JBJS

Outcomes Associated with Choice of Prophylactic Antibiotics in Open Fractures

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):19-27. doi: 10.2106/JBJS.24.01123.

ABSTRACT

BACKGROUND: The ideal antibiotic prophylaxis for open fractures is unknown. We evaluated outcomes following different antibiotic prophylaxis regimens for open fractures.

METHODS: This is a secondary analysis of data from PREP-IT. Prophylactic antibiotics were defined as any intravenous antibiotic given on the day of admission. The outcomes were surgical site infection (SSI) within 90 days and reoperation within 1 year. Logistic regression and an instrumental variable analysis that leveraged site-level variation accounted for confounding. Subgroup variation was evaluated by stratifying by Gustilo-Anderson classification (Types I and II versus III).

RESULTS: Of the 3,331 included participants, the mean age was 45 ± 18 years, 63% were male, 73% were White, 21% were Black, 2% were Asian, and 10% were Hispanic. Cefazolin monotherapy (58% of patients), ceftriaxone monotherapy (10%), and cefazolin plus gentamicin (6%) were the most common regimens. In the instrumental variable analysis, the odds of infection did not significantly differ with ceftriaxone use (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.70 to 2.20; p = 0.45) or cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.04; p = 0.20) compared with cefazolin monotherapy. There were no significant differences between the regimens with respect to infection when stratified by Gustilo-Anderson type. However, we did observe a nearly 3-fold increase in the odds of infection with ceftriaxone use compared with cefazolin monotherapy (OR, 2.73; 95% CI, 0.96 to 7.79; p = 0.06) in Type-I and II fractures, and a 75% decrease in the odds of infection with cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.02; p = 0.19) compared with cefazolin monotherapy in Type-III fractures.

CONCLUSIONS: Among patients with open fractures, antibiotic prophylaxis with ceftriaxone monotherapy did not provide significant benefits compared with cefazolin monotherapy in preventing infection in Type-I and II fractures. The findings suggest that cefazolin plus gentamicin might reduce the odds of infection in Type-III fractures compared with cefazolin monotherapy, but this difference was not statistically significant.

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

PMID:40531169 | DOI:10.2106/JBJS.24.01123

Performance of the OTA-OFC3 Classification System for Open Fractures

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):12-18. doi: 10.2106/JBJS.24.01182.

ABSTRACT

BACKGROUND: The purpose of this study was to compare the simplified modification of the Orthopaedic Trauma Association-Open Fracture Classification (OTA-OFC3) with the original OTA-OFC and Gustilo-Anderson classification systems in predicting surgical site infection and unplanned reoperation.

METHODS: This was a retrospective cohort study conducted using the PREP-IT (A Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma) trial data of patients with open fractures. The OTA-OFC and Gustilo-Anderson classifications for each included fracture were determined by the treating surgeon at the initial irrigation and debridement. The OTA-OFC3 classification was determined on the basis of the highest severity level in any OTA-OFC domain. The study outcomes included surgical site infection and unplanned reoperations within 1 year of injury. Prognostic performance was measured by the area under the receiver operating characteristic curve (AUC), and AUCs were compared between classifications with z-tests.

RESULTS: This cohort study included 3,338 patients with 3,627 open fractures. Surgical site infections occurred for 11% of the open fractures, and unplanned reoperations occurred for 15%. The prognostic performance of the new OTA-OFC3 score (AUC, 0.61; 95% confidence interval [CI], 0.58 to 0.64) did not differ significantly from that of the Gustilo-Anderson classification (AUC, 0.63; p = 0.40) or the 5 OTA-OFC domains (AUC, 0.64; p = 0.32) in predicting surgical site infection. The prognostic performance of the OTA-OFC3 system (AUC, 0.62; 95% CI, 0.59 to 0.64) was similar to that of the Gustilo-Anderson classification (AUC, 0.63; p = 0.34) but was significantly worse than that of the 5 OTA-OFC domains (AUC, 0.69; p < 0.001) in predicting unplanned reoperations.

