J Bone Joint Surg Am. 2025 Mar 6. doi: 10.2106/JBJS.23.01478. Online ahead of print.

ABSTRACT

BACKGROUND: When managing aggressive giant cell tumor of bone (GCTB) around the knee joint, surgeons are often caught in a dilemma when determining whether to perform marginal excision or intralesional curettage. The purpose of this study was to report the long-term results of different treatment strategies in our institute.

METHODS: We retrospectively reviewed 64 eligible cases (34 female and 30 male) with a GCTB (37 in the distal femur, 27 in the proximal tibia) treated from 2002 to 2013. Forty patients received intralesional curettage (group A). Twenty-four received marginal excision of the tumor, with 18 of them undergoing reconstruction with unicondylar osteoarticular allograft (UOA) (group B) and 6 receiving arthroplasty reconstruction (group C). The minimum follow-up was 8 years, and the oncological status, clinical outcomes, and cartilage condition were analyzed.

RESULTS: Tumor recurrence was most common in group A (10 of 40, 25.0%), followed by group B (1 of 18, 5.6%) and group C (0 of 6). Eleven patients in group A (27.5%) and 6 in group B (33.3%) developed osteoarthritis (Kellgren-Lawrence grade 3 or 4). Five patients in group A (12.5%) and 3 patients in group B (16.7%) received total knee arthroplasty. Risk factors for the development of osteoarthritis in group A included a centrally located tumor, tumor length of >6 cm, a tumor-cartilage distance of ≤3 mm, and >50% subchondral bone involvement. In group B, osteoarthritis mostly resulted from postoperative complications. The mean Musculoskeletal Tumor Society (MSTS) score was 87.9 in group A, 84.8 in group B, and 93.3 in group C.

CONCLUSIONS: Although intralesional curettage preserved cartilage and resulted in better function, it was associated with a higher tumor recurrence rate in our series. For advanced tumors close to the articular cartilage with significant subchondral bone involvement, marginal excision with UOA reconstruction might be a viable alternative. Arthroplasty should be reserved for patients who have bicondylar involvement with severe bone and cartilage loss making cartilage preservation impossible.

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

PMID:40048502 | DOI:10.2106/JBJS.23.01478

J Bone Joint Surg Am. 2025 Mar 6. doi: 10.2106/JBJS.24.00640. Online ahead of print.

ABSTRACT

BACKGROUND: The risk factors for fracture-related nerve injury in pediatric Monteggia fracture-dislocations are not well understood. As such, this study aimed to determine the incidence of, and preoperative risk factors for, nerve injury in pediatric Monteggia fracture-dislocations.

METHODS: Patients aged ≤18 years with acute Monteggia or Monteggia-equivalent fracture-dislocations that underwent reduction in the operating room, including closed reduction and casting under general anesthesia and internal fixation of the ulnar fracture with or without opening the radiocapitellar joint, from 2011 to 2021 were retrospectively identified. Exclusion criteria included reduction in the emergency department, concomitant ipsilateral upper-extremity fractures, malunions, or patients without preoperative imaging. Nerve function was assessed preoperatively, and nerve injury was defined as persistent motor and/or sensory deficits on postoperative examination. Patients were followed until nerve-related symptoms resolved. Logistic regression controlled for age and fracture pattern to determine preoperative risk factors.

RESULTS: Of 148 patients (mean age, 6.4 ± 2.8 years), 18.2% (27) had preoperative nerve injury. The posterior interosseous nerve (PIN) was injured in 15 patients, the anterior interosseous nerve (AIN) was injured in 7 patients, and other nerves were injured in 6 patients. All the nerve injuries resolved spontaneously, with a mean resolution time of 63.6 days (range, 8 to 150 days). Risk factors for nerve injury included patient age of ≥8 years (odds ratio [OR], 7.7; 95% confidence interval [CI], 2.6 to 22.8; p < 0.001), lateral radial head dislocation (OR, 6.8; 95% CI, 2.0 to 22.4; p = 0.002), an open fracture (OR, 4.5; 95% CI, 1.2 to 16.5; p = 0.025), and a comminuted ulnar fracture (OR, 4.1; 95% CI, 1.4 to 12.2; p = 0.012). PIN injury was associated with lateral radial head dislocation (p < 0.001) and a comminuted ulnar fracture (p < 0.001). AIN injury was associated with an open fracture (p = 0.002) and diaphyseal ulnar fracture (p = 0.004).

