Fracture-related infection (FRI) can be a devastating complication after fracture surgery and presents many challenges for the treating clinician. A consensus definition including clinical, radiographic, and laboratory components has standardized the diagnosis and investigative efforts into this complex problem. Orthopaedic surgeons managing fractures must be able to appropriately diagnose and treat FRI, while adhering to basic principles to eradicate or suppress infection and promote fracture consolidation. From a multidisciplinary perspective, this review article examines contemporary literature regarding the definition, prevention, patient evaluation, management, and societal effect of FRI.
BACKGROUND:Low back pain (LBP) is a common musculoskeletal complaint and the leading cause of disability worldwide. Studies involving limited cohorts have investigated risk factors for LBP; however, few have examined a comprehensive range of variables including personal factors within a large population-level database. The purpose of this study was to investigate personal factors associated with LBP with the intent to understand how it could be more effectively treated. METHODS:The UK Biobank is a large prospectively collected, population-level database, which contains numerous sociodemographic, clinical, lifestyle, and personal factors. Patients who reported LBP during a visit with their primary care provider between 2006 and 2010 were included. Continued/recurrent LBP was evaluated at follow-up in 2014. Bivariate and multivariable logistic regression analyses were done. RESULTS:Of 501,509, there were 145,855 (29.1%) who reported LBP at initial visit. LBP was associated with being overweight/obese (OR, 1.17/1.45), identifying as Asian (OR, 1.5), driving to work (OR, 1.13), active job (OR, 1.15), salaries <30K/yr (OR, 1.15), >3 hr/d watching TV (OR, 1.2), decreased sleep (OR, 1.09), anxiety/depression (OR, 1.20/1.26), and opioid use (OR, 3.8). Of the 145,855 who reported LBP, 51,131 were seen at follow-up in 2014, 10,706 (21.0%) reported LBP again. Significant factors were being male (OR, 1.36), active job (OR, 1.16), thyroid disease (OR, 1.19), and being retired (OR, 1.20) (P < 0.05 for all variables). CONCLUSIONS:Numerous personal factors are associated with LBP which present opportunities for the expansion of how care is provided for patients with this issue. A whole-person approach, focusing on activity modifications, sleep, nutrition, weight control, and mental/social health support, would be beneficial. LEVEL OF EVIDENCE:Level III retrospective cohort study.
INTRODUCTION:Osteogenesis imperfecta (OI) is a type I collagen disorder. Fragile and deformed bones increase fracture risk with noninvasive blood pressure (NIBP) cuff use. Patients with OI require multiple surgeries, with blood loss and pain medications risking hypotension. There is not currently a widely accepted protocol for NIBP measurements in patients with OI. We designed a protocol demonstrating the safe implementation of "busting the myth" that this is not feasible. METHODS:We prospectively enrolled patients with OI undergoing spine or extremity procedures. Inclusion criteria were approval by an orthopaedic surgeon, age 1 to 35 years, and postoperative admittance to a non-intensive care unit (ICU). To minimize fracture risk and detect hypotension, low maximum inflation pressures were used: 120 mmHg-neonatal/infant/pediatric-sized cuffs; 140 mmHg-adult cuffs. Blood pressure (BP) measurements were taken per standard institutional postoperative care: no more than every 4 hours for 24 hours and every 8 hours or less thereafter. Upper extremity BP was measured manually by registered nurses who inspected the limb and inquired regarding signs of fracture (pain with palpation and bruising) before and after each measurement. RESULTS:Fifty participants were enrolled (median age 12.5 years; 25 girls). Most had moderate (48%) or severe (42%) disease. Twenty-eight patients underwent extremity surgery, and 22 underwent spine surgery. Thirty-three percent of the humeri used were rodded, with an average of 9.5 BP measurements taken postoperatively. Clinical assessment revealed that no fractures occurred. Two participants (4%) withdrew for reasons unrelated to BP cuff complications. CONCLUSION:Noninvasive BP measurements may be safely obtained in the postoperative period for patients with OI. This study was conducted in a system with a high volume of OI care, and OI-specialized orthopaedic surgeons screened the patients. Within these limitations, we recommend manual cuff use and careful fracture monitoring. This protocol may help patients with OI across other hospitals avoid postoperative arterial catheters and ICU admission and could facilitate preventive care for cardiovascular disease.
