Background: Proximal tibia reconstruction after tumor resection is technically challenging due to the dual requirement of skeletal stability and extensor mechanism restoration. Multiple reconstruction methods exist, but comparative data on complications, survival, and functional outcomes remain limited. This study aimed to compare complication rates and implant survival across different proximal tibia reconstruction methods (megaprostheses, osteoarticular allografts [OAs], intercalary allografts [ICAs], and allograft-prosthetic composites [APCs]) and to evaluate how extensor mechanism reconstruction technique influences functional outcomes. Methods: A systematic review and meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and Embase databases were searched through September 2025. Studies reporting outcomes of proximal tibia and/or extensor mechanism reconstruction for oncologic indications were included. Complications were classified using the Henderson system. Random-effects meta-analysis was performed for complication rates, implant survival, and extension lag. Subgroup analyses were performed by reconstruction type. Results: Seventy-eight studies including 2,825 patients were analyzed (mean age 25.9 years, mean follow-up 84.7 months). Prosthetic reconstruction demonstrated the lowest overall complication rate (39.2%, 95% confidence interval [CI] 32%-45%) compared with OAs (69.6%, 95% CI 55%-82%), APCs (52.7%, 95% CI 32%-73%), and ICAs (53.4%, 95% CI 34%-70%) (p = 0.004). Biological reconstructions had significantly higher structural failure rates (OA 31.0%, ICA 24.5% vs. prosthesis 5.5%, p < 0.001). Five-year implant survival showed no significant differences between prosthesis (75.3%), OA (67.4%), and APC (74.3%). At 10 years, survival rates converged across all methods (63%-71%). Extensor mechanism reconstruction technique significantly influenced extension lag: direct tendon-to-metal reattachment (11.0°) resulted in worse outcomes than synthetic augmentation (5.7°), allograft reattachment (4.6°), or autograft reconstruction (2.3°) (p < 0.001). Conclusion: While prosthetic reconstruction offers lower short-term complication rates, long-term implant survival is comparable across reconstruction methods. Extensor mechanism reconstruction technique is a critical determinant of functional outcome. Surgeons should consider techniques beyond simple direct reattachment, particularly synthetic augmentation or biological reconstruction, when feasible to optimize extension function. Individual patient factors should guide selection between prosthetic and biological reconstruction. Level of Evidence: Level IV . See Instructions for Authors for a complete description of levels of evidence.
Background: Distal radius fractures (DRFs) are among the most prevalent in upper-extremity injuries, particularly in older adults and individuals with osteoporosis. The common treatment options include surgical interventions such as volar locking plate (VLP) fixation and percutaneous pinning, as well as conservative strategies like splinting and bracing. However, the comparative effectiveness of these modalities remains unclear. This study aims to compare the functional outcomes and complication rates associated with VLP, percutaneous pinning, bracing, and splinting in the treatment of DRFs. Methods: A systematic search of PubMed, Google Scholar, and the Cochrane Library (September 2001-February 2025) identified randomized controlled trials, prospective cohort studies, and retrospective cohort studies comparing DRF treatments. Functional outcomes and complication rates (superficial infection, malunion, nonunion, delayed union) were analyzed. Data were analyzed using Review Manager Web with significance set at p ≤ 0.05. Results: Twenty-seven studies involving 3,200 patients met inclusion criteria: VLP fixation (n = 896), percutaneous pinning (n = 666), splinting (n = 718), and bracing (n = 903). No significant differences were observed between VLP and splinting or between bracing and splinting for Disabilities of the Arm, Shoulder, and Hand (DASH); Patient-Rated Wrist Evaluation (PRWE); or grip strength. Compared with VLP, percutaneous pinning demonstrated better PRWE scores but a higher infection rate. Compared with bracing, percutaneous pinning showed significantly better DASH, PRWE, and grip strength outcomes, although with substantial heterogeneity. Compared with bracing, VLP fixation yielded significantly better DASH, PRWE, and grip strength outcomes and a lower malunion rate. Conclusion: All 4 treatments achieved acceptable outcomes, but with key trade-offs: Percutaneous Pinning had the best functional results but a higher infection risk. VLP provided better function and lower malunion rates than bracing. Splinting and bracing were effective conservative options, often yielding results similar to VLP, but were inferior in some specific measures. The findings suggest that a perfect anatomic repair is not always necessary for a good recovery. Ultimately, the choice of treatment must be individualized, weighing the functional benefits against the risks of complications, while considering patient health factors and preferences. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
» Distal clavicle fractures are less common, accounting for 10% to 30% of all clavicle fractures. » The presence of radiographic nonunion does not correlate with symptomatic nonunion, with a variable percentage of patients necessitating subsequent surgical intervention (20%). » Fracture displacement is associated with a higher risk of nonunion (31%-37%), particularly in Neer type II and V fracture patterns. » Nondisplaced distal clavicle fractures can be treated with nonoperative management (Neer types I, III, and IV). » Surgical treatment is indicated for displaced Neer type II and V fractures. Increased radiographic coracoclavicular (CC) distance in type II and V fractures is an indication for CC stabilization. However, there is no consensus on ideal fixation techniques for fracture fixation and CC stabilization. » Surgical treatment may require secondary implant removal, regardless of the fixation construct used (28%-55%) but especially common with hook plate fixation.
