Injury. 2025 Jan 11;56(2):112156. doi: 10.1016/j.injury.2025.112156. Online ahead of print.

ABSTRACT

BACKGROUND: Determining trauma as an act of Self-directed violence (SDV) or from high risk or unclear behaviours is challenging for trauma clinicians and may be affected by patient sex and mechanism of injury. The aim of this study was to examine the differences in characteristics and outcomes between those who have intentionally directed violence towards themselves with those of unclear intent, within a regional trauma system.

METHODS: Data was collected between January 2018 and December 2021 in patients who had been identified as a result of either self-directed violence (SDV) defined as any intentional act that can cause injury to one's self, including death or participated in high-risk behaviours, where the intent was unclear (UI). Differences between female and male patients presenting with SDV and unclear intent were explored.

RESULTS: Overall, 2760 patients were identified, with a median age of 39 years (IQR 28-54) and just over a quarter of females (28 %). Falls from height were the most common mechanism of injury in all groups. SDV was recorded in 45 % of patients, and previous mental health diagnoses were almost three times as prevalent in this group compared to those of unclear intent (SDV: 42 % vs UI: 13 %). In the sex-based analysis females were more likely than males to have a history of depression (49 % vs 31 %, p < 0.0001). There were few sex differences in the SDV group but women of unclear intent were older, with a quarter being aged 65 years or over (Females: 26 % vs. Males: 11 %, p < 0.0001). Females of unclear intent were also more likely to have sustained a high level fall (Females: 29 % vs. Males:11 %, p < 0.001).

CONCLUSION: Previous mental health co-morbidity was associated with self-directed violence in our cohort. Yet the determinants of intent for over half of the patients were unclear. Trauma clinicians should actively enquire regarding intent of injury and escalate to clinical psychology or psychiatry teams as indicated. Those with mental health comorbidities, previous depression and older women may all have an increased risk where intent is unclear and warrants further investigation. Understanding the predictors and characteristics of unclear intent and high-risk behaviours are key to implementation of public health strategies around prevention of self-directed violence and suicide.

PMID:39823920 | DOI:10.1016/j.injury.2025.112156

J Bone Joint Surg Am. 2025 Jan 17. doi: 10.2106/JBJS.24.00486. Online ahead of print.

ABSTRACT

BACKGROUND: Reoperation is a major adverse event following surgical treatment but has yet to be used as a primary outcome measure in population studies to assess current treatments for developmental dysplasia of the hip (DDH). The purpose of the present study was to explore the risk factors associated with reoperations following procedures under anesthesia ("operations") for DDH in patients between the ages of 1 and 3.00 years, with the goal of deriving treatment recommendations.

METHODS: This retrospective birth cohort study included children who had undergone closed reduction, open reduction, or osteotomy for the treatment of unilateral DDH between the ages of 1 and 3.00 years, identified using the Taiwan National Health Insurance Research Database. The children were followed until 10 years of age for reoperations, excluding implant removal and sequential closed reduction within 3 months postoperatively. A comparison between patients with and without reoperations was conducted, and binary logistic regression was used to identify factors associated with reoperation. Patients were further stratified by age and procedure for developing treatment recommendations.

RESULTS: Among 2,261,455 live births from 2000 to 2009, 701 patients underwent operations for unilateral DDH between 1 and 3.00 years of age (an incidence of 31.0 per 1,000 live births). The initial operations included closed reduction (n = 86; mean age, 1.34 years), open reduction (n = 73; mean age, 1.53 years), pelvic osteotomy (n = 405; mean age, 1.59 years), femoral osteotomy (n = 93; mean age, 1.76 years), and pelvic osteotomy plus femoral osteotomy (n = 44; mean age, 1.84 years). Reoperations were performed in 91 patients (13%) at a mean age of 3.80 years. Comparison between patients with and without reoperations revealed the operative procedure as a significant factor. Logistic regression revealed that closed reduction was associated with a 1.8 to 9.0 times higher reoperation risk than open reduction, depending on age, whereas pelvic osteotomy was associated with 0.34 times the risk of reoperation than open reduction in patients 1.5 to 2.0 years of age.

