Patellofemoral positioning CT protocol has diagnostic ability to differentiate patellar maltracking phenotype

Introduction

Traditional radiographs often fail to capture the dynamic nature of patellar maltracking in patellofemoral pain syndrome (PFPS) and patellar instability, necessitating improved diagnostic protocols. This study aimed to: (1) introduce a CT protocol with scans at three knee positions (45° flexion, extension, and extension with quadriceps contraction), (2) assess how positioning influences patellofemoral indices measured from radiographs and CT, and (3) to evaluate the protocol's ability to classify maltracking phenotypes: dislocator, subluxator, or symptomatic without dislocation/subluxation (Neither).

Methods

Patients who underwent surgery for PFPS from April to December 2022 were retrospectively reviewed. Patellofemoral indices from the three scans within the CT protocol were compared among themselves and with standard radiographs. Patients were grouped by maltracking phenotype, and their patellofemoral indices on radiographs and CT were compared to determine which imaging modality best distinguished the phenotypes. Statistical analyses included bivariate and multivariate logistic regression.

Results

The study included 65 patients (51 females, 14 males) with mean age of 27. Patellofemoral indices measured on CT-45° versus CT-Extended differed significantly (p < 0.05), indicated the influence of knee position. Quadriceps contraction further worsened most indices, highlighting the importance of load-bearing conditions. Radiographs and CT-45° had limited capability to differentiate Dislocator, Subluxator, and Neither, but CT-Extended and CT-Quad showed significant differences among these groups. Multivariate analysis identified four independent predictors of patellar maltracking severity (p < 0.05): (1) Lateral Offset and (2) Insall-Salvati Ratio measured on CT-Extended, as changes in (3) Lateral Offset and (4) Lateral patellofemoral angle (LPFA) between extension and quadriceps contraction.

Conclusions

Radiographs alone cannot reliably distinguish Dislocator, Subluxator, and Neither. A dedicated CT protocol featuring scans in neutral extension and with quadriceps contraction better delineates patellofemoral maltracking phenotypes and offers improved diagnostic accuracy in PFPS. This approach may guide tailored interventions to address distinct underlying mechanics of each phenotype.

Level of evidence

III.

Fatigue failure of constrained total knee replacement: A case report

Hinged implants for total knee arthroplasty (TKA) improve stability and joint function in a ligamentously compromised knee, but potentially at the cost of reduced implant longevity due to increased mechanical stress on the construct. This report details the case of an 83-year-old woman who underwent a revision total knee arthroplasty for a chronically dislocated hinged knee prosthesis in August 2024 at our institution. The patient presented with a several month history of pain and instability with reported self-reduction of the prosthesis to aid in ambulation. The revision surgery revealed that the axle had fractured into three pieces. This finding represents a unique case of hinged TKA failure. The primary purpose of this case report is to describe the patient presentation and revision technique to contribute to the literature available on causes of hinged TKA mechanical failure.

Comparison of short-term clinical outcomes of intra-articular injection of micro-fragmented adipose tissue and stromal vascular fraction cells for knee osteoarthritis treatment: A retrospective single-center cohort study

Background

Stromal vascular fraction (SVF) cells and micro-fragmented adipose tissue (MFAT) have potential for treating knee osteoarthritis (OA), but their efficacy has not been compared. This study aimed to compare the clinical outcomes of SVF and MFAT for knee OA. We hypothesized that SVF provides stronger short-term effects, while MFAT offers more sustained benefits.

Methods

A retrospective single-center cohort study was conducted on patients with knee OA, with 36 SVF and 36 MFAT cases selected through propensity score matching between September 2017 and February 2022. Patients with KL grades I-IV varus knee OA, significant pain (VAS ≥40), and functional impairment despite conservative treatments were included. Those with knee trauma, severe bony defects, infections, genu valgus, osteonecrosis, rheumatoid arthritis, or severe deformities were excluded. Clinical outcomes were assessed using the visual analog scale, KOOS, knee range of motion, extension/flexion strength, and MRI T2 mapping.

Results

SVF and MFAT groups demonstrated significant improvements in VAS (p < 0.01 for both groups). Both groups showed notable improvements in extension angle, extension/flexion muscle strength, and KOOS, with no significant differences between them. However, the MFAT group demonstrated significantly greater improvement in flexion angle compared to the SVF group (p = 0.03). No serious adverse events were reported. T2 mapping showed significant improvements in cartilage quality in both groups, with the MFAT group demonstrating superior improvements in specific lateral regions. Responder rate in SVF group initially improved but declined over time; however, the MFAT group showed sustained improvement from six months onward.

Conclusion

T2 mapping revealed that MFAT had better cartilage preservation than that of SVF cells in less-loaded areas, with a potentially longer-lasting therapeutic effect. These findings offer important insights for clinicians to tailor treatment strategies based on patient needs and disease progression.

Outcomes After Patellofemoral Arthroplasty With the Arthrex iBalance-A Third Generation Implant

Background

Patellofemoral arthroplasty (PFA) is an attractive option for patients who have isolated patellofemoral disease. This study aimed to assess the functional outcomes and revision rates of primary PFA with a third-generation implant with short- to medium-term follow-up.

Methods

We retrospectively reviewed the records of 49 patients (70 knees) undergoing PFA with the iBalance system by a single surgeon at a quaternary center between January 2015 and September 2022 for demographic and surgical data, as well as complications and revision rates. Patient-reported outcome scores were then collected.

