Scapula fracture is an uncommon high-velocity injury often missed in a polytrauma setting. Most are managed conservatively. Operative management is indicated in select situations, though there are no guidelines currently available to help make such a decision. Surgery is challenging due to the rarity of scapular fractures, their complex anatomy, the need for specialized implants and the technical skill required for such fixation. In the case of neglected scapular fractures, these issues are further exacerbated by the patient’s delayed presentation. A thorough knowledge of anatomy is required to restore the essential strut stability of the scapula during minimally invasive surgery. This is essential for early mobilization of the shoulder girdle and good functional outcome.A narrative review of the various types of scapular fracture and their classification system is provided below with clinical cases and operative pearls. It also summarizes the diagnostic challenges, indications for delayed surgical intervention, technical considerations, current evidence, emerging technologies including three-dimensional planning, and practical recommendations for managing neglected scapular fractures.
Background Total Hip Arthroplasty (THA) is one of the most frequently performed orthopaedic procedures worldwide. The direct anterior approach (DA) is increasingly utilised as a minimally invasive, muscle-sparing technique that allows quicker recovery. However, concerns remain regarding component positioning due to the limited access to the acetabulum and femur, particularly in the absence of robotic assistance. This study aimed to compare radiological parameters of implant positioning in conventional THA performed via DA and the posterolateral approach (PL). Methods A retrospective case-control study was conducted on 100 patients (50 DA, 50 PL) who underwent primary THA for end-stage osteoarthritis or avascular necrosis. All procedures were performed by a single surgeon experienced in both approaches. Postoperative radiographs were assessed by two independent, blinded observers for acetabular inclination, anteversion, femoral offset, and limb length discrepancy (LLD). Statistical analysis was performed using an unpaired Student’s t-test and Mann-Whitney U test, with p < 0.05 considered significant. Results The mean acetabular inclination was 42.7° ± 3.1° in the DA group and 40.2° ± 4.7° in the PL group (p = 0.045). Mean anteversion (16.3° ± 3.9° vs. 16.8° ± 3.3°, p = 0.895) and LLD (10.7 mm ± 11.1 vs. 9.5 mm ± 7.6, p = 0.703) showed no significant difference. No periprosthetic fractures or LFCN injuries were noted in the DA group. Conclusion Implant positioning in the DA can be comparable to that achieved with the posterior approach when performed by an experienced surgeon. The use of intraoperative fluoroscopy in DA provides an added advantage. As a minimally invasive, muscle-sparing technique with proven early functional benefits and comparable radiological parameters, the DA represents a reliable option for primary THA.
Background Surgical site infection (SSI) and periprosthetic joint infection (PJI) are high-impact complications after orthopaedic surgery. Chronic systemic corticosteroids are commonly prescribed and associated with increased infection risk, but published estimates vary by procedure type and patient population. Methods We conducted a PRISMA-concordant systematic review and meta-analysis of comparative studies reporting SSI and/or PJI after orthopaedic surgery in adults with and without chronic preoperative oral corticosteroid exposure (PROSPERO registration ID: CRD420251005435). Dichotomous outcomes were converted to 2×2 tables and pooled as odds ratios (ORs) using a random-effects model. Prespecified subgroup analyses evaluated immunocompromised status, orthopaedic surgery type, and practice registry versus database cohorts. Results The 29 studies included 1,316,521 patients, of whom 98,512 were chronic oral corticosteroid users; 26 studies contributed to the meta-analysis. Follow-up was most commonly 30 days in database cohorts but ranged up to 84 months. Mean reported age ranged from 32–70 years; females accounted for 37–88% overall. Chronic preoperative oral corticosteroid use was associated with increased odds of SSI/PJI (pooled OR 1.40, 95% CI 1.32–1.49). Odds of infection were elevated in immunocompromised cohorts (OR 1.35 (95% CI 1.12-1.63) and in non-immunocompromised cohorts (OR 1.41, 95% CI 1.32-1.51). Registry-only studies showed higher odds (OR 1.90, 95% CI 1.21-2.97) than database-only studies (OR 1.39, 95% CI 1.31–1.49). By procedure, odds were higher in spine surgery (OR 1.48, 95% CI 1.36–1.60), hip/knee arthroplasty (OR 1.29, 95% CI 1.17–1.42), and other orthopaedic procedures (OR 2.36, 95% CI 1.40–4.00). Conclusion Chronic preoperative oral corticosteroid exposure demonstrated increased odds of SSI/PJI across major orthopaedic procedures. These findings support risk counseling and multidisciplinary preoperative optimization for patients requiring chronic systemic oral corticosteroids.