CONCLUSIONS: Reoperations may not be directly linked to radiographic and functional outcomes but are important from the patient's perspective and in terms of cost-effectiveness. To reduce the risk of reoperation, the findings of the present study support open reduction to properly reduce the hip joint at walking age and additional pelvic osteotomy for patients beyond 1.5 years of age.

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

PMID:39823351 | DOI:10.2106/JBJS.24.00486

J Bone Joint Surg Am. 2025 Jan 17. doi: 10.2106/JBJS.24.00911. Online ahead of print.

ABSTRACT

BACKGROUND: The relative advantages and disadvantages of 2-stage versus 1-stage management of infection following total hip arthroplasty (THA) are the current subject of intense debate. To understand the merits of each approach, detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of the present study was to assess the long-term results of 2-stage exchange arthroplasty following THA in one of the largest series to date.

METHODS: We identified 331 periprosthetic joint infections (PJIs) that had been treated with a 2-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had had prior treatment for infection. The mean age at the time of reimplantation was 66 years, 38% of the patients were female, and the mean body mass index (BMI) was 30 kg/m2. The diagnosis of PJI was based on the 2011 Musculoskeletal Infection Society criteria. A competing-risk model accounting for death was utilized. The mean duration of follow-up was 8 years.

RESULTS: The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI ≥30 kg/m2 (hazard ratio [HR] = 2; p = 0.049) and the need for a spacer exchange (HR = 3.2; p = 0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years); 15 (45%) required revision. Factors predictive of dislocation were female sex (HR = 2; p = 0.047) and BMI <30 kg/m2 (HR = 3; p = 0.02). The mean Harris hip score (HHS) improved from 54 to 75 at 10 years.

CONCLUSIONS: In this series of 331 two-stage exchange arthroplasties that were performed for the treatment of infection, we found a low rate of aseptic revision (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to 1-stage exchanges.

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

PMID:39823350 | DOI:10.2106/JBJS.24.00911

Injury. 2025 Jan 9;56(2):112148. doi: 10.1016/j.injury.2025.112148. Online ahead of print.

ABSTRACT

BACKGROUND: Ballistic fractures of the femoral neck, rare injuries that overwhelmingly affect younger adults, pose significant challenges to the treating surgeon. However, there is limited literature that the treating surgeon can leverage to guide their treatment decisions. The goal of this study is to describe the demographics, associated injuries, outcomes, and complications associated with ballistic femoral neck fractures.

PATIENTS AND METHODS: This retrospective case series, performed at a single, academic, urban, level-one trauma center, evaluated patients with a ballistic fracture of the femoral neck (AO/OTA 31B) between 2003 and 2022. International Classification of Disease codes were utilized to identify patients in the electronic medical record. Chart review was performed to assess patient demographics, associated injuries, success rate of operative and nonoperative intervention, and post-operative complication rate and types.

RESULTS: Seventeen patients were included (94 % male; median age 22.5 years). Median follow up was 12.2 months (range 1-84 months). Five patients (29 %) sustained a concomitant vascular injury. Eight patients (47 %) sustained an additional osseous injury. The median injury severity score was 9 (interquartile range 4-17). Thirteen patients were treated with operative reduction and fixation, 3 patients with incomplete fractures were treated nonoperatively, and one was treated with acute total hip arthroplasty (THA). Overall, 12 of 17 patients (71 %) healed their fracture or had an uncomplicated recovery after acute THA. Of the 13 patients treated with operative reduction and fixation, 8 (62 %) healed their fracture and 5 (38 %) developed one or more post-operative complications.

CONCLUSIONS: Nearly 1 in 3 patients with ballistic femoral neck fractures sustain concomitant vascular injury and almost half sustain another osseous injury. In this series, only 62 % of patients who underwent operative reduction and fixation healed their fractures, and nearly 40 % of patients treated with operative reduction and fixation developed a post-operative complication. Given the poor outcomes and high complication rates associated with these injuries, surgeons should counsel patients with ballistic femoral neck fractures accordingly. Further research into the optimal treatment of ballistic femoral neck fractures is needed.

PMID:39813950 | DOI:10.1016/j.injury.2025.112148

J Bone Joint Surg Am. 2025 Jan 15. doi: 10.2106/JBJS.24.00749. Online ahead of print.