CONCLUSIONS: Simplifying the OTA-OFC to the new OTA-OFC3 significantly decreased its ability to predict unplanned reoperations and did not improve the ability to predict surgical site infection. These findings indicate that this newly proposed classification system, although clinically simpler, omits important prognostic information captured in the original OTA-OFC. Despite this limitation, the OTA-OFC3 demonstrated prognostic performance similar to that of the commonly used Gustilo-Anderson classification, and it may provide a clinically convenient way to communicate critical OTA-OFC information when all OTA-OFC domains are being assessed for research or quality-improvement purposes.

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

PMID:40531166 | DOI:10.2106/JBJS.24.01182

Intraneural Ganglion Cysts Arising from the Hip Joint as Rare Causes of Sciatic Neuropathy: A Case Series of 13 Patients Treated with Hip Arthroscopy

J Bone Joint Surg Am. 2025 Jun 9. doi: 10.2106/JBJS.24.00737. Online ahead of print.

ABSTRACT

BACKGROUND: Sciatic neuropathy can result from pressure, injury, or inflammation around the sciatic nerve. In rare instances, sciatic neuropathy is caused by an intraneural ganglion cyst (IGC) originating from the hip joint. However, an effective treatment modality for this condition has not yet been established. The purpose of the present study was to evaluate the clinical and radiographic outcomes of hip arthroscopy for the treatment of IGCs involving the sciatic nerve.

METHODS: We reviewed the records on a consecutive series of hip arthroscopy procedures that had been performed by a single surgeon for the treatment of sciatic IGCs between July 2016 and February 2022. Thirteen Asian patients (13 hips) with symptomatic sciatic neuropathy were included. During arthroscopic surgery, IGCs were decompressed by enlarging their periarticular connection. Magnetic resonance imaging (MRI) and electrodiagnostic evaluation were routinely performed. The visual analog scale (VAS) for pain and modified Harris hip score (mHHS) were used for clinical evaluations. The mean age at the time of surgery was 57 years (range, 23 to 72 years), and the mean duration of follow-up was 41 months (range, 24 to 87 months).

RESULTS: The mean VAS score decreased from 8.3 preoperatively to 1.9 at the latest evaluation (p < 0.001). Satisfactory pain relief was reported by 12 patients (92%), including 9 patients (69%) who had complete remission. Four of the 6 patients with sensory impairment and 3 of the 4 patients with motor weakness reported complete recovery. The mean mHHS improved from 51.5 to 94.1 (p < 0.001). In MRI comparisons, the mean largest diameter and length of IGCs decreased from 2.6 to 0.5 cm (p < 0.001) and from 6.8 to 0.6 cm (p < 0.001), respectively. IGCs completely disappeared on MRI in 9 patients (69%). The latest electrodiagnostic studies confirmed improvement in all 12 patients with preoperative abnormalities. One patient (8%) with symptomatic recurrence was successfully treated with revision arthroscopic decompression.

CONCLUSIONS: In patients with sciatic neuropathy, the possibility of IGCs arising from the hip should be considered. Our findings suggest that arthroscopic hip surgery is a less-invasive and more-effective treatment for relieving neuropathic pain and neurological deficits associated with sciatic IGCs.

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

PMID:40489564 | DOI:10.2106/JBJS.24.00737

PGE2 Ameliorates Aging-Aggravated Rotator Cuff Muscle Atrophy

J Bone Joint Surg Am. 2025 Jun 6. doi: 10.2106/JBJS.24.00866. Online ahead of print.

ABSTRACT

BACKGROUND: The aging-related escalation of muscle degeneration impacts the structure and function of rotator cuff muscles, contributing to spontaneous and tear-induced muscle atrophy. This study investigated how prostaglandin E2 (PGE2), a regulator of muscle regeneration, influences muscular structure and mitochondrial function in aged mice by using SW033291 to inhibit PGE2 degradation, revealing potential therapeutic pathways for mitigating rotator cuff muscle deterioration.