Family planning and maternity leave concerns contribute to reasons why the percentage of women in orthopedic surgery is disproportionally and consistently low. Without institutional policies, these stressors are often placed on the pregnant resident in training. The establishment of formal department policies allows for clear, universal expectations, which helps decrease negative peer perception and overall dissatisfaction. This practice not only supports current trainees but can also help attract more diverse applicants to create a sustainable workforce. This is the first of a two-part paper that outlines key evidence-based considerations for pregnancy during residency. Importantly, we address the balance of early disclosure with confidentiality, call schedules, medical appointments, and return-to-work considerations, including lactation policies. Creation of these formal guidelines will require an investment in the department but can lay the foundation for a new generation of surgeons who thrive both at home and in the operating room.
Introduction: There are limited opportunities for orthopaedic trainees to practice placing Kirschner wires for fracture fixation outside the operating room. We created an inexpensive, low-fidelity simulator to meet this need. Methods: The simulator is composed of a bone model, soft-tissue model, light fixture “radiograph,” and an electronic component and costs US$53. Validation evidence relevant to test content was evaluated by five fellowship-trained pediatric orthopaedic surgeons using a Likert scale to assess the physical characteristics of the models and their ability to result in transfer of skills to the operating room. Results: Model 3 had the highest average score for feel of the near (3.4) and far (3.4) cortex. Model 2 had the highest average score for feel of the medullary canal (3.2) and pin visualization (2.6). The simulator had high scores for ease of use and implementation and was rated highly for its ability to support residents' learning to triangulate to a defined target (4.8) and improve motor skills (4.4). Discussion: We were able to create an inexpensive, low-fidelity simulator with potential for high transferability, which can be used by orthopaedic surgery residents to improve their motor skills in a low risk, high-reward environment.
BACKGROUND:Percutaneous kyphoplasty is routinely indicated in elderly patients with osteoporotic vertebral compression fractures (VCFs) who have failed conservative management. Although it can effectively stabilize the vertebra and alleviate pain, kyphoplasty has been associated with various complications, including pulmonary embolism and adjacent level fractures. However, there is a lack of consensus on whether office-based kyphoplasty is safer than inpatient or outpatient ambulatory surgery center (outpatient-ASC)-based kyphoplasty. METHODS:PearlDiver was queried to identify adults undergoing percutaneous kyphoplasty for new age-related osteoporotic VCF between 2016 to 2022. Patients were stratified by service location (ie, inpatient, outpatient-ASC, outpatient office) and matched 1:1 by age, sex, and Charlson Comorbidity Index. Medical complications 90 days after the procedure were compared. RESULTS:In total, 71,084 patients underwent kyphoplasty for osteoporotic VCFs between 2016 to 2022. The mean age was 74.3 years, 76.2% were female, and mean Charlson Comorbidity Index was 3.5. The proportion of annual kyphoplasty cases performed in the outpatient-office setting increased markedly from 21.7% in 2016 to 29.6% in 2022 ( P = 0.002). After matching, 11,340 patients remained in each cohort. Multivariate logistic regression analyses revealed that the inpatient cohort had the highest odds of acute kidney injury, cardiac arrest, deep vein thrombosis, pneumonia, transfusion, urinary tract infection, site complications, wound complications, and readmissions (all P < 0.004). Both the inpatient and the outpatient-ASC cohorts had higher odds of infection than the outpatient-office cohort ( P < 0.001). Finally, the outpatient-office cohort had the highest odds of nerve injury and secondary fractures ( P < 0.004). DISCUSSION:In this retrospective cohort study of kyphoplasty performed for osteoporotic VCFs, office-based kyphoplasty procedures were observed to have a lower rate of medical complications compared with inpatient or outpatient-ASC-based kyphoplasty procedures. These findings suggest that office-based kyphoplasty may represent an appropriate treatment setting for carefully selected patients with osteoporotic VCFs.
