J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.00331. Online ahead of print.

ABSTRACT

BACKGROUND: A lumbosacral hemivertebra poses a unique problem, as it leads to a long compensatory curve above it and an obvious main curve. One-stage posterior hemivertebra resection with short segmental fusion is a standard surgery for patients with congenital scoliosis, but curve progression often occurs after surgery. The objective of this study was to investigate the risk factors for curve progression in patients who underwent 1-stage posterior hemivertebra resection with short segmental fusion.

METHODS: This study included 58 Han Chinese patients with congenital scoliosis who underwent 1-stage posterior hemivertebra resection with short segmental fusion. Baseline information, radiographic parameters, and the Scoliosis Research Society-22r questionnaire were collected preoperatively, 3 months postoperatively, and at the last follow-up. Risk factors for curve progression were evaluated using logistic regression analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS: The mean age at surgery was 7.3 years, and the mean follow-up was 7.5 years. Nine patients (15.5%) were diagnosed with curve progression at the final follow-up. Compared with their preoperative condition, patients exhibited a significant reduction in the main curve (95% confidence interval [CI], 25.2° to 28.9° preoperatively versus 6.8° to 9.4° at 3 months; p < 0.001), compensatory curve (95% CI, 15.0° to 19.8° versus 5.5° to 8.1°; p < 0.001), and coronal balance (95% CI, 12.4 to 16.9 mm versus 7.0 to 10.5 mm; p < 0.001) at 3 months postoperatively. The progression group had larger preoperative pelvic obliquity values than the non-progression group (95% CI, 3.19° to 6.55° versus 2.01° to 2.63°; p = 0.008). The logistic regression analysis revealed that preoperative pelvic obliquity was a significant independent risk factor for curve progression (odds ratio, 1.653; 95% CI, 1.096 to 2.495; p = 0.017). The ROC analysis revealed that preoperative pelvic obliquity had good discriminatory capability (area under the ROC curve, 0.876; 95% CI, 0.677 to 1.000; p < 0.001).

CONCLUSIONS: In summary, preoperative pelvic obliquity was an independent risk factor for curve progression, which means that preoperative measures should be taken to ensure minimal pelvic obliquity in patients in order to effectively prevent curve progression. The presence of pelvic obliquity should alert the surgeon and patients to the high risk of deformity progression and to the need for scheduling more frequent follow-ups as appropriate.

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

PMID:40279408 | DOI:10.2106/JBJS.24.00331

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.00993. Online ahead of print.

ABSTRACT

BACKGROUND: Traditional Medicare (TM) claims data are widely used by researchers and registries to report survivorship following total knee arthroplasty (TKA). The purpose of the present study was to investigate whether the mass exodus of patients from TM to Medicare Advantage (MA) has compromised the fidelity of TM data.

METHODS: We identified 11,717 Medicare-eligible patients (15,282 knees) who had undergone primary TKA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 84% of TKAs were covered by TM. The rates of survivorship free from revision or reoperation were calculated for patients with TM coverage. The same survivorship end points were recalculated after censoring of patients who transitioned to MA after primary TKA, thereby modeling the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean duration of follow-up was 10 years.

RESULTS: From 2000 to 2020, there was a decrease in TM insurance (from 94% to 68%) and a corresponding increase in MA insurance (from 0% to 19%) among patients undergoing TKA. Following TKA, 25% of patients with TM coverage switched to MA. For patients with TM at the time of surgery, the 15-year rates of survivorship free from any reoperation or revision were 90% and 96%, respectively. When patients were censored upon transition from TM to MA, the 15-year rates of survivorship free from any reoperation (92% versus 90%; hazard ratio [HR] = 1.2; p = 0.001) or any revision (97% versus 96%; HR = 1.3; p = 0.002) were significantly higher.

CONCLUSIONS: One in 4 patients left TM for MA after primary TKA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM resulted in falsely elevated estimates of survivorship free from reoperation and from revision, with increasing divergence in survivorship over time, when MA data were excluded. As MA continues to grow, efforts to incorporate these data will become increasingly important.

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

PMID:40279407 | DOI:10.2106/JBJS.24.00993

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.00670. Online ahead of print.