METHODS: A total of 20 young (5 to 6-month-old) and 100 aged (18 to 20-month-old) female C57BL/6J mice were divided into 2 groups: the first group included young, aged, and aged+SW033291 subgroups and was used to study sarcopenia, and the second group consisted of tear, tear+repair, and tear+repair+SW033291 subgroups and was used to examine the outcomes following a rotator cuff tear (RCT). Tissue staining, muscle mass assessments, functional assays, and mitochondrial function tests were performed.

RESULTS: Rotator cuff muscle degeneration was observed in the setting of natural aging and in the setting of an RCT. These conditions together worsened muscle atrophy and fatty infiltration into the muscle, with the aged tear group demonstrating a decrease in muscle mass from a mean and standard deviation of 45.45 ± 4.04 to 25.18 ± 1.82 mg (p < 0.001) and a reduction in fiber cross-sectional area (CSA) from 1,697.3 ± 108.4 to 1,263.0 ± 56.8 μm2 (p < 0.001). This was linked to increased 15-prostaglandin dehydrogenase (15-PGDH) activity and a reduction in PGE2 levels in the aged tear group (from 2.897 ± 0.177 to 1.873 ± 0.179 ng/g muscle; p < 0.001). SW033291 treatment increased the level of PGE2, reversing muscle atrophy by mitigating mitochondrial dysfunction in both models, as demonstrated by a muscle mass of 33.50 ± 3.05 mg and a CSA of 1,423.6 ± 81.3 μm2 in the presence of both conditions.

CONCLUSIONS: These findings support the hypothesis that elevated PGE2 levels can improve muscle health by reversing mitochondrial dysfunction, offering a strategy to combat sarcopenia and to enhance rotator cuff repair.

CLINICAL RELEVANCE: Large or massive RCTs are associated with muscle atrophy, a higher retear rate, and suboptimal surgical outcomes, especially in elderly patients. This study showed that the occurrence of rotator cuff muscle degeneration and muscular mitochondrial dysfunction in both the natural aging and RCT mouse models was mitigated by enhanced PGE2 levels. This finding demonstrates the efficacy of the application of a 15-PGDH inhibitor and suggests a possible new therapeutic approach.

PMID:40479501 | DOI:10.2106/JBJS.24.00866

Immobilization Time for Conservative Treatment of Distal Radial Fractures in Elderly Patients: A Randomized Controlled Trial

J Bone Joint Surg Am. 2025 Jun 5. doi: 10.2106/JBJS.24.01480. Online ahead of print.

ABSTRACT

BACKGROUND: The management of distal radial fractures (DRFs) in elderly patients remains controversial. Although conservative treatment with cast immobilization is widely accepted, the optimal duration for immobilization is unclear. This study aimed to compare pain control, functional outcomes, and complication rates between 4-week and 6-week immobilization periods in elderly patients treated nonoperatively for displaced DRFs.

METHODS: A single-center randomized controlled trial was conducted, including 150 patients who were ≥65 years of age and had displaced DRFs. Patients were randomized into 2 groups: 4-week immobilization and 6-week immobilization. Pain was assessed using a visual analog scale (VAS) at 10 days after removing the cast and then at 3, 6, and 12 months after injury. Functional outcomes were measured using the Patient-Rated Wrist Evaluation (PRWE) and QuickDASH (the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) at 3, 6, and 12 months. Radiographs were reviewed for malunion, and complications and range of motion were also evaluated.

RESULTS: In the 135 patients analyzed, no differences were observed in pain or functional outcomes between the 2 groups at any time point. VAS scores 10 days after the cast removal were similar (3.87 for the 4-week immobilization group and 4.00 for the 6-week group; p = 0.67), as were PRWE scores (14.18 for the 4-week group and 15.51 for the 6-week group; p = 0.686) and QuickDASH scores (15.46 for the 4-week group and 17.86 for the 6-week group; p = 0.449) after 1 year. The malunion rates were 29.9% in the 4-week group and 32.8% in the 6-week group (p = 0.85), and there were no significant differences in complications or range of motion between groups.

