Aims:In undisplaced femoral neck fractures, fixation failure remains a concern. In vitro studies suggest that interlocking plates increase torsional stability. However, whether this leads to clinically relevant improvement in fixation stability in vivo remains unclear. Accordingly, we tested whether interlocking plate fixation provides increased in vivo fixation stability over 52 weeks in undisplaced femoral neck fractures. Methods:Having been recruited from the Emergency Departments of two hospitals between May 2016 and January 2019, patients were randomized to Hansson pin fixation (n = 12) or Hansson Pinloc plate fixation (n = 13). Postoperative fracture motion was quantified using radiostereometric analysis (RSA) at baseline and at four, 12, 26, and 52 weeks. Clinical outcomes (Harris Hip Score, EuroQol five-dimension (EQ-5D) questionnaire, Timed Up and Go test, and pain and satisfaction using the Numeric Rating Scale) were assessed at the same timepoints. Data were analyzed using linear mixed model to account for missing RSA points. Results:A total of 17 patients completed the 52-week follow-up. The Pinloc group showed a smaller mean total rotation than the pin group, with a mean difference of -7.77° (95% CI -13.27° to -2.28°; p = 0.006) at 52 weeks. The groups diverged significantly in torsional stability at 12 weeks, with a larger between-group difference during follow-up. No between-group differences were observed in total translation or clinical outcomes. Five patients required reoperation: three in the Pinloc group and two in the pin group. Avascular necrosis occurred in three patients. Sub-trochanteric fractures occurred in two patients, both in the Pinloc group. Conclusion:Interlocking plate fixation resulted in increased torsional stability compared with pin fixation during healing of undisplaced femoral neck fractures, consistent with previous in vitro studies. The clinical implications of this finding remain uncertain.
Aims:Diabetes mellitus (DM) is associated with adverse outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA), yet optimal perioperative risk stratification remains unclear. This study evaluated the association of insulin dependence with: 1) 90-day complications; 2) perioperative glucose control; and 3) mid-term reoperations in diabetic patients undergoing primary THA and TKA. Methods:We performed a retrospective, single-centre study of patients with DM undergoing primary THA or TKA between 2015 and 2022. Patients with preoperative glycated haemoglobin (HbA1c) ≥ 6.5 were categorized as insulin-dependent DM (IDDM) or insulin-independent DM (NIDDM). Demographic and clinical variables including preoperative haemoglobin A1C and oral DM medication usage were recorded. The primary outcome was 90-day complications. Secondary outcomes included mean and maximum perioperative glucose levels and reoperations. Multivariable logistic and linear regression analyses were used to evaluate association between insulin dependence and outcomes while adjusting for relevant confounders. Results:A total of 830 patients were included: 351 (42.3%) with IDDM and 479 (57.7%) with NIDDM. Overall, 90-day complications were more common in the IDDM cohort (35.9% vs 16.3%, p < 0.01). Insulin dependence was associated with increased odds of 90-day complications (odds ratio 2.81, 95% CI 1.98 to 3.98). Male sex, metformin use, and glucagon-like peptide-1 receptor agonist use were associated with lower complication risk. Preoperative HbA1c was not independently associated with complications. Insulin dependence and preoperative haemoglobin A1C were associated with worse perioperative glucose control. Reoperation rates were similar between groups. Conclusion:Insulin dependence is an independent risk factor for 90-day complications and poorer perioperative glucose control, but not reoperation, following primary THA and TKA. These findings suggest insulin dependence is a clinically meaningful risk marker beyond glycaemic indices. Further investigation into optimization strategies to mitigate this perioperative risk is warranted.
Aims:Our aim was to explore Swedish orthopaedic surgeons' and trainees' perceptions of receiving individual surgeon feedback following total hip arthroplasty (THA) from a national arthroplasty quality register. Methods:A qualitative study with a phenomenographic approach was conducted. Informants were strategically selected to maximize variation in perceptions, based on hospital type (according to the national arthroplasty register classification) and level of surgical experience (trainee or years since specialist certification). A total of 15 orthopaedic specialists and four trainees from 15 hospitals in Sweden were interviewed. Data were analyzed using the established seven-step phenomenographic analysis procedure. Results:Four qualitatively distinct perceptions of individual surgeon feedback from a national quality register were identified: 1) progression in the profession; 2) exposure to inaccurate criticism; 3) potential impairment of patient benefit; and 4) does not contribute to enhanced feedback for surgeons. Feedback was perceived as a means of professional development but was also considered to carry a risk of misinterpretation and unfair criticism if results were used inappropriately. Participants further expressed concern that surgeon-specific outcome reporting could shift the focus from patient benefit to performance metrics, potentially influencing patient selection and clinical decision-making. Finally, some informants questioned the need for a national feedback programme, citing existing local and organizational mechanisms that already provide meaningful feedback. Conclusion:Swedish orthopaedic surgeons and trainees hold diverse perceptions of individual surgeon feedback from a national arthroplasty quality register. Awareness of these perceptions is important when refining or designing future surgeon-specific feedback programmes. Development and refining of feedback systems should occur in close collaboration with orthopaedic surgeons to ensure clinical relevance and acceptance.