Infections associated with Orthopaedic implants, particularly periprosthetic joint infections and fracture-related infections, represent complications of extremely high morbidity, lethality, and cost. Massive contamination of the surgical field by accidental intraoperative faecal discharge is a catastrophic event from a microbiological standpoint — owing to the high burden of biofilm-forming pathogens such as Enterococcus spp. — yet it remains an underreported phenomenon without standardized management in the Orthopaedic literature. The objective was to map available evidence on the impact of peri- and intraoperative faecal discharge on surgical site infection (SSI) and to propose a risk classification algorithm and immediate management protocol to mitigate inoculation in clean Orthopaedic surgeries. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) criteria. The structured search was designed to encompass the period from anesthetic induction to procedure completion, and was performed in MEDLINE/PubMed, Embase, Scopus, and Cochrane Library databases. Given the scarcity of direct Orthopaedic data, studies from related surgical fields on intestinal spillage and intraoperative adverse events were included for translational extrapolation. Eighteen studies were included. The literature demonstrated that enteric content inoculation is independently associated with severe rates of therapeutic failure, lethality, and the need for reoperations. Current Orthopaedic guidelines focus on primary prevention and do not provide rescue protocols for dramatic aseptic breaches. A three-dimensional classification system is proposed based on the extent of the event (A0 to A3), stool consistency (B1 to B3), and the biological vulnerability of the procedure (C0 to C2), generating risk classes that guide redraping, instrument exchange, irrigation, reassessment of antibiotic therapy, and even procedure suspension. Peri- and intraoperative faecal discharge should be institutionally recognized as a formal "Intraoperative Adverse Event." The application of a pragmatic, multidimensional protocol standardizes actions, reduces team inertia, and minimizes the potential bacterial inoculum, thereby mitigating the biological catastrophe associated with biofilm formation.
Early-onset scoliosis (EOS) comprises a heterogeneous group of spinal deformities diagnosed before the age of ten years, including idiopathic, congenital, neuromuscular, and syndromic etiologies. Management remains particularly demanding because treatment must simultaneously address deformity progression while preserving spinal growth, thoracic development, and pulmonary function. Despite major advances over the past two decades, treatment strategies continue to vary considerably and no universally accepted algorithm has been established.This review examines the current role of conservative and surgical treatment modalities for EOS and discusses their respective indications, benefits, and limitations. Nonoperative management remains the preferred initial approach for most progressive deformities. Bracing may delay curve progression, particularly in idiopathic EOS, although outcomes are influenced by curve magnitude, patient age, brace compliance, and family support. In congenital, neuromuscular, and syndromic scoliosis, its effectiveness is generally more limited. Serial casting represents a valuable option for younger children and for more severe deformities, especially in idiopathic EOS, where substantial correction may occasionally be achieved. However, repeated cast applications may be associated with local complications and, when performed under general anesthesia, expose patients to cumulative anesthetic risks.When conservative treatment fails or when progressive deformity threatens thoracic growth and respiratory function, surgical intervention becomes necessary. Contemporary management favors growth-preserving techniques rather than early definitive fusion, which has been shown to compromise spinal and thoracic development. Magnetically controlled growing rods currently represent the most widely adopted growth-friendly strategy, although complication and reoperation rates remain substantial. Emerging technologies, including modern Luque trolley constructs, one-way self-expanding rods, and spring-based distraction systems, may further reduce the burden of repeated surgical procedures.Successful management of EOS requires individualized decision-making based on etiology, deformity severity, growth potential, and overall patient condition. Regardless of the selected treatment pathway, families should be counselled regarding the prolonged nature of care and the persistent risk of complications throughout childhood.