CONCLUSIONS: The incidence of preoperative nerve-related injury in pediatric Monteggia fracture-dislocations was 18.2%. Risk factors for preoperative nerve injury included patient age of ≥8 years, lateral radial head dislocation, an open fracture, and a comminuted ulnar fracture. All the nerve injuries resolved within 150 days, suggesting that early operative intervention may be unnecessary.

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

PMID:40048500 | DOI:10.2106/JBJS.24.00640

J Bone Joint Surg Am. 2025 Mar 5;107(5):e15. doi: 10.2106/JBJS.24.01497. Epub 2025 Mar 5.

NO ABSTRACT

PMID:40042508 | DOI:10.2106/JBJS.24.01497

J Bone Joint Surg Am. 2025 Mar 5;107(5):e14. doi: 10.2106/JBJS.24.01097. Epub 2025 Mar 5.

NO ABSTRACT

PMID:40042507 | DOI:10.2106/JBJS.24.01097

J Bone Joint Surg Am. 2025 Mar 5;107(5):e13. doi: 10.2106/JBJS.24.01157. Epub 2025 Mar 5.

NO ABSTRACT

PMID:40042506 | DOI:10.2106/JBJS.24.01157

J Bone Joint Surg Am. 2025 Mar 3. doi: 10.2106/JBJS.24.01454. Online ahead of print.

NO ABSTRACT

PMID:40029939 | DOI:10.2106/JBJS.24.01454

J Bone Joint Surg Am. 2025 Feb 28. doi: 10.2106/JBJS.24.00050. Online ahead of print.

ABSTRACT

➢ Orthopaedic surgeon pay structures are diverse, but most commonly are productivity-based.➢ Physician ownership of ambulatory surgery centers is a growing phenomenon and may have effects on clinical decision-making.➢ Hospital systems are paid by multiple mechanisms, including case-based reimbursement (based on Diagnosis-Related Groups). Incentives are substantially different between the types of payers (Medicare and Medicaid compared with private insurance).➢ Payer revenues stem from risk-adjusted premiums and investments in income-generating assets; a growing focus on cost-effective care and outcome-focused data by payers has led to changes in pay structures.

PMID:40020042 | DOI:10.2106/JBJS.24.00050

J Bone Joint Surg Am. 2025 Feb 28. doi: 10.2106/JBJS.24.00473. Online ahead of print.

ABSTRACT

BACKGROUND: Preoperative planning is critical for the operative management of any fracture. Unfortunately, conventional planning methods for pilon fractures have not yielded satisfactory results. Therefore, the purpose of this study was to evaluate whether the outcomes of surgically treated pilon fractures could be improved with computer-assisted preoperative planning.

METHODS: Between January 2010 and December 2019, 611 East Asian patients (≥18 years old) with a pilon fracture were identified. After 107 patients were excluded, the final cohort comprised 504 patients: 294 received conventional planning and 210 received computer-assisted preoperative planning. The primary outcome measure was the Olerud-Molander Ankle Score (OMAS) at 12 months. The secondary outcomes were lower-limb function, pain, quality of life, quality of fracture reduction, and complications related to soft-tissue and bone healing. Propensity score matching for 20 baseline characteristics yielded 204 patient pairs.