Aims:Necrotizing fasciitis (NF) is a rapidly progressive surgical emergency. The effects of time from hospital presentation to theatre on short- and long-term outcomes, as well as specific modifiable aspects of the care pathway that would enable early surgery, remain poorly defined. Methods:A retrospective cohort study of all suspected cases of limb NF presenting across a large health board region over ten years (January 2015 to April 2025) was undertaken. Early surgery was defined as ≤ six hours from presentation (triage time) to theatre (operation start time). The independent associations between surgical timing and 30-day mortality or amputation were assessed. A timeline analysis identified areas where delays occurred. Survivors completed the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and Toronto Extremity Salvage Score (TESS) outcome assessments. Results:Of 359 referrals, four patients died prior to surgery and 80 patients underwent emergency surgery due to surgeon suspicion of NF. For cases of intraoperatively confirmed NF (n = 63/80), early surgery was associated with a five-fold reduction in 30-day mortality rate (overall rate 22% (n = 14/63); adjusted hazard ratio 0.19, 95% CI 0.04 to 0.87, p = 0.032; absolute risk difference 25%). Additionally, early surgery was associated with reduced rates of 30-day amputation (overall rate 30% (n = 19/63); adjusted hazard ratio 0.19, 95% CI 0.05 to 0.66, p = 0.009; absolute risk difference 32%). At a median of 27 months' follow-up (IQR 16 to 48), only 35 patients (56%) were alive. Survivors having early surgery reported significantly better patient-reported outcomes (EQ-5D: 0.785 vs 0.133, p = 0.003; TESS combined: 64.9 vs 28.7, p = 0.007). Conclusion:Early surgery for patients with NF was associated with a lower risk of mortality, amputation, and severe long-term disability. Early recognition and transfer to theatre represent modifiable targets for improving survival and outcomes.
Aims The primary aim of the Action on Hip Fracture Management Quality Improvement (ACTIVE) trial is to evaluate whether a context-tailored quality improvement programme improves health-related quality of life at 120 days after hospital admission, among adults aged 65 years or older with a hip fracture, in less-resourced hospitals in China. Secondary aims are to compare health-related quality of life at 30 days, complication and morbidity at 30 and 120 days, proportion of patients receiving surgery, proportion of patients on full weightbearing at one week after surgery, time from admission to surgery, length of hospital stay, 120-day mortality, and inpatient costs between the two groups, and to evaluate the implementation and cost-effectiveness of the intervention. Methods This is a multicentre, open-label, pragmatic, parallel-group, cluster-randomized controlled trial conducted in 80 less-resourced county- or district-level public general hospitals across ten provinces in China (all hospitals are graded 3B or below; 3A is considered the most high-ranking or well-resourced hospital). Hospitals are randomized 1:1 within each province to either intervention or the control group. Eligible participants are adults aged 65 years or older with acute unilateral hip fracture confirmed by radiography or CT. The intervention consists of optimization of in-hospital management processes, empowerment of surgeons and physicians, and health education for patients and their family members. Hospitals allocated to the control group continue usual orthopaedic-led care. Participants are followed up at 30 and 120 days after admission. The primary outcome is health-related quality of life at 120 days after admission. A total of 8,800 participants will be recruited. Conclusion The results of the ACTIVE trial will inform whether a context-tailored quality improvement programme, consisting of interventions on health administrators, health providers, and patients, can improve outcomes for older adults with hip fracture in less-resourced hospitals in China, and many countries beyond with emerging burden of ageing population. Cite this article: Bone Jt Open 2026;7(8):1101–1109.