Background:Subchondral cysts of the femoral head have been commonly regarded as indicators of joint degeneration in developmental dysplasia of the hip (DDH), attributed to excessive stress and mechanical overload. Whether such cysts constitute a contraindication to periacetabular osteotomy (PAO) in young hips remains controversial. The aim of this study was to determine early outcomes after PAO in young dysplastic hips in which a subchondral femoral head cyst with an intact cartilage cap was identified. Methods:An institutional PAO database was utilized, and hips undergoing PAO between January 2022 and December 2023 were identified. Preoperative magnetic resonance imaging (MRI) studies were reviewed for the presence of subchondral femoral cysts, and hips were stratified into groups with and without such cysts. Radiographic and demographic data were compared between groups. Preoperative and 1-year postoperative patient-reported outcome measures (PROMs; mHHS, iHOT-12) were collected and compared. Proportions of hips achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) following PAO were calculated and compared. Results:A total of 107 hips were included; 21 (20%) were found to have subchondral femoral cysts and 86 (80%) were found not to have cysts. No significant differences in demographic or radiographic parameters were identified between groups. PROMs for hips with subchondral cysts were observed to be slightly lower pre- and postoperatively. Significant improvements in PROMs were observed in both groups at 1-year follow-up. A higher proportion of hips with subchondral cysts achieved MCID for both mHHS and iHOT-12. For PASS, the proportion of hips reaching the threshold was higher in the cyst group for mHHS, whereas it was higher in the non-cyst group for the iHOT-12. Conclusion:Periacetabular osteotomy yielded significant improvements in PROMs despite the presence of a structural cystic subchondral lesion under an intact cartilage cap. The greater improvements in mHHS and iHOT-12 observed among hips with subchondral cysts are suggested to reflect a higher baseline symptom burden, indicating that greater potential for functional improvement may be achieved once dysplastic biomechanics and associated overload and instability are corrected.
Antibiotic-eluting bone void fillers have emerged as an important adjunct in the management of orthopaedic infections, combining defect reconstruction with high local antibiotic delivery. Although these materials are increasingly utilized in trauma, oncologic reconstruction, and chronic osteomyelitis, the literature lacks a comprehensive clinical review focused specifically on antibiotic-eluting systems. Therefore, the purpose of this study was to evaluate the material characteristics and clinical applications of antibiotic-eluting bone void fillers used in orthopaedic practice. A review of the current literature highlighting the uses of antibiotic-eluting bone void fillers in orthopaedic trauma, oncology, and infection management was performed utilizing peer-reviewed sources from PubMed, SCOPUS, and Google Scholar. Polymethylmethacrylate (PMMA) remains the historical standard for local antibiotic delivery but is limited by non-resorbability and incomplete antibiotic elution. Resorbable calcium-based carriers, particularly calcium sulfate and biphasic calcium sulfate-hydroxyapatite composites, demonstrate high infection eradication rates in chronic osteomyelitis and fracture-related infection while eliminating the need for secondary removal procedures. Calcium phosphate ceramics provide sustained structural support with variable antibiotic release kinetics. Bioactive glass exhibits intrinsic antimicrobial activity without antibiotic incorporation and has shown favorable outcomes in selected infection settings. Across reviewed studies, calcium sulfate carriers demonstrated infection eradication rates approaching 92%, while biphasic calcium sulfate-hydroxyapatite composites achieved eradication rates up to 96% in chronic osteomyelitis series. Similarly, S53P4 bioactive glass demonstrated infection control rates of approximately 90-92.6% despite not requiring direct antibiotic incorporation. Local antibiotic carriers consistently achieve high local drug concentrations with minimal systemic toxicity, though complication profiles vary by material composition and resorption behavior. Antibiotic-eluting bone void fillers have expanded antimicrobial and reconstructive capabilities in orthopaedic trauma, oncology, and infection management. While no single material is universally superior, optimal outcomes require integration of these materials with meticulous debridement, stable fixation, and appropriate systemic therapy. Continued comparative clinical studies are needed to refine material selection and generate standardized treatment algorithms.