CONCLUSIONS: A 4-week immobilization period provided equivalent pain control, functional outcomes, and complication rates as a 6-week immobilization period in elderly patients with displaced DRFs treated nonoperatively. Therefore, a shorter immobilization period may be safely recommended for treating these fractures.

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

PMID:40472139 | DOI:10.2106/JBJS.24.01480

The Future Is Mobile: Pilot Validation Study of Apple Health Metrics in Orthopaedic Trauma

J Bone Joint Surg Am. 2025 Jun 4. doi: 10.2106/JBJS.24.00842. Online ahead of print.

ABSTRACT

BACKGROUND: Surgeons often lack objective data on patient functional outcomes, particularly as compared with the patient's baseline. The present study aimed to determine whether gait parameters recorded on Apple iPhones provided longitudinal mobility data following lower-extremity fracture surgery that matched clinical expectations. We hypothesized that iPhones would detect the mobility changes of injury and early recovery, correlate with patient-reported outcome measures, and differentiate nonunion.

METHODS: This cross-sectional study included 107 adult patients with lower-extremity fractures who owned iPhones and had at least 6 months of follow-up. Participants shared Apple Health data and completed Patient Reported Outcomes Measurement Information System (PROMIS) surveys. The primary outcome was the daily step count. Four other gait-related parameters were analyzed: walking asymmetry, double support, walking speed, and step length. Mixed-effects models compared mobility parameters at pre-injury, immediate post-injury, and 6-months post-injury time points. Correlations between mobility parameters and PROMIS surveys were assessed. A mixed-effect model evaluated the relationship between step count recovery and surgery for nonunion.

RESULTS: There was a 93% reduction in daily step count from the pre-injury period to the immediate post-injury period (95% confidence interval [CI], -94% to -93%). Other gait parameters also showed increased impairment from pre-injury to post-injury. At 6 months, step count improved sixfold relative to the immediate post-injury period but remained 52% below baseline (95% CI, -55% to -49%). PROMIS Physical Function correlated moderately with step count (r = 0.42; 95% CI, 0.25 to 0.57) and weakly with other gait parameters. Patients with a known nonunion had a 55% slower recovery of step count than those without a nonunion (95% CI: 44% to 66%).

CONCLUSIONS: Apple Health mobility parameters captured changes in mobility following lower-extremity fracture and throughout the subsequent recovery period. These metrics distinguished between patients with and without nonunions, demonstrating their potential usefulness as objective, real-world functional outcome measures. These "digital biomarkers" may aid clinical decision-making and research and could be utilized for the early identification of patients at risk for poor outcomes.

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

PMID:40465739 | DOI:10.2106/JBJS.24.00842

Long-Term Mortality Associated with Periprosthetic Infection in Total Hip Arthroplasty: A Registry Study of 4,651 Revisions for Infection

J Bone Joint Surg Am. 2025 Jun 3. doi: 10.2106/JBJS.24.01629. Online ahead of print.

ABSTRACT

BACKGROUND: While the morbidity associated with revision total hip arthroplasty (THA) or periprosthetic infection (PJI) has been well characterized, less is known about the risk of mortality. With this study, we aimed to determine the long-term mortality associated with revision THA for PJI and associated risk factors.

METHODS: Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were used to study mortality associated with THA procedures for osteoarthritis and subsequent revisions from September 1999 through December 2022. Kaplan-Meier estimates of survivorship and standardized mortality ratios (SMRs) based on Australian period life tables were used to summarize the overall survival following the primary and first revision THA. Risk factors associated with mortality were identified using Cox proportional hazards models, adjusted for age and gender.