RESULTS: In the entire cohort of 504 patients, the median age was 41 years (interquartile range, 37 to 46 years) and 375 patients (74.4%) were male. After matching (408 patients; 204 patients in each cohort), patients who received computer-assisted preoperative planning had a better mean OMAS value at 12 months (80.3 points [95% CI, 79.5 to 81.1]) than patients for whom the conventional planning method was used (73.2 points [95% CI, 72.5 to 74.0]; mean difference, -7.1 points [95% CI, -8.2 to -6.0]; p < 0.001). Similarly, better outcomes were observed for lower-limb function, pain, quality of life, and reduction quality in the computer-assisted planning group. Patients who received computer-assisted planning had a lower rate of soft-tissue complications (9.3% [19 of 204 patients]) than patients who received conventional planning (18.6% [38 of 204 patients]; absolute rate difference, -9.3% [95% CI, -16.1% to -2.6%]; relative risk, 0.45 [95% CI, 0.25 to 0.81]; p = 0.008), but a significant difference was not found with respect to bone-healing complications.

CONCLUSIONS: In patients with a pilon fracture, the use of computer-assisted preoperative planning yielded better functional and radiographic outcomes and a lower rate of soft-tissue complications compared with the use of conventional planning methods.

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

PMID:40020040 | DOI:10.2106/JBJS.24.00473

J Bone Joint Surg Am. 2025 Feb 28. doi: 10.2106/JBJS.24.00564. Online ahead of print.

ABSTRACT

BACKGROUND: There has been historical concern that the use of intramedullary nails could present undue risk of osteonecrosis of the femoral head due to compromise of the femoral blood supply. Intramedullary lengthening nails are rapidly becoming commonplace in lengthening procedures. As such, the primary objective of this study was to analyze the rates of osteonecrosis following femoral lengthening. The secondary objective was to characterize general trends in femoral lengthening.

METHODS: This retrospective cohort study evaluated patients who had undergone femoral lengthening at a single institution from 2012 to 2021. Retrospective chart review and radiographic evaluation of osteonecrosis were conducted. The primary end point was radiographic evidence of osteonecrosis. The secondary variables were the starting point of the femoral nail, the total amount of lengthening, and the time to consolidation.

RESULTS: Two hundred and forty-seven patients were included in the analysis, including 111 males and 136 females, with a mean age of 17 years. No patient had radiographic evidence of osteonecrosis (0%) or coxa valga (0%). The average amount of lengthening was 4.88 cm (range, 1.5 to 8.5 cm). No patient had any extensive complications, such as alterations in the proximal femoral anatomy.

CONCLUSIONS: This largest study to date investigating complications following femoral lengthening using intramedullary lengthening nails revealed that femoral lengthening is a well-tolerated procedure, and osteonecrosis is an infrequent complication.

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

PMID:40020038 | DOI:10.2106/JBJS.24.00564

J Bone Joint Surg Am. 2025 Feb 28. doi: 10.2106/JBJS.24.00825. Online ahead of print.

ABSTRACT

BACKGROUND: The pericapsular nerve group (PENG) block has been shown to reduce pain and opioid consumption in posterior total hip arthroplasty (THA). The present study assessed the effects of the PENG block versus a placebo on postoperative (1) pain, (2) morphine consumption, and (3) length of stay in patients undergoing primary anterior THA.

METHODS: This was an institutional review board-approved, single-center, parallel-group, prospective, randomized, double-blinded, controlled trial of patients undergoing primary anterior THA between June 2022 and April 2023. Both groups underwent ultrasound-guided injection of a 20-mL solution (0.5% ropivacaine in the PENG group, 0.9% NaCl in the placebo group), according to the PENG block procedure. Sixty patients were included (32 in the PENG group, 28 in the placebo group). We assessed (1) postoperative pain at 1, 6, 12, and 24 hours with use of the visual analogue scale; (2) total morphine consumption as the morphine-equivalent dose (MED) during the first 24 hours postoperatively; and (3) the length of stay in days.

