BACKGROUND:Cemented femoral fixation is considered the gold standard in hip arthroplasty for femoral neck fractures (FNFs), given lower periprosthetic fracture risk than cementless fixation. However, one major concern with cementation is bone-cement implantation syndrome (BCIS), a phenomenon involving cardiopulmonary distress attributed to cement pressurization. This study compared outcomes based on fixation method and stem design and evaluated the utilization of cemented versus cementless fixation following FNF. METHODS:A retrospective review identified 2,829 patients who underwent total hip arthroplasty or hemiarthroplasty for FNF between December 2017 and January 2024 within a multi-institutional hospital enterprise. Cementless fixation was performed in 598 patients (21%), who were younger (75 versus 83 years; P < 0.001) and more likely men (66 versus 56%; P < 0.001) than those who received cemented fixation. Patients were propensity-matched for age, sex, body mass index, and comorbidities to compare fixation type and stem design. Following propensity matching, 346 matched pairs were analyzed. Outcomes including BCIS, periprosthetic fracture, and mortality were compared using Fisher's exact tests and a conditional logistic regression model. RESULTS:Cemented fixation was associated with fewer periprosthetic fractures (4 versus 7%; P < 0.04) but more Grade 1 BCIS (43 versus 32%; P < 0.01). A separate propensity match was performed comparing collared cemented stems to metaphyseal filling and collared cementless implants, resulting in 213 matched pairs. There were no differences in BCIS (P < 0.56), periprosthetic fracture (3 versus 2%; P < 0.75), mortality (all P > 0.05), deep vein thrombosis, or surgical site infection between cohorts. CONCLUSIONS:Vital sign abnormalities consistent with BCIS, observed in both fixation cohorts, were primarily low-grade and clinically inconsequential. Surgeons should remain vigilant for the development of BCIS, but results from this study suggest that fears over morbidity and mortality due to cementation should not discourage the usage of cemented femoral fixation.

The goal of this study is to compare the sensitivity, accuracy, and specificity of detection of musculoskeletal sarcoma local recurrence (LR) using axial-only MRI compared with multiplanar MRI. This retrospective study included 101 patients (47 with pathology-proven LR, 54 without recurrence) who underwent pre- and post-operative MRIs between 2013 and 2023 at a single academic center. Three fellowship-trained musculoskeletal radiologists independently reviewed anonymized MRIs. Initial review included only the axial sequences from the surveillance MRIs. Secondary review following a 6-month washout included all sequences from the multiplanar surveillance MRIs. No statistically significant differences in accuracy, sensitivity, and specificity were observed between axial-only and complete (multiplanar) MRI analyses (p > 0.05). Accuracy of LR detection with axial-only vs. complete (multiplanar) MRI was 94.5

Comparison of desmoid tumor PRO information between baseline, 6-month, and 24-month follow-up.

Comparison of SF-12 and VAS information between baseline, 6-month, and 24-month follow-up.

A Scatterplot demonstrating correlation between the early changes in post-contrast signal intensity and 24-month tumor volume.

A Scatterplot demonstrating correlation between the early changes in T2 signal intensity and 24-month tumor volume.