Background: Unimalleolar, bimalleolar, and trimalleolar ankle fractures and syndesmosis injuries represent a spectrum of increasing instability and surgical complexity. Although the work Relative Value Unit (wRVU) system is designed to account for surgical time and technical complexity, previous studies suggest a mismatch between procedural complexity and proportional reimbursement rate. Our study aims to evaluate whether current wRVU allocation across ankle fracture types adequately reflects procedural complexity and to assess whether more complex cases are relatively undercompensated. Methods: The national surgical quality improvement program (NSQIP) database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation for ankle fractures and syndesmosis injuries, using current procedural terminology (CPT) codes. Cases involving tibial shaft or pilon fractures or multiple CPT codes were excluded. Compensation metrics included surgical time, total wRVUs, wRVUs per hour (wRVU/hr), and hourly reimbursement rate ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics. Results: Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/hr) followed a similar inverse pattern (unimalleolar: 361.9 ± 214.2; syndesmosis: 382.0 ± 234.4; bimalleolar: 335.4 ± 182.6; trimalleolar: 296.1 ± 188.7; P = 0.006). Conclusion: Our study suggests that the current compensation structure for ankle fracture and syndesmosis fixation procedures may not adequately reflect the surgical time and effort required for more complex injuries. Additional evaluation of wRVU allocation for ankle fracture and syndesmosis injury management may be necessary to ensure that compensation more accurately aligns with physician time and effort. Level of Evidence: Level III.
BACKGROUND:Unrestricted kinematic alignment (KA) in total knee arthroplasty (TKA) seeks to restore patient-specific limb geometry and ligamentous balance, yet uncertainty persists regarding patellofemoral (PF) complications and postoperative interventions. Comparative evidence centered on objective mechanical outcomes remains limited, and prior meta-analyses have included heterogeneous alignment strategies or mixed implant constructs. The purpose of this study was to compare unrestricted KA with mechanical alignment (MA) in primary TKA with respect to PF safety, postoperative motion, and intraoperative soft-tissue release requirements. METHODS:A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Randomized and comparative observational studies directly comparing unrestricted KA with MA in primary TKA were eligible without language or date restrictions. Studies were required to report at least 1 predefined objective outcome: postoperative flexion, terminal extension, manipulation under anesthesia (MUA), PF complications, intraoperative soft-tissue releases, or all-cause revision surgery. Data were extracted in duplicate, and random-effects models were used for pooled analyses. Risk of bias was assessed using ROB2 for randomized trials and ROBINS-I for observational studies, and certainty of evidence was graded using GRADE methodology. RESULTS:Seven studies (five randomized trials and two comparative cohorts) comprising 1,068 primary TKAs met inclusion criteria. Compared with MA, KA resulted in greater postoperative flexion (mean difference [MD], 4.58°; 95% confidence intervals (CI), 1.83° to 7.32°; moderate certainty) and slightly improved terminal extension (MD, -0.99°; 95% CI, -1.86° to -0.12°; moderate certainty). KA required substantially fewer intraoperative soft-tissue releases (risk ratio [RR], 0.34; 95% CI, 0.24 to 0.49; moderate certainty). No significant differences were observed for PF complications (RR, 1.90; 95% CI, 0.63 to 5.74; low certainty), MUA (RR, 0.47; 95% CI, 0.09 to 2.44; low certainty), or all-cause revision surgery (RR, 1.96; 95% CI, 0.75 to 5.14; low certainty). Sensitivity analyses demonstrated stable effect direction across fixed-effects and random-effects models. DISCUSSION:Unrestricted KA TKA improves postoperative flexion, slightly enhances extension, and markedly reduces soft-tissue releases without increasing early PF complications, MUA, or revision surgery compared with MA TKA. Longer term randomized studies are needed to refine PF-specific risk estimates and assess survivorship. LEVEL OF EVIDENCE:II.
Background: Patients with spinopelvic risk factors such as lumbar fusion or stiff spine exhibit a 5- to 10-fold increased risk of dislocation following total hip arthroplasty (THA), primarily due to altered spinopelvic mechanics that influence cup positioning. The utilization of robotic-assisted THA facilitates personalized planning, enhancing component placement in this high-risk population. This study aims to compare rates of implant-related and medical complications between robotic-assisted and manual THA in these high-risk patients. Methods: Data were retrospectively obtained from the TriNetX Research Network. Patients with prior lumbar fusion or spinal conditions associated with stiffness or malalignment, and who subsequently underwent THA, were identified using ICD-10 and CPT codes. Procedure codes defined robotic-assisted and manual THA. After 1:1 propensity score matching for age, sex, body mass index, smoking status, and other comorbidities, outcomes were compared at 3, 6, 12 months and 2 years. A subgroup analysis compared both groups in spinal fusion (SF) and nonfusion (no-SF/stiff spine) patients. Results: After 1:1 propensity score matching, each cohort included 2,147 patients. At 3 months, robotic THA was associated with lower prosthetic complications (1.4 vs 2.7%; odds ratio [OR]: 1.86, 95%; P = 0.01) and postoperative blood transfusion (0.9 vs. 1.8%; OR: 2.02, P = 0.01). At 1 year, dislocation was reduced (0.9 vs. 1.8%; OR: 2.07; P = 0.01). Revisions were also lower at 1 and 2-year follow-up in the robotic group (1.7 vs. 2.7%, OR: 1.61; 2.0 vs 3.7%, OR: 1.86; all P < 0.05; respectively), and the manual group had 1.9 times the hazard of having revision surgery at 2 years (HR: 1.9, 95%; P = 0.02). In no-SF patients, robotic THA was associated with markedly lower rates of prosthetic complications and revision surgery. Conclusion: Robotic-assisted THA was associated with fewer complications than manual THA in patients with lumbar fusion or clinically relevant spinal stiffness, a population at elevated risk for instability after THA. Precision-based implant positioning may improve outcomes in patients with altered spinopelvic mobility, including those without spinal fusion.
