms of demographics, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk were more often women (9.2% versus 3.6%; p < 0.001), more often had a DO degree (11.2% versus 6.6%; p < 0.001), more recently graduated from medical school (mean, 23.0 ± 12.9 versus 25.7 ± 10.9 years; p < 0.001), and worked in areas with higher Distressed Communities Index (DCI) distress scores (mean, 56.9 ± 27.3 versus 35.1 ± 25.2; p < 0.001). Similar findings were present in 2017.

CONCLUSIONS: The addition of the Complex Patient Bonus to the MIPS in 2020 may have reduced performance inequities in MIPS scoring for surgeons with caseloads at high social risk. However, the demographics and practice patterns of the orthopaedic surgeons caring for populations at the highest social risk remained consistent between years.

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

PMID:40560965 | DOI:10.2106/JBJS.24.01419

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01126. Online ahead of print.

ABSTRACT

BACKGROUND: Glenoid component loosening remains a challenge in anatomic total shoulder arthroplasty (aTSA). The aims of this study were to evaluate complications, implant survival, and revision rates in patients with primary and secondary osteoarthritis (OA) undergoing stemless aTSA using the Arthrex Eclipse humeral implant with a cemented pegged all-polyethylene glenoid component and to identify risk factors leading to revision.

METHODS: Of 211 patients who underwent primary stemless aTSA (using the Eclipse humeral component with a cemented pegged all-polyethylene glenoid) with prospectively documented data in a local registry, 197 were evaluated, grouped by OA pathology (primary OA, 153 patients; secondary OA, 44 patients). Demographic and functional data (e.g., age, sex, shoulder function) and the cause of OA were documented preoperatively in both groups. Comparative analyses were conducted to assess complications and implant revisions between the study groups. In addition, various radiographic parameters (e.g., glenoid morphology, critical shoulder angle, lateral acromion index, implant sizing [humeral component overhang], radial matching of the humeral and glenoid components, glenohumeral distance, and medial glenoid cement penetration) were evaluated to explore their potential association with revision. A subset of these parameters was subsequently included in the multivariable Cox model on the basis of clinical relevance.

RESULTS: After a median postoperative period of 72 months, the overall revision rate was 51%. The reasons for revision were glenoid component loosening (85%), periprosthetic humeral fracture (9%), early rotator cuff failure (3%), and low-grade infection (3%). The median implant survival in patients with primary OA (95 months; 95% confidence interval [CI]: 84 to 108) was significantly longer than that in patients with secondary OA (71 months; 95% CI: 60 to 88; p = 0.027). Female patients had a significantly shorter time to revision than male patients (p = 0.016). There were no significant differences in complications or revision rates by OA pathology. Secondary OA, the presence of medial glenoid cement penetration, and an anterior overhang of the humeral component were associated with an increased risk of revision.

CONCLUSIONS: Our findings indicate a high rate of glenoid component loosening as the primary cause of revision in patients with primary and secondary OA undergoing stemless aTSA with the Eclipse and a cemented pegged all-polyethylene glenoid component. This outcome emphasizes the need for careful consideration of implant design, patient selection criteria, and implant positioning and cementation in order to optimize implant survival.

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

PMID:40560961 | DOI:10.2106/JBJS.24.01126

J Bone Joint Surg Am. 2025 Jun 24. doi: 10.2106/JBJS.24.01373. Online ahead of print.

ABSTRACT

Medical slang is commonly used in the orthopaedic community to improve communication, enhance team cohesion, and provide humor in intense work environments. However, when used carelessly, inappropriate terminology can alienate certain groups of physicians. When encountered in clinical settings, these terms can create uncomfortable environments, reduce trust, and discourage trainees from pursuing orthopaedics. To create more inclusive and effective clinical teams, it is important to regularly reassess medical slang and develop alternative terms that are respectful, practical, and consistent. This contemporary article highlights 8 examples of inappropriate terminology that are used in the orthopaedic community, explores their history of use, and suggests more appropriate alternatives.

