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

Int Orthop. 2025 Mar 1. doi: 10.1007/s00264-025-06473-9. Online ahead of print.

ABSTRACT

PURPOSE: Athletes face a higher risk of upper limb nerve entrapment due to repetitive stress, trauma, and biomechanics. Diagnosis is challenging, and delayed treatment can impair performance. When conservative care fails, surgery may be needed to restore function and enable return to play (RTP).

METHODS: This systematic review adhered to PRISMA guidelines and evaluated surgical outcomes, RTP rates, and complications in athletes with upper limb nerve entrapment. A comprehensive search was conducted using MeSH terms and keywords for surgical interventions, nerve entrapment syndromes, and sports. Eligible studies included case series, cohort studies, and comparative studies that reported postoperative outcomes in athletes. Data extraction included nerve involvement, surgical techniques, clinical outcomes, and RTP rates.

RESULTS: Thirty-one studies, comprising 1,297 athletes across 23 sports, were included. The most common nerve entrapments involved the ulnar nerve (50.1%), brachial plexus (39.2%), and suprascapular nerve (9.5%). Surgical interventions included ulnar nerve decompression/transposition, first rib resection with scalenectomy for thoracic outlet syndrome (TOS), and suprascapular nerve decompression. RTP rates ranged from 62 to 100%, with an average of 87%. Suprascapular nerve decompression had the highest RTP success (100%), while TOS demonstrated greater variability (62.5-97%). Functional improvements included pain reduction, increased grip strength, and enhanced patient-reported outcomes. The overall complication rate was low, but TOS procedures had the highest reoperation rates (3.8-27%).

CONCLUSION: Surgical treatment of upper limb nerve entrapment in athletes yields high RTP rates and functional recovery. Ulnar and suprascapular nerve decompressions show consistent success, while TOS surgery outcomes vary.

PMID:40021549 | DOI:10.1007/s00264-025-06473-9

Int Orthop. 2025 Feb 28. doi: 10.1007/s00264-025-06459-7. Online ahead of print.

NO ABSTRACT

PMID:40019503 | DOI:10.1007/s00264-025-06459-7

SICOT J. 2025;11:11. doi: 10.1051/sicotj/2025008. Epub 2025 Feb 27.

ABSTRACT

INTRODUCTION: This biomechanical study evaluated the effect of screw reinsertion with a locking plate on fixation strength and the stability of osteosynthesis in medial tibial plateau fractures using porcine bone.

MATERIALS AND METHODS: Thirty porcine tibiae were divided into three groups: group A (underwent biomechanical testing after medial tibial fixation with a large fragment T-shaped locking plate), group B (underwent plate fixation, followed by the removal of all screws and plates and refixation with the same screws and plates using the same holes before biomechanical testing), and group C (underwent biomechanical testing once after plate fixation, followed by the removal of all screws and plates, refixation with the same screws and plates using the same holes, and then biomechanical testing). The translation pattern of the constructs in each group was examined using cyclic loading tests. The changes in the joint gap and step-off after 2000 cycles were compared among the three groups.

RESULTS: Significant differences in displacement were observed at 10-100 cycles (group A: -0.01 ± 0.04 mm, group B: -0.02 ± 0.04 mm, group C: -0.13 ± 0.15 mm, P = 0.021). However, no significant differences were found in other displacement and translation measurements among the groups. Regarding the gap and step-off among groups, significant differences were observed in anterior and posterior gap changes. Despite the statistical significance, the absolute displacement values were small, suggesting minimal clinical relevance. These findings indicate that reinserting screws and plates into the same hole may not substantially compromise overall fixation strength.

CONCLUSION: Screw reinsertion in the same holes after removal did not significantly compromise the stability of osteosynthesis in this biomechanical model. These findings suggest that reinsertion may be a viable option in revision surgery.

PMID:40014800 | PMC:PMC11867604 | DOI:10.1051/sicotj/2025008

Injury. 2025 Feb 21:112222. doi: 10.1016/j.injury.2025.112222. Online ahead of print.