Aims:The Coronal Plane Alignment of the Knee classification (CPAK) describes nine knee phenotypes by defining arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO). In this study, the CPAK classification was used to analyze the development of lower-limb alignment in children and adolescents, providing reference values and allowing insights into the morphogenesis of the knee joint during skeletal maturation. Methods:Angular measurements of 655 knees taken on CT scans of 333 children aged between four and 18 years from a publicly available radiological database were analyzed, applying the CPAK classification by calculating the aHKA and JLO. Results:The mean aHKA was 3.4° (SD 3.1°). JLO became more pronounced with age, decreasing from a mean of 176.8° (SD 4.2°) at the age of four years to 172.8° (SD 3.1°) at the age of 18 years. The most common CPAK type between four and 18 years was CPAK III (58.2%), the second most common type was CPAK II (24.7%), and the third most prevalent type was CPAK IV (10.1%). Conclusion:This is the first study analyzing lower-limb alignment in children and adolescents using the CPAK classification. By simultaneously developing a distal femoral valgus and a counteracting proximal tibial varus morphology, overall constitutional alignment as represented by the aHKA remains almost constant between the age of four and 18 years. Conversely, joint line obliquity changes significantly with age towards an apex distal phenotype. We provide a comprehensive explanation for the physiological development of lower-limb alignment during skeletal growth.
Aims The Coronal Plane Alignment of the Knee classification (CPAK) describes nine knee phenotypes by defining arithmetic hip-knee-ankle angle (aHKA) and joint line obliquity (JLO). In this study, the CPAK classification was used to analyze the development of lower-limb alignment in children and adolescents, providing reference values and allowing insights into the morphogenesis of the knee joint during skeletal maturation. Methods Angular measurements of 655 knees taken on CT scans of 333 children aged between four and 18 years from a publicly available radiological database were analyzed, applying the CPAK classification by calculating the aHKA and JLO. Results The mean aHKA was 3.4° (SD 3.1°). JLO became more pronounced with age, decreasing from a mean of 176.8° (SD 4.2°) at the age of four years to 172.8° (SD 3.1°) at the age of 18 years. The most common CPAK type between four and 18 years was CPAK III (58.2%), the second most common type was CPAK II (24.7%), and the third most prevalent type was CPAK IV (10.1%). Conclusion This is the first study analyzing lower-limb alignment in children and adolescents using the CPAK classification. By simultaneously developing a distal femoral valgus and a counteracting proximal tibial varus morphology, overall constitutional alignment as represented by the aHKA remains almost constant between the age of four and 18 years. Conversely, joint line obliquity changes significantly with age towards an apex distal phenotype. We provide a comprehensive explanation for the physiological development of lower-limb alignment during skeletal growth. Cite this article: Bone Jt Open 2026;7(8):1084–1092.
Aims:Musculoskeletal (MSK) injuries are a major cause of morbidity and mortality worldwide. However, research into MSK injuries is hampered by significant challenges and barriers, particularly in low-and middle-income countries (LMICs). Our aim was to identify the most important challenges and barriers to MSK injury care research across Malawi, South Africa, and Tanzania. Methods:We conducted a three-stage modified Delphi study. In Stage 1, healthcare professionals and researchers involved in MSK injury care listed challenges and barriers to conducting MSK injury research, which were consolidated in 25 themes. In Stage 2, participants rated each theme on a five-point Likert scale. In Stage 3, to drive consensus, participants re-rated the themes after viewing group and country-specific feedback from the previous stage. Challenges and barriers were ranked by mean score. Consensus was defined as ≥ 75% of respondents rating a theme as 4 or 5 ('important' and 'most important' on the Likert Scale). Results:A total of 396 participants completed Stage 1, 424 completed Stage 2, and 434 completed Stage 3. Across all participants, consensus (≥ 75%) was reached on nine key challenges and barriers to MSK injury research, including: lack of funding, high clinical workloads, limited training and mentorship, poor-quality data collection practices, healthcare facility resource constraints, patient loss to follow-up, limited research opportunities outside academic institutions, poverty and financial barriers, and healthcare delays. At the country level, the challenges of lack of funding, high clinical workload, and inconsistent data collection practices consistently achieved consensus in Malawi, South Africa, and Tanzania. Conclusion:MSK injuries impose a substantial burden in sub-Saharan Africa, yet research remains limited by funding shortages, high clinical workloads, and inconsistent data collection practices. These challenges, consistently identified across Malawi, South Africa, and Tanzania, highlight the need for targeted investment and regional collaboration to strengthen research capacity and improve patient outcomes.
