BACKGROUND:Surgical planning for adolescent idiopathic scoliosis (AIS) is complex. Large language models (LLMs) like DeepSeek Reasoning Model R1 (DeepSeek-R1) offer potential for decision support, but their accuracy in determining fusion levels is unproven. HYPOTHESIS:The DeepSeek-R1 model could generate surgically reasonable fusion levels for AIS with clinically acceptable accuracy. PATIENTS AND METHODS:This study enrolled 203 consecutive AIS patients meeting surgical indications. Comprehensive clinical and radiological data, including Lenke classification, were structured into standardized prompts. DeepSeek-R1 was tasked with determining the upper and lower instrumented vertebrae (UIV, LIV) for each case. Its outputs were evaluated independently by three experienced spinal surgeons using a 5-point Likert scale (≥3 defined as reasonable). Inter-rater reliability was assessed using Intraclass Correlation Coefficient (ICC). Performance across Lenke subtypes was analyzed using Fisher's exact test with Monte Carlo simulation. RESULTS:DeepSeek-R1 generated surgically reasonable fusion levels (Likert score ≥3) in 70.9% (144/203) of cases, with excellent inter-expert agreement (ICC = 0.840, 95% CI [0.798, 0.875]). Performance varied significantly by Lenke subtype, demonstrating high reasonable rates for types 1A (87.0%), 1B (82.9%), 5C (81.1%), and 6C (87.5%). However, suboptimal performance was observed for types 1C (19.0%), 2A (42.9%), and 2C (25.0%). CONCLUSION:DeepSeek-R1 demonstrated clinically acceptable accuracy in planning AIS fusion levels overall, particularly excelling in specific Lenke curve patterns (e.g., 1A, 1B, 5C, 6C). Its performance, however, was inconsistent across all subtypes, highlighting limitations in complex curve scenarios (notably 1C, 2A, 2C). While promising as a decision-support tool, further refinement and validation are necessary before clinical implementation. LEVEL OF EVIDENCE:III.
BACKGROUND:Adductor canal block (ACB) offers opioid-sparing analgesia after total knee arthroplasty (TKA), with limited quadriceps weakness. A practical alternative is a surgeon‑performed intraoperative ACB. This study aimed to evaluate: (Q1) Does surgical ACB (S-ACB) reduce pain at rest 24 h after TKA versus anesthesiologist‑performed ultrasound‑guided ACB (US‑ACB)?, (Q2) Does S-ACB reduce 24‑h opioid consumption?, (Q3) Are there differences in early pain, rescue blocks, or adverse events?, (Q4) Does S-ACB impact length of stay (LOS)? HYPOTHESIS:We hypothesized that S-ACB would be superior to US-ACB in reducing rest pain at 24 h after TKA. MATERIAL AND METHODS:Single-center, randomized, open-label trial of adults undergoing unilateral primary TKA (January 2025-June 2025). Patients were randomized 1:1 to S‑ACB (intraoperative injection into the adductor canal using predefined anatomical landmarks) or US‑ACB (preoperative in‑plane injection adjacent to the femoral artery, beneath vastus medialis). Both groups received 15 mL ropivacaine 0.475% for ACB and 40 mL ropivacaine 0.2% posterior capsular infiltration. The primary outcome was NRS pain at rest 24 h. SECONDARY OUTCOMES:included 24-h morphine consumption, NRS in post-anesthesia care unit (PACU), at post-operative day 3 (POD3), last in-hospital, rescue block, adverse events, and length of hospital stay (LOS). Intention‑to‑treat analyses were performed. RESULTS:Fifty‑one TKAs were analyzed (S‑ACB n = 27; US‑ACB n = 24). Baseline characteristics were balanced except for diabetes (more frequent in US-ACB). PRIMARY OUTCOME:mean 24‑h NRS was 1.6 ± 1.8 (S‑ACB) vs 2.0 ± 2.2 (US‑ACB); mean difference -0.33 (S‑ACB-US‑ACB), 95% CI -1.44 to 0.78; not statistically significant. 24‑h morphine: 5.6 ± 4.0 mg (S‑ACB) vs 5.8 ± 3.7 mg (US‑ACB); difference -0.16 mg, 95% CI -2.67 to 2.37 mg; not significant. No block‑related adverse events occurred. Rates of rescue block were low (two in US‑ACB). LOS was similar (6.5 ± 3.1 vs 6.7 ± 2.4 nights). Across timepoints (PACU, POD3, discharge), NRS and opioid use did not differ. DISCUSSION:Surgical ACB did not provide superior analgesia compared to US-ACB at 24 h, with low pain scores and opioid needs overall and no safety issue. Larger multicenter trials are warranted to confirm equivalence and explore functional recovery. LEVEL OF EVIDENCE:II; Randomized trial.