ABSTRACT

INTRODUCTION: Despite disproportionately bearing the global injury burden, low- and middle-income countries often lack emergency medical services(EMS). Equipping lay first responders(LFRs) with emergency medical dispatch(EMD) is a critical next step for formal EMS development. However, few context-appropriate mobile dispatch solutions are available for LFRs, and implementation feasibility and impact on response intervals are not well understood MATERIALS AND METHODS: A simulation-based feasibility trial assessed a novel EMD tool, previously used for shipping in resource-limited settings without formal addresses. Two cohorts of 10 non-EMD enabled LFRs trained in 2019 in Sierra Leone were recruited. 100 total simulations were launched in randomized order over 6 months(Cohort 1 distributed along 10 kms of highway(n = 50), Cohort 2 distributed across 24 square-kilometers of an urban setting(n = 50)). On-scene first aid skill performance was assessed under direct observation with a standardized patient actor using checklists. Participants were blinded to randomized dispatch timing/scenario to assess response intervals, replicating real-world conditions, and compared with two-sample t-tests. At six-month follow-up, participants were surveyed on tool ease-of-use and appropriateness, confidence, and ranked dispatch variable relative importance.

RESULTS: Median total response interval (initial notification to LFR arrival on scene) for Cohort 1 for linearly-plotted highway simulations was 6 mins 33 ss(IQR: 2m27 s; 10m48 s), while Cohort 2 for dispersed urban simulations was 6m41s(IQR:3m59 s;14m47 s) (p = 0.720). Median distance between simulated emergency and LFR at the time of notification acceptance=1.675 km(IQR:1.13 km;2.47 km) and 1.73 km(IQR:0.82 km;2.28 km). Mean completion percentage of all discrete first aid steps across all 10 simulation scenario types for Cohort 1 = 89.8 %(IQR: 80 %;100 %) and Cohort 2 = 94.9 %(IQR: 88.89 %;100 %) (p = 0.017). Mean confidence was 9.4/10(median=10) and 9.5/10(median=10)(p = 0.889). 75 % of LFRs (15/20) used the compass feature for navigation while 25 % used turn-by-turn directions (5/20). 70 % LFRs (14/20) reported no unexpected data costs. Emergency location was considered the most important dispatch variable factor, followed by nature/severity of injury.

DISCUSSION: A novel mobile navigation tool for EMD accurately dispatches LFRs to simulated emergency incidents across linear/dispersed settings without significant difference in response interval. Equipping LFRs with EMD tools may facilitate efficient dispatch in resource-limited settings to trauma while expanding emergency care access, meriting further study.

PMID:40016018 | DOI:10.1016/j.injury.2025.112222

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

Int Orthop. 2025 Feb 27. doi: 10.1007/s00264-025-06462-y. Online ahead of print.

ABSTRACT

PURPOSE: If the pain persists for a long time in the treatment of plantar fasciitis (PF) or if there is no response to treatment, central sensitization (CS) may develop and the pain may transform into nociplastic pain (NP). This study aimed to evaluate the frequency of CS and NP in patients with PF.

METHODS: This cross-sectional study was undertaken between November 2023 and March 2024. The Foot Function Index (FFI) scale, which evaluates the foot's functionality, was applied to the patient group. The Visual Analog Scale (VAS), which evaluates pain intensity; the Pain-DETECT scale, which evaluates NP; and the Central Sensitization Scale (CSI), which evaluates CS, were applied to patient and control groups.

RESULTS: A total of 206 people were included in the study; 106 were in the patient group with PF, and 100 constituted the control group. While we detected NP in 67 (63.2%) patients according to Pain-DETECT and CS was detected in 91 (85.8%) patients according to CSI among 106 patients with chronic PF; we detected NP in seven (7%) patients according to Pain-DETECT and CS in 44 (44.0%) patients according to CSI among 100 control patients. VAS-score and FFI-pain are moderately and positively correlated with pain-DETECT scores and fairly and positively correlated with CSI scores in the PF group. The pain-DETECT score is moderately and positively correlated with the CSI score in the two groups.

CONCLUSIONS: This is the first study to evaluate the presence of CS and NP in PF patients. We found NP and CS to be common in patients with chronic PF. Effective pain management in patients with PF before it becomes chronic can prevent the development of CS and NP.

PMID:40014141 | DOI:10.1007/s00264-025-06462-y

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

Int Orthop. 2025 Feb 26. doi: 10.1007/s00264-025-06455-x. Online ahead of print.

ABSTRACT

PURPOSE: The optimal coronal alignment in total knee arthroplasty (TKA) remains debatable, necessitating a clear, simple, and universal classification system. The Coronal Plane Alignment of the Knee (CPAK) classification introduced in 2021 provides a nuanced method for categorizing knee alignment. This study aimed to evaluate the distribution of CPAK types among Chinese patients with osteoarthritis (OA) and clarify the differences in surgical outcomes among different CPAK types.