Background: Total joint arthroplasty (TJA) is a frequent and safe procedure; however, some patients experience complications requiring intensive care unit (ICU) admission, which increases morbidity, longer hospital stays, and healthcare costs. This study aimed to estimate the pooled prevalence of ICU admission following TJA and identify associated risk factors to aid perioperative risk stratification. Methods: PubMed, Embase, Scopus, and Web of Science were systematically searched for studies reporting ICU admission rates and risk factors after TJA. Two reviewers independently performed study selection, data extraction, and quality assessment. A meta-analysis of proportions was used to estimate the pooled prevalence of ICU admissions. Subgroup analyses were performed by surgical site, procedure type, region, and study design. Pooled odds ratios (ORs) for 17 predefined risk factors were calculated using random-effects models. Heterogeneity was assessed using I 2 statistics, and publication bias was evaluated with the Egger test. Results: Ninety-six studies were included, and the pooled prevalence of ICU admission was 5.68% (95% confidence interval [CI] 4.24-7.62%, I 2 = 99.98%). The strongest predictors of ICU admission were intraoperative vasopressor use (OR 5.03, 95% CI 2.78-9.1), coronary artery disease (CAD) (OR 4.31, 95% CI 2.18-8.55), chronic kidney disease (CKD) (OR 3.09, 95% CI 1.56-6.13), anemia (OR 3.20, 95% CI 1.45-7.06), and revision hip arthroplasty (OR 3.59, 95% CI 2.36-5.46). Age older than 75 (OR 2.81, 95% CI 1.5-5.26) and body mass index >35 (OR 2.42, 95% CI 1.38-4.24) were also associated with increased risk. Conclusion: ICU admission occurs in approximately 5.6% of TJA cases. Major predictors include vasopressor use, revision hip surgery, anemia, CAD, and CKD. These findings provide a foundation for evidence-based perioperative risk assessment and optimized resource allocation. PROSPERO Registration Code: CRD42024558273. Level of Evidence: Level III . See Instructions for Authors for a complete description of levels of evidence.