Orthopaedic surgeons frequently treat patients on antirheumatic medications for rheumatoid arthritis, psoriatic arthritis, lupus, and other inflammatory conditions. When these patients require surgery, surgeons face competing therapeutic priorities: continuing medications risks impaired wound healing and infection, whereas discontinuing them may trigger disease flares and functional decline. Management decisions are further complicated by inconsistent guidelines and limited data on newer biological therapies. Antirheumatic medications disrupt wound healing at multiple stages,some affect early inflammatory responses, whereas others interfere with collagen remodeling. These wound healing disruptions are especially concerning in high-risk patients, such as those with cancer, where complications can derail overall treatment plans. Current knowledge is largely limited to joint arthroplasty in rheumatoid arthritis patients, leaving notable gaps for other procedures and newer medications. This review addresses these gaps by providing evidence-based guidance for medication timing, dosing adjustments, and monitoring strategies, emphasizing multidisciplinary approaches to optimize surgical outcomes.
BACKGROUND:There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears. PURPOSE:The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears. STUDY DESIGN:This was an economic and decision-analysis study; Level II. METHODS:A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D-based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty. RESULTS:Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%. CONCLUSION:Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.
Introduction: The combination of disproportionate pain intensity and limb disuse is often diagnosed as complex regional pain syndrome (CRPS), a label that may imply a specific measurable pathophysiology. In a review of studies of pathophysiology associated with diagnosis of CRPS, we asked, “How often are studies based on comparisons of diagnosed limbs and either undiagnosed limbs or healthy controls, and how many different research groups have addressed specific measures?” Methods: We searched PubMed, Embase, and Cochrane using keyword terms to identify studies of CRPS pathophysiology. Peer-reviewed experiments measuring pathophysiology in ≥10 people diagnosed with CRPS were included. Pilot searches demonstrated sufficient attempts to measure pathophysiology, and a structured review was deemed feasible. A formal search yielded 1,207 studies. Fifty studies from each database (150 in total) were audited revealing no eligible studies, confirming that initial screening captured the relevant evidence. Results: Thirty-seven studies measured different aspects of pathophysiology: molecular concentrations (serum cytokines, induced blister fluid and CSF cytokines, and serum autoantibodies, protease, and CGRP), neuropathophysiology in skin biopsy (fiber degeneration and nerve fiber density), cell type (mast cells/keratinocytes, monocytes, and T lymphocytes), metabolism (skin lactate, tissue oxygenation, and protein extravasation), and others (serum OPG, amino acids/antioxidants/B-endorphin, alpha-1 adrenoceptors, and MMP) among 1,340 people diagnosed with complex regional pain syndrome and 960 control subjects. Ten studies compared measurements between diagnosed and undiagnosed limbs and eight reported a difference. Thirty-four studies compared measurements between people diagnosed and not diagnosed with CRPS and 30 reported a difference. Conclusion: To date, the measured physiological differences between limbs diagnosed with CRPS and other limbs are compatible with known consequences of limb disuse and are somewhat inconsistent. While experiments continue to search for treatable pathophysiology, CRPS can be accurately and usefully associated with universal and treatable aspects of human illness behavior such as kinesiophobia and worst-case thinking.
