Background: Periprosthetic distal femur fractures (PDFFs) are increasing in frequency with the rise in primary total knee arthroplasty in an aging global population. Optimal surgical fixation remains controversial, with both plate and nail constructs widely utilized. Purposes: We sought to compare clinical and radiographic outcomes between plate and intramedullary nail fixation for PDFFs. Methods: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines comparing plate versus nail constructs for PDFFs. We searched PubMed, Embase, Scopus, Cochrane CENTRAL, and Web of Science with search terms including “periprosthetic distal femur fracture,” “distal femoral fracture,” “retrograde intramedullary nail,” “locking plate,” and “total knee arthroplasty.” We included clinical studies that compared lateral plate fixation (PF) versus intramedullary nailing (IMN) fixation for PDFFs. Only single implant constructs were included. Only studies published in English with data on human patients were considered. We excluded cadaveric studies, biomechanical studies, technical notes, and case series without a comparison group. Outcomes analyzed included all cause revision surgery, nonunion, delayed union, time to union, implant failure, fracture alignment, infection, medical complications, mortality, Knee Society Scores (KSS), and postoperative range of motion (ROM). Risk ratios or mean differences were calculated using fixed-effects models. Results: We included 13 studies (all retrospective cohort studies, Level III) published between 2012 and 2024, that included a total of 1011 patients with PDFFs, 674 treated with PF, and 337 treated with IMN fixation. We found no significant differences between plate and nail fixation in all-cause revision, nonunion, time to union, medical complications, mortality, KSS, ROM, or time to ambulation. Nail fixation was associated with a significantly lower risk of delayed union, implant failure, and wound infection. However, nail fixation had significantly greater risk of coronal and sagittal fracture malalignment. Conclusions: The findings of this systematic review and meta-analysis of Level-III studies suggest that plate and nail fixation offer comparable outcomes for most clinical parameters in PDFFs. Nail fixation was associated with lower risks of infection, delayed union, and implant failure, but with higher rates of radiographic malalignment. Level of Evidence: Level III: systematic review and meta-analysis of Level-III studies.
This review article discusses the critical role of nutrition in optimizing recovery for overhead athletes following intense or damaging exercise that induces oxidative stress. The components of recovery nutrition include replenishing glycogen stores, repairing muscle tissue, and rehydrating, while also addressing inflammation, promoting sleep, and matching workload to level of recovery. Detailed information is provided on subjects such as postactivity carbohydrate and fluid requirements, protein synthesis, nutrition that strengthens the immune system, and meal timing that can reset circadian rhythms. Level of Evidence: Expert opinion Level V.
Background:Progressive radiographic collapse after osteoporotic vertebral fractures (OVFs) may lead to kyphotic deformity. Predictors remain inconsistent, partly because prior studies used heterogeneous conservative treatment protocols that may alter collapse risk. Questions/Purposes:We asked (1) how much vertebral compression progressed after a standardized body-cast protocol, (2) which factors were associated with progression, and (3) whether computed tomography (CT)-detected intravertebral cleft (IVC) independently predicted progression. Methods:We retrospectively reviewed 162 patients with 202 acute OVFs from a single institution who were treated with early body-cast immobilization followed by rigid bracing between April 2013 and March 2016. Follow-up radiographs obtained 6 to 13 months after injury were used to assess collapse progression, defined as the change in anterior vertebral body compression percentage between baseline and follow-up. Baseline CT and magnetic resonance imaging (MRI) obtained within 2 weeks of injury were used to assess cortical wall fractures, MRI signal patterns, and IVCs. Variables with P < .10 on univariate analysis entered multivariable linear regression models. Results:Mean anterior vertebral body compression percentage increased from 22.2% to 29.0% (mean progression, 6.9%). Vertebrae with IVCs progressed more than those without IVCs (≥3 mm, 13.8%; 1-<3 mm, 14.0%; none, 4.9%). In multivariable analysis, IVC was the only independent predictor of greater radiographic collapse progression. Conclusions:This retrospective observational study found that baseline CT-detected IVC of at least 1 mm identified vertebrae at risk for radiographic collapse progression despite standardized body-cast treatment. This finding should be interpreted as a radiographic risk marker, not direct evidence of treatment failure. Level of Evidence:Level III, retrospective prognostic study.