PMID:40554618 | DOI:10.2106/JBJS.24.01373

J Bone Joint Surg Am. 2025 Jun 24. doi: 10.2106/JBJS.24.01538. Online ahead of print.

ABSTRACT

BACKGROUND: The usage of medial unicompartmental knee arthroplasty (mUKA) is increasing, but concerns remain regarding the risk of early periprosthetic tibial fracture (PPTF), particularly following cementless mUKA. The aims of this study were to compare the risk of PPTF between cemented and cementless mUKAs and to analyze risk factors for early PPTF.

METHODS: Using data from the Danish Knee Arthroplasty Register and the Danish National Patient Registry, all mUKAs from 1997 to 2022 were identified and stratified as cemented or cementless mUKAs. Subsequent fractures were identified through the reason for revision, diagnosis codes, and fracture-specific procedure codes.

RESULTS: This study included 9,700 cemented mUKAs (mean follow-up of 9 years) and 12,380 cementless mUKAs (mean follow-up of 3 years). The 4-month cumulative proportions of PPTF were 0.2% (95% confidence interval [CI], 0.2% to 0.4%) after cemented mUKA and 0.7% (95% CI, 0.6% to 0.9%) after cementless mUKA. Risk factors for early PPTF (≤4 months) were cementless mUKA (hazard ratio [HR], 2.9; 95% CI, 1.6 to 5.5), female sex (HR, 2.6; 95% CI, 1.6 to 4.2), an age of ≥70 years (HR, 4.0; 2.5 to 6.4), body mass index (BMI) of ≥40 kg/m2 (HR, 2.4; 95% CI, 1.0 to 5.8), and a height of <160 cm (HR, 2.2; 95% CI, 1.3 to 3.6). Female patients ≥70 years of age with a BMI of ≥40 kg/m2 and/or a height of <160 cm represented 3% of all mUKAs. In this group, patients with cementless mUKA had a 4-month cumulative proportion of PPTF of 4.5% (95% CI, 2.9% to 6.9%).

CONCLUSIONS: The risk of early, surgery-related PPTF was higher after cementless mUKA compared with cemented mUKA. Risk factors for early PPTF include cementless mUKA, female sex, an age of ≥70 years, a BMI of ≥40 kg/m2, and a height of <160 cm. Our data highlight the need for careful, bone-conserving tibial preparation and consideration of cemented tibial fixation for female patients ≥70 years of age with a height of <160 cm and/or a BMI of ≥40 kg/m2.

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

PMID:40554616 | DOI:10.2106/JBJS.24.01538

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01225. Online ahead of print.

ABSTRACT

BACKGROUND: Implant-associated infections (IAIs) require aggressive debridement to eliminate microbial bioburden. The use of irrigants may improve microbial killing during debridement. This study compared the efficacy of surgical irrigants in vitro against Staphylococcus aureus alone and in combination with Candida albicans, in both planktonic and biofilm states.

METHODS: Full-strength Dakin's solution, 0.35% povidone-iodine (PI), 10% PI, 3% hydrogen peroxide (HP), a 1:1 combination of 10% PI and 3% HP (PI + HP), Irrisept, XPERIENCE, Bactisure, and normal saline solution were tested. For planktonic testing, 1 × 106 colony-forming units (CFUs) of S. aureus and C. albicans were utilized, and biofilms were grown in these conditions on 0.8 × 10-mm titanium alloy Kirschner wires for 48 hours. Killing assays were performed using 5-minute dwell times. Success was defined by complete eradication of planktonic or biofilm CFUs.

RESULTS: PI + HP and Bactisure were the only irrigants to eradicate S. aureus in both planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states.

CONCLUSIONS: PI + HP and Bactisure were superior irrigants against S. aureus, eliminating it in planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states. In vivo studies are needed to evaluate the clinical effectiveness.