BACKGROUND:Orthopaedic surgeons routinely delay surgical management of femoral neck fractures in patients taking direct oral anticoagulants (DOACs) to decrease perioperative bleeding and associated complications. However, this practice contradicts the principles of hip fracture management, as early surgery is associated with morbidity and mortality benefits. The purpose of this study was to quantify the association of DOAC use and perioperative outcomes in patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures. We hypothesized that early surgical intervention on a patient taking a DOAC medication would not lead to worse perioperative outcomes. METHODS:A retrospective cohort study was conducted on 2,833 patients who underwent primary THA or HA for femoral neck fractures between December 31, 2017, and January 29, 2024, across our hospital system. The patients taking a DOAC were divided into 3 groups based on the time since the last DOAC intake: 1 day, 2 days, and ≥3 days. Propensity matching was performed 1:1, accounting for age, sex, Elixhauser Comorbidity Index, preoperative chronic kidney disease stage, preoperative hemoglobin, body mass index, and hospital type. Subanalyses utilizing linear and conditional logistic regression models were performed to assess differences in outcomes between the groups that had a DOAC withheld and the control groups. RESULTS:The mean age of all patients was 81 ± 10 years, 1,805 patients (64%) were women, and 207 patients (7%) were taking a DOAC prior to surgery. Despite comparable preoperative and postoperative hemoglobin levels between the groups that had a DOAC withheld and the control groups (all p > 0.05), the patients who had a DOAC withheld for 1 day were more likely to receive a postoperative blood transfusion (23.1% compared with 0%; p = 0.002). This difference in transfusion rate was not observed in other cohorts. There were no differences in medical complications, reoperation, discharge disposition, or mortality between the groups that had a DOAC withheld and the matched controls at any time point. CONCLUSIONS:Delaying surgical management due to DOAC medications may be unnecessary in patients undergoing arthroplasty for femoral neck fractures. Consideration should be given to adjusting transfusion triggers to reduce unwarranted blood transfusions in patients taking a DOAC. LEVEL OF EVIDENCE:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION:The United States has experienced a notable increase in opioid abuse over the past several years, with orthopaedic surgeons reported as the third-highest prescribers by specialty. Several studies have addressed opioid use after major orthopaedic procedures but largely focused on prescribing practices. There is limited data on the utility of adding adductor canal pain catheters to multimodal regimens following total knee arthroplasty for improved pain control and reduced opioid dependence. The purpose of this preliminary study was to compare single-shot adductor canal blocks to continuous infusion or intermittent bolus catheters, evaluating postoperative pain levels and duration of opioid use. METHODS:Sixty opioid-naive patients participated in a prospective, randomized, double-blinded, placebo-controlled trial. Following total knee arthroplasty, patients were randomized into one of three cohorts based on preoperative pain levels: (1) single-shot adductor canal block with placebo catheter, (2) continuous infusion catheter, or (3) intermittent bolus catheter. Postoperative protocols were similar except for the catheter. Patient outcomes were recorded for 60 days postoperatively. RESULTS:We found no difference in length of stay, oral morphine equivalents, use of on-demand medication, or pain scores (all P > 0.05) between the groups. Although the single-shot cohort trended toward a longer duration of opioid use (median 21 days) compared with the catheter groups (median 14 days for both), this did not approach statistical significance ( P = 0.59). We found no difference in Knee Injury and Osteoarthritis Outcome Score Jr scores between the groups at 30 or 60 days postoperatively (all P > 0.05). CONCLUSION:In our preliminary study, we found no differences in clinical outcomes, pain scores, or patient-reported scores between a single-shot adductor canal block, a continuous infusion adductor canal catheter, and an intermittent bolus adductor catheter following total knee arthroplasty. Larger studies are needed to more definitively assess differences in outcomes between the treatment groups, particularly in the opioid-tolerant population.

Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

Introduction Many studies focused on the positive impact of virtual visits during the COVID-19 pandemic. In the post-pandemic era, research exploring telemedicine's impact on the orthopedic physical examination, particularly for the lower extremities, continues to expand. This research evaluates the validity and reliability of telemedicine measuring ankle and great toe range of motion (ROM). Methods In this prospective study, 59 ankles and 59 great toes were measured by a researcher trained by a licensed occupational therapist for goniometer use both in-person and through telemedicine. Telemedicine measurements were also made by a second researcher. Mean differences and intraclass correlation coefficients (ICCs) were used to assess validity by comparing the ROM between in-person and telemedicine ROM measures. ICCs were used to evaluate reliability by assessing agreement in telemedicine ROM measures between the two different researchers. Results In the evaluation of validity, in-person and telemedicine measurements for both ankle dorsiflexion and plantarflexion revealed ICCs of 0.81, with mean differences equal to -0.64 and -0.93 degrees, respectively. In-person and still-shot photography for ankle dorsiflexion had an ICC of 0.83 and plantarflexion had an ICC of 0.82, with respective mean differences of -1.39 and -0.24 degrees. Hallux extension measurements between in-person and telemedical visits had an ICC of 0.87 (mean difference: 2.34 degrees), whereas still-shot showed an ICC of 0.86 (mean difference: 2.58 degrees). Hallux flexion had an ICC of 0.93 (mean difference: -0.98 degrees) for in-person and telemedical visits and an ICC of 0.95 (mean difference: -1.51 degrees) for in-person and still-shot measures. Conclusion Ankle and great toe joint ROM can be measured effectively during an orthopedic telemedicine visit equivalent to that of an in-person measurement.​ This supports the idea that a virtual physical ROM exam can increase efficiency for both patients and providers.

Representativeness of Study Participants.

BackgroundManagement of periprosthetic fractures has been guided by the Vancouver classification, which recommends revision for fractures around a loose femoral implant (B2). New studies have challenged this approach, demonstrating acceptable outcomes with internal fixation. This study evaluates our experience with Vancouver B2 fractures, comparing internal fixation to femoral revision. We hypothesized that in select cases with cementless stems, internal fixation would provide acceptable results with reduced morbidity.MethodsA retrospective review was performed of periprosthetic hip fractures treated at our institution between 1 January 2012 and 4 November 2022. We excluded patients who did not have prior radiographs and evidence of stem subsidence, suggestive of a Vancouver B2 fracture. Thirteen patients were included in the analysis.ResultsFour patients (31%) underwent revision of the femoral component, 4 patients (31%) underwent plating, and 5 patients (38%) underwent internal fixation with cerclage cabling. The average operative duration was 158 minutes, 203 minutes, and 62 minutes for the revision, plating, and cabling cohorts, respectively (P = .009). Blood loss was 463 cc, 510 cc, and 90 cc for the revision, plating, and cabling cohorts, respectively (P = .036). Three patients in both the revision and plating cohorts each received a transfusion (75%), whereas no patients in the cabling cohort required a transfusion (P = .033). All patients demonstrated fracture healing on the postoperative radiographs. No patients required additional surgery during the follow-up period.ConclusionsWe have demonstrated that Vancouver B2 periprosthetic fractures with intact lateral cortices may be treated with internal fixation with cerclage cabling with excellent results.

Aims: Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients. Methods: Lifetime Markov models were developed evaluating active healthy middle-aged male amputees. Costs of the prostheses, associated complications, use/non-use, and annual costs of arthroplasty parts and service for both a socket and osseointegrated (OPRA) prosthesis were included. Effectiveness was evaluated using the questionnaire for persons with a transfemoral amputation (Q-TFA) until death. All costs and Q-TFA were discounted at 3% annually. Sensitivity analyses on those cost variables which affected a change in treatment (OPRA to socket, or socket to OPRA) were evaluated to determine threshold values. Incremental cost-effectiveness ratios (ICERs) were calculated. Results: For treatment-naïve patients, the lifetime ICER for OPRA was $279/quality-adjusted life-year (QALY). For treatment-refractory patients the ICER was $273/QALY. In sensitivity analysis, the variable thresholds that would affect a change in the course of treatment based on cost (from socket to OPRA), included the following for the treatment-naïve group: yearly replacement components for socket > $8,511; cost yearly replacement parts OPRA < $1,758; and for treatment-refractory group: yearly replacement component for socket of > $12,467. Conclusion: The use of the OPRA prosthesis in physically active transfemoral amputees should be considered as a cost-effective alternative in both treatment-naïve and treatment-refractory socket prosthesis patients. Disease-specific quality of life assessments such as Q-TFA are more sensitive when evaluating cost-effectiveness. Cite this article: Bone Jt Open 2024;5(3):218–226.