Arthrofibrosis following total knee arthroplasty (TKA) is a challenging complication that contributes to failure to achieve functional range of motion and results in physical impairment, pain, and revision surgery. Despite increasing recognition of arthrofibrosis as a biological disease process rather than a purely mechanical complication, there is no single document that integrates current evidence on diagnosis, surgical management, and preventive strategies. In June 2025, the Stavros Niarchos Foundation Complex Joint Reconstruction Center at Hospital for Special Surgery convened an international symposium to address arthrofibrosis following TKA. Invited experts in orthopedic surgery, basic science, biomechanics, and outcomes research were organized into 3 panels focused on (1) basic science, diagnosis, and risk stratification; (2) surgical management and postoperative rehabilitation; and (3) prevention strategies and adjunctive therapies. Each panel reviewed the literature, addressed predefined clinical questions, and developed consensus through structured discussion. This summary describes the recommendations from each panel, emphasizing early, multispecialty evaluation, stage-specific intervention, and procedure-specific rehabilitation strategies. Gaps in the evidence and priorities for future research are highlighted. These recommendations aim to standardize care, guide clinical decision-making, and shift the focus from late salvage toward early identification and prevention of arthrofibrosis following TKA. Level of Evidence: Level V: expert opinion.
Background:Post-traumatic stiffness is a pathological condition that results from injury and the soft tissue response, leading to reduced or lost joint motion and functional impairments. Purpose:This pilot study aimed to compare the efficacy of Kaltenborn mobilization and Mulligan Mobilization with movement (MWM) in managing post-traumatic elbow stiffness. Methods:A 6-month prospective non-randomized comparative interventional pilot study was conducted at Independent University Hospital, Faisalabad, Pakistan. Forty-five participants were equally divided into 3 groups: Group A (Active range of motion [A-RoM] + actinotherapy), Group B (Kaltenborn Grade III glides + actinotherapy), and Group C (MWM with sustained end-range glides + actinotherapy). Baseline assessments included demographics, elbow RoM (flexion, extension, pronation, supination), manual muscle testing, Mayo Elbow Performance Score, and Numeric Pain Rating Scale. This study was registered in the Clinical Trials Registry of Australia and New Zealand (ACTRN12625000820404). Post-intervention analysis using paired t-tests and 2-way analysis of variance was conducted. Results:The interventions in Group C were associated with the greatest improvements in RoM, strength, and pain relief compared to A-RoM exercises and Kaltenborn mobilization. Kaltenborn mobilization resulted in significant clinical improvement, whereas A-RoM exercises did not show any difference. Conclusion:The findings of this pilot study suggest that MWM may address biomechanical dysfunctions more effectively than Kaltenborn mobilization in patients with post-traumatic elbow stiffness. Further study is needed to confirm that MWM should be integrated into standard post-traumatic elbow rehabilitation protocols. Level of Evidence:Level III, Therapeutic Study.
Pediatric overhead athlete injuries are increasing in frequency, many of them unique to the youth musculoskeletal system. Conditions relate not only to growth centers but also to subchondral bone and joint instability linked to immature connective tissue. Diagnosis depends on a thorough patient history, correct examination techniques, and use of imaging. Management of these patients requires a greater focus on neuromuscular rehabilitation principles than is needed for adults. There is a lack of consensus on the role of functional testing in rehabilitation decisions, and further investigation is necessary. In addition, practitioners need to be mindful of the psychosocial dynamics among players, parents, and coaches, who may not understand appropriate workloads for young athletes and feel pressured to accelerate the pace of recovery. This narrative review covers the most current principles of diagnosis, treatment, and return-to-play strategies for pediatric overhead athlete injuries including preventing of recurrent injuries and avoiding long-term sequelae.
Background:Post-dural puncture headache (PDPH) after unintended dural puncture is a known complication of neuraxial anesthesia, especially with puncture by 20 gauge or larger catheter or needle. PDPH can impact post-operative recovery; however, PDPH in patients undergoing total joint arthroplasty (TJA) is less well documented because the majority of studies address obstetric patients. Purposes:We sought to answer the following questions: What is the incidence of PDPH after unintended dural puncture in the TJA population? What are risk factors for PDPH? How is PDPH managed? Methods:A retrospective chart review was performed for patients undergoing TJA surgeries under neuraxial anesthesia between January 1, 2016, and April 30, 2023, at a single high-volume orthopedic hospital. Cases with documented dural puncture with 20 gauge epidural catheter, 18 gauge Weiss epidural needle, or 17 gauge Weiss epidural needle were identified and reviewed for PDPH. Results:Among 77 586 patients who received neuraxial anesthesia of any kind (spinal, epidural, combined spinal/epidural), 640 patients (0.8%) experienced unintended dural puncture and were included in the analysis. Among those with unintended dural puncture, 29 (4.5%) patients subsequently developed PDPH. The final logistic regression identified older age and higher body mass index (BMI) as protective and associated with reduced risk of PDPH. Among the 29 PDPH cases, non-steroidal anti-inflammatory drugs were employed in 86.2% of patients, and acetaminophen was used in 93.1%. Seven patients (24.1%) required an epidural blood patch, and 3 (10.3%) reported long-term sequelae. Conclusions:This large retrospective case series of TJA patients at a single institution found that the incidence of PDPH after unintended dural puncture was low (4.5%). Lower age and lower BMI were risk factors associated with higher odds of being diagnosed with PDPH. Level of Evidence:Level IV: retrospective case series.