Orthopaedic surgeons routinely consult search engines, journals, and curated websites to stay current on orthopaedic knowledge. The emergence of large language models, such as OpenAI ChatGPT and Google MedGemma, is changing the way we search for information and how residents learn. Although many orthopaedic surgeons are users of artificial intelligence (AI), most are uncertain about how these tools actually work and why they sometimes give impressively accurate explanations alongside glaring factual errors and fabricated citations. This review provides an overview of the underlying preclinical studies behind large language models at the level of detail needed to empower orthopaedic surgeons with the knowledge needed to critically evaluate AI outputs, design future research projects, and effectively incorporate AI tools into clinical practice and resident education. Through clinical examples including a Schatzker VI tibial plateau fracture and an L4 pedicle screw sizing question, we illustrate two distinct classes of AI failure—retrieval failures and reasoning failures—and demonstrate how understanding the preclinical studies behind these errors equips surgeons to evaluate any AI tool regardless of where or how it runs.
Introduction: Pregnancy during orthopedic surgery practice presents unique challenges related to family planning, workplace accommodations, occupational exposures, board certification requirements, and postpartum return to work. Despite increasing numbers of women entering orthopedic surgery, there remains a lack of centralized guidance addressing pregnancy-related considerations. The purpose of this review is to summarize current evidence, to provide practical recommendations for orthopedic surgeons navigating pregnancy during their career, and to guide practice partners and organizations on how to create a culture of support and belonging during this time frame. Methods: Available literature, professional society guidance, federal workplace regulations, and occupational safety data were reviewed. Key topics included advanced maternal age and fertility considerations, American Board of Orthopaedic Surgery (ABOS) certification accommodations, workplace disclosure and legal protections, occupational exposure to methyl methacrylate (MMA) and ionizing radiation, physical demands of orthopedic practice, postpartum support, parental leave, and breastfeeding accommodations. Results: Delayed childbearing associated with orthopedic training and career progression may contribute to increased rates of infertility and obstetric complications among female orthopedic surgeons. Federal protections, including the Pregnant Workers Fairness Act, Family and Medical Leave Act, and Equal Employment Opportunity Commission regulations, provide important frameworks for workplace accommodations. Contemporary evidence demonstrates that occupational exposure to MMA and radiation during orthopedic procedures remains below established safety thresholds when appropriate precautions are employed. Physical demands such as prolonged standing, heavy lifting, and extended work hours may warrant workplace modifications during pregnancy. Postpartum support, equitable parental leave policies, and access to lactation accommodations may improve surgeon well-being and facilitate successful return to clinical practice. Conclusion: Pregnancy should be recognized as a normal life event rather than a barrier to success in orthopedic surgery. Evidence-based accommodations, occupational safety measures, supportive workplace policies, and equitable parental leave practices can promote maternal and infant health while supporting professional development. Normalizing pregnancy and postpartum support within orthopedic surgery is essential to fostering a more inclusive and sustainable workforce.
Our collective understanding of the pathogenesis, risk factors, and management of adjacent segment disease (ASD) following lumbar fusion has expanded markedly in recent years, necessitating an updated and comprehensive review. ASD is now recognized as a multifactorial process in which postoperative biomechanical changes accelerate degeneration, further amplified by predisposing genetic factors. Key risk factors have been identified and linked to increased rates of ASD, including elevated body mass index, preexisting degeneration at adjacent levels, and inadequate restoration of sagittal alignment, particularly pelvic incidence-lumbar lordosis mismatch. Innovative surgical techniques, including minimally invasive approaches and robotic-assisted instrumentation, have been increasingly used and researched over the past decade with the goal of reducing the incidence and progression of ASD, although long-term evidence remains mixed. Although these advancements are promising, it is important to evaluate their efficacy, limitations, indications, and contraindications using the most current available evidence. Finally, advances in diagnostic imaging and emerging biologic therapies represent a potential paradigm shift in our understanding of the pathogenesis and preventability of ASD.