CLINICAL RELEVANCE: Surgical irrigants have variable efficacy in eradicating microbes depending on their state of existence (planktonic versus biofilm). In this study, the most effective eradication of polymicrobial S. aureus + C. albicans bioburden was a 1:1 combination of 10% PI and 3% HP, which is of nominal cost.

PMID:40536949 | DOI:10.2106/JBJS.24.01225

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01485. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-level value analysis (PLVA) has been applied to several orthopaedic procedures but has not yet been utilized to assess the value of total knee arthroplasty (TKA). The purpose of this study was to evaluate the 1-year episode of care for TKA with use of PLVA to identify characteristics that influence value at both the patient and surgeon level.

METHODS: The institutional patient-reported outcome (PRO) database was queried for all patients who underwent TKA from 2020 to 2022. Patients were excluded on the basis of an index revision procedure, a pathology other than primary osteoarthritis, unicompartmental knee arthroplasty, robotic-assisted TKA, incomplete baseline or 1-year PROs, concomitant procedures (i.e., bilateral TKA or hardware removal), complications requiring readmission or reoperation, TKA without patellar resurfacing, the use of constrained implants, incomplete cost information, or other hip or knee arthroplasty procedure during the 1-year episode of care. PROs of interest included preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) scores. Episode-of-care costs were calculated using time-driven activity-based costing. The 1-year value quotient (VKOOS) was calculated for each patient as the ratio of the 1-year change in KOOS-JR score to the total episode-of-care cost.

RESULTS: A total of 684 patients (62% female; mean age, 68 ± 8 years) met the inclusion criteria. The mean KOOS-JR score significantly increased from baseline (53 ± 11) to 1 year (79 ± 14; p < 0.001), with a mean improvement of 26 ± 16. The mean total episode-of-care cost was $9,563 ± $2,370. There was no significant correlation between episode-of-care costs and the change in KOOS-JR score (r = 0.02; p = 0.581). Surgery performed at an ambulatory surgery center (p < 0.001) and as an outpatient procedure (p = 0.036) were predictive of lower costs. Patient-specific instrumentation (p < 0.001) and a tibial stem extension (p < 0.001) were predictive of higher costs. Older age (p = 0.023) and male sex (p = 0.007) were predictive of less improvement in KOOS-JR scores from baseline to 1 year.

CONCLUSIONS: Our study identified patient and surgical characteristics that drive costs and PROs in TKA. PLVA can be used to identify "bright spots" in orthopaedic procedures to optimize care delivery.

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

PMID:40536933 | DOI:10.2106/JBJS.24.01485

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01484. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-education materials (PEMs) are essential to improve health literacy, engagement, and treatment adherence, yet many exceed the recommended readability levels. Therefore, individuals with limited health literacy are at a disadvantage. This study evaluated the readability of spine-related PEMs from the American Academy of Orthopaedic Surgeons (AAOS), the North American Spine Society (NASS), and the American Association of Neurological Surgeons (AANS), and examined the potential of artificial intelligence (AI) in optimizing PEMs for improved patient comprehension.

METHODS: A total of 146 spine-related PEMs from the AAOS, NASS, and AANS websites were analyzed. Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG) Index scores, as well as other metrics, including language complexity and use of the passive voice. ChatGPT-4o was used to revise the PEMs to a sixth-grade reading level, and post-revision readability was assessed. Test-retest reliability was evaluated, and paired t tests were used to compare the readability scores of the original and AI-modified PEMs.

RESULTS: The original PEMs had a mean FKGL of 10.2 ± 2.6, which significantly exceeded both the recommended sixth-grade reading level and the average U.S. eighth-grade reading level (p < 0.05). ChatGPT-4o generated articles with a significantly reduced mean FKGL of 6.6 ± 1.3 (p < 0.05). ChatGPT-4o also improved other readability metrics, including the SMOG Index score, language complexity, and use of the passive voice, while maintaining accuracy and adequate detail. Excellent test-retest reliability was observed across all of the metrics (intraclass correlation coefficient [ICC] range, 0.91 to 0.98).