BACKGROUND:Joint awareness is a key determinant of patient satisfaction after knee arthroplasty, yet the comparative impact of unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) remains unclear. This study evaluates joint awareness differences between UKA and TKA using the Forgotten Joint Score (FJS-12) to provide updated evidence for clinical decision-making. METHODS:A systematic search of PubMed, EMBASE, Web of Science, and Cochrane databases was conducted on January 28, 2026, identifying cohort studies or RCTs comparing UKA and TKA. The primary outcome was FJS-12, categorized by follow-up duration into short-term (<2 year), mid-term (2-3 years), and long-term (>3 years). Study quality was evaluated using the Cochrane Risk of Bias tool and Newcastle-Ottawa Scale. Meta-analysis was performed with the Inverse Variance method, including sensitivity analyses. RESULTS:This study included 25 studies with a total of 5445 participants, comprising 11 short-term, 9 mid-term, and 7 long-term follow-up studies. Meta-analysis results indicated that UKA outperformed TKA in FJS-12 scores across short-term (mean difference (MD): 12.89; 95% confidence interval (CI): 5.60-20.17; P = 0.0005), mid-term (MD: 6.01; 95% CI: 3.29-8.74; P < 0.001), and long-term (MD: 12.42; 95% CI: 8.88-15.96; P < 0.001) follow-up. CONCLUSIONS:This updated analysis incorporates a larger number of high-quality studies, demonstrating that UKA offers superior joint awareness compared to TKA during long-term follow-up, further validating and reinforcing the advantages of UKA in joint awareness recovery reported in previous research. LEVEL OF EVIDENCE:I; Systematic Review and Meta-Analysis.
BACKGROUND:Patient satisfaction is a key dimension of healthcare quality and is increasingly recognized as an outcome that influences engagement, recovery, and trust. In hip and knee arthroplasty, the overall experience is shaped not only by surgical success but also by communication, symptom control, perioperative logistics, and postoperative support. This study evaluated whether structured, periodic measurement of patient satisfaction could identify modifiable aspects of care and guide targeted quality-improvement interventions in a high-volume private orthopedic hospital. METHODS:Since 2021, all patients undergoing primary hip or knee arthroplasty at a private orthopedic hospital were asked to complete an 11-item visual analogue satisfaction questionnaire at discharge, with free-text comments. Responses were analyzed annually. Between 2022 and 2024, sequential quality-improvement measures were introduced based on survey findings. Year-to-year trends in satisfaction scores and the proportion of negative comments were examined. RESULTS:A total of 2137 surveys were completed over the study period (response rate: 68.7%). Overall satisfaction was consistently high (≥9.7/10). Quality improvement measures included enhanced nursing follow-up, refinements in perioperative analgesia and anesthetic protocols, improvements to food services, and expanded preoperative information. Significant improvements were observed in domains targeted by interventions. The proportion of negative comments declined markedly across almost all domains. Free-text analysis highlighted the importance of clear communication, personalized support, rapid access to staff, and a sense of emotional safety. CONCLUSION:Structured, periodic satisfaction assessment is a practical and effective method to identify actionable gaps in the patient experience and to support rapid-cycle improvements in arthroplasty care. Even within a high-performing environment, small, targeted adjustments informed by patient feedback led to measurable gains across multiple domains. These findings reinforce the value of integrating patient-experience data into continuous quality-improvement frameworks, particularly in settings capable of agile implementation. LEVEL OF EVIDENCE:IV, continuous case series with no comparison group.
INTRODUCTION:The incidence of ankle fragility fractures is increasing. These insufficiency fractures frequently occur in a frail geriatric population and are associated with an increased risk of skin complications. The objective of this study was to evaluate the clinical and radiological outcomes of geriatric ankle fracture fixation using locked fibular nailing. HYPOTHESIS:We hypothesized that fixation of geriatric ankle fractures with a locked fibular nail would allow bone union without skin complications or mechanical failure. METHODS:This retrospective single-center study included 21 patients with a mean age of 70.8 ± 5.2 years (range 65-85) who sustained an ankle fragility fracture treated with a locked fibular nail between January 2021 and August 2024. Fracture patterns included two isolated lateral malleolar fractures (9.5%), 17 bi-malleolar fractures (81%), one tri-malleolar fracture (4.8%), and one fracture of the distal quarter of the leg (4.8%). Pain was assessed using the Numerical Analog Scale (NAS), and functional outcomes were evaluated using the European Foot and Ankle Society (EFAS) questionnaire and the Olerud and Molander Score (OMS), with comparison to the contralateral ankle. Epidemiological and operative data, as well as complications (wound-healing disorders, mechanical failure, and non-union), were recorded. Fibular union was assessed according to the criteria described by McLennan and Ugersma. RESULTS:An anatomical or acceptable reduction of the fibula was achieved in 100% of patients. No wound-healing complications occurred, despite preoperative skin compromise in 17 patients (81%). No mechanical failures were observed at a mean follow-up of 13.6 months. The mean NAS score was 1.0 ± 1.2 (range 0-4). The mean EFAS score was 19.4 ± 2.4 (range 14-22), and the mean OMS score was 78.3 ± 19.1 (range 45-95). No statistically significant differences were found when compared with the contralateral ankle (p = 0.26 and p = 0.35, respectively). Complications included one early surgical site infection successfully treated with DAIR (debridement, antibiotics, and implant retention) and one secondary fracture involving both leg bones due to bone insufficiency. Mortality at final follow-up was 14.3% (3/21). CONCLUSION:Locked fibular nailing appears to be a reliable fixation technique for geriatric ankle fragility fractures, enabling bone union, restoration of anatomical alignment, and the absence of mechanical failure, while reducing the high rate of wound-related complications in this high-risk population. LEVEL OF EVIDENCE:IV; retrospective study.