RESULTS: There were 548,061 primary THA procedures for osteoarthritis; 4,651 first revision procedures for infection and 15,891 first revisions for reasons other than infection and fracture were recorded. At 5, 10, and 15 years, the cumulative mortality rate for revision for PJI was 14.5%, 34.7%, and 57.5%, respectively. Patients who underwent revision for PJI had higher mortality rates than expected compared with the general population, and the corresponding SMR (1.31; 95% confidence interval [CI]: 1.24 to 1.39) was greater than that for patients undergoing primary THA (0.81; 95% CI: 0.81 to 0.82) or aseptic revision (0.95; 95% CI: 0.92 to 0.99). A higher SMR following revision for PJI was observed in patients <65 years of age and in female patients, and continued to increase beyond 15 years. There were no differences in mortality rates according to whether a major or minor revision was performed to manage PJI.

CONCLUSIONS: Patients revised for infection had increased mortality rates compared with the general population and those undergoing primary THA or aseptic revision. This excess risk persisted beyond 15 years, especially in younger patients.

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

PMID:40460198 | DOI:10.2106/JBJS.24.01629

Myocardial Infarction Prior to TKA Is Associated with Increased Risk of Medical and Surgical Complications in a Time-Dependent Manner

J Bone Joint Surg Am. 2025 Jun 2. doi: 10.2106/JBJS.24.01210. Online ahead of print.

ABSTRACT

BACKGROUND: There has been minimal literature evaluating how a prior myocardial infraction (MI) influences outcomes after total knee arthroplasty (TKA). Thus, the purpose of this study was to evaluate how the timing, type, and treatment of MI prior to TKA affect postoperative cardiac complications, general medical complications, and surgical complications.

METHODS: A retrospective comparative study was conducted using a large insurance database. Patients undergoing primary TKA for osteoarthritis were included. Patients who had experienced MI within 2 years before TKA were identified and were matched 1:4 with patients who had not had such an MI on the basis of demographic variables and comorbidities. Patients who had a prior MI were stratified into 4 groups based on the timing of the MI: 0 to <6 months, 6 to <12 months, 12 to <18 months, and 18 to 24 months before TKA. The rates of postoperative cardiac, general medical, and surgical complications were compared between groups. Subanalyses on the prior MI type, treatment, and location were performed.

RESULTS: Prior MI was associated with increased risks of postoperative MI (odds ratio [OR], 3.97 [95% confidence interval (CI), 3.20 to 4.93]), heart failure (OR, 1.45 [95% CI, 1.24 to 1.75]), and 90-day mortality (OR, 2.15 [95% CI, 1.41 to 3.28]). The risk of postoperative MI was highest for those with MI within 6 months before TKA (OR, 6.86 [95% CI, 5.34 to 8.82]). Type-1 MI, ST-elevation MI (STEMI), non-ST-elevation MI (NSTEMI), and anterior and inferior MIs were linked to elevated postoperative MI and/or mortality risks, with timing closer to surgery further amplifying the risk. Percutaneous coronary intervention within 6 months before TKA also increased postoperative risks. Type-2 MI within 6 months before TKA was associated with an increased risk of periprosthetic joint infection compared with controls (OR, 4.23 [95% CI, 1.67 to 10.67]).

CONCLUSIONS: Patients who had a prior MI, particularly within 6 months before TKA, had significantly elevated risks of postoperative MI, heart failure, and mortality. Outcomes varied by MI type, treatment, and location, with type-1 MIs and STEMIs increasing the postoperative mortality risk.

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

PMID:40455939 | DOI:10.2106/JBJS.24.01210

Evaluating Artificial Intelligence-Based Writing Assistance Among Published Orthopaedic Studies: Detection and Trends for Future Interpretation

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.01462. Online ahead of print.

ABSTRACT

BACKGROUND: The integration of artificial intelligence (AI), particularly large language models (LLMs), into scientific writing has led to questions about its ethics, prevalence, and impact in orthopaedic literature. While tools have been developed to detect AI-generated content, the interpretation of AI detection percentages and their clinical relevance remain unclear. The aim of this study was to quantify AI involvement in published orthopaedic manuscripts and to establish a statistical threshold for interpreting AI detection percentages.