CONCLUSIONS: Spine-related PEMs from the AAOS, the NASS, and the AANS remain excessively complex, despite minor improvements to readability over the years. ChatGPT-4o demonstrated the potential to enhance PEM readability while maintaining content quality. Future efforts should integrate AI tools with visual aids and user-friendly platforms to create inclusive and comprehensible PEMs to address diverse patient needs and improve health-care delivery.

PMID:40536932 | DOI:10.2106/JBJS.24.01484

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01483. Online ahead of print.

ABSTRACT

BACKGROUND: Computer navigation and patient-specific instrumentation in unicompartmental knee replacement (UKR) improve the precision of implant positioning, but there is limited information regarding their impact on implant survival and patient-reported outcomes. We aimed to compare postoperative implant survival, Oxford Knee Score (OKS) values, health-related quality of life (measured using the EuroQol-5 Dimension 3-level version [EQ-5D-3L]), and intraoperative complications between UKRs performed using computer navigation or patient-specific instrumentation versus conventional instrumentation.

METHODS: Using National Joint Registry data, an observational study of patients who underwent primary UKR for osteoarthritis between 2003 and 2020 was performed. The primary analyses focused on all-cause revision, and the secondary analyses focused on differences in the OKS and EQ-5D-3L at 6 to 12 months postoperatively. To account for several covariates, weights based on propensity scores were generated. Cox proportional hazards models and generalized linear models were used to assess for differences in revision risk, and OKS and EQ-5D-3L change scores, respectively, between patient groups. Sensitivity analyses accounting for body mass index were performed. Effective sample sizes (ESSs) were computed, representing the statistical power comparable with that of an unweighted sample.

RESULTS: Compared with conventional instrumentation, the hazard ratio (HR) for all-cause revision was 1.126 (95% confidence interval [CI], 0.909 to 1.395; p = 0.277; ESS, 4,273) with computer navigation and 0.805 (95% CI, 0.442 to 1.467; p = 0.478; ESS, 1,199) with patient-specific instrumentation. No difference was found in the change in OKS between the groups (-1.287; 95% CI, -2.851 to 0.278; p = 0.107; ESS, 470), although improvement in the EQ-5D-3L scores was relatively lower for computer-navigated UKR compared with conventional instrumentation (-0.049, 95% CI, -0.093 to -0.005; p = 0.028; ESS, 455). However, sensitivity analyses demonstrated that computer navigation was associated with an increased risk of all-cause revision (HR, 1.446; 95% CI, 1.102 to 1.898; p = 0.008; ESS, 3,011) and relatively smaller improvements in the OKS (-2.845; 95% CI, -5.006 to -0.684; p = 0.010; ESS, 272) and EQ-5D-3L scores (-0.087; 95% CI, -0.145 to -0.030; p = 0.003; ESS, 286). There were no differences in intraoperative complications (p = 0.073).

CONCLUSIONS: This study found no clinically meaningful differences in patient-reported outcomes following computer-navigated UKR. Although likely underpowered, the primary analyses showed no difference in implant survival. While a sensitivity analysis suggested that computer navigation could worsen implant survival, this analysis had a smaller sample size. These findings highlight potential signals that warrant further investigation.

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

PMID:40536918 | DOI:10.2106/JBJS.24.01483

J Bone Joint Surg Am. 2025 Jun 18. doi: 10.2106/JBJS.24.01601. Online ahead of print.

ABSTRACT

BACKGROUND: Accurate and timely differential diagnosis of hip prosthesis failures remains a major clinical challenge. Radiographic examination remains the most cost-effective and common first-line imaging modality for hip prostheses, and integrating deep learning has the potential to improve its diagnostic accuracy and efficiency.