Background: Loss of reduction during nonoperative management of distal radius fractures can lead to delayed operative treatment, malunion, and corrective osteotomy. This study aimed to systematically review and synthesize the available literature on predictors of loss of reduction of distal radius fractures for adult patients undergoing nonoperative treatment. Methods: MEDLINE, Embase, CINAHL, and Cochrane databases were searched from inception to June 9, 2025. Screening, data extraction, risk of bias assessment, and evidence grading were completed in duplicate. Data were pooled using random-effects models with inverse of variance weights to produce summary of effect odds ratios (ORs) with 95% confidence intervals (CIs). Bivariable prognostic factors and coefficients from multivariable models were pooled separately. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. Results: A total of 7,926 citations were screened, and 30 studies (7,495 fractures) met inclusion criteria. In bivariable analyses, 5 predictors demonstrated moderate certainty associations with loss of reduction: dorsal comminution (OR 2.69, 95% CI 1.67-4.32), failure to re-establish volar cortical alignment (OR 3.22, 95% CI 1.93-5.37), prereduction dorsal angulation >20° (OR 1.90, 95% CI 1.04-3.48), displacement beyond acceptable criteria vs minimally displaced fractures (OR 6.15, 95% CI 3.35-11.31), and age older than 60 years (OR 2.24, 95% CI 1.06-4.74, moderate certainty). In multivariable analyses, age older than 60 years (adjusted OR 3.80, 95% CI 1.59-9.10) and prereduction ulnar positive variance (adjusted OR 1.49 per 1-mm increase, 95% CI 1.09-2.06) demonstrated high certainty associations with loss of reduction. The weighted proportion of patients who lost reduction was 43.4% (95% CI 38.7-48.2). Conclusion: Age older than 60 years and increasing prereduction ulnar positive variance demonstrated high certainty associations with loss of distal radius reduction from available multivariable analyses. Further well-designed prognosis studies are needed to better delineate the predictors of loss of reduction with nonoperative management of distal radius fractures. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Background: Tibial intramedullary nailing (IMN) is the standard treatment for tibial shaft fractures, yet anterior knee pain (AKP) remains common, affecting nearly 47% of patients. Despite the reported advantages of suprapatellar techniques, infrapatellar approaches—medial parapatellar (MPP) and transpatellar (TP)—remain the most commonly used methods for tibial IMN. This systematic review and meta-analysis compares MPP and TP approaches regarding pain, AKP incidence, range of motion (ROM), knee function, and fracture healing. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, Embase, Scopus, and Web of Science were searched up to November 2024. Randomized clinical trials (RCTs) and comparative observational studies in adults undergoing tibial IMN via MPP or TP approaches were included. Outcomes were AKP incidence, pain intensity, knee function, ROM, and union-related variables. Pooled mean differences (MDs) and risk ratios (RRs) were calculated using random-effects and common-effects models. Results: Twelve cohort studies (782 patients) and 9 RCTs (462 patients) were included. Across cohort studies, MPP was associated with a significantly lower AKP risk at latest follow-up (RR = 0.76 [0.63; 0.90]) and at 6 months. Visual analog scale pain at 3-month postoperative also favored MPP (MD = −1.27 [−1.94; −0.60]) but did not reach the minimal clinically important difference. RCTs demonstrated similar trends toward lower pain and AKP with MPP, but without statistical significance. Functional outcomes and ROM generally favored MPP across both study designs, though findings were inconsistent and unsuitable for pooling. Fracture healing and union rates were comparable between approaches. Conclusion: The MPP approach for tibial IMN was linked to a lower incidence of AKP compared with the TP approach, while offering comparable or better functional outcomes, ROM, and pain intensity. These findings suggest MPP as the preferred infrapatellar approach in appropriate clinical settings. Nonetheless, high-quality studies with standardized outcome measures are essential to validate these findings. Level of Evidence: Level III (systematic review of RCTs and retrospective comparative studies). See Instructions for Authors for a complete description of levels of evidence.
» Cervical disk arthroplasty (CDA) is a Food and Drug Administration (FDA)-approved motion-preserving alternative to anterior cervical diskectomy and fusion for 1-level and 2-level degenerative disk diseases, supported by high-level evidence and associated with reduced adjacent segment degeneration and comparable or improved clinical outcomes. » FDA-approved CDA implants differ in biomechanical design, degrees of freedom (DoF), and constraint, affecting motion preservation, segmental control, and long-term kinematics. Devices range from constrained (3 DoF) to semiconstrained and viscoelastic designs (4-6 DoF). Implant articulation and materials impact wear, imaging compatibility, and biomechanical behavior and should be considered during device selection. » Constraint-based classification provides a practical, biomechanics-informed framework for CDA implant selection. Constraint level should be matched to patient pathology. Constrained implants may be preferable in cases of segmental instability, compromised endplate integrity, or poor bone quality. Semiconstrained or viscoelastic devices may offer better outcomes for patients with preserved motion, healthy facets, and high functional demands. » A structured understanding of failure modes is critical for safe and effective CDA use. Complications and failure can result from surgical technique errors (e.g., endplate violation, malposition), biologic response (e.g., osteolysis, heterotopic ossification), or mechanical complications (e.g., implant fracture, subsidence). Technical considerations aid the surgeon in reducing risk of complications.