METHODS: To establish a baseline, 300 manuscripts published in the year 2000 were analyzed for AI-generated content with use of ZeroGPT. This was followed by an analysis of 3,374 consecutive orthopaedic manuscripts published after the release of ChatGPT. A 95% confidence interval was calculated in order to set a threshold for significant AI involvement. Manuscripts with AI detection percentages above this threshold (32.875%) were considered to have significant AI involvement in their content generation.

RESULTS: Empirical analysis of the 300 pre-AI-era manuscripts revealed a mean AI detection percentage (and standard deviation [SD]) of 10.84% ± 11.02%. Among the 3,374 post-AI-era manuscripts analyzed, 16.7% exceeded the AI detection threshold of 32.875% (2 SDs above the baseline for the pre-AI era), indicating significant AI involvement. No significant difference was found between primary manuscripts and review studies (percentage with significant AI involvement, 16.4% and 18.2%, respectively; p = 0.40). Significant AI involvement varied significantly across journals, with rates ranging from 5.6% in The American Journal of Sports Medicine to 38.3% in The Journal of Bone & Joint Surgery (p < 0.001).

CONCLUSIONS: This study examined AI assistance in the writing of published orthopaedic manuscripts and provides the first evidence-based threshold for interpreting AI detection percentages. Our results revealed significant AI involvement in 16.7% of recently published orthopaedic literature. This finding highlights the importance of clear guidelines, ethical standards, responsible AI use, and improved detection tools to maintain the quality, authenticity, and integrity of orthopaedic research.

PMID:40446076 | DOI:10.2106/JBJS.24.01462

Five-Year Functional Outcomes After Acetabular Labral Repair with and without Bone Marrow Aspirate Concentrate

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.00602. Online ahead of print.

ABSTRACT

BACKGROUND: Bone marrow aspirate concentrate (BMAC) augmentation at the time of hip arthroscopy is a potential solution to improve functional outcomes in patients with cartilage damage concomitant with acetabular labral tearing; however, follow-up functional scores to date have not exceeded 24 months. Therefore, the present study compares minimum 5-year outcomes in patients treated with or without BMAC augmentation to address chondral damage during arthroscopic labral repair.

METHODS: This was a prospective cohort study analyzing patients who underwent acetabular labral repair performed by a single surgeon. Patients were stratified into either the BMAC cohort or the control cohort depending on whether BMAC was utilized in conjunction with arthroscopic labral repair. Demographic and intraoperative variables, including chondrolabral junction breakdown and articular cartilage damage, were compared between cohorts, as were patient-reported outcome measures (PROMs) at enrollment and at 3, 6, 12, 24, and 60 months postoperatively.

RESULTS: Eighty-one hips were included for analysis: 39 (38 patients) in the BMAC cohort and 42 (39 patients) in the control cohort. Univariate analyses demonstrated similar baseline characteristics between groups, including body mass index, Tönnis angle, lateral center-edge angle (LCEA), and alpha angle (p > 0.05 for each). Patients treated with BMAC and patients in the control group reported similar PROMs between enrollment and the 12-month follow-up. By the 24-month follow-up, patients treated with BMAC reported significantly higher scores for the modified Harris hip score (mHHS) (p = 0.004), the International Hip Outcome Tool-33 (iHOT-33) (p = 0.012), and the Hip Outcome Score-Activities of Daily Living (HOS-ADL) (p = 0.008). This trend persisted over time, with the BMAC cohort demonstrating significantly higher scores for the mHHS (p < 0.001), iHOT-33 (p = 0.006), and the Hip Outcome Score-Sports Subscale (HOS-SS) (p = 0.012) at 60 months.

CONCLUSIONS: Patients undergoing acetabular labral repair with BMAC augmentation reported significantly greater functional improvements compared with patients undergoing repair without BMAC. These differences generally did not become significant until 24 months after surgery, at which point they increased in magnitude until the 60-month follow-up. These findings, the first intermediate-term outcomes reported following hip arthroscopy with BMAC, therefore suggest favorable benefit at an extended follow-up.

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

PMID:40446023 | DOI:10.2106/JBJS.24.00602

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