RESULTS: For the primary outcome, the median visual analogue scale pain score was 3.5 (range, 0 to 10) in the PENG group versus 4 (range, 0 to 10) in the placebo group at 1 hour postoperatively (p = 0.335); 1 (range, 0 to 7) versus 2 (range, 0 to 6) at 6 hours postoperatively (p = 0.306); 1 (range, 0 to 8) versus 1 (range, 0 to 6) at 12 hours postoperatively (p = 0.895); and 1.5 (range, 0 to 6) versus 1.5 (range, 0 to 6) at 24 hours postoperatively (p = 0.914). For secondary outcomes, the mean ± standard deviation 24-hour morphine consumption was 24 ± 17 MED in the PENG group versus 35 ± 29 MED in the placebo group (p = 0.110). The median length of stay was 2 days (range, 2 to 5 days) in the PENG group versus 4 days (range, 2 to 7 days) in the placebo group (p = 0.003).

CONCLUSIONS: In this trial, the PENG block showed a significant decrease in hospital length of stay; however, no significant difference was found for visual analogue scale pain scores or morphine consumption following primary anterior THA compared with a placebo.

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

PMID:40020036 | DOI:10.2106/JBJS.24.00825

J Bone Joint Surg Am. 2025 Feb 28. doi: 10.2106/JBJS.24.01078. Online ahead of print.

ABSTRACT

BACKGROUND: The readability of most online patient educational materials (OPEMs) in orthopaedic surgery is above the American Medical Association/National Institutes of Health recommended reading level of sixth grade for both English- and Spanish-language content. The current project evaluates ChatGPT's performance across English- and Spanish-language orthopaedic OPEMs when prompted to rewrite the material at a sixth-grade reading level.

METHODS: We performed a cross-sectional study evaluating the readability of 57 English- and 56 Spanish-language publicly available OPEMs found by querying online in both English and Spanish for 6 common orthopaedic procedures. Five distinct, validated readability tests were used to score the OPEMs before and after ChatGPT 4.0 was prompted to rewrite the OPEMs at a sixth-grade reading level. We compared the averages of each readability test, the cumulative average reading grade level, average total word count, average number of complex words (defined as ≥3 syllables), and average number of long sentences (defined as >22 words) between original content and ChatGPT-rewritten content for both languages using paired t tests.

RESULTS: The cumulative average reading grade level of original English- and Spanish-language OPEMs was 9.6 ± 2.6 and 9.5 ± 1.5, respectively. ChatGPT significantly lowered the reading grade level (improved comprehension) to 7.7 ± 1.9 (95% CI of difference, 1.68 to 2.15; p < 0.05) for English-language content and 8.3 ± 1.3 (95% CI, 1.17 to 1.45; p < 0.05) for Spanish-language content. English-language OPEMs saw a reduction of 2.0 ± 1.8 grade levels, whereas Spanish-language OPEMs saw a reduction of 1.5 ± 1.2 grade levels. Word count, use of complex words, and long sentences were also reduced significantly in both languages while still maintaining high accuracy and similarity compared with original content.

CONCLUSIONS: Our study supports the potential of artificial intelligence as a low-cost, accessible tool to assist health professionals in improving the readability of orthopaedic OPEMs in both English and Spanish.

CLINICAL RELEVANCE: TK.

PMID:40020034 | DOI:10.2106/JBJS.24.01078

J Bone Joint Surg Am. 2025 Feb 27. doi: 10.2106/JBJS.24.00747. Online ahead of print.

ABSTRACT

BACKGROUND: The medial patellofemoral ligament (MPFL) serves as the primary stabilizer of the patellofemoral joint, and surgical reconstruction aims to replicate its biomechanical properties. However, misplacement of the femoral tunnel remains a major problem that leads to revision after surgery for patellar instability. The C-arm technique for identifying the femoral origin of the MPFL (fMPFL) during surgery may not account for individual variability. Magnetic resonance imaging (MRI) allows for personalized fMPFL identification. The CLASS (Compressed Lateral and Anteroposterior Anatomical Systematic Sequences) method compresses MRI data into a lateral view, similar to intraoperative C-arm imaging. Recent research has shown that C-arm positioning directly affects fMPFL localization. The aim of this study was to investigate how accurate the identification of the femoral MPFL footprint is with the CLASS method and on which side the C-arm must be positioned.