ABSTRACT

BACKGROUND: Musculoskeletal abnormalities have been reported among female professional ballet performers due, in part, to intrinsic predispositions related to joint and/or connective tissue laxity and extrinsic effectors such as reduced energy availability, low body mass, and high training volumes that may increase the risk of developing idiopathic scoliosis (IS). The purpose of this investigation was to characterize IS prevalence in this population. We hypothesized that there would be elevated prevalence in female performers and that those with IS would exhibit reduced bone mineral density (BMD), body mass, fat mass, and lean mass.

METHODS: A retrospective analysis of whole-body anteroposterior radiographs was performed on 98 professional ballet dancers (49 male performers [mean age, 25 ± 6 years] and 49 female performers [mean age, 27 ± 5 years]) from a single company. Body composition and BMD were assessed via dual x-ray absorptiometry. The criterion for IS was defined as a Cobb angle of >10°. The frequency of IS was plotted against general-population norms. A t test was used to compare demographic characteristics, anthropometrics, and BMD between performers with and without IS and to compare the Cobb angles between sexes. A Fisher exact test was used to compare the IS prevalence between sexes. The Type-I error was set at α = 0.05.

RESULTS: Compared with male performers, female performers had greater spinal asymmetry (mean Cobb angle, 7.98° [95% confidence interval (CI) width, 1.76°] for men and 4.02° [95% CI width, 1.00°] for women; p = 0.027). The prevalence of IS among male performers (3 [6.12%] of 49) was comparable with the general-population norms (0.31% to 5.60%). Women had an elevated prevalence of IS compared with men (10 [20.41%] of 49; p = 0.037) and with general-population norms (0.65% to 8.90%). Among women, performers with IS were observed to have a reduced percentage of body fat (p = 0.021) and reduced fat mass (p = 0.040) compared with performers without IS.

CONCLUSIONS: Female professional ballet performers demonstrate a heightened prevalence of IS that, in addition to intrinsic predisposition, is associated with modifiable factors such as reduced fat mass commonly associated with reduced energy availability known to impact musculoskeletal health in athletes. Future investigations should seek to determine the prevalence of IS in other young female athlete populations commonly exposed to high degrees of activity and reduced energy availability.

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

PMID:40273227 | DOI:10.2106/JBJS.24.00670

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.00857. Online ahead of print.

ABSTRACT

BACKGROUND: At our institution, surgeons were observing cases of failed total knee arthroplasties (TKAs) with surface delamination of the tibial insert fabricated by direct compression molding. The increase in unexpected failure led us to investigate the prevalence of delamination and its causes through the use of retrieval analysis and reviews of clinical, demographic, and radiographic data.

METHODS: Between 2000 and 2019, a total of 519 Exactech Optetrak posterior-stabilized direct-compression-molded polyethylene inserts had been retrieved. To determine prevalence, we utilized institutional usage data, manufacturer sales to our institution, and hospital records to determine the delamination rate. Eighty-six retrieved specimens (16 with delamination) were assessed for oxidation with use of infrared spectroscopy.

RESULTS: Sixty-four (12%) of the 519 inserts had delamination. The delamination rate was 0.36% across the 20-year period. Osteolysis was the reason for revision in 25% of delaminated cases, compared with 4% of non-delaminated cases. The mean oxidation index of the delaminated inserts was 2.67 ± 1.4 (range, 1.2 to 6.6). Delamination was not associated with surgical factors (cement viscosity and tibial insert thickness) or processes associated with manufacturing and implantation of the inserts into the patients (implantation year, shelf life, and packaging and sterilization dates).

CONCLUSIONS: The lack of causative factors for the increase in delamination was perplexing. In 2021, following the completion of our study, the manufacturer determined that since 2004, polyethylene inserts were packaged in "non-conforming" vacuum bags that were missing a secondary barrier layer intended to markedly lessen oxygen permeation. The use of non-conforming bags apparently increased the risk of premature oxidation, delamination, and associated osteolysis.

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

PMID:40273225 | DOI:10.2106/JBJS.24.00857

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01118. Online ahead of print.

ABSTRACT

BACKGROUND: Sarcopenia increases postoperative complication and mortality rates in elderly patients. Although measurement of the psoas muscle area on computed tomography (CT) scans is traditionally used to diagnose sarcopenia, CT is not routine in orthopaedic practice and causes unnecessary radiation exposure. EOS, a low-dose full-body imaging modality, captures musculoskeletal structures in an upright position, offering an alternative for sarcopenia diagnosis.