BACKGROUND:Cup protrusion has been recognized as the most sensitive and specific radiological parameter to predict iliopsoas (IP) impingement after total hip arthroplasty (THA): it is a necessary but not sufficient factor. We aimed to investigate the following: (1) whether radiological differences exist between protruding cups associated with symptomatic IP impingement and asymptomatic ones; (2) which positional parameters correlate with symptomatic IP impingement in THA with cup protrusion. METHODS:This retrospective case-control study included 35 noncemented THAs with CT-confirmed IP impingement (clinical, radiographic, and arthroscopic diagnosis) and 17 asymptomatic noncemented THAs with comparable protrusion and ≥5 years of follow-up. Postoperative CT scans were evaluated for cup protrusion in all planes, inclination, anteversion, cup tilt, femoral and acetabular offsets, eccentric reaming, leg length discrepancy (LLD), and stem antetorsion. Groups were comparable for age, sex, side, diagnosis, and protrusion magnitude. RESULTS:Symptomatic hips showed markedly greater acetabular diameter mismatch (1.7 mm vs-1.8 mm; Cohen's d = 1.16), higher cup anteversion (19.8° vs 11.5°; d = 0.88), greater sagittal tilt (19.9° vs 11.2°; d = 0.81), and smaller LLD (1.4 vs 6.8 mm; d = 0.73). In the exploratory Firth penalized logistic regression model, acetabular diameter mismatch was the only variable associated with symptomatic IP impingement (OR 1.33, 95% CI, 1.09 to 2.26), whereas anteversion, tilt, and LLD did not retain independent associations. CONCLUSION:Among THAs with comparable cup protrusion, cup oversizing showed the strongest and most consistent association with symptomatic IP impingement, whereas increased anteversion and sagittal tilt appeared to modulate the mechanical consequences of protrusion. LEVEL OF EVIDENCE:Level of Evidence: III.
Aims: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for perioperative analgesia, but effect on bone healing remains controversial. This umbrella review and reconstructed meta-analysis assessed whether NSAIDs impair bone healing and how risk varies by population, fracture type, dose, and duration. Methods: We conducted an umbrella review of systematic reviews/meta-analyses and a reconstructed meta-analysis of primary studies (PRIOR/PRISMA-compliant; PubMed, EMBASE, Web of Science, and Scopus to 9 November 2025). Two reviewers independently screened, extracted, and assessed quality (AMSTAR-2) and risk of bias. Overlapping cohorts were removed, and random-effects models were applied. Prespecified subgroups included age, clinical context (traumatic vs elective procedures), bone type (long bones vs spine), dose, and exposure duration (≤14 days). Results: Sixteen reviews (10 meta-analyses, six systematic reviews) were included; most suggested that NSAIDs increase impaired bone healing risk, particularly with higher doses or prolonged use, with minimal signal for short, low-dose perioperative regimens, especially in spinal fusion. Quality was low/critically low. The meta-analysis pooled 38 primary studies. NSAID exposure was associated with higher nonunion risk (OR, 1.56, 95% CI, 1.18 to 2.11), but not clearly with delayed union (OR, 1.58, 95% CI, 0.65 to 3.67). Risk increased in adults (OR, 1.67, 95% CI, 1.25 to 2.47) but not in pediatric patients (OR 0.77, 95% CI 0.58 to 1.02), was higher in long-bone fractures than in spinal fusion, trended upward with higher doses, and was not elevated with short-term (≤14 days) use. Risk also differed by clinical context, higher in traumatic versus elective procedures. Conclusions: NSAID-related impairment of bone healing seems dose and context-dependent, with clinically important risk particularly in adults, long-bone fractures, and higher dose regimens. Short-term use (≤14 days) was not associated with increased nonunion risk. Risk seemed higher in traumatic fractures than in elective procedures. These findings support caution in higher risk scenarios, suggesting that short-duration NSAID use may be safe when avoiding higher dose exposure.
Severe acetabular bone loss and pelvic discontinuity in revision total hip arthroplasty present substantial reconstructive challenges, particularly when standard hemispherical cups, augments, or cages cannot achieve durable fixation or restore appropriate hip biomechanics. Custom pelvic implants (CPIs) are designed from patient-specific CT data and produced using additive manufacturing to create monoblock constructs that conform to bony defects and maximize fixation to remaining viable bone. This review summarizes the evolution of CPIs from early "triflange" devices to contemporary porous-coated, biomechanically optimized designs and outlines current nomenclature and indications. Key elements of preoperative evaluation, imaging protocols, and CT-based modeling are reviewed, along with implant design considerations including flange geometry, ischial fixation strategies, and screw trajectory planning. Surgical techniques for managing pelvic discontinuity are discussed with emphasis on achieving construct stability and promoting osseointegration. Published midterm to long-term outcomes demonstrate high implant survivorship, improved function, and low mechanical failure rates, with most revisions attributable to infection or instability. Economic analyses suggest CPIs are cost-comparable with other advanced reconstructive options while offering reliable fixation in complex cases. When applied with appropriate patient selection, careful design collaboration, and meticulous surgical execution, CPIs provide an effective and reproducible strategy for challenging acetabular reconstruction.