Aims Musculoskeletal (MSK) injuries are a major cause of morbidity and mortality worldwide. However, research into MSK injuries is hampered by significant challenges and barriers, particularly in low-and middle-income countries (LMICs). Our aim was to identify the most important challenges and barriers to MSK injury care research across Malawi, South Africa, and Tanzania. Methods We conducted a three-stage modified Delphi study. In Stage 1, healthcare professionals and researchers involved in MSK injury care listed challenges and barriers to conducting MSK injury research, which were consolidated in 25 themes. In Stage 2, participants rated each theme on a five-point Likert scale. In Stage 3, to drive consensus, participants re-rated the themes after viewing group and country-specific feedback from the previous stage. Challenges and barriers were ranked by mean score. Consensus was defined as ≥ 75% of respondents rating a theme as 4 or 5 (‘important’ and ‘most important’ on the Likert Scale). Results A total of 396 participants completed Stage 1, 424 completed Stage 2, and 434 completed Stage 3. Across all participants, consensus (≥ 75%) was reached on nine key challenges and barriers to MSK injury research, including: lack of funding, high clinical workloads, limited training and mentorship, poor-quality data collection practices, healthcare facility resource constraints, patient loss to follow-up, limited research opportunities outside academic institutions, poverty and financial barriers, and healthcare delays. At the country level, the challenges of lack of funding, high clinical workload, and inconsistent data collection practices consistently achieved consensus in Malawi, South Africa, and Tanzania. Conclusion MSK injuries impose a substantial burden in sub-Saharan Africa, yet research remains limited by funding shortages, high clinical workloads, and inconsistent data collection practices. These challenges, consistently identified across Malawi, South Africa, and Tanzania, highlight the need for targeted investment and regional collaboration to strengthen research capacity and improve patient outcomes. Cite this article: Bone Jt Open 2026;7(8):1076–1083.
Aims:Fracture laterality is routinely recorded in large hip fracture registries for administrative purposes, yet rarely evaluated as a prognostic variable. We aimed to test whether laterality is independently associated with short-term outcomes after hip fracture surgery. Methods:This retrospective cohort study used a regional, prefecture-wide administrative database based on Japan's Diagnosis Procedure Combination system. We identified 72,008 patients who underwent primary surgery for hip fracture between 2015 and 2023. The primary outcome was in-hospital mortality. The secondary outcome was impaired independence in activities of daily living (ADL) at discharge, defined as a Barthel index (BI) score < 60. We used multivariable logistic regression to assess the association between fracture laterality and outcomes, adjusting for age, sex, BMI, smoking history, fracture type, admission BI, diabetes mellitus, and the Charlson Comorbidity Index (CCI). Results:Left-sided fractures were significantly more frequent than right-sided fractures (51.5% vs 48.5%, p < 0.001). In-hospital mortality did not differ significantly between right- and left-sided fractures in either unadjusted (2.0% vs 2.0%, p = 0.093) or adjusted analyses (adjusted odds ratio (aOR), 1.10; 95% CI 0.99 to 1.22; p = 0.075). In contrast, right-sided fracture was independently associated with impaired ADL at discharge (aOR 1.09; 95% CI 1.05 to 1.13; p < 0.001). In a prespecified sub-group analysis, right-sided fracture was associated with higher mortality among patients with high comorbidity burden (CCI ≥ 2; aOR 1.29; 95% CI 1.09 to 1.53; p = 0.004; p for interaction = 0.022). A sensitivity analysis using double-selection lasso logistic regression yielded materially unchanged estimates. Conclusion:In our cohort, right-sided hip fractures were independently associated with impaired ADL at discharge, and with higher in-hospital mortality among patients with substantial comorbidity. These associations persisted across sensitivity analyses but, given the observational design and the inability of administrative data to capture limb dominance, require confirmation in independent cohorts. Fracture laterality, which is a variable routinely captured at presentation but seldom analyzed, nonetheless merits consistent reporting and consideration in registry-based prognostic research.