This technical note describe the feasibility of a reproducible laparoscopic technique for acetabular fracture fixation, focusing on the feasibility of using infra-pectineal and supra-pectineal plates and proper screw placement. A standardized preperitoneal laparoscopic approach was performed on ten adult cadavers. Infra-pectineal and supra-pectineal plates were inserted under laparoscopic control, and screw placement was guided using an eight-zone pelvic classification. Feasibility criteria included exposure quality, implant positioning, operative time, and complications. The procedure was successfully completed in 9 of 10 specimens (90%). Key anatomical landmarks were consistently identified. All implants were positioned as planned. Mean operative time was 115 min (range 90-120), with no major vascular, visceral, or neurological injuries. This technique appears feasible and reproducible and may offer a minimally invasive alternative for selected acetabular fractures, particularly in fragile patients. LEVEL OF EVIDENCE: IV; cadaveric study.
BACKGROUND:No previous studies have investigated the association between the risk of greater trochanteric fractures and the Hounsfield Unit (HU) of the greater trochanter in muscle-sparing minimally invasive total hip arthroplasty (MIS-THA). This study aimed to investigate the risk factors for greater trochanteric fractures in anterolateral MIS-THA. HYPOTHESIS:Lower HU values of the greater trochanter are associated with a higher risk of intraoperative and early postoperative greater trochanteric fractures. PATIENTS AND METHODS:This single-center retrospective observational study included 223 patients (257 hips) who underwent primary THA for osteoarthritis or osteonecrosis between January 2010 and August 2024 using a minimally invasive anterolateral approach in the lateral position. All surgeries were performed by four surgeons. Preoperative CT was used to reconstruct coronal sections including the femoral head center and proximal femoral axis, and cancellous HU values of the greater trochanter were measured. Postoperative CT (1 week) with metal artifact reduction was routinely performed; fractures were defined as cortical fracture lines on 3D-reconstructed CT and assessed by two independent orthopedic surgeons. Patients were divided into two groups according to the presence or absence of fractures. RESULTS:The incidence of greater trochanteric fractures was 6.6% (17/257 hips). Twelve of these fractures (70.6%) were recognized intraoperatively or immediately postoperatively. Full hydroxyapatite (HA)-coated stems were associated with an increased fracture risk compared with other designs (relative risk [RR], 2.68; 95% CI, 1.07-6.68). Age, sex, BMI, ASA physical status, and diagnosis were not significantly associated with fractures. Multivariate analysis identified lower HU values (odds ratio [OR], 0.973; p < 0.0001) and full HA-coated stems (OR, 13.3; p = 0.04) as independent predictors. Receiver operating characteristic (ROC) analysis determined an optimal cut-off of 72.0 HU (sensitivity, 0.941; specificity, 0.742), with a value ≤72.0 HU demonstrating high predictive power (RR, 36.7; p < 0.0001). CONCLUSION:Preoperative measurement of HU values in the greater trochanter is a useful screening tool for identifying patients at increased risk of fractures in anterolateral MIS-THA. While an HU value of ≤ 72.0 necessitates careful intraoperative management and increased vigilance, it should be interpreted as an indicator of risk rather than a definitive predictor of fracture due to its moderate specificity. LEVEL OF EVIDENCE:IV; retrospective study.
BACKGROUND:Posterior Humeral Head Subluxation (PHHS) is a critical aspect to consider during the preoperative planning for Total Shoulder Arthroplasty (TSA). This study aims to investigate how variations in the initial arm position affect PHHS measurements obtained from CT scans. METHODS:A prospective analysis was conducted involving patients diagnosed with primary osteoarthritis (OA) or rotator cuff tear arthropathy (CTA) from February 2021 to February 2025. The focus was on cases planned for TSA, utilizing data sourced from a single shoulder arthroplasty planning platform (Equinoxe, Exactech GPS, Blue Ortho). Validated three-dimensional (3D) bone models were employed to compute scapular and humeral landmarks automatically. The positioning of the humerus relative to the scapula was calculated, allowing assessment of abduction, flexion, and internal rotation angles at the scapulohumeral joint. HHS was measured as the ratio between the distance from the posterior border of the head to the Friedman axis and the diameter of a best-fit circle aligned with the humeral head. RESULTS:The study encompassed 21,863 patients. Preoperative measurements indicated a median abduction of 10.3 ± 12.4° (percentile range: -14.0°; 36.6°), median flexion of 3.5 ± 8.9° (percentile range: -16.0°; 26.1°), and median internal rotation of 7 ± 18.9° (percentile range: -41.4°; 48.9°). The median PHHS recorded was 57.9 ± 10.8% (percentile range: 23.7%; 81.2%). A correlation between preoperative humeral positioning and subluxation was identified-positive for abduction (β = 0.1302, p < 0.0001) and negative for flexion (β = -0.2490, p < 0.0001) as well as internal rotation (β = -0.1570, p < 0.0001). This correlation is weak but highly significant, probably due to the large cohort size. Thus, a change of 10° in abduction corresponded to a shift of approximately +1% in subluxation values while similar adjustments in flexion or internal rotation resulted in roughly -2%. CONCLUSION:Posterior humeral head subluxation is significantly influenced by patient posture during scanning, particularly sensitive to changes in flexion and internal rotation which tend to decrease subluxation more than abduction does; however, these alterations remain minimal at about ±1-2%. LEVEL OF EVIDENCE:IV; Case series with no comparison group.