METHODS: We analyzed the data from 961 patients with OA. All patient information was derived from a single-centre retrospective cohort. Radiological measurements from full-length radiographs were used to classify patients into CPAK types. Propensity score matching was used to compare outcomes among different CPAK types. Demographic and clinical data, information regarding patient satisfaction, and Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Forgotten Joint Score (FJS) scores were also collected.

RESULTS: Among Chinese patients with OA, the most common type was Type I (56.8%), followed by Type II (16.1%). After TKA, CPAK types IV and V, were predominant, accounting for 28% and 31% of patients; CPAK types did not change with OA progression. No significant differences in satisfaction, KSS, or WOMAC scores were observed among patients with CPAK types IV, V, and VII. However, Type V patients had significantly higher FJS scores, potentially due to corrected preoperative varus alignment.

CONCLUSION: This study established the CPAK type distribution among Chinese patients with OA to guide alignment strategies for TKA. Different CPAK types did not significantly affect overall satisfaction but influenced functional recovery, underscoring the need for personalized TKA approaches.

PMID:40009175 | DOI:10.1007/s00264-025-06455-x

Int Orthop. 2025 Feb 26. doi: 10.1007/s00264-025-06466-8. Online ahead of print.

ABSTRACT

BACKGROUND: Total knee arthroplasty (TKA) is a common surgical procedure aimed at relieving pain and restoring function in patients with advanced knee osteoarthritis. However, up to 25% of patients report persistent postoperative pain, which remains a major clinical challenge. While mechanical and biological causes are well-documented, neuropathic pain due to dynamic nerve compression is often overlooked, particularly involving the common peroneal and saphenous nerves.

OBJECTIVE: This study aims to highlight the role of dynamic nerve compressions in persistent post-TKA pain and propose an enhanced diagnostic approach by expanding Hagert's triad into a tetrad (pain, weakness, Scratch Collapse Test + , and orthogonal taping).

METHOD: Dynamic nerve compression differs from static entrapment as it occurs intermittently, often escaping detection in standard electromyography (EMG) or imaging studies. The common peroneal nerve is commonly compressed in the peroneal tunnel, leading to lateral knee pain, ankle weakness, and gait instability. The saphenous nerve, entrapped in Hunter's canal, is associated with medial knee pain, fatigability in standing, and pain while climbing stairs. Incorporating orthogonal taping in the clinical assessment enhances diagnostic sensitivity by providing a reproducible mechanical relief test.

CONCLUSION: Dynamic nerve compression should be systematically considered in cases of persistent post-TKA pain. A thorough clinical examination, including Hagert's tetrad, helps improve early detection. When conservative management fails, surgical nerve release offers a valuable solution, with significant potential for pain relief and functional recovery. Further studies are needed to optimize treatment protocols and validate long-term outcomes.

PMID:40009174 | DOI:10.1007/s00264-025-06466-8

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

Int Orthop. 2025 Feb 24. doi: 10.1007/s00264-025-06435-1. Online ahead of print.

ABSTRACT

PURPOSE: Complete acromioclavicular (AC) dislocation associated with fracture of the coracoid process (CP) is uncommon. The strong coracoclavicular ligaments, instead of rupture, may avulse the CP near its base, and with disruption of the AC joint may allow complete dislocation of the clavicle. We report ten cases, one of the largest series in literature, and reviewed the findings and treatment previous reported cases, to allow potential readers to establish the most appropriate treatment.

METHODS: We have prospectively collected those cases in which we had identified an association of an AC dislocation with a fracture of the CP, as well as retrospectively reviewed the records that were coded as AC dislocations and CP fracture looking for this association in the senior author institutions. A literature search was completed on PubMed, Web of Science and Scholar Google, using a sensitive search strategy.

RESULTS: We have collected a total of ten patients with the association of a CP fracture to an AC dislocation in a period of twenty-five years. A review of the cases reported in literature shows a great variability in treatment methods from conservative to more surgically in recent years.

CONCLUSIONS: When an AC dislocation is identified by clinical examination and X-rays, one should be aware of a possible fracture of the CP. It is possible this association to be more frequent than shown in literature because of the CP fracture can easily be missed out or mistaken with an unfussed epiphysis in routine anteroposterior radiography. Multiple approaches have been opted for by surgeons to deal with this combined injury and are the basis of this review.

PMID:39992382 | DOI:10.1007/s00264-025-06435-1