ABSTRACT

➢ Jehovah's Witnesses refuse allogeneic blood products based on religious beliefs that create clinical, ethical, and legal challenges in orthopaedic surgery, requiring detailed perioperative planning and specific graft selection.➢ Detailed perioperative planning is particularly important for procedures with high intraoperative blood loss.➢ Graft selection must align with Jehovah's Witnesses patients' religious beliefs, with options including autografts, allografts, and synthetic materials; this requires shared decision-making between the patient and surgeon.➢ A multidisciplinary approach, integrating medical, ethical, and religious considerations, ensures optimal care, with innovative techniques and open dialogue being key to successful outcomes.

PMID:39813667 | DOI:10.2106/JBJS.24.00749

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.24.00386. Online ahead of print.

ABSTRACT

BACKGROUND: An accurate knowledge of a patient's risk of cord-level intraoperative neuromonitoring (IONM) data loss is important for an informed decision-making process prior to deformity correction, but no prediction tool currently exists.

METHODS: A total of 1,106 patients with spinal deformity and 205 perioperative variables were included. A stepwise machine-learning (ML) approach using random forest (RF) analysis and multivariable logistic regression was performed. Patients were randomly allocated to training (75% of patients) and testing (25% of patients) groups. Feature score weights were derived by rounding up the regression coefficients from the multivariable logistic regression model. Variables in the final scoring calculator were automatically selected through the ML process to optimize predictive performance.

RESULTS: Eight features were included in the scoring system: sagittal deformity angular ratio (sDAR) of ≥15 (score = 2), type-3 spinal cord shape (score = 2), conus level below L2 (score = 2), cervical upper instrumented vertebra (score = 2), preoperative upright largest thoracic Cobb angle of ≥75° (score = 2), preoperative lower-extremity motor deficit (score = 2), preoperative upright largest thoracic kyphosis of ≥80° (score = 1), and total deformity angular ratio (tDAR) of ≥25 (score = 1). Higher cumulative scores were associated with increased rates of cord-level IONM data loss: patients with a cumulative score of ≤2 had a cord-level IONM data loss rate of 0.9%, whereas those with a score of ≥7 had a loss rate of 86%. When evaluated in the testing group, the scoring system achieved an accuracy of 93%, a sensitivity of 75%, a specificity of 94%, and an AUC (area under the receiver operating characteristic curve) of 0.898.

CONCLUSIONS: This is the first study to provide an ML-derived preoperative scoring system that predicts cord-level IONM data loss during pediatric and adult spinal deformity surgery with >90% accuracy.

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

PMID:39813599 | DOI:10.2106/JBJS.24.00386

J Bone Joint Surg Am. 2024 Nov 19. doi: 10.2106/JBJS.24.00706. Online ahead of print.

ABSTRACT

BACKGROUND: Fractures of the thoracic and lumbar spine are increasingly common. Although it is known that such fractures may elevate the risk of near-term morbidity, the natural history of patients who sustain such injuries remains poorly described. We sought to characterize the natural history of patients treated for thoracolumbar fractures and to understand clinical and sociodemographic factors associated with survival.

METHODS: Patients treated for acute thoracic or lumbar spine fractures within a large academic health-care network between 2015 and 2021 were identified. Clinical, radiographic, and mortality data were obtained from medical records and administrative charts. Survival was assessed using Kaplan-Meier curves. We used multivariable logistic regression to evaluate factors associated with survival, while adjusting for confounders. Results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS: The study included 717 patients (median age, 66 years; 59.8% male; 69% non-Hispanic White). The mortality rate was 7.0% (n = 50), 16.2% (n = 116), and 20.4% (n = 146) at 3, 12, and 24 months following injury, respectively. In adjusted analysis, patients who died within the first year following injury were more likely to be older (OR = 1.03; 95% CI = 1.01 to 1.05) and male (OR = 1.67; 95% CI = 1.05 to 2.69). A higher Injury Severity Score, lower Glasgow Coma Scale score, and higher Charlson Comorbidity Index at presentation were also influential factors. The final model explained 81% (95% CI = 81% to 83%) of the variation in survival.