METHODS: Ten Caucasian cadaveric knees were utilized in this study. MRIs of the native and dissected knee were obtained. The MRIs, with the fMPFL anatomy dissected and marked, were used to create the "anatomical CLASS" (aCLASS) data. Additionally, the "native MRI" was used to identify the fMPFL in order to simulate preoperative planning, generating the "planned CLASS" (pCLASS) data. True-lateral fluoroscopic images with the image receptor contralaterally or ipsilaterally positioned were obtained. Statistical tests included the Wilcoxon signed-rank test for positional comparisons across all groups. A 1-way analysis of variance (ANOVA) with the Bonferroni adjustment was conducted for clinically relevant groups. Significance was set at p < 0.05.

RESULTS: The pCLASS showed no significant differences compared with the aCLASS. The 1-way ANOVA showed significant differences between the ipsilateral group and the pCLASS and between the ipsilateral and contralateral groups only in the distal-proximal axis.

CONCLUSIONS: This time-zero cadaveric study offers a novel method for determining the individual fMPFL. Various locations for femoral MFL attachment have been described in the literature, highlighting the need for individualized assessment methods. The CLASS method offered a reliable and reproducible approach for fMPFL identification. Also, proper intraoperative positioning of the C-arm, with the image receptor kept contralaterally, should be performed to increase the effectiveness of identifying the fMPFL using the CLASS method.

CLINICAL RELEVANCE: The CLASS method offers a personalized approach for accurately identifying the fMPFL during surgery, which could potentially reduce tunnel misplacement and revision rates. Proper C-arm positioning with contralateral image receptor placement enhances the effectiveness of this technique, which has the potential to improve outcomes for patients undergoing MPFL reconstruction for patellar instability.

PMID:40014682 | DOI:10.2106/JBJS.24.00747

J Bone Joint Surg Am. 2025 Feb 27. doi: 10.2106/JBJS.24.00148. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with lower-extremity amputations experience various pain types. Osseointegration allows for prosthesis wear through a bone-anchored implant. Patient-reported outcome measures following osseointegration have not been well studied. Our aim was to evaluate differences in pain and quality of life at 1 year after osseointegration of a bone-anchored limb.

METHODS: We analyzed the severity and types of pain as measured by validated patient-reported outcome measures. Data were compared between the initial visit and the 1-year postoperative visit.

RESULTS: Fifty-four patients were included in this study and demonstrated improvement in pain intensity as measured by the Numeric Rating Scale (p < 0.001) and Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-GH) (p < 0.001), as well as residual limb pain when walking (p < 0.001), at 1 year postoperatively. The self-reported impact of pain on quality of life improved in both transfemoral and transtibial amputees (p < 0.001).

CONCLUSIONS: The osseointegration of a bone-anchored limb improved patient-reported pain and quality of life in lower-extremity amputees.

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

PMID:40014677 | DOI:10.2106/JBJS.24.00148

J Bone Joint Surg Am. 2025 Feb 26. doi: 10.2106/JBJS.24.01110. Online ahead of print.

ABSTRACT

BACKGROUND: Many surgeons use body mass index (BMI) cutoffs when offering total hip arthroplasty (THA). However, little is known about who loses weight before THA, and if weight loss improves outcomes. This study determined how many patients lost weight before primary THA, identified predictors of preoperative weight loss, and evaluated whether preoperative weight loss was associated with improved outcomes.

METHODS: Among 53,038 primary THAs that were performed between 2002 and 2019, we identified 2,463 patients who had a BMI of ≥30 kg/m2 (measured 1 to 24 months before surgery) and had their weight measured at the time of surgery. The mean age was 66 years; 47% were women. The mean BMI was 35 kg/m2. Nonparametric models evaluated potential associations with weight loss. Univariable and multivariable logistic regression and Cox proportional hazards models evaluated the impact of preoperative weight change on hospital length of stay, discharge disposition, operative time, periprosthetic joint infection (PJI), complications, revision, and reoperation. The mean follow-up was 5 years.