Aims Fracture laterality is routinely recorded in large hip fracture registries for administrative purposes, yet rarely evaluated as a prognostic variable. We aimed to test whether laterality is independently associated with short-term outcomes after hip fracture surgery. Methods This retrospective cohort study used a regional, prefecture-wide administrative database based on Japan’s Diagnosis Procedure Combination system. We identified 72,008 patients who underwent primary surgery for hip fracture between 2015 and 2023. The primary outcome was in-hospital mortality. The secondary outcome was impaired independence in activities of daily living (ADL) at discharge, defined as a Barthel index (BI) score < 60. We used multivariable logistic regression to assess the association between fracture laterality and outcomes, adjusting for age, sex, BMI, smoking history, fracture type, admission BI, diabetes mellitus, and the Charlson Comorbidity Index (CCI). Results Left-sided fractures were significantly more frequent than right-sided fractures (51.5% vs 48.5%, p < 0.001). In-hospital mortality did not differ significantly between right- and left-sided fractures in either unadjusted (2.0% vs 2.0%, p = 0.093) or adjusted analyses (adjusted odds ratio (aOR), 1.10; 95% CI 0.99 to 1.22; p = 0.075). In contrast, right-sided fracture was independently associated with impaired ADL at discharge (aOR 1.09; 95% CI 1.05 to 1.13; p < 0.001). In a prespecified sub-group analysis, right-sided fracture was associated with higher mortality among patients with high comorbidity burden (CCI ≥ 2; aOR 1.29; 95% CI 1.09 to 1.53; p = 0.004; p for interaction = 0.022). A sensitivity analysis using double-selection lasso logistic regression yielded materially unchanged estimates. Conclusion In our cohort, right-sided hip fractures were independently associated with impaired ADL at discharge, and with higher in-hospital mortality among patients with substantial comorbidity. These associations persisted across sensitivity analyses but, given the observational design and the inability of administrative data to capture limb dominance, require confirmation in independent cohorts. Fracture laterality, which is a variable routinely captured at presentation but seldom analyzed, nonetheless merits consistent reporting and consideration in registry-based prognostic research. Cite this article: Bone Jt Open 2026;7(8):1064–1074.
Aims:Anatomical total shoulder arthroplasty (aTSA) has been the traditional treatment for glenohumeral osteoarthritis (OA) with an intact rotator cuff. However, reverse total shoulder arthroplasty (rTSA) is now being more frequently performed, with its utility in consistent fixation and severe bony deformity. This study systematically reviews available literature comparing aTSA and rTSA in patients with OA with an intact rotator cuff. Methods:A literature review was conducted to identify studies comparing aTSA and rTSA in patients with glenohumeral OA and intact rotator cuffs. Primary postoperative outcomes were analyzed, including range of motion, patient-reported outcomes, complications, revisions, cost, radiological changes, and satisfaction. Results:In all, 18 articles met the inclusion criteria. aTSA demonstrated better range of motion with no difference in American Shoulder and Elbow Surgeons scores and pain outcomes. While complication and revision reasons varied slightly, there was no difference in overall complication and revision rates. Of four studies reporting patient satisfaction, two favoured aTSA. Conclusion:In our population, aTSA and rTSA yield comparable postoperative outcomes. While aTSA may offer a superior range of motion, its clinical value remains uncertain. These findings support the growing consideration of rTSA as a viable alternative to aTSA in this population, although longer follow-up time is required.
Aims Hip and knee arthroplasty are among the most commonly performed surgical procedures worldwide but carry a risk of cardiovascular complications, including myocardial infarction (MI). Therefore, this study aimed to assess the long-term incidence of MI following hip and knee arthroplasty, and subsequent mortality, in a UK-based cohort. Methods A retrospective cohort study was conducted using linked Hospital Episode Statistics (HES), Office for National Statistics (ONS) mortality data, and Clinical Practice Research Datalink (CPRD) records. Patients undergoing total hip arthroplasty (THA), hip resurfacing arthroplasty (HRA), total knee arthroplasty (TKA), or unicompartmental knee arthroplasty (UKA) between 2 January 1998 and 29 March 2021 were identified. An inverse probability weighting approach based on propensity scores was used, and outcomes were assessed using weighted logistic regression for MI incidence at 30, 90, and 365 days postoperatively, and multiple Cox proportional hazards models for MI-related mortality. Results In total, 1,148,298 procedures were included in the final analysis. Of those undergoing hip arthroplasty, 713 (0.13%) patients experienced a MI within 30 days postoperatively, rising to 947 (0.17%) at 90 days and 1,989 (0.38%) patients at one year. In the knee arthroplasty cohort, the number of patients experiencing a MI was 656 (0.11%) at 30 days, 890 (0.15%) at 90 days, and 1,853 (0.32%) at one year postoperatively. Factors associated with increased MI incidence included age, male sex, non-white ethnicities, geographical region, higher deprivation status, and elevated comorbidity scores. Weighted logistic regression demonstrated significantly lower odds of MI, and MI-related mortality in patients undergoing UKA and HRA compared with TKA and THA, respectively. Conclusion In England, post-arthroplasty MI remains uncommon but carries significant mortality risk. Bone-preserving procedures are associated with a significantly reduced incidence of MI and subsequent mortality. These findings emphasize the importance of careful patient and treatment selection, and targeted cardiovascular risk mitigation, to optimize postarthroplasty outcomes. Cite this article: Bone Jt Open 2026;7(8):1046–1055.