BACKGROUND:Sepsis is a cause of delayed morbidity and mortality after pelvic fracture surgery. Rectal injuries, although rare, may be underdiagnosed and contribute to infectious complications. Recent studies on this topic are scarce and often lack radiologic correlation. This study aimed to address the following questions: (1) What is the incidence of sepsis in surgically treated pelvic and/or acetabular fractures? (2) Which clinical and injury-related factors are associated with sepsis? (3) Are rectal injuries underdiagnosed? and (4) Do radiologic perirectal abnormalities correlate with sepsis? HYPOTHESIS:We hypothesized that sepsis is associated with identifiable clinical risk factors and that radiologic signs of rectal injury are underrecognized contributors to sepsis. PATIENTS AND METHODS:In this retrospective cohort study, we included 1059 patients who underwent pelvic or acetabular fracture surgery at a Level 1 Trauma Center between 2009 and 2020. Clinical data and CT imaging were reviewed. Patients were stratified by sepsis status. Sepsis was defined according to the Sepsis-3 criteria. The primary outcome was occurrence of sepsis; secondary outcomes included ICU stay, length of hospitalization, and 90-day mortality. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for sepsis. RESULTS:Sepsis occurred in 71 patients (7%). In multivariate analysis, an Injury Severity Score ≥20 (OR 2.88, 95% CI 1.36-6.07), emergency laparotomy (OR 6.70, 95% CI 2.84-15.78), heart disease (OR 4.80, 95% CI 1.82-12.69), and liver disease (OR 3.67, 95% CI 1.11-12.08) were independently associated with sepsis. Rectal injury was diagnosed in 1 patient (0.1%), while perirectal CT abnormalities were observed in 107/766 (14%) patients. Sepsis was associated with longer ICU stays, longer hospitalization, and increased 90-day mortality. DISCUSSION:The incidence of sepsis remains clinically significant in pelvic fracture patients and is associated with identifiable injury and patient-related factors. Radiologic perirectal findings are more frequent than clinically diagnosed rectal injuries and may signal occult injury. These findings suggest a need for heightened vigilance and further investigation of subtle imaging abnormalities. LEVEL OF EVIDENCE:IV; retrospective cohort study.
INTRODUCTION:Total hip arthroplasty (THA) in obese patients (BMI ≥ 30 kg/m2) is technically more demanding and associated with a higher risk of postoperative morbidity. Its realization seems more complex by the direct anterior approach. The hypothesis was that muscular mass would have a stronger impact than BMI on intraoperative difficulty during anterior THA. The study objectives were; 1. To assess the influence of body composition and BMI on intraoperative difficulty, 2. To determine the influence of body composition on early complications (<3 months) and short-term functional outcomes. METHODS:A total of 162 anterior approach THAs without traction table were included. Body composition (muscle and fat mass) was assessed preoperatively by bioelectrical impedance analysis of the operated limb and trunk. Subgroup analyses were performed according to BMI (<30, 30-35, or ≥35) and muscle mass (threshold set at 67%). Intraoperative difficulty was evaluated based on operative time in minutes and total blood loss in mL, calculated using the OSTHEO formula. Perioperative complications, early complications (<3 months), and 3-month functional outcomes (Oxford Hip Score and Forgotten Joint Score) were assessed. RESULTS:In univariate analysis, operative time (+19 min) and total blood loss (+615 mL) were significantly higher in patients with BMI ≥ 35 compared to those with BMI < 30 (p < 0.001). Operative time was also longer (+6 min) in muscular patients (≥67%) (p = 0.009), with no significant difference in total blood loss. No significant differences were observed in perioperative or early postoperative complications, nor in 3-month functional outcomes between obese/non-obese or muscular/non-muscular groups. In multivariate analysis, BMI and total muscle mass were independently associated with intraoperative difficulty: Operative time (min) = 22.2 + 0.25 × total muscle mass (kg) + 1.1 × BMI (R2 = 0.24, p < 0.001) Total blood loss (mL) = -692.6 + 13.3 × total muscle mass (kg) + 31.1 × BMI (R2 = 0.29, p < 0.001) CONCLUSION: BMI and total muscle mass are two preoperative factors associated with greater intraoperative difficulty, as reflected by increased operative time and total blood loss in anterior approach THA. These factors can be anticipated through a more detailed assessment of body composition. Despite the increased surgical complexity, they do not appear to be associated with a higher risk of early postoperative complications. In this cohort, muscle mass did not demonstrate a stronger impact than BMI on operative difficulty, contrary to the initial hypothesis. LEVEL OF EVIDENCE:III; Prospective comparative study.