METHODS: Patients ≥18 years of age were included in this retrospective study if they had undergone non-contrast CT spine and EOS imaging between May 2022 and May 2024. Psoas muscle measurements at L3 and L4 were made using non-contrast CT scans, while thigh muscle measurements were obtained with EOS imaging. Inter- and intra-rater reliabilities were assessed using intraclass correlation coefficients (ICCs). Predicted probabilities for L4-psoas sarcopenia were determined through logistic regression, controlling for demographic covariates and validated with an 80% to 20% train-validate split. Sarcopenia cutoffs for anteroposterior (AP) thigh thickness and lateral (LAT) quadriceps thickness were determined with use of the Youden index.

RESULTS: Sarcopenia was identified in 23.1% of 134 patients (85 female and 49 male; 121 White, 7 Black, and 6 Hispanic) on the basis of L4-psoas muscle index thresholds. EOS and CT measurements showed excellent ICCs (≥0.90). Multivariable regressions identified AP thigh thickness and LAT quadriceps thickness as significant predictors of psoas area and L4-psoas sarcopenia. The area under the receiver operating characteristic curve for identifying L4-psoas sarcopenia was 0.85 for AP thigh thickness and 0.77 for LAT quadriceps thickness. Cutoffs were 12.47 cm (males) and 10.68 cm (females) for AP thigh thickness, and 3.23 cm (males) and 2.20 cm (females) for LAT quadriceps thickness. In the validation cohort of 27 patients, the AP thigh thickness model showed 0.94 sensitivity and 0.89 specificity, while the LAT quadriceps thickness model showed 0.70 sensitivity and 1.00 specificity. Applying these cutoffs to the entire data set showed that 66.7% of males and 75.0% of females with measurements below both cutoffs had sarcopenia.

CONCLUSIONS: EOS is a reliable alternative to CT for muscle mass assessment and sarcopenia diagnosis. EOS may be a valuable tool for assessing sarcopenia without a CT scan, as thigh muscle measurements via EOS correlate well with CT-derived psoas measurements. This imaging modality aids in early sarcopenia diagnosis, potentially enhancing preoperative planning and reducing radiation exposure, unnecessary costs, and resource utilization.

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

PMID:40273215 | DOI:10.2106/JBJS.24.01118

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01212. Online ahead of print.

ABSTRACT

BACKGROUND: Although it is well established that the type of organism can be a risk factor for failure in patients with periprosthetic joint infection (PJI), no study to date has examined the impact of the number of positive cultures on treatment outcomes in patients undergoing 2-stage exchange. The purpose of this multicenter study was to determine the prognostic utility of multiple positive cultures at resection as a predictor of failure following reimplantation.

METHODS: This retrospective multicenter study identified 437 patients with chronic knee PJI who had undergone 2-stage exchange arthroplasty with a minimum of 1 year of follow-up following reimplantation. PJI was defined with use of the 2013 Musculoskeletal Infection Society (MSIS) criteria. Patients with culture-negative PJI were excluded (n = 138). Treatment failure was defined as either any reoperation for infection or PJI-related mortality. Multivariable regression controlling for risk factors for failure after a 2-stage arthroplasty was performed to determine whether ≥2 positive intraoperative cultures at resection can predict outcomes following reimplantation when compared with a single positive culture.

RESULTS: Two hundred and ninety-nine patients were included. At a mean follow-up of 6.2 ± 2.6 years, 48 patients (16.1%) experienced failure. Patients who had a failure were more likely to have had a longer interstage interval (p = 0.038) and were also more likely to have had ≥2 positive cultures at the time of resection arthroplasty (95.8% versus 75.3%; p = 0.001). On regression analysis, ≥2 positive cultures at resection was the only variable that was identified as a risk factor for failure following reimplantation in both the univariate (odds ratio [OR], 7.55 [95% CI, 2.24 to 47.0]; p = 0.006) and multivariable models (OR, 8.12 [95% CI, 2.31 to 51.9]; p = 0.005).

CONCLUSIONS: This is the first study to examine the impact of the number of positive cultures on outcomes in patients with PJI. We found that the presence of ≥2 positive cultures at resection was an indicator of a poor prognosis and resulted in a greater than eightfold increase in the risk of treatment failure in patients undergoing a 2-stage exchange.