CONCLUSIONS: We identified a previously underappreciated fact: thoracolumbar fractures are associated with a mortality risk comparable with that of hip fractures. The risk of mortality is greatest in elderly patients and those with multiple comorbidities. The results of our model can be used in patient and family counseling, informed decision-making, and resource allocation to mitigate the potential risk of near-term mortality in high-risk individuals.

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

PMID:39813477 | DOI:10.2106/JBJS.24.00706

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.24.00347. Online ahead of print.

ABSTRACT

Published in 2003 by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care placed an unprecedented spotlight on disparities in the U.S. health-care system. In the 2 decades since the publication of that landmark report, disparities continue to be prevalent and remain an important significant national concern. This article synthesizes the evolution, current state, and future of racial and ethnic disparities in the use of elective total joint replacement surgeries. We contextualize our impressions with respect to the recommendations of the Unequal Treatment Report.

PMID:39813469 | DOI:10.2106/JBJS.24.00347

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.23.01351. Online ahead of print.

ABSTRACT

BACKGROUND: Rotator cuff repair (RCR) is a frequently performed outpatient orthopaedic surgery, with substantial financial implications for health-care systems. Time-driven activity-based costing (TDABC) is a method for nuanced cost analysis and is a valuable tool for strategic health-care decision-making. The aim of this study was to apply the TDABC methodology to RCR procedures to identify specific avenues to optimize cost-efficiency within the health-care system in 2 critical areas: (1) the reduction of variability in the episode duration, and (2) the standardization of suture anchor acquisition costs.

METHODS: Using a multicenter, retrospective design, this study incorporates data from all patients who underwent an RCR surgical procedure at 1 of 4 academic tertiary health systems across the United States. Data were extracted from Avant-Garde Health's Care Measurement platform and were analyzed utilizing TDABC methodology. Cost analysis was performed using 2 primary metrics: the opportunity costs arising from a possible reduction in episode duration variability, and the potential monetary savings achievable through the standardization of suture anchor costs.

RESULTS: In this study, 921 RCR cases performed at 4 institutions had a mean episode duration cost of $4,094 ± $1,850. There was a significant threefold cost variability between the 10th percentile ($2,282) and the 90th percentile ($6,833) (p < 0.01). The mean episode duration was registered at 7.1 hours. The largest variability in the episode duration was time spent in the post-acute care unit and the ward after the surgical procedure. By reducing the episode duration variability, it was estimated that up to 640 care-hours could be saved annually at a single hospital. Likewise, standardizing suture anchor acquisition costs could generate direct savings totaling $217,440 across the hospitals.

CONCLUSIONS: This multicenter study offers valuable insights into RCR cost as a function of care pathways and suture anchor cost. It outlines avenues for achieving cost-savings and operational efficiency. These findings can serve as a foundational basis for developing health-economics models.

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

PMID:39813412 | DOI:10.2106/JBJS.23.01351

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.23.01480. Online ahead of print.

ABSTRACT

BACKGROUND: Oblique lumbar interbody fusion (OLIF) results in less tissue damage than in other surgeries, but immediate postoperative pain occurs. Notably, facet joint widening occurs in the vertebral body after OLIF. We hypothesized that the application of a facet joint block to the area of widening would relieve facet joint pain. The purpose of this study was to evaluate the analgesic effects of such injections on postoperative pain.

METHODS: This double-blinded, placebo-controlled study randomized patients into 2 groups. Patients assigned to the active group received an intra-articular injection of a compound mixture of bupivacaine and triamcinolone, whereas patients in the placebo group received an equivalent volume of normal saline solution injection. Back and dominant leg pain were evaluated with use of a visual analog scale (VAS) at 12, 24, 48, and 72 hours postoperatively. Clinical outcomes were evaluated preoperatively and at 6 months postoperatively with use of the Oswestry Disability Index (ODI) and VAS for back and dominant leg pain.

RESULTS: Of the 61 patients who were included, 31 were randomized to the placebo group and 30 were randomized to the active group. Postoperative fentanyl consumption from patient-controlled analgesia was higher in the placebo group than in the active group at up to 36 hours postoperatively (p < 0.001) and decreased gradually in both groups. VAS back pain scores were significantly higher in the placebo group than in the active group at up to 48 hours postoperatively. On average, patients in the active group had a higher satisfaction score (p = 0.038) and were discharged 1.3 days earlier than those in the placebo group.