BACKGROUND:Knee osteoarthritis increasingly affects active adults under 65 years of age. As total and unicompartmental knee arthroplasty (TKA/UKA) become common treatments, return to work (RTW) emerges as a key milestone in recovery. While age, obesity, and comorbidities have been identified as predictors, the specific impact of professional occupation remains underexplored. This prospective study addresses this gap by investigating (1) how socio-professional category (SPC) influences the duration of sick leave after knee arthroplasty; and (2) whether physically demanding jobs; higher body mass index (BMI), age, and/ or other demographic or clinical factors are associated with prolonged sick leave. HYPOTHESIS:The authors hypothesized that the type of profession is the most significant predictor of extended sick leave following knee arthroplasty. METHODS:A prospective, single-center study was conducted involving 120 professionally active patients aged 18-65 years who underwent TKA or UKA between February 2020 and December 2023. Sociodemographic data, job classification (using PCS-ESE 2017), job physical demands, and clinical characteristics were collected. RTW status was evaluated at three months postoperatively, with an additional follow-up at four months for patients with extended sick leave (>90 days). Univariate and multivariate logistic regression analyses were performed to identify predictors of prolonged sick leave (> 90 days). RESULTS:While patients in SPC-3 (executives and intellectual professions) and SPC-5 (employees) were significantly associated with prolonged sick leave in univariate analysis (OR = 0.35; 95% CI: 0.15-0.81; p = 0.014 and OR = 3.95; 95% CI: 1.73-8.98; p = 0.001, respectively), neither association was confirmed in multivariate analysis (SPC-3: OR = 1.52; 95% CI: 0.47-4.88; p = 0.484; SPC-5: OR = 2.41; 95% CI: 0.89-6.51; p = 0.0837). Secondly, physically demanding jobs strongly predicted extended sick leave, with nearly a fivefold increase in risk (OR = 4.58 95% CI:1.63-12.87; p = 0.0038). Thirdly, while a trend was observed for higher BMI to be associated with longer sick leave (OR = 1.09; 95% CI: 0.99-1.19; p = 0.060), no significant associations were found for sex, age, ASA score, length of hospital stay, discharge modality, or caregiver availability. CONCLUSION:Physically demanding occupations and not professional status are the main factors delaying return to work after knee arthroplasty. In contrast, traditional demographic factors such as sex, BMI and ASA score appear less influential. These findings highlight the importance of integrating occupational context and modifiable risk factors into preoperative planning to facilitate earlier RTW and optimize patient recovery trajectories. LEVEL OF EVIDENCE:II; prospective study.
BACKGROUND:Knee osteoarthritis (KOA) is a common degenerative disease impairing elderly mobility. Oxford Unicompartmental Knee Arthroplasty (OUKA) is effective for unicompartmental degenerative osteoarthritis, yet traditional intramedullary alignment methods may cause inaccuracies, compromising outcomes. The purpose of this study was to assess the safety and accuracy of a 3D-printed intramedullary femoral positioning guide in Oxford Unicompartmental Knee Arthroplasty (OUKA), with subgroup analysis by femoral mechanical-anatomical angle (FMA). METHODS:A prospective randomized controlled trial enrolled 120 patients with severe medial knee osteoarthritis undergoing OUKA. Patients were randomly divided into two groups: the experimental group (n = 60) used a 3D-printed intramedullary femoral positioning guide, while the control group (n = 60) employed traditional femoral intramedullary localization. The primary outcome measures were femoral component valgus/varus angle (FCVA) and femoral component posterior slope angle (FCPSA). Secondary outcomes included operative time, tourniquet time, and early postoperative complications. Stratified analyses were performed based on the femoral mechanical-anatomical angle (FMA) using cutoff values of <5°, 5-7 °, and >7°. RESULTS:Among the 119 patients with complete data (one lost to follow-up), no significant differences in FCVA (experimental: -0.63 ° [-2.46 ° to 1.60 °]; control: 2.31 ° [-4.17 ° to 3.12 °], P = 0.438) or FCPSA (9.72 ° [7.24 ° to 11.64 °] vs. 6.93 ° [3.96 ° to 15.70 °], P = 0.401) were observed overall. However, subgroups with FMA <5° or >7° showed significant improvements in FCVA (mean difference: -2.42 °, 95% CI: -3.12 ° to -1.72 °) and FCPSA (3.79 °, 95% CI: 2.45 ° to 5.13 °, both P < 0.05). No differences in operative time, complications, or functional scores were noted. Safety outcomes, including rates of deep vein thrombosis, infection, and prosthesis-related complications, were comparable between groups, with no severe adverse events reported. CONCLUSION:3D-printed guides improve prosthesis alignment in OUKA for patients with FMA <5° or >7° but not for FMA 5-7 °. Clinicians should consider patient-specific anatomical variations when deciding whether to use 3D-printed guides in OUKA. LEVEL OF EVIDENCE:I; Randomized controlled trial.