Background:Managing pain after total knee arthroplasty (TKA) without opioids remains a priority. Aspirin is often used after joint surgery for venous thromboembolism prophylaxis and is unique among non-steroidal anti-inflammatory drugs (NSAIDs) in providing this protection through irreversible cyclooxygenase inhibition. Oral ketamine has demonstrated analgesic benefit, but its combination with aspirin for postoperative pain control is not well established. Purpose:We sought to investigate the following: (1) Is combined administration of oral ketamine and aspirin safe in patients undergoing TKA? (2) What are the observed pain control outcomes and opioid requirements associated with this regimen? Methods:We conducted a single-institution pilot study of patients undergoing primary TKA to test the safety of a proprietary oral aspirin/ketamine combination; the study was funded by the manufacturer, Vitalis Pharmaceuticals. Eligible patients were prospectively identified from the operative schedules of 7 participating arthroplasty surgeons and approached at their preoperative office visits between February 2023 and March 2023. Patients were excluded from the study if they were age <18 or >80 years, if they had a primary diagnosis other than primary osteoarthritis, an allergy to aspirin or another NSAID, any contraindications to NSAID use, use of anti-coagulant or anti-thrombotic medication, recent active bleeding requiring a transfusion or hospitalization, or scheduled for same-day discharge. Twenty patients were included. Patients received oral ketamine (40 mg) and aspirin (162 mg) every 6 hours postoperatively until discharge. The primary outcome was safety, assessed using the Side Effect Rating Scale for Dissociative Anesthetics and the Richmond Agitation Sedation Scale (RASS). Secondary outcomes included a numeric rating scale for pain and morphine milligram equivalents (MME). Descriptive statistics were used. Results:Of the 20 patients in the final cohort, 14 patients completed the full 4-dose regimen during their 24-hour postoperative inpatient stays; 18 of the 20 patients reported no adverse effects. Two patients experienced mild dizziness after later doses, with no reported agitation or sedation on the RASS scale. Most patients (19/20) required rescue opioid doses; pain scores were similar, regardless. Mean 24-hour opioid consumption was 30.2 ± 20.4 MME. Conclusion:This single-institution pilot study observed that an oral aspirin/ketamine combination appeared to be safe after TKA, with minimal adverse effects. A future randomized controlled trial is needed to evaluate efficacy and opioid-sparing benefits. Level of Evidence:Level IV, pilot study.
Medial ulnar collateral ligament (MUCL) injuries of the elbow have increased over the past 2 decades, particularly among adolescent and young adult overhead throwing athletes. Over time, operative techniques for MUCL injuries have evolved, with the goals of improving time to return and rates of return to sport and meeting athlete-specific demands. The purpose of this review is to evaluate the state of surgical management of MUCL injuries, assessing indications, techniques, and outcomes. Surgical techniques reviewed included MUCL-augmented repair with internal bracing, traditional reconstruction, reconstruction augmented with internal bracing, and revision MUCL reconstruction. While MUCL reconstruction has been the gold standard of treatment, augmented reconstruction and repair techniques have shown promising outcomes; these strategies emphasize anatomic restoration, preservation of native tissue, and individualized patient selection.
Background:People with Marfan syndrome (MFS) exhibit a high incidence of hip joint pain and earlier onset of osteoarthritis than those without MFS. Imaging-related biomarkers of hip joint health that provide an earlier indication of hip cartilage degeneration in the MFS population have yet to be assessed. Purpose:We sought to determine whether people with MFS exhibit biochemical alterations of proteoglycan content and collagen structure within the hip joint cartilage compared to individuals without MFS as documented by quantitative magnetic resonance imaging (MRI) including both T1ρ and T2 mapping. Methods:Fourteen individuals with MFS and 14 healthy, asymptomatic controls matched for age, sex, and body mass index underwent radiographic imaging and unilateral hip quantitative MRI including both T1ρ and T2 mapping to evaluate cartilage proteoglycan content and collagen structure. Results:People with MFS showed significantly higher T1ρ values in the anterior superior acetabular cartilage compared to the asymptomatic controls. No significant between-group differences were noted in the femoral T1ρ values or in any of the T2-related values. Conclusion:This cross-sectional, observational study found elevated anterior superior acetabular cartilage T1ρ values, indicating a lower proteoglycan content within this specific sub-region, in individuals with MFS. The anterior superior acetabular cartilage may be prone to degeneration and may contribute to the high rates of early onset osteoarthritis observed in the MFS population. Our results suggest T1ρ cartilage imaging may be a potential biomarker of early cartilage degradation in the MFS population. Clinically, T1ρ imaging may allow for better informed decisions regarding interventional timing to prevent the onset and progression of hip osteoarthritis in individuals with MFS. Level of Evidence:Level III, prognostic study.