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

PMID:40273213 | DOI:10.2106/JBJS.24.01212

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.23.01391. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this study was to determine the risk factors associated with deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30 days after multilevel adult spinal deformity (ASD) surgery and to develop risk prediction models.

METHODS: A retrospective observational study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2019. Current Procedural Terminology (CPT) codes 22843 and 22844 were used to query the database and to identify patients who underwent surgical correction of ASD with ≥7 levels of posterior instrumentation. The primary outcomes were the incidences of, and risk factors for, postoperative DVT and PE. Multiple logistic regression was utilized to identify variables associated with an elevated risk of DVT or PE within 30 days after surgery and to develop prediction models for assessing risk.

RESULTS: A total of 7,445 patients (56% female; 73% Caucasian; mean age, 61 years) met the inclusion criteria. Postoperatively, the rate of any venous thromboembolism (VTE; i.e., DVT or PE) was 3.4% (254 patients), the rate of DVT was 2.0% (151 patients), and the rate of PE was 1.7% (127 patients). The following independent predictors of any VTE were identified: weight (odds ratio [OR], 1.054; 95% confidence interval [CI]: 1.027 to 1.081), age per decade of life (OR, 1.106; 95% CI: 1.012 to 1.209), body mass index (BMI; OR, 1.032; 95% CI: 1.015 to 1.049), medicated hypertension (OR, 1.523; 95% CI: 1.168 to 1.987), chronic corticosteroid use (OR, 2.654; 95% CI: 1.848 to 3.812), American Society of Anesthesiologists (ASA) class (OR, 1.768; 95% CI: 1.426 to 2.192), and total operative time (OR, 1.002; 95% CI: 1.002 to 1.003) (p < 0.05 for all). When incorporated into a single model, total operative time, BMI, ASA class, and chronic corticosteroid use were associated with VTE risk.

CONCLUSIONS: Four major risk factors were identified as being associated with postoperative VTE risk in patients undergoing surgery for ASD. Corticosteroid use for a chronic medical condition was the strongest predictor of VTE risk, followed by ASA class, BMI, and operative time. Knowledge of these risk factors can aid in preoperative risk assessment, informed consent, and medical decision-making, such as in determining the clinical thresholds for VTE testing and chemoprophylaxis.

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

PMID:40273208 | DOI:10.2106/JBJS.23.01391

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01265. Online ahead of print.

ABSTRACT

BACKGROUND: Osseous reconstructive surgery for hip displacement in children with cerebral palsy (CP) consists of proximal femoral reorientation by varus derotational osteotomy (VDRO) combined with pelvic osteotomy when indicated. The rate of recurrent hip instability after the index surgery can be as high as 77%. We evaluated the association between femoral diaphyseal medialization at the VDRO site and recurrent instability. We hypothesized that medialization may modify the hip joint reaction force (HJRF), reducing the femoral remodeling that leads to recurrent coxa valga and instability.

METHODS: A retrospective evaluation of the clinical and radiographic records of 140 patients (280 hips) with CP, Gross Motor Function Classification System (GMFCS) Level IV or V, who had been treated with bilateral VDRO as the index surgery for hip displacement between 1998 and 2012 (mean follow-up, 11.3 years) was conducted. Radiographic measurement of medialization was performed using the medialization index (MeI) preoperatively, at 6 weeks and 12 months postoperatively, and at skeletal maturity. Recurrent instability was defined as the need for revision surgery before skeletal maturity or a final migration percentage (MP) of >40%.The influence of the MeI was determined by Poisson regression with multiple variances. The inter- and intra-observer reliability of the MeI, measured by 4 different observers, was assessed using the Cohen d test.

RESULTS: Groups with and without relapse were comparable preoperatively regarding femoral and acetabular parameters. The baseline MP was higher in the relapse group (p < 0.001). The MeI at 6 weeks postoperatively was significantly lower in the relapse group (p = 0.004, relative risk [RR] = 0.07, 95% confidence interval [CI] = 0.01 to 0.42) than in the no-relapse group in multivariable analysis. The MeI showed good inter- and intra-observer reliability, with a Cohen d of <0.5.