Aims:Adult reconstruction surgeons face unique occupational challenges during joint arthroplasty procedures, including sustained physical demands, ergonomic strain, noise exposure, and psychological pressure from high patient expectations. This systematic review aimed to synthesize existing evidence regarding physical and psychological stressors encountered by surgeons performing hip and knee arthroplasty. Methods:Following PRISMA guidelines, we searched PubMed, EMBASE, Web of Science, and Cochrane Library through to December 2024. Studies evaluating occupational hazards during adult hip and knee arthroplasty were included, focusing on noise exposure, ergonomic challenges, musculoskeletal strain, and robotic-assisted platforms' impact on surgeon performance. Risk of bias was assessed using Appraisal tool for Cross-Sectional Studies (AXIS) and Methodological Index for Non-Randomized Studies (MINORS) tools. Results:In total, 38 studies were included, revealing five key hazard categories. Work-related injury prevalence ranged from 66% to 96.5%, predominantly affecting spine (28% to 34.2%), shoulders, and upper limbs. Risk factors included age > 55 years, high surgical volume (> 100 procedures annually), and > 20 years' practice. CO2 accumulation in helmet systems exceeded safety limits in 10/11 configurations tested. Joint arthroplasties generated the highest noise levels (77 dBA to 88.2 dBA) among orthopaedic procedures, with arthroplasty surgeons showing nearly triple the hearing loss rate compared with non-surgical clinicians (31% vs 11%, odds ratio 3.63). Total hip arthroplasty demonstrated higher physiological demands than total knee arthroplasty (heart rate: 95.7 vs 90.2 bpm; energy: 290.2 vs 189.4 kcal). Revision surgeries imposed doubled mental demand scores compared with primary procedures. Robotic assistance improved ergonomics through reduced neck and lumbar flexion, but increased operating times and generated higher noise levels. Conclusion:Arthroplasty surgeons face substantial occupational hazards with high musculoskeletal injury rates, significant noise-induced hearing loss, and considerable physiological demands. While emerging technologies show promise in reducing some physical demands, they introduce new ergonomic considerations, highlighting the need for comprehensive occupational health strategies to ensure sustainable surgical careers.
Aims Adult reconstruction surgeons face unique occupational challenges during joint arthroplasty procedures, including sustained physical demands, ergonomic strain, noise exposure, and psychological pressure from high patient expectations. This systematic review aimed to synthesize existing evidence regarding physical and psychological stressors encountered by surgeons performing hip and knee arthroplasty. Methods Following PRISMA guidelines, we searched PubMed, EMBASE, Web of Science, and Cochrane Library through to December 2024. Studies evaluating occupational hazards during adult hip and knee arthroplasty were included, focusing on noise exposure, ergonomic challenges, musculoskeletal strain, and robotic-assisted platforms’ impact on surgeon performance. Risk of bias was assessed using Appraisal tool for Cross-Sectional Studies (AXIS) and Methodological Index for Non-Randomized Studies (MINORS) tools. Results In total, 38 studies were included, revealing five key hazard categories. Work-related injury prevalence ranged from 66% to 96.5%, predominantly affecting spine (28% to 34.2%), shoulders, and upper limbs. Risk factors included age > 55 years, high surgical volume (> 100 procedures annually), and > 20 years’ practice. CO 2 accumulation in helmet systems exceeded safety limits in 10/11 configurations tested. Joint arthroplasties generated the highest noise levels (77 dBA to 88.2 dBA) among orthopaedic procedures, with arthroplasty surgeons showing nearly triple the hearing loss rate compared with non-surgical clinicians (31% vs 11%, odds ratio 3.63). Total hip arthroplasty demonstrated higher physiological demands than total knee arthroplasty (heart rate: 95.7 vs 90.2 bpm; energy: 290.2 vs 189.4 kcal). Revision surgeries imposed doubled mental demand scores compared with primary procedures. Robotic assistance improved ergonomics through reduced neck and lumbar flexion, but increased operating times and generated higher noise levels. Conclusion Arthroplasty surgeons face substantial occupational hazards with high musculoskeletal injury rates, significant noise-induced hearing loss, and considerable physiological demands. While emerging technologies show promise in reducing some physical demands, they introduce new ergonomic considerations, highlighting the need for comprehensive occupational health strategies to ensure sustainable surgical careers. Cite this article: Bone Jt Open 2026;7(8):1037–1045.