RESULTS: Overall, 17% of the patients gained >5 pounds (2.27 kg), 38% maintained their weight, 16% lost 5 to <10 pounds (4.54 kg), 17% lost 10 to <20 pounds (9.07 kg), and 12% lost ≥20 pounds before THA. Only 28% of patients with a preoperative BMI of ≥40 kg/m2 achieved a BMI of <40 kg/m2 by the time of surgery; those who did required a mean of 1.3 years to lose the weight. In multivariable analyses, there were no significant improvements in operative time, length of stay, and discharge disposition, or survivorship free of PJI, complication, revision, or reoperation for any weight-loss category when compared with those who maintained their weight.

CONCLUSIONS: Only 12% of patients lost ≥20 pounds, and only 28% of patients with a BMI of ≥40 kg/m2 achieved a BMI of <40 kg/m2 before primary THA. There was no decrease in complications, revisions, or reoperations for any preoperative weight-loss category when compared with those who maintained their weight. While weight loss benefits overall health, the results of this study call into question whether preoperative weight loss alone is enough to reduce postoperative complications for most patients.

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

PMID:40009699 | DOI:10.2106/JBJS.24.01110

J Bone Joint Surg Am. 2025 Feb 25. doi: 10.2106/JBJS.24.01521. Online ahead of print.

NO ABSTRACT

PMID:39999209 | DOI:10.2106/JBJS.24.01521

J Bone Joint Surg Am. 2025 Feb 25. doi: 10.2106/JBJS.24.00580. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic osteolysis after total ankle arthroplasty (TAA) is a substantial problem. Bone grafting may be beneficial in the treatment of large osteolytic cysts; however, the literature regarding the outcomes of bone grafting is limited. This study analyzed the outcomes of autogenous bone grafting performed for the management of periprosthetic osteolysis following TAA.

METHODS: We retrospectively reviewed 42 ankles (41 Korean patients) that underwent autogenous bone grafting for periprosthetic osteolysis following TAA. Clinical outcomes were evaluated using visual analog scale for pain scores, Ankle Osteoarthritis Scale pain and disability scores, and American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores. Computed tomography (CT) was performed preoperatively and for at least 2 years postoperatively in order to evaluate the treatment response. Histology, prosthesis survivorship, reoperations, and complications were also evaluated.

RESULTS: The mean time to autogenous bone grafting was 64.4 months (range, 10 to 128 months), and the mean follow-up duration after autogenous bone grafting was 70.7 months (range, 24 to 137 months). All clinical scores significantly improved from preoperatively to the last follow-up visit. The mean osteolytic cyst volume improved from 4.8 cm3 (range, 1.1 to 19.4 cm3) to 0.8 cm3 (range, 0 to 6.5 cm3). A Kaplan-Meier survival analysis revealed that TAA with subsequent bone grafting was associated with similar prosthesis survivorship (100% and 85.7% at 5 and 10 years, respectively) but inferior reoperation-free survivorship (93.4% and 68.4% at 5 and 10 years, respectively) compared with TAA without osteolysis or with non-progressive osteolysis.

CONCLUSIONS: Autogenous bone grafting performed for the management of periprosthetic osteolysis after TAA produced favorable clinical and radiographic outcomes. However, there was still a higher risk of subsequent surgery even after successful bone grafting, compared with TAA without osteolysis or with non-progressive osteolysis. Our results suggest that autogenous bone grafting and serial CT scan monitoring over time may prolong the survivorship of TAA prostheses in ankles with periprosthetic osteolysis.

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

PMID:39999208 | DOI:10.2106/JBJS.24.00580

J Bone Joint Surg Am. 2025 Feb 25. doi: 10.2106/JBJS.24.01628. Online ahead of print.

NO ABSTRACT

PMID:39999199 | DOI:10.2106/JBJS.24.01628

J Bone Joint Surg Am. 2025 Feb 25. doi: 10.2106/JBJS.24.00481. Online ahead of print.