CONCLUSIONS: Patients with greater medialization had lower rates of recurrent hip instability at long-term follow-up. The MeI proved to be reliable as a radiographic measurement, and medialization did not increase mechanical instability.

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

PMID:40273207 | DOI:10.2106/JBJS.24.01265

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.25.00101. Online ahead of print.

NO ABSTRACT

PMID:40273198 | DOI:10.2106/JBJS.25.00101

J Bone Joint Surg Am. 2025 Apr 22. doi: 10.2106/JBJS.24.00248. Online ahead of print.

ABSTRACT

BACKGROUND: We previously established a small animal model of femoral head-neck cam-type hip deformity by inducing physeal injury in immature rabbits. We investigated whether this induced deformity led to hip osteoarthritis (OA) within 4 months.

METHODS: Six-week-old immature New Zealand White rabbits underwent surgery to induce physeal injury in the right femoral head, causing growth arrest and secondary head-neck deformity. Animals were divided into early-pre-OA (4 weeks) and late-OA (16 weeks) groups. Left hips served as (nonsurgical) controls. Radiographs were made to visualize deformities and OA progression. The Beck classification was used to assess macroscopic cartilage damage and OA on the acetabulum and femoral head. Micro-computed tomography (CT), histological scoring, and gene expression were used to evaluate OA progression. The Wilcoxon signed-rank test was used for group comparisons. Significance was set at p < 0.05.

RESULTS: At 16 weeks, the injured hips showed radiographic evidence of joint space narrowing and a higher OA grade than the control hips (p = 0.0002). Micro-CT confirmed degenerative OA changes and a higher femoral head bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) in the injured hips than in the control hips (BV/TV: p = 0.0001, Tb.Th: p = 0.0007). Macroscopically, the injured hips exhibited a greater prevalence and severity of chondral lesions at 4 weeks (83.3%, p = 0.015) and 16 weeks (100.0%, p = 0.002) post-injury compared with the control hips (0%), with worsening over time (4 versus 16 weeks: p = 0.016). The Osteoarthritis Research Society International (OARSI) score and synovitis score increased from 4 to 16 weeks post-injury. Compared with the control hips, the injured hips showed decreased Col2 expression and increased Col10 and MMP13 expression at 16 weeks post-injury (p = 0.062, p = 0.016, p = 0.041, respectively), confirming catabolism and OA progression.

CONCLUSIONS: To our knowledge, we have created the first small animal model of hip OA secondary to experimentally induced head-neck deformity. In this model, the deformity resulted in hip OA at 16 weeks post-injury.

CLINICAL RELEVANCE: This model can be used to test future interventional therapies and study mechanisms of femoroacetabular impingement-mediated hip OA.

PMID:40261969 | DOI:10.2106/JBJS.24.00248

J Bone Joint Surg Am. 2025 Apr 18. doi: 10.2106/JBJS.24.00542. Online ahead of print.

ABSTRACT

BACKGROUND: Accelerated recovery from bone injuries is a paramount health-care goal with substantial impacts on physical status and overall well-being. The aim of this study was to evaluate the impact of colostrum supplementation on bone healing in patients with a traumatic extracapsular hip fracture (ECF).

METHODS: Patients with an ECF undergoing internal fixation were randomly assigned to receive either bovine colostrum or whey protein. Bone healing was assessed using the Radiographic Union Score for Hip (RUSH). Physical rehabilitation was evaluated using the Harris hip score (HHS) and the Short Musculoskeletal Functional Assessment (SMFA) within 3 months postoperatively. A generalized estimating equation (GEE) was used to assess the time-by-group interactions of these longitudinal variables. Patients were monitored for postoperative complications for 12 months, with the risk difference (RD) and risk ratio (RR) calculated.

RESULTS: A total of 116 patients with an ECF were included in the final analysis (colostrum group, n = 59; whey group, n = 57). Baseline characteristics, including age, gender, ethnicity, and body mass index, were similar between the groups (p > 0.05 for all). The colostrum group had a significantly greater increase in the RUSH score (β = 0.88; p = 0.001) and HHS (β = 1.2; p = 0.001) over time compared with the whey group. SMFA dysfunction and bother indices demonstrated significantly greater decreases over time in the colostrum group compared with the whey group (β = -1.2 and -2.4, respectively; p < 0.001 for both).