METHODS: A deep learning-based clinical classification system (Hip-Net) was developed to classify multiple causes of total hip arthroplasty failure, including periprosthetic joint infection (PJI), aseptic loosening, dislocation, periprosthetic fracture, and polyethylene wear. Hip-Net employed a dual-channel ensemble of 4 deep learning models trained on 2,908 routine dual-view (anteroposterior and lateral) radiographs for 1,454 patients (Asian) across 3 medical centers. An interpretive subnetwork generated spatially resolved disease probability maps. Discrimination performance and interpretability were tested in external and prospective cohorts, respectively. The correlation between model-generated individual PJI risk and inflammatory biomarkers was assessed.

RESULTS: Hip-Net demonstrated strong generalizability across different settings, effectively distinguishing between 5 common types of hip prosthesis failures with an accuracy of 0.904 (95% confidence interval [CI], 0.894 to 0.914) and an area under the receiver operating characteristic curve (AUC) of 0.937 (95% CI, 0.925 to 0.948) in the external cohort. The spatially resolved disease-probability maps for PJI closely aligned with intraoperative and pathological findings. The model-generated individual PJI risk scores exhibited a positive correlation with the C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR).

CONCLUSIONS: Hip-Net provided a clinically applicable strategy for accurately classifying and characterizing multiple etiologies of hip prosthesis failure. Such an approach is highly beneficial for providing interpretable, pathology-aligned probability maps that enhance the understanding of PJI. Its integration into clinical workflows may streamline decision-making and improve patient outcomes.

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

PMID:40531980 | DOI:10.2106/JBJS.24.01601

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):51-59. doi: 10.2106/JBJS.24.01223.

ABSTRACT

BACKGROUND: Initial surgical management of Gustilo-Anderson type-I to IIIA open fractures varies from surgical fixation of the fracture with immediate closure of the traumatic wound to various combinations of staged fracture and wound management. The decision to choose staged management has historically been based on wound contamination and the severity of the open fracture. The purpose of this study was to compare the rates of surgical site infection (SSI), wound complication, nonunion, and 1-year reoperation between patients with type-I to IIIA open fractures who underwent fix-and-close treatment and those who underwent planned, staged treatment.

METHODS: This is a secondary analysis of participants who were enrolled in the Aqueous-PREP and PREPARE-Open studies, excluding those with type-IIIB and IIIC open fractures. Participants were divided into fix-and-close or planned, staged groups and were matched using propensity scores that were computed with multiple variables, including patient and injury characteristics. Associations between treatment type and outcomes were analyzed.

RESULTS: A total of 3,170 participants (staged, 872: 70% White, 20% Black, and 10% other or unknown race; fix-and-close, 2,298: 62% White, 21% Black, and 17% other) with Gustilo-Anderson type-I to IIIA open fractures were identified. Eight hundred and thirty-six participants who underwent planned, staged treatment were propensity score-matched to 836 participants who underwent fix-and-close treatment. Staged treatment was significantly associated with increased odds of deep SSI within 90 days (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.15 to 3.47]; p = 0.01) and reoperation specifically for infection within 1 year (OR, 1.47 [95% CI, 1.06 to 2.04]; p = 0.02) but was not associated with increased odds of wound dehiscence (OR, 0.85 [95% CI, 0.49 to 1.49]; p = 0.57), wound necrosis or failure of the wound to heal (OR, 1.37 [95% CI, 0.83 to 2.25]; p = 0.21), reoperation requiring any free or local flap coverage (OR, 0.96 [95% CI, 0.55 to 1.68]; p = 0.89), or reoperation for delayed union or nonunion (OR, 1.30 [95% CI, 0.92 to 1.83]; p = 0.14).

CONCLUSIONS: Fix-and-close treatment of open fractures of type IIIA and lower was associated with decreased odds of deep SSI within 90 days and reoperation for infection within 1 year without an increased risk of wound complications or nonunion and may be considered even in fractures with embedded contamination provided that adequate debridement is performed.