BACKGROUND A common treatment strategy for PJI following THA is a two-stage revision THA, which includes a temporary antibiotic cement spacer (ACS). There are no standard guidelines on the safe and effective dose of antibiotics that can be added to an ACS. Thus, the aim of this study was to evaluate, using a self-controlled design, the safety profile of a very high-dose ACS, particularly as it related to renal function. METHODS All patients treated with a completed two-stage revision THA for PJI at a single centre between 2004 and 2023 were included. Patients were treated using an ACS with a mean 8g of antibiotics per bag of medium viscosity cement. The primary outcome was the difference in creatinine rise between the first and second stage, for each patient. Secondary outcomes included the proportion of patients experiencing acute kidney injury (AKI), and the cure rate of PJI treatment. Patients served as their own controls from the first to second stage, with creatinine rise compared between the two stages using a repeated measures analysis of variance (ANOVA). RESULTS A total of 68 patients were included. The repeated measures ANOVA revealed no significant within-patient differences between the first- and second-stage creatinine values. The overall incidence of AKI was 1.5% (1/68), with the only case coming after a 1st first-stage procedure. The single patient who developed AKI had a history of diabetes mellitus and experienced transient renal dysfunction, returning to baseline renal function within two weeks. CONCLUSIONS The key finding of this study is that a very high-dose ACS is a safe option for patients undergoing two-stage revision for THA PJI with a very high-dose ACS are not at an elevated risk of AKI, and that the impact on kidney function is similar between the first and second stage procedures.
Background The fractures of distal end radius, especially with an intraarticular component are common even in the developed world. Recently the advent of fragment specific anatomic plates for the distal radius have emerged as the implant of choice for these fractures. Despite the choices available for treating distal radius fractures, it is practically difficult to stabilize marginal volar fragments. In such situations, the k-wires with narrow diameter can be used as a spring wire in addition to plate to stabilize the fragment. In this article we tried to systematically review the outcomes of spring wire technique in volar marginal fragments of distal end radius fractures. Methods The registration ID of this study in PROSPERO is CRD4202613008653. The studies which described various treatment methods of fractures of distal radius with rim fragment on volar side using spring wires(K-wires) to stabilize the volar rim fragment were included. Outcomes such as change in grip strength, improvement in range of movements (ROM) and complications like loss of reduction, nerve injury, tendon injury, implant removal were recorded. Results The PRISMA methodology was followed to arrive at the selected studies. Among six included studies, four were retrospective studies and only one was prospective study. All the studies had a quality score of more than 9/14 and were subsequently included in the analysis. The review included a total of 56 patients. All the studies showed good outcomes after the spring wire technique. The movements at the wrist joint were reported by all the studies and grip strength was reported by two studies. Conclusion The spring wire technique is reliable and a low-cost measure to take care of the volar rim fragments. Though there are no studies reporting formal cost-analysis of this technique, the K-wires are readily available in all the setups which make this an attractive option.
Biofilm formation on prosthetic joint surfaces is a key mechanism causing treatment failure in prosthetic joint infection, and intraoperative irrigation is routinely used during debridement, antibiotics, and implant retention and revision surgery. Clinical evidence directly supporting biofilm-disrupting irrigation solutions in established PJI is limited and unclear. This scoping review mapped clinical evidence evaluating defined biofilm-disrupting irrigation strategies used during surgery for established hip and knee prosthetic joint infection and identified existing evidence gaps. A scoping review was structured in accordance with PRISMA-ScR guidance. PubMed, Scopus and Embase were searched. Clinical studies in adults undergoing surgery for established PJI that reported clinical outcomes associated with a defined irrigation solution with intended biofilm-disrupting activity beyond normal saline were eligible. Prevention-only arthroplasty studies were charted separately for context. Data were recorded on study design, population, causative organisms, surgical procedure, irrigant protocol, comparators, follow-up, outcome definitions and adverse events. Semi-quantitative descriptive analysis and MINORS risk of bias assessment was undertaken. Four clinical studies met inclusion criteria, all retrospective observational or comparative cohorts. The available evidence primarily involved povidone-iodine & hydrogen peroxide sequences, vancomycin-povidone iodine protocolised irrigation, and Bactisure® based irrigation during debridement, antibiotics and implant retention. Comparative studies reported variable findings: protocolised povidone-iodine/hydrogen peroxide and vancomycin-povidone iodine approaches were associated with lower failure in selected cohorts, whereas Bactisure® did not significantly reduce DAIR failure compared with standard DAIR in the largest comparative cohort. Interpretation is limited by small study numbers, retrospective design, heterogeneous infection timing, organism profiles, host factors, component exchange practices, antimicrobial regimens, and inconsistent outcome definitions. Prevention-only arthroplasty lavage studies were considered contextual evidence only and should not be extrapolated directly to established PJI. Current evidence does not identify a superior irrigant or justify treatment recommendations. Future multicentre prospective trials should evaluate standardised irrigation protocols within standardised treatment bundles, use musculoskeletal infection society definitions, report adverse events and cytotoxicity, and include patient-reported outcomes and cost-effectiveness analysis.