CONCLUSIONS: The present study provides preliminary evidence suggesting that colostrum may accelerate bone healing and enhance short-term physical rehabilitation outcomes more effectively than whey protein.

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

PMID:40249794 | DOI:10.2106/JBJS.24.00542

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.24.00810. Online ahead of print.

ABSTRACT

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a substantial cause of morbidity and mortality among hospitalized patients. Although rare in the general pediatric population, VTE remains a potential concern in hospitalized children, particularly those with lower-extremity (LE) fractures. With this study, we aimed to determine the risk of VTE in pediatric patients with surgically treated LE fractures through a retrospective, propensity-matched, cohort analysis.

METHODS: The TriNetX Research Network, encompassing data from >80 health-care organizations and >120 million patient records, was utilized for this retrospective cohort study comparing 3 age-based cohorts (children [age of <14 years], adolescents [age of 14 to 17 years], and adults [age of ≥18 years]) who underwent surgical treatment of LE fractures between January 1, 2003, and January 1, 2023.

RESULTS: A total of 634,880 patients with surgically treated LE fractures were included; 13.3% were children, 5.6% were adolescents, and 81.1% were adults. Propensity-score matching was used to compare VTE incidence across cohorts, resulting in 3 independent matched comparisons. Overall, the incidence of VTE (either DVT or PE) was 0.2% in children, 1.0% in adolescents, and 4.1% in adults. Adults had a significantly higher risk of developing DVT (risk ratio [RR]: 17.0; 95% confidence interval [CI]: 14.5 to 20.0) and PE (RR: 21.8; 95% CI: 17.0 to 28.1) compared with children. Similarly, adolescents had a higher risk of DVT (RR: 3.5; 95% CI: 2.7 to 4.4) and PE (RR: 3.1; 95% CI: 2.2 to 4.4) compared with children. The incidence of VTE varied by fracture location, with femoral and knee joint (incidence: 0.5% in children, 2.5% in adolescents) and pelvic and hip joint (incidence: 1.2% in children, 2.8% in adolescents) fractures presenting the highest risk across all age groups.

CONCLUSIONS: The incidence of VTE in a large cohort of pediatric patients undergoing surgical treatment of LE fractures was higher in adolescents than in children. These findings may warrant prophylactic VTE measures in adolescents undergoing surgical treatment of femoral or pelvic fractures.

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

PMID:40245162 | DOI:10.2106/JBJS.24.00810

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.23.01088. Online ahead of print.

ABSTRACT

BACKGROUND: The treatment of ankle fractures involving the posterior malleolus (PM) has changed in favor of open reduction and internal fixation (ORIF), and the need for additional syndesmotic stabilization has decreased; however, there are still doubts regarding the diagnosis and treatment of residual syndesmotic instability. The aim of the present study was to evaluate the effect of fixation of the PM and to assess the need for additional stabilization methods. We hypothesized that ORIF of the PM would not sufficiently stabilize the syndesmosis and that additional syndesmotic reconstruction would restore kinematics.

METHODS: Eight unpaired, fresh-frozen, cadaveric lower legs were tested in a 6-degrees-of-freedom robotic arm with constant loading (200 N) in the neutral position and at 10° dorsiflexion, 15° plantar flexion, and 30° plantar flexion. The specimens were evaluated in the following order: intact state; osteotomy of the PM; transection of the anterior inferior tibiofibular ligament (AITFL) and interosseous ligament (IOL); ORIF of the PM; additional syndesmotic screw; combination of syndesmotic screw and AITFL augmentation; and AITFL augmentation.

RESULTS: A complete simulated rupture of the syndesmosis (PM osteotomy with AITFL and IOL transection) caused translational (6.9 mm posterior and 1.8 mm medial displacement) and rotational instability (5.5° external rotation) of the distal fibula. ORIF of the PM could eliminate this instability in the neutral ankle position, whereas sagittal and rotational instability remained in dorsiflexion and plantar flexion. The remaining instability could be eliminated with an additional procedure, without notable differences between screw and AITFL augmentation.

CONCLUSIONS: In our model, isolated PM osteotomy and isolated AITFL and IOL rupture (after PM refixation) only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of PM osteotomy and AITFL and IOL rupture resulted in an unstable syndesmosis in all planes.