AIMS:The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) reported no notable difference in functional outcomes between surgical fixation and cast immobilization for minimally displaced scaphoid waist fractures in UK settings. We aimed to emulate SWIFFT using Chinese hospital electronic health record (EHR) data to evaluate whether similar treatment effects are observed in a population with different risk profiles and to identify subgroups that may benefit differentially from surgery. METHODS:This target trial emulation used a clone-censor-weight design with inverse probability of treatment and censoring weighting. Deidentified EHR data were extracted from three Tertiary A teaching hospitals in China (July 2018 to August 2024). Adults aged 16 years or older with a bicortical scaphoid waist fracture (displacement ≤2 mm) presenting within 14 days of injury were eligible. Patients received either headless compression screw fixation (n = 2,544) or below-elbow cast immobilization (n = 4,225). The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 52 weeks. RESULTS:Among 6,769 patients (mean age 32.1 years; 81.6% male; 42.4% current smokers), surgery produced statistically significant DASH improvements at all time points. At 52 weeks, the adjusted mean difference was -4.2 (95% CI, -4.9 to -3.5; P < 0.001), below commonly cited MCID estimates (10 to 15 points) but approaching lower proposed thresholds (7 to 10 points). Surgery halved nonunion risk (8.4% vs 17.5%; RR 0.48, 95% CI, 0.41 to 0.55) but increased complications sevenfold (14.1% vs 2.0%), predominantly screw-related. Subgroup analyses showed larger surgical benefits among patients with displaced fractures (-8.5) and current smokers (-6.7). Nearly one in five cast-treated patients (18.1%) ultimately required surgery for nonunion. CONCLUSION:Surgery was associated with statistically significant but modest DASH improvements, halved nonunion risk, and a sevenfold increase in complications. Cast immobilization remains a reasonable initial strategy for undisplaced fractures, while surgery offers measurable advantages for displaced fractures or smokers.
PURPOSE:To evaluate the effect of baseline dementia on postoperative outcomes in hip fracture patients undergoing hemiarthroplasty. METHODS:A retrospective review was conducted of patients aged 55 years or older who underwent hemiarthroplasty for displaced femoral neck fracture (AO/OTA 31B) between 2012 and 2024 at a large urban academic institution. Dementia was identified by ICD-10 codes and confirmed by chart review. A 3:1 propensity score matched cohort was created using the Score for Trauma Triage in Geriatric and Middle-aged (STTGMA). Demographics and baseline characteristics were compared to ensure similarity. Outcomes included total complications, major and minor complications, periprosthetic dislocation, length of stay, ICU admission, discharge location, 30- and 90-day readmission, revision surgery, inpatient, and 30-day and 1-year mortality. RESULTS:A total of 1,030 patients were included, with 241 patients with dementia and 839 controls. After 3:1 STTGMA propensity matching, baseline characteristics were comparable (mean age 82.75 vs. 83.0 years, P = 0.065; Charlson Comorbidity Index 1.96 vs. 1.92, P = 0.42; STTGMA 0.022 vs. 0.020, P = 0.50). Patients with dementia had increased major complications (17.92% vs. 10.93%, P = 0.013), including sepsis (5.00% vs. 2.21%, P = 0.027), urinary tract infections (13.33% vs. 6.78%, P = 0.002), and hip hemiarthroplasty dislocations (6.25% vs. 2.21%, P = 0.002). Patients with dementia also had longer length of stay (7.84 ± 5.83 vs. 6.80 ± 2.24 days, P = 0.030), increased 30-day readmissions (15.83% vs. 8.85%, P < 0.001), increased 90-day readmission (20.00% vs. 11.76%, P < 0.001), and higher 1-year mortality (16.25% vs. 8.02%, P < 0.001). No differences were observed in pneumonia, stroke, myocardial infarction, cardiac arrest, venothromboembolism, acute kidney injury, anemia, and revision surgery. CONCLUSION:Dementia was associated with increased major complications, hip hemiarthroplasty dislocations, higher readmission, and mortality after hemiarthroplasty. These findings highlight the need for targeted perioperative planning and multidisciplinary care pathways in cognitively impaired patients.