Background:Adequate cam resection during hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is necessary to restore femoral head-neck offset while avoiding under- or over-resection. The relationship between the extent of femoroplasty and postoperative patient-reported outcomes remains unclear. Purpose:We sought to answer the following questions: What is the association between the extent of cam femoroplasty resection and postoperative improvements? and is a 5% resection threshold associated with improved outcomes? Methods:We conducted a retrospective review of patients with adequate acetabular coverage who underwent primary hip arthroscopy with femoroplasty between January 2015 and December 2022 at our institution and had preoperative and 1- and/or 2-year postoperative modified Harris hip score (mHHS) and/or International Hip Outcome Tool (iHOT) scores. We included 400 patients (409 hips; ages 14-50 years). Outcomes included score changes and achievement of minimum clinically important difference (MCID) and substantial clinical benefit (SCB). Postoperative Dunn lateral radiographs quantified femoroplasty by resection depth percentage (resection depth/femoral head diameter), proximal resection angle, and postoperative α angle. Hips were classified as under-resection, neutral (0%-5%), or over-resection (>5%), and differences in outcomes were compared between resection groups. Multivariable regression analyses controlled for demographic, radiographic, and surgical variables. Results:Mean resection depth was 4.8%; mean proximal resection angle was 72.6°. No differences were observed in score improvements or MCID/SCB rates between groups with under-resection versus over-resection at 1 or 2 years. Greater resection depth was associated with larger 1-year mHHS and iHOT improvements and independently predicted 1-year iHOT MCID and SCB. Higher proximal resection angle predicted 2-year iHOT MCID. Conclusion:In this retrospective, single-institution cohort study, we found that in patients with FAIS, greater femoroplasty depth was associated with improved 1-year clinical outcomes. Level of Evidence:Level III, retrospective cohort study.
Background:Radiographic assessment is central to the diagnosis of femoroacetabular impingement (FAI) syndrome. However, the relationship between specific bony morphology and symptom severity remains unclear. Purpose:We sought to evaluate the relationship between FAI morphology, quantified through preoperative radiographic measures, and preoperative symptom burden in patients with FAI syndrome. Methods:We conducted a retrospective study of prospectively collected data that included a series of consecutive patients diagnosed with FAI syndrome who underwent hip arthroscopy by a single surgeon between January 2024 and October 2025. Inclusion criteria were (1) diagnosis of FAI syndrome and (2) availability of complete preoperative patient records, including X-ray images and preoperative patient-reported outcome measures. Exclusion criteria were (1) patients <14 or >60 years, (2) diagnosis that included FAI syndrome with concomitant intra-articular pathology, (3) hip surgery other than primary hip arthroscopy, (4) unavailable X-ray imaging, and (5) history of lower extremity osteotomy for abnormal rotational profile. Hip impingement measures were obtained on preoperative radiographs, including α angle, head-neck offset, anterior center-edge angle, and lateral center-edge angle, crossover sign, crossover ratio, and ischial spine sign. Preoperative symptom severity was assessed by the International Hip Outcome Tool-12 (iHOT-12). Multivariate models adjusted for demographics, mental health, physical activity, and corticosteroid injection history. Results:Among 285 patients (median age 34.9 years, 75.4% female), the median iHOT-12 score was 37.5. Proximal femur measures and acetabular coverage were not correlated with iHOT-12. The presence of crossover or ischial spine signs was associated with higher iHOT-12 on bivariate analysis and remained predictive of higher iHOT-12 after adjustment for demographics and injection status in multivariate modeling. All other radiographic measures were non-significant after further adjustment for mental health and activity level. Conclusion:Radiographic measures of retroversion are associated with better preoperative symptoms in patients with FAI syndrome. Other radiographic measures of hip impingement showed no meaningful association with preoperative symptom severity. For patients with FAI syndrome, psychological and functional factors exerted a larger influence on symptom severity than did impingement severity as reflected on radiograph. Level of Evidence:Level IV: retrospective case series.