BACKGROUND:Autologous osteochondral transfer (AOT) surgery yields favorable outcomes with appropriate patient selection. Although several factors influencing surgical outcomes have been identified, the effect of meniscal volume and quality on AOT outcomes remains unclear. HYPOTHESIS:Better meniscal status would be associated with reduced deterioration of cartilage repair over time following AOT. MATERIALS AND METHODS:Patients who underwent AOT between March 2002 and March 2021 were retrospectively reviewed. Inclusion criteria were: (1) magnetic resonance imaging (MRI) at 1-2 years postoperatively for evaluation of meniscal status, and (2) follow-up MRI after at least 2 years. Meniscal lesions were addressed during surgery, and postoperative residual meniscal status was graded using a 6-point scale (0-3 for volume, 0-3 for quality). Patients were divided into better meniscus (BM) and poorer meniscus (PM) groups using a cutoff score of 2.5, derived from a time-dependent receiver operating characteristic (ROC) curve that maximized early deterioration in the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score after AOT. Follow-up intervals were categorized into early (1-2 years), short-term (2-5 years), mid-term (5-10 years), and long-term (>10 years). Structural outcomes including MOCART scores, joint space width (JSW), and cartilage T2 relaxation times, and patient-reported outcome measurements (PROMs) including Lysholm score, IKDC subjective score, Tegner activity scale, and visual analog scale (VAS) for pain were compared. RESULTS:A total of 35 patients were finally included in the study, with a mean follow-up of 6.8 ± 5.2 years. Among them, 22 were classified into the BM group and 13 into the PM group. Significant group-by-time interaction effects were observed for MOCART scores (p = .048) and JSW (p = .03); the BM group demonstrated higher MOCART scores from the short-term follow-up (p = .005) and less JSW narrowing from the mid-term follow-up (p = .009). In contrast, no significant group differences were found in T2 relaxation times. Clinically, IKDC (53.5 ± 16.4 to 76.3 ± 11.0; p = .03), Lysholm (66.1 ± 18.3 to 91.7 ± 7.4; p = .02), and VAS pain scores (5.1 ± 2.3 to 1.8 ± 1.8; p = .01) significantly improved from preoperative to early postoperative follow-up and were maintained thereafter. However, no significant group differences were found. CONCLUSION:Meniscal lesions should be properly addressed during AOT, as residual meniscal status was associated with cartilage degeneration. However, structural improvements on MRI did not translate into better clinical outcomes, as T2 relaxation times and PROMs were not correlated. LEVEL OF EVIDENCE:IV.
Objective Severe osteoarthritis of the first metatarsophalangeal joint (MTPJ-1) is commonly treated through arthrodesis. Our aim was to evaluate whether percutaneous approaches to perform MTPJ-1 arthrodesis reduce the nonunion and complication (including reoperation) rate as compared to the standard open technique. Methods This systematic review was designed as per PRISMA checklist; Pubmed, Cochrane, Scopus and Web of Science databases were analyzed; all studies focused on patients diagnosed with MTPJ-1 osteoarthritis and treated through arthrodesis using exclusively crossed screws. Data related to the cohort (size, age, sex, type of osteoarthritis), the study design (level of evidence and type of study), the technique adopted (the number of screws, open/percutaneous approach, technique of preparation of the joint) and the final outcome (nonunion and complication and reoperation rate) were recorded. The quality of studies included was evaluated through the MINORS score (methodological index for nonrandomized studies). The nonunion, complication and reoperation rates of the percutaneous (PERC) vs the open (OPEN) technique were compared through a proportional meta-analysis. Results Overall, nine studies (including 225 arthrodeses in 211 patients) were analyzed (130 cases in the PERC group vs 95 cases in the OPEN group). In the two groups, the mean (± standard deviation) sample size (PERC: 26.6 ± 5.1 cases; OPEN: 23.7 ± 10.2 cases; p = 0.33), sex distribution (PERC: 81% ± 0.6; OPEN: 57% ± 0.2 females; p = 0.17) and length of follow-up (PERC: 20.8 ± 11.6 months; OPEN: 29.5 ± 16.8 months; p = 0.19), mean age (PERC: 62 ± 5.4 years; OPEN: 59.5 ± 5.4 years; p = 0.26), were not significantly different. The pooled nonunion rate (9% vs 5% in PERC vs OPEN; p = 0.57), complication rate (15% vs 23%; p = 0.46) and reoperation rate (3% vs 5%; p = 0.74) were not significantly different. The quality of studies was moderate and comparable in the two groups (mean MINORS at 8.4 ± 1.5 points vs 11.7 ± 4.3 in PERC vs OPEN; p = 0.08). Conclusions The nonunion and complication (including reoperation) rate after percutaneous vs open first metatarsophalangeal joint arthrodesis (fixed using screws) are comparable at 2 years of follow-up. Only moderate-quality evidence is available so far in this area. Further comparative and prospective studies with a robust design are needed to clarify which strategy allows to obtain the best outcome after MTPJ-1 arthrodesis. Level of evidence IV.
INTRODUCTION:Femoral neck fractures in the elderly require immediate postoperative weight bearing to preserve autonomy. Cementless stems rely on primary stability with close cortical contact. However, perioperative fracture may occur, and secondary subsidence remains a concern. The primary objective of this study was to assess early subsidence of a cementless femoral stem. Secondary objectives were to identify predictive factors for subsidence, dislocation, and perioperative fracture. MATERIAL AND METHODS:We conducted a retrospective study in patients over 65 years of age who underwent systematic implantation of an uncemented Avenir-Müller® stem. Epidemiological and radiological data were collected at 6 weeks and 3 months postoperatively. Subsidence was measured relative to the greater trochanter and expressed both as an absolute value and as a categorical variable (<2 mm or ≥2 mm). Morphological risk factors included the Canal Flare Index (CFI), Metaphyseal-Diaphyseal Index (MDI), Cortical Thickness Index (CTI), and Cortical Bone Ratio (CBR10). RESULTS:A total of 117 patients were evaluated, including 94 women, with a mean age of 83.1 years (range 65-103). Mean subsidence at 6 weeks was 1.1 ± 1.5 mm (median 0.6, range 0-9.1), and at 3 months 1.4 ± 1.6 mm (median 0.9, range 0-9.2). At 3 months, 22 patients (18.8%) had subsidence ≥ 2 mm. Dislocation occurred in 9 patients, with no association with subsidence ≥ 2 mm (p = 0.33). Five perioperative fractures were observed, with no identifiable predictive factor. No correlation was found between subsidence and preoperative autonomy (Rho = -0.2, p = 0.37) or surgeon experience (p = 0.66). A CTI ≤ 0.40 was predictive of subsidence (absolute value, p = 0.046; group ≥ 2 mm, p = 0.002). CONCLUSION:Early subsidence of cementless stems in patients over 65 years of age undergoing hip arthroplasty for fracture is minimal. Severe osteoporosis, indicated by a CTI ≤ 0.40 on preoperative imaging, should prompt consideration of a cemented stem. LEVEL OF EVIDENCE:IV; retrospective study.