CONCLUSIONS: The use of an intraoperative facet joint block decreased pain perception during OLIF, thereby reducing opioid consumption and the severity of postoperative pain. This effect was also associated with a reduction in the length of the stay.

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

PMID:39813409 | DOI:10.2106/JBJS.23.01480

J Bone Joint Surg Am. 2024 Nov 21. doi: 10.2106/JBJS.24.00012. Online ahead of print.

ABSTRACT

BACKGROUND: Risk factors for gluteal tears include age-related deterioration, female sex, and increased body mass index. As the literature that supports the sagittal relationship between the lumbar spine and the hip is increasing, there may be a parallel relationship between the perturbations in spinopelvic alignment caused by lumbar spine disease and gluteal muscle tears. Because no prior studies other than single-institution series have reported on this phenomenon, we investigated spine-abductor syndrome at the population level.

METHODS: This study utilized TriNetX, a federated research network that continuously aggregates deidentified electronic health record data from >92 million patients across the United States. The relative risks of gluteal tear encounter diagnoses and procedures were calculated for patients with and without the following characteristics: age ≥45 years, female sex, obesity, lumbar spine diagnoses, lumbar spine injections, and lumbar spine surgery. Utilizing the Cox proportional hazard model, we also analyzed gluteal tear-free survival over a period of ≥10 years in subgroups of patients who had been diagnosed with lumbar pathology, had been administered a lumbar injection, or had received lumbar surgery.

RESULTS: Of the 8,475,800 patients who had received lumbar spine diagnoses, undergone lumbar injections, and/or undergone lumbar surgeries, 458,311 patients (5.4%) had gluteal tears, representing a relative risk of 13.6 (95% confidence interval [CI]:13.6 to 13.6). After controlling for age, sex, and obesity, survival analysis showed markedly increased hazard ratios (HRs) for patients having a gluteal tear encounter diagnosis in the intervening 13 years (2010 to 2023) if they had had a previous lumbar spine pathology encounter diagnosis (HR: 4.8, 95% CI: 4.5 to 5.1), had undergone lumbar spine injections (HR: 7.7, 95% CI: 6.2 to 9.5), or had undergone lumbar spine surgery (HR: 6.6, 95% CI: 5.3 to 8.1) in 2010.

CONCLUSIONS: These findings suggest a strong association between lumbar spine pathology and abductor tears. Further biomechanical and neuroanatomic studies may elucidate the effects of lumbar spine disease in relation to gluteal tears. Additionally, there may be a need to optimize diagnostic protocols for lateral hip pain in patients with a history of lumbar spine disease.

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

PMID:39813406 | DOI:10.2106/JBJS.24.00012

J Bone Joint Surg Am. 2025 Jan 15;107(2):e6. doi: 10.2106/JBJS.24.01077. Epub 2025 Jan 15.

NO ABSTRACT

PMID:39812729 | DOI:10.2106/JBJS.24.01077

J Bone Joint Surg Am. 2025 Jan 15;107(2):e5. doi: 10.2106/JBJS.24.01004. Epub 2025 Jan 15.

NO ABSTRACT

PMID:39812728 | DOI:10.2106/JBJS.24.01004

J Bone Joint Surg Am. 2025 Jan 15;107(2):209-216. doi: 10.2106/JBJS.24.00357. Epub 2024 Nov 21.

ABSTRACT

➢ Advanced care planning most commonly refers to the act of planning and preparing for decisions with regard to end-of-life care and/or serious illness based on a patient's personal values, life goals, and preferences.➢ Over time, advanced care planning and its formalization through advanced directives have demonstrated substantial benefits to patients, their families and caregivers, and the larger health-care system.➢ Despite these benefits, advanced care planning and advanced directives remain underutilized.➢ Orthopaedic surgeons interact with patients during sentinel events, such as fragility hip fractures, that indicate a decline in the overall health trajectory.➢ Orthopaedic surgeons must familiarize themselves with the concepts and medicolegal aspects of advanced care planning so that care can be optimized for patients during sentinel health events.