Aims:Concerns persist that kinematic alignment (KA) in primary total knee arthroplasty (TKA) may adversely affect the patellofemoral (PF) joint, because most contemporary components were developed under mechanical alignment (MA) principles. This focused scoping review mapped head-to-head comparative clinical evidence on PF outcomes after KA versus MA TKA, and identified key evidence gaps relevant to clinical decision-making. Methods:A focused scoping review was conducted. PubMed/MEDLINE, the Cochrane Library, and CINAHL were searched from inception to 15 January 2026. We included head-to-head comparative studies directly comparing KA and MA in primary TKA that reported at least one PF-related outcome. PF outcomes were mapped into three domains: 1) PF symptoms and PF-specific patient-reported outcome measures (PROMs); 2) PF-related interventions and complications; and 3) PF imaging/radiological measures. Findings were synthesized descriptively. Results:A total of 12 studies met the inclusion criteria. Domain A was addressed by only one study and was insufficient for definitive conclusions. Domain B was addressed by six studies; no consistent signal of higher PF-related interventions/complications with KA was identified, and several studies reported numerically fewer PF-related procedures with KA, including lateral retinacular release. Domain C was addressed by ten studies and showed heterogeneous imaging findings; when PF radiological differences were observed, they were not consistently accompanied by worse symptoms or higher PF-related intervention rates. Postoperative rotational alignment was inconsistently assessed. Conclusion:Current head-to-head comparative evidence is insufficient to determine the definitive PF-specific clinical impact of KA versus MA, mainly because PF-specific PROMs are rarely reported. Although no consistent harm signal was identified, this should not be interpreted as evidence of equivalence. This review primarily defines current evidence gaps, including the need for prespecified PF-specific PROMs, systematic rotational verification, consistent reporting of PF-related interventions/complications, and longer follow-up.
Aims:Revision total knee arthroplasty (rTKA) is a treatment option for failed primary TKA but is associated with higher complication rates and technical challenges. Robotic-assisted rTKA (rarTKA) is an emerging technique that may improve component alignment and surgical precision. However, its effect on early postoperative outcomes in rTKA for instability remains unclear. Methods:A total of 133 consecutive rTKAs for instability (82 manual and 51 robotic) performed by two fellowship-trained arthroplasty surgeons at a single institution were retrospectively analyzed. All rarTKAs used the MAKO robotic-arm system. Operating time, length of stay (LOS), joint line change, posterior condylar offset (PCO) change, and all-cause 30-/90-day complications were compared using univariable analyses. Revision implant constructs were also compared. The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and range of motion (ROM) were assessed at three months and one year, respectively. Kaplan-Meier analysis assessed one-year reoperation-free survival. Results:RarTKA achieved a greater mean increase in PCO (3.4 mm vs 1.5 mm; p = 0.014), but required a longer operating time (186 minutes vs 173 minutes; p = 0.037). Joint line change, LOS, three-month KOOS-JR, and ROM did not differ significantly. The 30-day (4.9% vs 7.8%) and 90-day (7.3% vs 11.8%) complication rates and one-year reoperation-free survival (91.5% vs 94.1%; p = 0.900) were comparable. Although offset couplers were not used, rarTKA constructs incorporated augments more frequently. Conclusion:RarTKA demonstrated early postoperative outcomes and complication rates comparable to those of conventional manual rTKA, while achieving improved PCO restoration despite longer operating times. LOS, functional outcomes, and one-year survivorship were similar between groups. Overall, rarTKA appears to be safe and effective; however, further investigation is required to determine the long-term benefits and clinical significance.