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

PMID:40531233 | DOI:10.2106/JBJS.24.01223

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):60-70. doi: 10.2106/JBJS.24.01184.

ABSTRACT

BACKGROUND: Food deserts-communities with limited access to healthy food-have been linked with poor surgical outcomes; however, their impact on orthopaedic trauma outcomes remains unknown. The aims of this study were to determine the prevalence of food desert residency among orthopaedic trauma patients and to investigate the impact of food desert residency on the rate of unplanned reoperation with use of a large, high-quality, prospectively collected dataset with adjudicated outcomes. We hypothesized that orthopaedic trauma patients would reside in food deserts at a higher rate than the general U.S. population and that living in a food desert would be independently associated with an increased rate of unplanned reoperation.

METHODS: We included all patients from the Aqueous-PREP and PREPARE trials who had documented ZIP codes. The primary outcome was unplanned reoperation within 1 year, and the secondary outcomes included the reasons for reoperation. Residing in a food desert was the independent variable and was defined by the United States Department of Agriculture (USDA). Census tracts were converted to ZIP codes in order to assign food access for an individual's residence with use of the USDA Food Access Research Atlas.

RESULTS: Of the 2,607 patients included, 1,453 (55.7%) lived in a ZIP code containing a food desert compared with 49% of the U.S. population. Patients residing in a food desert were 42% female, 26.6% non-White, and 64% employed prior to injury, whereas patients not residing in a food desert were 41% female, 15% non-White, and 63% employed prior to injury, all of which was collected via patient self-report. Multivariable analysis demonstrated that living in a food desert was independently associated with 40% higher odds of unplanned reoperation (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.06 to 1.85; p = 0.019). This was driven by reoperation for delayed union or nonunion (OR, 1.75; 95% CI, 1.19 to 2.57; p = 0.004) and reoperation for a wound-healing complication (OR, 1.60; 95% CI, 1.01 to 2.54; p = 0.044).

CONCLUSIONS: This study found a strong association between residing in a ZIP code containing a food desert and an increased rate of unplanned reoperation, which was primarily driven by delayed union or nonunion and wound-healing complications. Addressing nutritional deficiencies in this population may help to effectively triage the use of health-care resources. Further research should focus on clarifying specific deficiencies and assessing the effectiveness of targeted interventions.

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

PMID:40531219 | DOI:10.2106/JBJS.24.01184

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):43-50. doi: 10.2106/JBJS.24.01250.

ABSTRACT

BACKGROUND: External fixation is often used in the management of open lower-extremity fractures. The objectives of this study were to identify hospital characteristics that are associated with greater use of temporary external fixation and to determine if external fixation reduces the odds of surgical site infection (SSI) and unplanned reoperation among patients with open lower-extremity fractures.

METHODS: This is a secondary analysis of the Aqueous-PREP and PREPARE-Open trials involving open lower-extremity fractures. Wilcoxon rank-sum and Fisher exact tests were used to assess if temporary external fixation use varied between hospital clusters. Mixed-effects logistic regression models controlling for hospital cluster and participant characteristics estimated the associations between temporary external fixation and SSI or unplanned reoperation.

RESULTS: There were 2,438 patients with an open lower-extremity fracture identified, with 568 (23.3%) undergoing temporary external fixation. There were 34 participating hospitals with a median external fixation rate of 21.5%. Hospitals with higher temporary external fixation use had a higher number of surgeons treating patients with fracture (p = 0.02). There was no difference in SSI at 90 days (odds ratio [OR], 1.16 [95% confidence interval (CI), 0.82 to 1.66]; p = 0.40) or 1 year (OR, 1.30 [95% CI, 0.97 to 1.75]; p = 0.08) between patients who did and did not undergo temporary external fixation. Patients who underwent temporary external fixation were more likely to have unplanned reoperations within 1 year (OR, 1.40 [95% CI, 0.96 to 1.79]; p = 0.05).