PMID:39812727 | DOI:10.2106/JBJS.24.00357

J Bone Joint Surg Am. 2025 Jan 15;107(2):196-207. doi: 10.2106/JBJS.23.01289. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: No studies have evaluated the impact of the cement distribution as classified on the basis of the fracture bone marrow edema area (FBMEA) in magnetic resonance imaging (MRI) on the efficacy of percutaneous vertebral augmentation (PVA) for acute osteoporotic vertebral fractures.

METHODS: The clinical data of patients with acute, painful, single-level thoracolumbar osteoporotic fractures were retrospectively analyzed. The bone cement distribution on the postoperative radiograph was divided into 4 types according to the distribution of the FBMEA on the preoperative MRI. The primary outcomes were the postoperative visual analog scale (VAS) for pain and Oswestry Disability Index (ODI) scores. Cement leakage, adjacent vertebral fractures (an important concern in complications after vertebroplasty and a subset of new fractures), and recollapse of the treated vertebra were also evaluated.

RESULTS: A total of 128 patients, 80.5% of whom were female, were included and had follow-up for 24 months. The mean patient age (and standard deviation) was 74.2 ± 8.6 years. The cement distribution was classified as Type I in 18 patients, Type II in 26, Type III in 46, and Type IV in 38. At the primary time point (6 months), there was a significant difference in the ODI score favoring the Type-III and Type-IV groups compared with the Type-I and Type-II groups (adjusted 95% confidence interval [CI]: Type I versus Type II, -2.40 to 4.50; Type I versus Type III, 1.35 to 7.63; Type I versus Type IV, 1.27 to 7.92; Type II versus Type III, 0.67 to 6.21; Type II versus Type IV, 0.63 to 6.46; adjusted p < 0.0083), whereas no significant differences were found between the 4 groups in the VAS pain score. The Type-II and Type-IV groups had a higher incidence of cement leakage, and the Type-III and Type-IV groups had a lower incidence of vertebral recollapse.

CONCLUSIONS: An adequate distribution of bone cement is advantageous for functional improvement, short-term pain relief, and a lower rate of vertebral recollapse. The FBMEA appears to be a feasible reference marker for evaluating the performance of the PVA procedure.

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

PMID:39812726 | DOI:10.2106/JBJS.23.01289

J Bone Joint Surg Am. 2025 Jan 15;107(2):174-183. doi: 10.2106/JBJS.24.00390. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: Although the majority of intertrochanteric femoral fractures in the United States are now treated with cephalomedullary nailing, it remains uncertain whether differences in clinical performance by nail type exist. The purpose of this study was to compare the aseptic revision rates associated with the 3 most commonly utilized cephalomedullary nails in the United States today: the Gamma nail (Stryker), the INTERTAN (Smith+Nephew), and the Trochanteric Fixation Nail/Trochanteric Fixation Nail Advanced (TFN/TFNA; DePuy Synthes).

METHODS: Using an integrated health-care system's hip fracture registry, patients ≥60 years of age who were treated with 1 of these 3 commonly used cephalomedullary nail devices were identified. Potential confounders were identified and controlled for, including age, gender, race or ethnicity, body mass index, smoking status, American Society of Anesthesiologists classification, anesthesia type, Elixhauser comorbidities, and the operating surgeon. Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) by cephalomedullary nail type, with mortality and revisions unrelated to the index fracture considered as competing events.

RESULTS: There were 19,215 patients included in the study sample (71.4% female, 77.0% White), including 4,421 in the Gamma nail group, 2,350 in the INTERTAN nail group, and 12,444 in the TFN/TFNA nail group. In the multivariable analysis involving nails of all lengths, the INTERTAN group was found to have a higher risk of aseptic revision compared with the TFN/TFNA group (8-year crude revision rate, 2.9% compared with 1.8%; hazard ratio [HR], 1.62 [95% confidence interval (CI), 1.15 to 2.27]; p = 0.006). The increased risk associated with the INTERTAN nail was primarily seen among the long nails (HR, 1.83 [95% CI, 1.16 to 2.87]; p = 0.009) rather than the short nails (HR, 1.36 [95% CI, 0.87 to 2.11]; p = 0.18). There were no differences in aseptic revision observed between the Gamma group and the TFN/TFNA group.