Introduction: Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups. Methods: A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis. Results: Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant. Conclusion: A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.

BackgroundRadiation-associated soft tissue sarcomas (RA-STS) are rare complications of patients receiving radiation therapy (RT) and are generally associated with a poor prognosis. Most of the literature surrounding RA-STS of the chest is centered on angiosarcoma. Therefore, we aim to document the management and outcome of patients with non-angiosarcoma RA-STS of the chest.MethodsWe reviewed 17 patients (all female, median age 65 years) diagnosed with RA-STS. The most common primary malignancy was breast carcinoma (n = 15), with a median RT dose of 57.9 Gy. All patients underwent surgical resection; five patients (29%) received radiotherapy; and five patients (29%) received peri-operative chemotherapy.ResultsThe 5-year local recurrence and metastatic-free survival were 61% and 60%, while the 5-year disease-specific survival was 53%. Local recurrence was associated with death due to disease (HR 9.06, p = 0.01). Complications occurred in nine of patients, most commonly due to a wound complication (n = 7). At the most recent follow-up, the median Musculoskeletal Tumor Society Score was 63%.ConclusionRA-STS involving the chest wall are aggressive tumors with a high risk of local relapse and death due to disease. Local recurrence was associated with death due to disease; as such, we recommend aggressive surgical management with evaluation for adjuvant therapies.

Abstract Purpose: The purpose of this pilot study was to examine the clinical efficacy and safety of serial triamcinolone injections for the treatment of desmoid tumors. Patients and Methods: Nine patients were enrolled into this prospective study and underwent three serial ultrasound-guided triamcinolone injections (120 mg) at 6-week intervals. MRI was compared at baseline and every 6 months, out to 24 months. Safety and tolerability were assessed by clinical evaluation and questionnaires, including the 12-item short form survey (SF-12), visual analog scale (VAS), and desmoid patient-reported outcome (PRO) tool. Results: At 24 months, 8 (88.9%) patients demonstrated a reduction in the volume of their tumor while 1 (11.1%) enlarged. Median tumor volume change was −26.9% (−81.1% to 34.6%; P = 0.055) All 9 tumors remained stable based on World Health Organization criteria, whereas 2 (22.2%) demonstrated partial response based on RECIST. There was a significant decrease in the tumor:muscle postcontrast mean signal intensity ratio at 6 months (P = 0.008) and 24 months (P = 0.004). There was a similar decrease in the tumor:muscle T2 mean signal intensity ratio at 24 months (P = 0.02). We found no difference in the SF-12 and VAS scores, but there were significant improvements in the desmoid PRO. Conclusions: Treatment of desmoid tumors with serial triamcinolone injections appears safe and well tolerated by patients, with a 22% partial response based on RECIST. Further research is needed to confirm our results and determine factors predictive of response.

IntroductionTranexamic acid (TXA) is an antifibrinolytic drug that has been shown to reduce blood loss following surgery. The use of TXA during orthopedic procedures has gained widespread acceptance, with multiple clinical studies demonstrating no increase in thrombotic complications. While TXA has been shown to be safe and effective for several orthopedic procedures, its use in orthopedic sarcoma surgery is not well established. Cancer-associated thrombosis remains a significant cause of morbidity and mortality in patients with sarcoma. It is unknown if intraoperative TXA use will increase the risk of developing a postoperative thrombotic complication in this population. This study aimed to compare the risk of postoperative thrombotic complications in patients who received TXA during sarcoma resection to patients who did not receive TXA. MethodsA retrospective review was performed of 1099 patients who underwent resection of a soft tissue or bone sarcoma at our institution between 2010 and 2021. Baseline demographics and postoperative outcomes were compared between patients who did and did not receive intraoperative TXA. We evaluated 90-day complication rates, including: deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA), and mortality. ResultsTXA was used more commonly for bone tumors (p < 0.001), tumors located in the pelvis (p = 0.004), and larger tumors (p < 0.001). Patients who received intraoperative TXA were associated with a significant increase in developing a postoperative DVT (odds ratio [OR]: 2.22, p = 0.036) and PE (OR: 4.62, p < 0.001), but had no increase in CVA, MI, or mortality (all p > 0.05) within 90 days of surgery, following univariate analysis. Multivariable analysis confirmed that TXA was independently associated with developing a postoperative PE (OR: 10.64, 95% confidence interval: 2.23-50.86, p = 0.003). We found no association with DVT, MI, CVA, or mortality within 90 days postoperatively, following intraoperative TXA use. ConclusionOur results demonstrate a higher associated risk of PE following TXA use in sarcoma surgery and caution is warranted with TXA use in this patient population.