CONCLUSIONS: More temporary external fixation for open lower-extremity fractures was performed at hospitals with more surgeons treating fractures. There was no difference in SSI at 90 days or 1 year between patients who did and did not undergo temporary external fixation. Temporary external fixation tended to be used in more critically ill patients and patients with more severe fractures but was not associated with increased unplanned reoperations at 90 days or at 1 year.

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

PMID:40531191 | DOI:10.2106/JBJS.24.01250

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):71-79. doi: 10.2106/JBJS.24.01249.

ABSTRACT

BACKGROUND: The purpose of this study was to describe the culture and speciation results of patients with surgical site infection (SSI) from the PREPARE and Aqueous-PREP studies from the PREP-IT Investigators.

METHODS: Patients with suspected SSI underwent collection of deep or organ tissue samples for culture. The culture positivity rate was estimated as a percentage along with the exact binomial 95% confidence interval (CI). Microbial species were reported as percentages. Comparisons between open and closed fractures were conducted with the Z-test for proportions. Significance was set at p < 0.05.

RESULTS: Among the 2 primary studies, a total of 484 cases (defined as an anatomic fracture area; some patients had multiple fractures, which were each defined as a case if they developed an infection) had culture samples taken from deep or organ tissue. The culture positivity rate was 96.7% (95% CI, 94.7% to 98.0% [468 of 484 cases]). There were no significant differences (p = 0.507) in culture positivity between open fractures (97.2% [95% CI, 94.5% to 98.6%]; 273 of 281 cases) and closed fractures (96.1% [95% CI, 92.4% to 98.0%]; 195 of 203 cases). There was information on microbial species in 84.4% (395) of 468 cases. For patients with positive cultures, 43.3% (171 of 395 cases) were polymicrobial infections. Open fractures (47.8% [111 of 232 cases]), compared with closed fractures (36.8% [60 of 163 cases]), were more likely to be polymicrobial (p = 0.029). Staphylococcus aureus microbes (methicillin-sensitive S. aureus, methicillin-resistant S. aureus, and coagulase-negative S. aureus) accounted for 43.3% (462 of 1,066) of all positive cultures. The median time to infection was 58.5 days (95% CI, 49.0 to 67.0 days). The median time to infection was not significantly different in cases of open fractures (61.0 days [95% CI, 51.0 to 71.0 days]) compared with closed fractures (54.0 days [95% CI, 43.0 to 67.0 days]) (hazard ratio [HR], 0.92 [95% CI, 0.72 to 1.12]). SSIs associated with gram-negative bacteria had a shorter median time to infection at 46.0 days (95% CI, 36.0 to 58.0 days) compared with SSIs not associated with gram-negative bacteria at 70.0 days (95% CI, 56.0 to 88.0 days) (HR, 1.79 [95% CI, 1.55 to 2.03]). There was also a shorter median time to infection for patients with polymicrobial infections (47.0 days [95% CI, 38.8 to 52.1 days]) compared with patients with monomicrobial infections (78.6 days [95% CI, 57.2 to 86.8 days]) (HR, 1.26 [95% CI, 1.03 to 1.49]).

CONCLUSIONS: In patients with SSI, tissue samples yielded high rates of microbial culture results. There was a higher proportion of gram-negative organisms in open fractures. Gram-negative infections were also associated with earlier time to infection. Clinicians should not hesitate to take deep-tissue culture samples in patients with suspected SSI and should be prepared to encounter polymicrobial infections.

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

PMID:40531188 | DOI:10.2106/JBJS.24.01249

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):36-42. doi: 10.2106/JBJS.24.01224.

ABSTRACT

BACKGROUND: A preoperative chlorhexidine gluconate (CHG) bath is used to reduce the risk of surgical site infection (SSI) in elective surgery, but its efficacy in the trauma setting is unknown. We compared the incidence of SSI between patients who did versus did not receive a CHG bath before operative fixation of extremity and/or pelvic fractures.