» Subacromial balloon spacer (SBS) implantation has been proposed as a minimally invasive treatment for massive irreparable rotator cuff tears (MIRCTs), particularly in elderly patients with preserved glenohumeral articulation and limited functional demands. » Across observational studies, SBS has been associated with short to midterm improvements in pain and shoulder function, reflected by increases in ASES and Constant-Murley scores. » Evidence from randomized controlled trials is mixed; the SPACE trial showed SBS is noninferior to partial repair, while the START:REACTS trial found it less effective than debridement alone. » Complications are uncommon and primarily include balloon migration, synovitis, and rare infections, supporting SBS's safety profile when patient selection is appropriate. » Based on current high-level evidence, SBS is not recommended for routine treatment of MIRCT. Its use should be restricted to carefully selected elderly patients with chronic, nonarthritic MIRCT who are poor candidates for other reconstructive procedures.
» Based on the available evidence, there are numerous strategies that may reduce infection risk in primary shoulder arthroplasty. Preoperatively, optimization of iron deficiency anemia and smoking cessation are associated with lower rates of periprosthetic joint infection and perioperative complications. In addition, risk of infection may be mitigated by deferring shoulder arthroplasty for at least three months following a corticosteroid injection. Management of biologic and targeted immunosuppressive therapies should be coordinated with medical specialists and tailored to the specific agent’s pharmacokinetics and surgical risk. » Preoperative skin preparation with agents such as benzoyl peroxide or chlorhexidine gluconate may decrease bacterial colonization. Antibiotic prophylaxis with a single preoperative dose of cefazolin administered within one hour of incision reduces infection risk, and in patients with true beta-lactam allergy, fully infused vancomycin prior to incision is an effective alternative. Intraoperatively, measures such as dilute betadine lavage, vancomycin powder, chlorhexidine wash, and antibiotic irrigation can reduce bacterial contamination. Additional intraoperative techniques including electrocautery after skin incision may further decrease bacterial burden, although higher level evidence for these latter interventions remains limited or conflicting.
Background: Administering recombinant human growth hormone (rHGH) in a medically directed fashion has emerged as an investigational therapeutic intervention in clinical research to improve orthopaedic and sports medicine-related outcomes. Literature suggests that rHGH administration may improve athletic performance and influence osteoporosis and hip fracture outcomes. The purpose of this systematic review is to examine dosage regimens, identify adverse events, and summarize published peer-reviewed data of clinical outcomes where rHGH has been used in orthopaedic surgery human clinical studies to identify potential patient population targets, gaps in knowledge, and risks of use. Methods: Three databases (Embase, PubMed, and MEDLINE) were searched using search terms including but not limited to “human growth hormone,” “muscle strength,” and “bone healing.” Duplicate studies were removed and were subsequently screened first by title and abstract, followed by full-text. The reference lists of included studies were also evaluated with title screen. Data were abstracted and underwent pooled analysis, including meta-analysis where possible. Results: The initial search produced 2,047 unique studies. A total of 22 studies with moderate methodological quality were included, which comprised 1,157 total patients, with a mean age of 54.3 years and a mean daily rHGH dose of 1.49 mg/d. Administration of rHGH led to a dose-dependent increase in serum insulin-like growth factor 1 (mean increase +133.2%). Lean body mass increased in 15 of the 23 studies (mean difference of +3.63% vs. placebo). Leg extension strength increased for rHGH administration vs. placebo (mean difference +3.17%). The most common adverse events in GH patients were peripheral edema (odds ratio [OR] = 3.03), carpal tunnel symptoms (OR = 3.85), and arthralgias (OR = 2.94). Conclusion: rHGH administration led to improvements in clinical outcomes; however, the noteworthy side effects should also be taken into consideration when designing a treatment regimen for orthopaedic-related pathologies. Level of Evidence: Therapeutic Level II , systematic review of Level I and II studies. See Instructions for Authors for a complete description of levels of evidence.