CLINICAL RELEVANCE: In complex ankle fractures, ORIF of the PM is essential to restore syndesmotic stability; however, residual syndesmotic instability can be detected by a specific posterior shift of the fibula on stress testing. In these cases, anatomical AITFL augmentation is biomechanically equivalent to the use of a syndesmotic screw.

PMID:40245116 | DOI:10.2106/JBJS.23.01088

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.24.01493. Online ahead of print.

ABSTRACT

Orthopaedic surgeons are called upon to lead in numerous clinical settings, but the importance of physician leadership is also relevant to administrative roles. As the complexity of health care has increased, the challenges confronting the orthopaedic physician leader have increased as well. During the past century, there has been a substantial increase in the number of non-physician CEO leaders, and this is particularly critical in the academic health system, for which investment in the research and education missions is heavily dependent upon the clinical enterprise. Therefore, physician leadership becomes even more important, with heightened influence. Being an orthopaedic surgeon, or any type of physician, is not synonymous with excellence in leadership. Rather, growth as a leader requires hard work dedicated to the acquisition and nurturing of the knowledge, behaviors, and competencies that result in excellence. We readily acknowledge that physicians must work with a multidisciplinary administrative team of content experts but believe that true expert leaders also possess the inherent knowledge and expertise in the core business for which the organization exists. We encourage our physician colleagues to work to become stronger leaders regardless of their ultimate career aspirations.

PMID:40245106 | DOI:10.2106/JBJS.24.01493

J Bone Joint Surg Am. 2025 Apr 16;107(8):e38. doi: 10.2106/JBJS.24.01481. Epub 2025 Apr 16.

NO ABSTRACT

PMID:40237720 | DOI:10.2106/JBJS.24.01481

J Bone Joint Surg Am. 2025 Apr 16;107(8):e37. doi: 10.2106/JBJS.24.01375. Epub 2025 Apr 16.

NO ABSTRACT

PMID:40237719 | DOI:10.2106/JBJS.24.01375

J Bone Joint Surg Am. 2025 Apr 10. doi: 10.2106/JBJS.24.01080. Online ahead of print.

ABSTRACT

BACKGROUND: Vitamin C shows strong anti-inflammatory and analgesic effects, so we explored whether it can replace glucocorticoids in reducing pain and inflammation after total hip arthroplasty (THA).

METHODS: In this prospective trial, a consecutive series of 107 patients (43.0% men, 56.8 ± 10.1 years of age, 100% Han Chinese) who underwent THA due to end-stage hip disease at our medical center between January 2023 and January 2024 were randomized to receive vitamin C, dexamethasone, or neither dexamethasone nor vitamin C after surgery. The 3 groups were compared in terms of the primary outcomes of pain reported on a visual analogue scale (VAS), perioperative morphine use, and blood indices of inflammation and fibrinolysis as well as in terms of secondary outcomes of efficacy and safety.

RESULTS: Compared with patients in the control group, those who received vitamin C or dexamethasone reported a significantly lower VAS pain score on postoperative day 1, had significantly lower perioperative morphine consumption, and demonstrated significantly lower blood levels of C-reactive protein on days 1 and 2. The 2 groups also showed a significantly lower rate of rescue analgesia on postoperative day 1 and significantly higher Harris hip scores of joint function at 2 and 12 weeks after surgery, as well as significantly smaller thigh circumference and a lower rate of swelling on the first 2 days after surgery. Either treatment was associated with a significantly lower rate of postoperative nausea and vomiting. Dexamethasone was associated with greater blood glucose levels after surgery.

CONCLUSIONS: Vitamin C may be an effective substitute for glucocorticoids for reducing morphine use and the risk of nausea or vomiting and for improving joint function after THA without side effects causing blood glucose fluctuations.

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

PMID:40208930 | DOI:10.2106/JBJS.24.01080

J Bone Joint Surg Am. 2025 Apr 9. doi: 10.2106/JBJS.24.01181. Online ahead of print.

ABSTRACT

BACKGROUND: The present study aimed to assess the long-term outcomes of lumbosacral hemivertebra (LSHV) resection and short segmental fusion in a pediatric population and to assess the evolution of deformity curves.

METHODS: Patients who sought medical attention at our institution between 2010 and 2018 were assessed for eligibility. A classification of R10 and U9 or higher for the distal radius and ulna, respectively, was used to indicate maturity. Imaging parameters and quality-of-life scores were recorded at postoperative follow-up visits. Analyses were performed for the entire group and for subgroups of patients with and without a curve progression.