Aims Concerns persist that kinematic alignment (KA) in primary total knee arthroplasty (TKA) may adversely affect the patellofemoral (PF) joint, because most contemporary components were developed under mechanical alignment (MA) principles. This focused scoping review mapped head-to-head comparative clinical evidence on PF outcomes after KA versus MA TKA, and identified key evidence gaps relevant to clinical decision-making. Methods A focused scoping review was conducted. PubMed/MEDLINE, the Cochrane Library, and CINAHL were searched from inception to 15 January 2026. We included head-to-head comparative studies directly comparing KA and MA in primary TKA that reported at least one PF-related outcome. PF outcomes were mapped into three domains: 1) PF symptoms and PF-specific patient-reported outcome measures (PROMs); 2) PF-related interventions and complications; and 3) PF imaging/radiological measures. Findings were synthesized descriptively. Results A total of 12 studies met the inclusion criteria. Domain A was addressed by only one study and was insufficient for definitive conclusions. Domain B was addressed by six studies; no consistent signal of higher PF-related interventions/complications with KA was identified, and several studies reported numerically fewer PF-related procedures with KA, including lateral retinacular release. Domain C was addressed by ten studies and showed heterogeneous imaging findings; when PF radiological differences were observed, they were not consistently accompanied by worse symptoms or higher PF-related intervention rates. Postoperative rotational alignment was inconsistently assessed. Conclusion Current head-to-head comparative evidence is insufficient to determine the definitive PF-specific clinical impact of KA versus MA, mainly because PF-specific PROMs are rarely reported. Although no consistent harm signal was identified, this should not be interpreted as evidence of equivalence. This review primarily defines current evidence gaps, including the need for prespecified PF-specific PROMs, systematic rotational verification, consistent reporting of PF-related interventions/complications, and longer follow-up. Cite this article: Bone Jt Open 2026;7(8):1026–1036.
Aims:This study aimed to investigate the associations between performance-based outcomes (walking, sit-to-stand, and stair climbing) and impairment-level measures one year after primary unilateral total knee arthroplasty (TKA) using an analytic framework that mitigates multicollinearity. Methods:Prospectively collected data were analyzed in a cross-sectional design. We included 142 patients who underwent primary unilateral TKA. The performance-based outcomes one year postoperatively were the 40 m fast-paced walk test (FPWT), 30 s chair stand test (CST), and 11-step stair-climbing test (SCT). Explanatory variables included age, sex, BMI, one-year postoperative muscle strength (bilateral quadriceps and hamstring strength), pain visual analogue scale (VAS) score, and knee flexion range of motion (ROM; SCT model only). We performed multivariate analyses using multiple linear regression and additionally applied ridge regression to mitigate multicollinearity. Relative importance was quantified using the Lindeman-Merenda-Gold (LMG) method. Results:For the FPWT, the primary determinants were bilateral quadriceps strength, contralateral hamstring strength, and age, while sex and pain VAS scores were lower-importance contributors. For CST, bilateral quadriceps strength, age, and contralateral hamstring strength were the primary determinants, with BMI contributing secondarily. For SCT, contralateral quadriceps strength and age were the main determinants, whereas pain VAS score and knee flexion ROM were additional, lower-importance contributors. Conclusion:One year after TKA, bilateral quadriceps strength played a central role across all tasks. Walking and sit-to-stand performances were additionally associated with contralateral hamstring strength and age, whereas stair performance was influenced by pain control and adequate knee flexion ROM. These findings support personalized rehabilitation strategies that prioritize bilateral quadriceps strengthening and layer-task-specific requirements.
Aims Revision total knee arthroplasty (rTKA) is a treatment option for failed primary TKA but is associated with higher complication rates and technical challenges. Robotic-assisted rTKA (rarTKA) is an emerging technique that may improve component alignment and surgical precision. However, its effect on early postoperative outcomes in rTKA for instability remains unclear. Methods A total of 133 consecutive rTKAs for instability (82 manual and 51 robotic) performed by two fellowship-trained arthroplasty surgeons at a single institution were retrospectively analyzed. All rarTKAs used the MAKO robotic-arm system. Operating time, length of stay (LOS), joint line change, posterior condylar offset (PCO) change, and all-cause 30-/90-day complications were compared using univariable analyses. Revision implant constructs were also compared. The Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and range of motion (ROM) were assessed at three months and one year, respectively. Kaplan-Meier analysis assessed one-year reoperation-free survival. Results RarTKA achieved a greater mean increase in PCO (3.4 mm vs 1.5 mm; p = 0.014), but required a longer operating time (186 minutes vs 173 minutes; p = 0.037). Joint line change, LOS, three-month KOOS-JR, and ROM did not differ significantly. The 30-day (4.9% vs 7.8%) and 90-day (7.3% vs 11.8%) complication rates and one-year reoperation-free survival (91.5% vs 94.1%; p = 0.900) were comparable. Although offset couplers were not used, rarTKA constructs incorporated augments more frequently. Conclusion RarTKA demonstrated early postoperative outcomes and complication rates comparable to those of conventional manual rTKA, while achieving improved PCO restoration despite longer operating times. LOS, functional outcomes, and one-year survivorship were similar between groups. Overall, rarTKA appears to be safe and effective; however, further investigation is required to determine the long-term benefits and clinical significance. Cite this article: Bone Jt Open 2026;7(8):1007–1014.