Introduction: The personality traits of those who become orthopaedic surgeons may also lead to overwork, work-life balance issues, and burnout. Health and wellness practices of orthopaedic surgeons have not been widely explored. This study evaluated the personal health habits, wellness, and burnout of practicing orthopaedic surgeons in the United States. Methods: An anonymous self-assessment survey was completed by 234 practicing orthopaedic surgeon alumni from two large residency programs. The survey assessed exercise habits according to Centers for Disease Control and Prevention recommendations, compliance with preventive medical care practices according to the United States Preventive Services Task Force, prioritization of occupational wellness strategies, and the presence of burnout via an adapted Maslach Burnout Inventory. Survey responders' mean age was 52 years, 88% were male, and 93% had a body mass index <30 kg/m2. Surgeons were stratified according to practice type, years in practice, and subspecialty. Results: Among orthopaedic surgeons, compliance with aerobic and strength exercise recommendations was 31%. Surgeons in academic practice were significantly (P = 0.007) less compliant with exercise recommendations (18%) compared with private (34%) or employed (43%) practicing surgeons. Most (71%) had seen their primary care provider within 2 years and were up to date on age-appropriate health care screening including a cholesterol check within 5 years (79%), colonoscopy (89%), and mammogram (92%). Protecting time away from work for family/friends and finding meaning in work were the most important wellness strategies. The overall burnout rate was 15% and remained not significantly different (P > 0.3) regardless of years in practice, practice type, or subspecialty. Conclusion: This survey study identifies practicing orthopaedic surgeons' health habits and wellness strategies, including limited compliance with aerobic and strength exercise recommendations. Orthopaedic surgeons should be aware of areas of diminished personal wellness to improve quality of life and avoid burnout.

Background: While there has been much interest in the increased dislocation rate in total hip arthroplasty (THA) patients with a lumbar spine fusion (LSF), there is minimal literature comparing the risk based on surgical approach. The purpose of this study was to determine if a direct anterior (DA) approach was protective against dislocation when compared to the anterolateral and posterior approaches in this high-risk patient population. Methods: A retrospective review was performed of 6554 THAs performed at our institution from January 2011 to May 2021. 294 (4.5%) patients had a prior LSF and were included in the analysis. The surgical approach, timing of LSF in relation to THA, vertebral levels fused, timing of THA dislocation, and the need for revision surgery were recorded for statistical analysis. Results: In total, 39.7.3% of patients underwent a DA approach (n = 117), 25.9% underwent an anterolateral approach ( n = 76), and 34.3% underwent a posterior approach ( n = 101). There was no difference in number of vertebral levels fused between groups (mean 2.5, all p > 0.05). There was a total of 13 (4.4%) THA dislocation events, with an average time from surgery to dislocation of 5.6 months (0.3–30.5 months). There were fewer dislocations in the DA cohort (0.9%) in comparison to both the anterolateral (6.6%, p = 0.036) and posterior groups (6.9%, p = 0.026). Conclusions: The DA approach demonstrated a significantly lower THA dislocation rate compared to both the anterolateral and posterior approaches in patients with a concomitant LSF.

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.