ABSTRACT

BACKGROUND: Accurately determining the presence and severity of pediatric musculoskeletal infection (MSKI) is crucial for effective triage and treatment. Although the white blood-cell (WBC) count is often used as a marker for MSKI, we hypothesized that the use of the WBC count is limited by age-related variability in children. We proposed that the absolute neutrophil-to-lymphocyte ratio (NLR), which has less age-related variability, is a more reliable indicator for both diagnosing and assessing the severity of MSKI. The present study aims to compare the utility of WBC against that of the NLR, as well as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), for predicting MSKI presence and severity in children.

METHODS: A retrospective cohort study was conducted with use of a database of pediatric orthopaedic consultations for suspected MSKI between January 2013 and July 2022. Diagnoses were categorized as MSKI or no infection, and the severity of any present infection was stratified as local or disseminated. Admission laboratory values were collected. Statistical modeling was performed to assess the capabilities of the WBC, NLR, CRP, and ESR to diagnose MSKI and to assess infection severity, with cutoff thresholds established for clinical use.

RESULTS: This study included 650 patients (median age, 5.2 years; 63% male; 75% White). Of these, 247 patients had no infection, while 403 were diagnosed with an MSKI. Median WBC count, NLR, CRP, and ESR were all significantly higher in pediatric cases of confirmed MSKI. WBC was a poor predictor of infection severity, whereas NLR, CRP, and ESR each positively correlated with infection severity. At the time of admission, an NLR of 4 was highly specific for detecting the presence of infection, and an NLR of 5.8 was highly specific for predicting infection dissemination. CRP was the best predictor of both infection presence and severity, demonstrating the highest specificity and sensitivity, followed by NLR, which outperformed ESR and WBC.

CONCLUSIONS: Because of considerable age-related variability, the predictive value of the WBC count for pediatric MSKI presence and severity is limited. NLR, which is less affected by age-related variability, is superior at predicting MSKI severity. Although CRP remains the benchmark, the NLR offers a valuable alternative to the WBC. Our study provides a comparative framework for these biomarkers, enhancing MSKI assessment across various clinical settings.

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

PMID:39999195 | DOI:10.2106/JBJS.24.00481

J Bone Joint Surg Am. 2025 Feb 21. doi: 10.2106/JBJS.24.00332. Online ahead of print.

ABSTRACT

BACKGROUND: The medial patellofemoral ligament (MPFL) is the most important passive restraint of the medial patella and provides approximately 53% to 80% of medial soft-tissue restraints, although its relationship to the parapatellar structures is still not completely understood.

METHODS: Twenty-six formalin-fixed knees (13 for P45 plastination, 10 for dissection, and 3 for histology) were obtained from cadavers donated to the Department of Anatomy at Dalian Medical University. The mean age of the donors was 78.1 years (range, 52 to 95 years). These specimens were obtained from 4 women and 10 men. The integration of the anterior end of the MPFL with the extensor apparatus of the knee was observed, and the morphological observations were captured using a digital camera.

RESULTS: The MPFL was found to be attached to the extensor apparatus in 3 ways: its main fibers ran deep to the vastus medialis obliquus (VMO) tendon and ultimately inserted into it; its upper portion extended from, and was reinforced by, the vastus intermedius (VI) tendon; and its lower portion merged weakly into the parapatellar tendon. No direct attachment to the patella was found.

CONCLUSIONS: The MPFL attachments to the extensor apparatus occur in 3 locations: the VMO tendon, the VI tendon, and the parapatellar tendon-and not the patella. No direct attachment to that bone was identified. This study provides a comprehensive anatomical relationship between the MPFL and the extensor apparatus of the knee (the patella and quadriceps). Clinically, we suggest that reconstruction of the MPFL be performed with fixation of its anterior end to the VMO rather than to the patella.

PMID:39983008 | DOI:10.2106/JBJS.24.00332

J Bone Joint Surg Am. 2025 Feb 21. doi: 10.2106/JBJS.24.01274. Online ahead of print.

NO ABSTRACT

PMID:39982981 | DOI:10.2106/JBJS.24.01274