Background Hip abductor tears are common and can cause severe limp and pain. Repair of gluteal tears often requires augmentation. Although current methods of gluteal augmentation have good reported outcomes, they can be costly and add an additional layer of complexity if they become infected because they rely on non-autologous materials. Based on the case series below, we report an alternative technique to augment gluteal tendon repair that uses vastus lateralis fascia. Methods Between 2022 and 2025, 23 hip abductor repairs augmented with a vastus lateralis fascia flap, following a primary or revision hip replacement, were performed. A functioning gluteus medius was confirmed intraoperatively using a superior gluteal nerve stimulator prior to repair. The patients were allowed to weight-bear as tolerated postoperatively and commenced abductor strengthening exercises at six weeks. Results Preoperatively, all patients had complaints of severe pain and weakness (excluding neck of femur fracture patients, who were not assessed preoperatively). At their last post-operative follow-up, 21 (91%) reported no pain and 20 (87%) had an abductor power ≥3/5. Six patients underwent subsequent operations on the same hip, during which good healing of the repair was observed. Of the 3 patients whose abductor power remained <3/5 postoperatively, 1 has since undergone a gluteal reconstruction with a deep muscle-sparing vastus lateralis to gluteus medius translational transfer/transposition, with the other patients awaiting the same. Conclusion Augmentation of hip abductor repair with a vastus lateralis fascia flap is a cost-effective autologous technique with encouraging early outcomes. To avoid performing gluteal repairs in patients who should undergo gluteal reconstruction, gluteal muscle function is tested with a nerve stimulator intraoperatively prior to every repair.
Background:Hamstring graft preparation in anterior cruciate ligament (ACL) reconstruction varies widely, with strand number often determined by tendon length or surgeon preference. The influence of internal strand geometry on graft mechanical behaviour and postoperative stability remains poorly understood. Methods:A geometric-mechanical framework was developed to characterize ACL graft constructs composed of two to six strands within a circular femoral tunnel. Spatial strand coordinates were used to derive four theoretical geometric descriptors: Symmetry Index (SI), effective polar moment of inertia (J_eff), Anisotropy Index (AI), and centroid displacement. Potential clinical relevance was explored in 162 patients undergoing primary ACL reconstruction with autologous hamstring grafts. Outcomes included anterior tibial translation, pivot-shift grade, and subjective IKDC score. Exploratory multivariable analyses adjusted for age, sex, pivoting sport participation, graft diameter, and follow-up duration. Results:Even-strand constructs, particularly four- and six-strand grafts, demonstrated greater symmetry, higher polar moment of inertia, and lower anisotropy. Odd-strand constructs showed greater centroid displacement and geometric asymmetry. Exploratory clinical analyses showed numerical associations between greater theoretical geometric symmetry and lower anterior laxity and residual pivot shift. These descriptors represent theoretical structural properties rather than direct measurements of biomechanical performance. Conclusion:Internal graft topology may represent a structural characteristic influencing ACL graft behaviour beyond diameter alone. However, this hypothesis was not directly tested biomechanically or through in vivo topology measurements. The observed clinical associations are exploratory and hypothesis-generating. This geometric framework provides a conceptual basis for future biomechanical, computational, and clinical investigations of strand configuration. Level of evidence:III.