RESULTS: A total of 15 male and 15 female patients were included, with a mean age of 6.9 ± 2.4 years at the time of surgery. The main curve averaged 26.6° ± 6.5° preoperatively, 7.5° ± 4.6° (p < 0.001) at 3 months postoperatively, and 8.6° ± 3.2° (p = 0.205) at the latest follow-up. In the coronal plane, the coronal balance averaged 21.3 ± 16.7 mm preoperatively, 11.4 ± 8.5 mm (p = 0.007) at 3 months postoperatively, and 11.2 ± 8.9 mm (p = 0.858) at the latest follow-up. A total of 7 complications were recorded in 6 patients (20.0%). The Scoliosis Research Society 22-Item Questionnaire (SRS-22) total score (p < 0.001), appearance score (p < 0.001), and satisfaction score (p < 0.001) were all significantly different from preoperatively to postoperatively. Compared with the compensatory curve progression group, the non-progression group had a higher SRS total score (p = 0.013) and satisfaction (p < 0.001).

CONCLUSIONS: For pediatric patients <10 years old, LSHV resection and short segmental fusion could provide correction and global spine balance improvement. However, the observed loss of correction in the compensatory curve in some patients during the follow-up may compromise the satisfaction.

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

PMID:40203129 | DOI:10.2106/JBJS.24.01181

J Bone Joint Surg Am. 2025 Apr 9. doi: 10.2106/JBJS.24.01119. Online ahead of print.

ABSTRACT

BACKGROUND: The sequelae of open reduction of developmental and/or syndromic hip dislocations include osteonecrosis/proximal femoral growth disturbance and residual dysplasia. There is limited information comparing the rates of these sequelae in patients with developmental dysplasia of the hip (DDH) and arthrogryposis multiplex congenita (AMC). We performed a dual-center retrospective cohort study to compare rates of proximal femoral growth disturbance and residual dysplasia between patients with DDH and AMC who had undergone open hip reduction for the treatment of non-traumatic hip dislocations.

METHODS: We identified patients <18 years of age who had undergone open reduction for the treatment of hip dislocation between 1981 and 2020 at 2 tertiary pediatric hospitals. Patients with AMC were matched by age against patients with DDH in a 1:2 ratio. Preoperative data included demographic characteristics, the severity of dislocation according to the International Hip Dysplasia Institute (IHDI) classification system, and the acetabular index. Outcomes included the acetabular index at 2 years postoperatively, the IHDI classification at the time of final follow-up, and the presence and grade of proximal femoral growth disturbance according to the Salter criteria at 2 years postoperatively and according to the Kalamchi and MacEwen (KM) classification system at the time of final follow-up.

RESULTS: Eighty-two patients (98 hips) with DDH were matched against 39 patients (49 hips) with AMC. The mean follow-up was 107 months (range, 24 to 443 months). There was no difference in the mean age at surgery (1.5 ± 0.7 versus 1.4 ± 1.3 years; p = 0.86), preoperative IHDI classification, acetabular index, or spica cast duration (p > 0.05 for all), but the DDH cohort had more females (83% versus 56%; p = 0.003). Postoperatively, the prevalence of proximal femoral growth disturbance was higher in the AMC group than in the DDH group according to the Salter criteria at 2 years (57% versus 21%; p < 0.001) and according to the KM criteria at the time of final follow-up (59% versus 16%; p < 0.001). At 2 years postoperatively, there was no difference between the DDH and AMC groups in terms of the acetabular index (31° ± 6.2° versus 29° ± 6.9°; p = 0.3) or reoperation rate (24% versus 20%; p = 0.68), but the AMC cohort had more IHDI grade II-IV hips than the DDH cohort (24% versus 9%; p = 0.02), reflecting re-subluxation/dislocation.

CONCLUSIONS: Open reduction for hip dislocation in patients with AMC was associated with a significantly higher rate of proximal femoral growth disturbance and re-subluxation/dislocation compared with that in patients with DDH, despite similar preoperative characteristics. This information may guide perioperative counseling for families of patients with AMC.

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

PMID:40203125 | DOI:10.2106/JBJS.24.01119