BACKGROUND:In cases of chronic anterior shoulder instability, surgical indications are guided by clinical and morphological parameters that are largely integrated into the ISIS score. The glenoid bone defect is a central decision factor. Arthro-CT represents for many the frequently used examination, but is this superiority proven for the evaluation of glenoid lesions and is its systematic use justified? PURPOSE:Our aim was to compare the Bernageau view versus arthro-CT for the assessment of glenoid bone defects in anterior glenohumeral instability, and to integrate our results into the diagnostic approach. PATIENTS AND METHODS:We report a retrospective study of 95 patients with chronic anterior shoulder instability, mean age 28.7 ± 11.6 years. A sample of 23 patients was selected who underwent arthro-CT of the pathological shoulder and bilateral Bernageau views. The bone defect on the Bernageau view is expressed as a percentage of the width of the healthy glenoid; on the arthro-CT it was assessed using the Sugaya method. Associated lesions (Bankart, notches, SLAP, HAGL and rotator cuff tear) were collected on the various examinations. The measurement method on the two images was validated by two examiners with high inter- and intra-observer reproducibility (ICC between 0.84 and 1). Statistical evaluation was based on non-parametric tests. RESULTS:The glenoid defect calculated on the Bernageau view was 5.90% (±7.56) compared with 5.93% (±6.59) for arthro-CT, the mean difference between the two measurements was 1.92 (±1.86). There were no statistically significant differences based on the Wilcoxon test (p = 0.85, CI95% [0.577; 0.911]). The Spearmann correlation coefficient between the two methods was 0.8 (CI 95% [0.577; 0.911], p < 0.001). Associated lesions included: 44% glenoid fracture, 81% Bankart lesion, 8.3% HAGL, 73% Hill-Sachs lesions, 5% SLAP and 2.1% rotator cuff tears. DISCUSSION:Our study supports the finding that bilateral Bernageau views provide accuracy comparable to arthro-CT in quantifying glenoid defects. Arthro-CT, which is more invasive, requires more radiation and is a potential source of infectious complications, provides additional information that is only relevant in the case of SLAP and rotator cuff tears. We therefore recommend reserving arthro-CT for the pre-therapeutic assessment of instability in specific cases: Bankart indication, patients ≥ 40 years old, or symptomatic patients of any age (functional deficits, muscle weakness, or pain during rotator cuff testing). LEVEL OF EVIDENCE:IV.
BACKGROUND - INTRODUCTION:Cuff repairs are associated with a relatively high risk of retear for which reverse total shoulder arthroplasty (rTSA) represents a treatment option. The objective of this study was to evaluate the mid-term results of rTSA after failed rotator cuff repair and to analyze the factors that may influence these results. MATERIALS AND METHODS:We conducted a retrospective multi-center analysis of 117 rTSA after failed cuff repair with 2 years minimum follow-up. Clinical scores (Constant, SSV and EVA pain scores) and active range of motion were pre- and postoperatively assessed. RESULTS:A total of 117 shoulders with a mean follow-up of 60 months (range 24-144) were identified with a mean age of 70 years (range 49-86). Preoperatively, according to Collin classification, the supraspinatus tear with posterior extend (type D: 34%) and with antero-posterior extend (type C: 33%) were the most frequent feature. Preoperatively, according to Hamada classification, there was no osteoarthritis in 32% of cases and proven glenohumeral osteoarthritis in 46% of cases. Postoperatively, the mean Active Anterior Elevation improved from 89° ± 41° to 136° ± 33° (p < 0.001). Postoperatively, the mean Constant's score improved from 29 ± 12 to 61 ± 18 (p < 0.001) and the mean SSV score improved from 26 ± 15 to 71 ± 21 (p < 0.001). A greater Constant score was associated with an isolated Supraspinatus tear and a lower Constant score was associated with tears involving the supraspinatus and the Infraspinatus (type D) with also a negative influence on active external rotation. In absence of glenohumeral osteoarthritis, the mean Constant score was significatively lower. We also found a significantly lower mean Constant score and mean activity sub-score in younger patients. A total of 14 complications (12%) and 8 revision surgeries (7%) were reported. DISCUSSION/CONCLUSION:Our results are consistent with recent series in the literature on similar indication of rTSA after failed cuff repair, and lower than those of primary rTSA. Association of an infraspinatus tear, absence of glenohumeral arthritis and a younger age were identified as predictive preoperative factors responsible for a lower result. These observations further encourage caution in the indication of a rTSA in the younger patients and in absence of glenohumeral osteoarthritis. LEVEL OF EVIDENCE:IV; Case series with no comparison group.