Background:Scaphoid nonunion remains a challenging condition due to its tenuous vascularity and complex wrist biomechanics, often resulting in deformity, instability, and progressive degenerative changes. The modified Fisk-Fernandez technique combines structural bone grafting with stable fixation to address both biological and mechanical factors. Methods:This retrospective cohort study included 82 patients with scaphoid waist nonunion treated between 2017 and 2026. Clinical outcomes were assessed using QuickDASH and Visual Analog Scale (VAS) scores, while radiological evaluation included scapholunate angle and fracture union. Patients were followed for a minimum of 12 weeks and up to 9 years. Statistical analysis was performed using paired t-tests and regression analysis, with significance set at p < 0.05. Results:Union was achieved in 95.1% (78/82) of patients, with a mean time to union of 14.2 weeks. Significant improvement was observed in functional outcomes, with QuickDASH scores improving from 81.6 to 6.9 and VAS scores from 7.8 to 0.6 (p < 0.001). Radiological parameters demonstrated significant correction of scapholunate angle (68° to 46°, p < 0.001). Most patients reported good to favorable outcomes, with minimal complications and a low incidence of progression to SNAC wrist (3.6%). Conclusion:The modified Fisk-Fernandez technique provides reliable union, effective deformity correction, and sustained functional recovery in scaphoid nonunion. It represents a safe and reproducible surgical option, particularly in young and active patients. Level of evidence:Level IV.
The anterior approach to the hip joint has evolved from a broad, muscle-detaching exposure used for resections in the late 19th century to a refined, muscle-sparing technique, now widely employed for total hip arthroplasty (THA) and hip-preserving procedures. This review synthesises the surgical, technical, and conceptual developments that have shaped the modern anterior approach, with emphasis on contemporary refinements relevant to arthroplasty practice. Historical and technical literature, spanning from the original descriptions (Roser, Lücke, Hueter) to 20th and 21st century innovators (Kocher, Smith-Petersen, Levine, the Judets, Laude, Keggi, Matta, Berger, Leunig, and others), was synthesised to delineate chronological advances in exposure, femoral preparation, implant insertion, perioperative management, and cosmetic or ergonomic modifications. This review focused on changes that reduced soft-tissue injury, found solutions to femoral exposure challenges, and the introduction of adjuncts such as traction or positioning tables, intraoperative fluoroscopy, and navigation. The anterior approach has transitioned from a resection technique to a contemporary, muscle-sparing, inter-nervous approach for total hip arthroplasty (THA). Historical advances and modern refinements now enable reproducible acetabular and femoral procedures including revision arthroplasty, providing potential benefits in early recovery and cosmetic outcomes.
Background:Residual anterolateral rotatory laxity and graft failure remain important challenges following anterior cruciate ligament reconstruction (ACLR). Lateral extra-articular procedures (LEAPs), including Lateral Extra-articular Tenodesis (LET) and Anterolateral Ligament Reconstruction (ALLR), have gained renewed interest as adjuncts to ACLR; however, evidence comparing their effectiveness remains limited. The objective was to evaluate and compare the clinical and functional outcomes of LET and ALLR when performed in conjunction with ACLR. Methods:A systematic review (PROSPERO: CRD420251082815) was conducted according to PRISMA 2020 guidelines. PubMed, EMBASE, and Scopus databases were searched for studies published within the last 10 years. Randomized controlled trials, cohort studies, and case-control studies comparing LET and/or ALLR combined with ACLR and reporting clinical or functional outcomes were included. Risk of bias was assessed using the ROBINS-I tool, and methodological quality was evaluated using the CASP checklist. Due to limited direct comparative evidence and heterogeneity among studies, a qualitative synthesis was performed. Results:Seventeen studies met the inclusion criteria. Both LET and ALLR combined with ACLR demonstrated improved rotational stability, reduced pivot shift, and decreased instrumented anterior laxity compared with isolated ACLR. The addition of a LEAP was associated with lower graft failure rates. LET provided slightly superior control of rotatory instability, whereas ALLR was associated with faster return to sport, likely due to its anatomical reconstruction and less extensive soft-tissue dissection. Functional outcomes assessed using Lysholm, IKDC, KOOS, and Tegner scores were generally comparable. Hardware-related complications and reoperations were slightly more frequent with LET, although overall adverse event rates remained low. Conclusion:Augmentation of ACLR with either LET or ALLR improves knee stability and graft integrity, particularly in high-risk patients. ALLR may facilitate earlier return to sport, whereas LET may offer greater biomechanical restraint. Further high-quality randomized controlled trials with long-term follow-up are needed to establish definitive recommendations.