CONCLUSIONS: In this study of 19,215 patients with a hip fracture treated with cephalomedullary nailing, the INTERTAN nail was found to have a significantly higher risk of aseptic revision. Further research is required to determine whether these results could be related to the unique design of this implant.

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

PMID:39812725 | DOI:10.2106/JBJS.24.00390

J Bone Joint Surg Am. 2025 Jan 15;107(2):163-173. doi: 10.2106/JBJS.24.00184. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

METHODS: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

RESULTS: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

CONCLUSIONS: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

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

PMID:39812724 | DOI:10.2106/JBJS.24.00184

J Bone Joint Surg Am. 2025 Jan 15;107(2):144-151. doi: 10.2106/JBJS.24.00245. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: In the setting of cervical open-door laminoplasty, the question of whether or not every opened laminar level should be instrumented has not been sufficiently investigated. We postulated that the surgical outcomes of open-door laminoplasty with instrumentation of every second opened level (skip-fixation) might not be inferior to those of laminoplasty with instrumentation of every opened level (all-fixation). The purpose of the present study was to test the noninferiority of laminoplasty with skip-fixation in improving myelopathy at 2 years postoperatively compared with all-fixation. Additionally, we compared radiographic and surgical outcomes between the 2 types of procedures.

METHODS: This prospective, multicenter, unblinded randomized controlled trial included patients ≥60 years of age who underwent C3 to C6 open-door cervical laminoplasty for the treatment of degenerative cervical myelopathy. Patients were allocated to the skip-fixation group (n = 80) or the all-fixation group (n = 75) using a permuted block method. The primary outcome was the between-group difference in the Japanese Orthopaedic Association (JOA) score at 2 years postoperatively. Secondary outcomes included surgical data, complications, 2-year change in the JOA score, Neck Disability Index (NDI), EQ-5D-5L (EuroQol 5-dimension 5-level instrument) score, visual analog scale (VAS) score for neck pain, and radiographic outcomes.

RESULTS: One hundred and thirty patients (including 66 in the skip-fixation group and 64 in the all-fixation group) completed the trial at 2 years (follow-up rate, 83.9%). The difference in the JOA score at 2 years was 0.0298 (95% confidence interval [CI], -0.706 to 0.766), which was within the noninferiority margin (p < 0.0001; noninferiority test). In the secondary analyses, laminoplasty with skip-fixation demonstrated a significantly shorter surgical time (p = 0.010; Mann-Whitney U test) and greater improvement in the VAS score for neck pain, NDI, and EQ-5D-5L score (p = 0.006, p = 0.047, p = 0.037, respectively; mixed-effect model) compared with all-fixation. There were no significant between-group differences in radiographic outcomes, including the hinge union rate.

CONCLUSIONS: Skip-fixation may be sufficient to achieve noninferior 2-year postoperative improvement in myelopathy. Additionally, laminoplasty with skip-fixation potentially can lead to improvements in terms of neck pain, neck disability, and quality of life compared with all-fixation.

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

PMID:39812723 | DOI:10.2106/JBJS.24.00245

J Bone Joint Surg Am. 2025 Jan 15;107(2):134-143. doi: 10.2106/JBJS.24.00309. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Early knee effusion is a common phenomenon after total knee arthroplasty (TKA), with potential clinical implications. Unlike traditional alloy knee prostheses, the polyetheretherketone (PEEK) knee system has radiographic transparency on magnetic resonance (MR) scans, which allows analysis of prosthetic knee effusion. We aimed to identify the distribution and volume of knee effusion after TKA with the PEEK prosthesis with use of MR imaging and to analyze whether dynamic changes in effusion were correlated with serum inflammatory marker changes and knee function recovery.

METHODS: Nine patients with osteoarthritis who were 59 to 74 years old underwent unilateral TKA with the PEEK prosthesis between June 2021 and August 2021. Dynamic early postoperative changes in the volume and distribution of knee effusion were evaluated with use of 3D MR stereoscopic images. Serum inflammatory markers were measured via blood tests, and joint function was evaluated with use of the subjective functional score of the Knee Society Score (KSS) and knee range of motion (ROM). Linear regression analyses were performed to assess for correlations between knee effusion volume and inflammatory markers and between knee effusion volume and joint function.