Background Supracondylar humerus fractures are common injuries, representing more than half of pediatric elbow fractures. Given the limited growth potential around the elbow, achieving an anatomic reduction has traditionally been emphasized. However, the extent to which residual postoperative frontal or sagittal translation can be tolerated without cosmetic or functional consequences remains unclear. Hypothesis We hypothesized that an initial reduction defect, particularly translational, would not result in functional impairment at skeletal maturity due to growth-related remodeling, whereas angular deformities would persist. Material and methods We included 97 children who underwent surgical fixation for a supracondylar humerus fracture between 2004 and 2017 and had reached skeletal maturity at final follow-up. Baumann’s angle, percentages of frontal and sagittal translation, and the position of the anterior humeral line were assessed postoperatively, at the time of hardware removal, and at skeletal maturity. Results Overall, 55% of patients demonstrated an initial reduction defect, regardless of the parameter considered. Frontal translation underwent complete remodeling with growth, whereas a mean residual sagittal translation of 7% persisted but had no clinical impact. In contrast, only 6% of patients with an abnormal postoperative Baumann’s angle showed normalization over time. Clinical evaluation at maturity revealed no significant functional differences compared with the contralateral elbow. Discussion This study underscores the excellent remodeling potential of translational deformities and confirms progressive correction of sagittal deviations. Although Baumann’s angle demonstrates poor remodeling capacity, the absence of functional impairment precludes defining corrective thresholds that would mandate surgical revision. Level of evidence IV; Retrospective observational study.
BACKGROUND:Intramedullary nailing (IMN) for proximal humerus fractures is commonly performed through an anterolateral approach. A percutaneous approach through the Neviaser portal has been shown to be an alternative to avoid cuff tendon insertion violation and be used for a third-generation IMN. The aim of the present cadaver study was to confirm whether the Neviaser approach was reproducible to reach the optimal nail entry point, at the top of the humeral head, passing through the muscular portion of the supraspinatus and to evaluate the risk of biceps and neurovascular bundle damage. METHODS:This was a basic science surgical technique study with sixteen preserved frozen shoulders from 11 donors (8 females, 3 males) used. All surgical procedures were performed using the third-generation AEQUALIS™ IM Nail. Dissection of each specimen was then performed. The nail entry point through the soft-tissue layer was assessed, determining whether the device was inserted through the supraspinatus muscular or tendinous part. A manual caliper with a precision of 0.1 mm was then used to measure the distances of the device to different anatomic structures. RESULTS:The nails were inserted through the muscular part in all specimens still having a rotator cuff (RC). The mean distances from the nail entry point to the myotendinous junction and RC footprint were 4 mm (range, 2-6 mm) and 39 mm (range, 36-42 mm), respectively. The distances from the lower tuberosity (LT) head screw and most lateral greater tuberosity (GT) head screw to the long head of the biceps (LHB) groove were 9 mm (range, 8-11 mm) and 15 mm (range, 14-17 mm), respectively. The distance of LT head screw to the anterior circumflex pedicle and the lateral cord of the brachial plexus was 15 mm (range 14-17 mm) and 41 mm (range 32-45 mm), respectively. The distance of the highest distal screw and the lowest proximal screw to the axillary nerve was respectively 32 mm (range, 28-40 mm) and 23 mm (range, 21-25 mm). The nail entry point was entirely within the humeral articular surface and at the bone-cartilage junction in 14 and 2 specimens respectively. CONCLUSION:This study demonstrated that a third-generation IMN might be inserted via the Neviaser portal. This approach is safe and allows the insertion of the device through the RC muscular part with a reproducible access to the hinge point and with no risk of neurovascular injury. LEVEL OF EVIDENCE:IV; Anatomy study; Cadaver Dissection.
BACKGROUND:Distal radius fractures are common upper limb injuries. Open reduction and internal fixation (ORIF) using a volar plate via the Henry approach often involves myotomy of the Pronator Quadratus (PQ) muscle, which may or may not be sutured postoperatively. The value of PQ repair remains debated, particularly regarding functional outcomes and protection of the Flexor Pollicis Longus (FPL) tendon. OBJECTIVE:To compare the ultrasonographic healing of the PQ muscle with and without repair after volar plating, and to assess its potential role in FPL tendon protection. The hypothesis of our study was that the absence of PQ muscle suturing did not alter the plate-FPL distance, functional outcomes, or complications compared to sutured PQ. METHODS:We conducted a retrospective single-center study (October 2024-April 2025) including 48 patients with displaced distal radius fractures (AO A2) treated by ORIF. Twenty-three underwent PQ repair, and 25 did not. Ultrasonographic evaluations and clinical assessments were performed at final follow-up. Primary outcomes included PQ morphology and FPL-plate distance on ultrasound. Secondary outcomes comprised range of motion, grip/pinch strength, QuickDASH score, patient satisfaction, return to activity, and complications. RESULTS:Ultrasonography showed significantly greater distances between the radius/FPL and plate/FPL in the non-repair group. PQ was morphologically thicker in the non-repair group, although not significantly. Functional outcomes favored the non-repair group in most metrics (VAS, ROM, QuickDASH), but without statistical significance. Two complications (carpal tunnel syndrome, tenosynovitis) occurred in the repair group only. CONCLUSION:Our results support the view that PQ repair after volar plating of distal radius fractures does not provide significant functional or protective advantages. The critical factor in preventing tendon complications remains correct plate placement relative to the watershed line. Future research should focus on prospective, multicenter, randomised studies with larger cohorts and longer follow-up to confirm these results. LEVEL OF EVIDENCE:III.