Background:Biologic augmentation is increasingly used across knee-preservation procedures, but evidence remains fragmented by procedure and biologic type. This review synthesised the available clinical evidence for biologic augmentation in meniscal repair, meniscus allograft transplantation (MAT), high tibial osteotomy (HTO), cartilage restoration, and osteochondral allograft (OCA) transplantation, with procedure-specific clinical interpretation. Methods:A systematic review on Ovid MEDLINE and OVID EMBASE was performed (PROSPERO CRD420261342726). Eligible studies were human clinical investigations evaluating a biologic adjunct used concurrently with knee-preservation surgery. Risk of bias was assessed using RoB 2 for randomised trials and MINORS for non-randomised studies. Because outcome measures were heterogeneous, formal pooled meta-analyses was not undertaken, and an exploratory study-level quantitative analysis was performed. Results:Twenty-three clinical studies were included: 5 meniscal repair studies, 1 MAT study, 10 HTO-based studies, and 7 cartilage restoration or OCA studies. Nineteen of 23 studies reported an overall favourable effect, although this proportion should be interpreted cautiously because uncontrolled study designs and selective publication of positive studies were common. Among 16 comparative studies, 12 (75.0%) showed favourable comparative outcomes. Cell-based comparative studies were more often favourable than non-cell-based strategies (8/9 [88.9%] vs 4/7 [57.1%]; odds ratio 6.0, 95% CI 0.46-77.75; Fisher exact p = 0.262). Formal risk-of-bias assessment identified 1 low-risk RCT and 4 with some concerns. Conclusion:Biologic augmentation should not currently be regarded as a routine strategy across knee-preservation surgery as a whole. The most coherent but still preliminary is selective use of cell-based augmentation in high tibial osteotomy-based cartilage-regeneration settings. Meniscal repair demonstrates a selective but inconsistent benefit, while evidence for meniscal allograft transplantation, focal cartilage restoration, and osteochondral allograft augmentation remains insufficient to support routine adoption. Future research should prioritise procedure-specific randomised trials, standardised reporting of biologic preparation and delivery methods, and greater emphasis on patient reported outcome measures alongside structural endpoints.
Background:Slipped Capital Femoral Epiphysis (SCFE) is an idiopathic hip disorder in adolescents. With or without surgery, avascular necrosis (AVN) is the most dangerous complication. For open reduction and internal fixation, the modified Dunn procedure is considered the gold standard. This study presents an open epiphyseal realignment through the Hueter-interval and reports on (1) surgical technique of direct anterior approach (DAA) based surgical realignment, (2) radiographic correction of biomechanics, and (3) AVN-incidence after surgery. Methods:A single-center retrospective case series was conducted including all patients who underwent open realignment for SCFE via the direct anterior approach between January 2014 and January 2025. Pre- and postoperative Southwick and alpha angles were measured by two independent observers. Complications, including avascular necrosis, chondrolysis, and degenerative changes, were assessed at final follow-up. Descriptive statistics were used. Interobserver agreement of radiographic measurements was assessed using the intraclass correlation coefficient (ICC). Results:Twelve patients (13 hips; 9 boys and 3 girls) were included. Median age and BMI were respectively 12.9 years old (IQR 12.2-13.7) and 23.1 kg/m2 (IQR 19.9-29.5) kg/m2. One patient showed bilateral involvement. Median preoperative AP - and lateral Southwick angle were respectively 117.5 (IQR 95.8-137.3) and 59.6 (IQR 35.1-71.8) degrees. After open realignment, median postoperative AP - and lateral Southwick angles were respectively 139.5 (IQR 135.0-143.3) and 14.7 (IQR 11.3-20.9). Thus, a correction of the lateral Southwick angle of 31.2 (IQR 17.4-54.2) was achieved. Follow-up was 6.0 years (IQR 2.4-8.3) and none of the patients developed AVN. Median Alpha-angle on Dunn view at final follow-up was 44.5 (IQR 42.8-68.1). Conclusion:The DAA described in this series, can be considered a reproducible technique for an open realignment of displaced SCFE. None of the cases had an AVN and the approach does not appear to limit correction potential. Level of evidence:Level 4 Therapeutic study.