RESULTS: The mean serum inflammatory marker levels increased significantly at 1 week after TKA with the PEEK prosthesis and then gradually decreased with time from 1 to 6 months. The mean total knee effusion volume gradually decreased over time. Concurrently, the mean KSS subjective functional score and mean knee ROM improved with time. Total knee effusion volume was positively correlated with C-reactive protein level (R2 = 0.16; p = 0.007) and negatively correlated with the change in KSS score between the preoperative and postoperative time points (R2 = 0.19; p = 0.003). Using the 1-week total knee effusion volume as a reference, a positive correlation was observed between the reduction in total knee effusion volume and the actual value of the ROM (R2 = 0.36; p = 0.0001) from 3 to 24 months postoperatively.

CONCLUSIONS: Through 3D MR imaging, the precise distribution and volume of, and dynamic changes in, knee effusion after TKA with the PEEK prosthesis were confirmed and were found to be correlated with inflammation and joint function in the early postoperative period. The results demonstrate the potential clinical benefit of the PEEK-based knee system for future use.

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

PMID:39812722 | PMC:PMC11717431 | DOI:10.2106/JBJS.24.00309

J Bone Joint Surg Am. 2025 Jan 15;107(2):127-133. doi: 10.2106/JBJS.23.01118. Epub 2024 Nov 22.

ABSTRACT

BACKGROUND: Antiseptic solutions are commonly utilized during total joint arthroplasty (TJA) to prevent and treat periprosthetic joint infection (PJI). The purpose of this study was to investigate which antiseptic solution is most effective against methicillin-sensitive Staphylococcus aureus (MSSA) and Escherichia coli biofilms established in vitro on orthopaedic surfaces commonly utilized in total knee arthroplasty: cobalt-chromium (CC), oxidized zirconium (OxZr), and polymethylmethacrylate (PMMA).

METHODS: MSSA and E. coli biofilms were grown on CC, OxZr, and PMMA discs for 24 and 72 hours. Biofilm-coated discs were treated with control or various antiseptic solutions for 3 minutes. Solutions included 10% povidone-iodine, a 1:1 mixture of 10% povidone-iodine plus 3% hydrogen peroxide, diluted povidone-iodine, 0.05% chlorhexidine gluconate, and a surfactant-based formulation of ethanol, acetic acid, sodium acetate, benzalkonium chloride, and water. Following treatment, discs were sonicated to quantify adherent bacteria or underwent imaging with scanning electron microscopy to identify biofilm. Antiseptic solutions were considered efficacious if they produced a 3-log (1,000-fold) reduction in colony-forming units compared with controls.

RESULTS: On both OxZr and CC, 10% povidone-iodine with hydrogen peroxide eradicated all MSSA, and it achieved clinical efficacy on PMMA at both 24-hour MSSA biofilm (p < 0.0002) and 72-hour MSSA biofilm (p = 0.002). On 72-hour MSSA biofilm, 10% povidone-iodine eradicated all bacteria on OxZr and CC, and it achieved clinical efficacy on PMMA (p = 0.04). On 24-hour MSSA biofilm, 10% povidone-iodine achieved efficacy on all surfaces (all p < 0.01). The surfactant-based formulation only achieved clinical efficacy on 72-hour MSSA biofilms on CC (p = 0.04) and OxZr (p = 0.07). On 72-hour E. coli biofilm, 10% povidone-iodine with or without hydrogen peroxide achieved clinical efficacy on all surfaces. No other solution achieved clinical efficacy on either MSSA or E. coli.

CONCLUSIONS: Antiseptic solutions vary considerably in efficacy against bacterial biofilm. The 10% povidone-iodine solution with or without hydrogen peroxide consistently removed MSSA and E. coli biofilms on multiple orthopaedic surfaces and should be considered for clinical use.

CLINICAL RELEVANCE: Clinicians should be aware of the differences in the efficacy of antiseptic solutions on different orthopaedic surfaces when treating MSSA or E. coli biofilms.

PMID:39812721 | DOI:10.2106/JBJS.23.01118