METHODS: We conducted a secondary analysis of the PREP-IT cluster-randomized crossover trials that enrolled patients undergoing operative treatment for open or closed extremity or pelvic fractures. Preoperative CHG bathing (yes or no) was recorded for each patient per study protocol. The association between CHG bathing and SSI within 90 days after definitive fracture surgery was assessed. We performed multivariable regression to adjust for prognostic variables. We also conducted a separate instrumental variable analysis to compare SSI rates between study sites that used CHG bathing for >90% of participants and those that used CHG bathing for <1% of participants.

RESULTS: Of the 10,103 participants (mean age, 51 ± 20 years; 47% female; 77% White; 17% Black; 4% Asian; 7% Hispanic) included in the analysis, 2,674 (26%) had a documented preoperative CHG bath and 7,429 (74%) did not. CHG bathing was not associated with a significant reduction in the odds of 90-day SSI in the multivariable (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.86 to 1.32; p = 0.56) or instrumental variable (OR, 0.88; 95% CI, 0.62 to 1.25; p = 0.48) analyses.

CONCLUSIONS: Among adult patients who underwent extremity or pelvic fracture surgery, preoperative CHG bathing was not associated with a significant reduction in SSI.

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

PMID:40531185 | DOI:10.2106/JBJS.24.01224

J Bone Joint Surg Am. 2025 Jun 18;107(12):1403-1404. doi: 10.2106/JBJS.25.00202.

NO ABSTRACT

PMID:40531184 | DOI:10.2106/JBJS.25.00202

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):28-35. doi: 10.2106/JBJS.24.01178.

ABSTRACT

BACKGROUND: We evaluated antimicrobial resistance (AMR) patterns following local antibiotic use in a large cohort of patients with fractures from the PREP-IT (A Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma) study. We hypothesized that, among patients with extremity fractures who developed fracture-related infection (FRI), there would be no difference in AMR rates between those who had or had not received local antibiotic therapy with surgical fixation.

METHODS: This was a secondary analysis of all patients in the PREP-IT trial who developed FRI. Patient demographics, injury and fracture characteristics, and the primary outcome of the presence of an antimicrobial-resistant FRI were evaluated on the basis of whether the patient had or had not received local antibiotics in the operating room prior to, or at, definitive fixation.

RESULTS: A total of 555 FRIs in 546 patients (mean age, 50 years; 39% female; and 82% White) were included. A total of 268 fractures (264 patients) received local antibiotics. The Injury Severity Score and the proportion of open fractures were higher among patients and fractures that received local antibiotics, respectively. There were more Gustilo-Anderson type-IIIB or IIIC fractures in the local antibiotic group, but the rate did not differ significantly from that in the group with no local antibiotics (20% versus 14%; p = 0.14). Other baseline and fracture characteristics were similar between the groups, with the exception of age (lower in the group with local antibiotics). When examining FRIs with gram-positive organisms, we found that 3 (1.7%) of the FRIs in fractures that had been treated with local vancomycin had organisms resistant to vancomycin compared with 2 (0.9%) of the FRIs in fractures for which local vancomycin had not been used (p = 0.67). When examining FRIs with gram-negative organisms, the number of FRIs with aminoglycoside-resistant organisms was 8 (11.6%) among fractures that received local aminoglycosides and 10 (6.2%) among fractures that did not receive local aminoglycosides (p = 0.26).

CONCLUSIONS: Among extremity fractures that developed FRI, we were unable to detect differences in the rates of AMR between fractures treated with or without local antibiotic prophylactic strategies in our analysis of a randomized trial of various skin preparation solutions for extremity trauma surgery. These findings provide cautious reassurance regarding the safety of local antibiotics but underscore the need for further prospective analysis.

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

PMID:40531179 | DOI:10.2106/JBJS.24.01178