Background: Fibrosis is a prevalent impediment to musculoskeletal healing, which contributes to poor outcomes across orthopaedic procedures and remains largely underaddressed in orthopaedic care. Purpose: To review the effects of losartan on fibrosis across musculoskeletal tissues, and to evaluate its mechanistic rationale, preclinical outcomes, delivery strategies, and translational potential in orthopaedic practice. Content Summary: Losartan inhibits transforming growth factor beta 1 signaling by antagonizing the angiotensin II type 1 receptor, thereby reducing myofibroblast activity, limiting extracellular matrix deposition, and preserving regenerative cell populations across musculoskeletal tissues. Preclinical models demonstrate histological and mechanical improvements in models of cartilage injury, joint capsule fibrosis, tendon-bone healing, and skeletal muscle regeneration. Therapeutic efficacy is strongly influenced by timing, delivery route, and the microenvironment of the injury. Biomaterial innovations such as nanofiber scaffolds and injectable angiotensin II receptor blocker (ARB) hydrogels may enhance delivery. Further studies stratifying outcomes by age and sex are warranted. Ongoing clinical trials are evaluating losartan for arthrofibrosis, skeletal muscle disorders, and comparative antifibrotic efficacy among ARBs. Conclusion: Losartan offers a mechanistically targeted, clinically familiar antifibrotic therapy with strong potential to improve surgical and rehabilitative outcomes in orthopaedics.
» Ramp lesions occur in up to 40% of anterior cruciate ligament (ACL) injuries and are easily missed without systematic posteromedial inspection. » Magnetic resonance imaging has 70% sensitivity; arthroscopic probing using the posteromedial portal remains the diagnostic gold standard. » Unstable ramp lesions require repair; stable lesions may heal spontaneously with ACL reconstruction. » Repair restores knee stability and yields excellent outcomes comparable with isolated ACL reconstruction. » Return-to-sport rates exceed 80%, with rehabilitation mirroring standard ACL reconstruction protocols.
» Surgeon experience is a well-recognized determinant of patient outcomes, with greater experience associated with lower complication rates, improved efficiency, and better patient recovery. » Experience has variable definitions across studies, including total or annual case volume, years in practice, surgeon age, and fellowship completion. » Surgeon case volume reflects procedural repetition, and tenure encompasses judgment and decision-making that develops over time. Both independently contribute to patient outcomes. » It is unclear whether surgeon subspecialty or age has an impact on objective outcomes, suggesting that experience and case volume are more reliable indicators of performance. » Significant gaps remain in the literature, including inconsistent definitions, limited longitudinal data, a lack of statistically significant preliminary results, and an overrepresentation of complex academic cases.
» Proximal humeral malunions: Arthroscopic techniques are effective for mild malunions, osteotomy is suitable for more significant deformities, and shoulder arthroplasty is ideal for cases with severe damage or nonviable humeral heads. » Humeral shaft malunions: Rotational and angled deformities should be addressed with an osteotomy, though malunions are generally well tolerated and more likely to be cosmetic deformities. » Distal humerus malunions are complex, but corrective osteotomy or arthroplasty can improve function and pain, especially with 3-dimensional imaging enhancing surgical accuracy.
Background: The lack of a gold standard in tarsal tunnel syndrome (TTS) diagnosis leads to diagnostic inconsistencies and variation in patient selection for treatment. Therefore, the aim of this review is to summarize the diagnostic criteria used in current studies on TTS based upon this best-evidence synthesis. Methods: Three databases were searched to identify all studies on TTS. Studies were included when they included (1) diagnosis or treatment of TTS as the primary focus, (2) a description of the diagnosis of TTS, (3) an original data set of TTS cases, and (4) a minimum of 10 adult patients diagnosed with TTS. A best-evidence synthesis was used to summarize the results. Results: In total, 4,213 patients were represented in 82 included studies. Among the varying diagnostic methods employed, aside from clinical symptoms, provocative testing was most often used (in 94% of studies, mandatory for diagnosis in 41% of studies) with the Tinel sign being the most prevalent (used in 89% of studies). Sensitivities of provocative tests, electrodiagnostic, and ultrasound measurements showed significant variability. Conclusion: We provided an overview of the diagnostic tools and workups reported in the literature on TTS. Our findings show that the lack of a standardized diagnostic approach results in considerable variability in clinical practice. Alongside typical clinical symptoms, the Tinel sign is the most frequently used diagnostic test. The varying sensitivities reported in literature underscore the need for evidence-based diagnostic guidelines on TTS diagnosis. Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.