Results

The population was majority female (81.6%) with a median age of 50 years. Four knees were revised to a total knee arthroplasty (5.7%) at an average time point of 2.3 years postoperatively (range: 1.3-3.5 years). The median Single Assessment Numeric Evaluation score at the time of follow-up was 82.5, while the median Kujala score was 72. Lower preoperative Kellgren-Lawrence grade was significantly associated with lower Knee Injury and Osteoarthritis Outcome Scores in all 5 domains (P < .05 for all). Additional procedures were required in 17 knees (24.3%), in most cases to improve patella tracking.

Conclusions

This study is, to our knowledge, the first to examine outcomes of the iBalance PFA system. The results show favorable patient-reported outcomes in this cohort consistent with other 2nd and 3rd generation PFA implants, along with a revision rate similar to its prosthetic peers.

Nanoscale surface modifications on Titanium plates- A strategy to mitigate MRSA biofilm-mediated implant infections: A pilot study

Orthopaedic implant infections pose a major threat after implantation. Biofilms of pathogenic bacteria resistant to antibiotics cause biomaterial mediated infections. Methicillin-resistant Staphylococcus aureus (MRSA) is one of the prevalent biofilm-forming pathogens associated with implant infection in high proportion. Loss of effectiveness of antibiotics against these drug-resistant pathogens demands alternative approaches to surmount this crisis. Various strategies involving antibiotics, biocides, and metal ions are employed as the prohibiting steps of biofilm formation. Hence, to prevent biofilm formation and infections caused by biofilms formed over the orthopaedic implants, we involved laser micro-machining to modify the surface of the Titanium (Ti) plate, the most widely used implant material. Interestingly, we found that the laser-peening process generated widespread nanosized pores and micro-roughness to the surface of the Ti plate. Laser-peened Ti plate reduced the adhesion of MRSA over the metal surface and also retained its capacity to inhibit biofilm formation, which was confirmed with scanning electron microscopy (SEM). The biofilm assays like quantification of biofilm by crystal violet, determination of colony forming unit from biofilm formed over the control and laser-peened Ti plates showed that the laser-peened Ti plate significantly reduced the adherence of biofilm-forming MRSA. Moreover, the genes responsible for biofilm adhesion were found to be downregulated which was confirmed by qPCR. From our results, it was found that laser-peened Ti implants would be an alternative strategy to prevent biofilm-mediated infection on orthopaedic implant material.

Comparative Perioperative Inflammatory and Functional Outcomes in Single Versus Multiple Joint Replacements for Hemophilic Arthritis: A Pilot Study

OBJECTIVE

Hemophilic arthritis is a progressive joint disease often requiring surgical intervention in advanced stages. However, comparative evidence on perioperative inflammatory and coagulation responses between single joint replacement (SJR) and multiple joint replacement (MJR) remains scarce. This study aimed to assess the differences in perioperative outcomes, including inflammatory responses, blood transfusion requirements, and functional recovery, to guide surgical decision-making for hemophilic arthritis patients.

METHODS

This retrospective study included 29 male patients with moderate-to-severe hemophilic arthritis who underwent SJR (n = 12) or MJR (n = 17) at a single institution from October 2020 to October 2023. Data on inflammatory markers (CRP, ESR, IL-6, WBC), hemoglobin levels, blood transfusion requirements, and joint mobility were collected for the immediate postoperative period (days 1-14). Trends in inflammatory markers were analyzed using average percent changes (APC), and differences in outcomes were evaluated using the Mann-Whitney U test for continuous variables and Fisher's exact test for categorical variables. Longitudinal changes were analyzed using mixed-model repeated measures ANOVA with time points as fixed effects and subjects as random effects. Statistical significance was set at p < 0.05.

RESULTS

Postoperative CRP levels declined significantly in both groups, with APCs of -9.06% (95% CI: -15.63 to -1.98, p < 0.05) for the SJR group and -8.42% (95% CI: -16.18 to 0.06) for the MJR group. ESR showed a significant upward trend, with APCs of 10.82% (95% CI: 0.95-21.65, p < 0.05) in the SJR group and 17.54% (95% CI: 11.71-23.67, p < 0.05) in the MJR group. Blood transfusion requirements were comparable, with median transfusion volumes of 0.00 units (IQR: 3.50) for SJR and 0.00 units (IQR: 3.75) for MJR (p = 0.761). Notably, joint mobility scores were significantly better in the MJR group (mean: 31.88, SD: 19.31) compared to the SJR group (mean: 18.33, SD: 10.39; p = 0.030). Despite the larger surgical scope of MJR, no significant differences in infection or bleeding risks (SJR:median transfusion = 0.00 units, IQR: 3.50; MJR:median transfusion, 0.00 units, IQR: 3.75. p = 0.761) were observed between the groups.

CONCLUSION

This study demonstrates that MJR offers superior functional recovery compared to SJR, without increasing the risks of infection, bleeding, or transfusion. These findings support MJR as a safe and effective surgical option for hemophilic arthritis patients when appropriate perioperative management protocols are implemented. Future studies with larger sample sizes and long-term follow-up are needed to validate these results and explore extended outcomes.

Application of artificial intelligence in X-ray imaging analysis for knee arthroplasty: A systematic review

BACKGROUND

Artificial intelligence (AI) is a promising and powerful technology with increasing use in orthopedics. The global morbidity of knee arthroplasty is expanding. This study investigated the use of AI algorithms to review radiographs of knee arthroplasty.

METHODS

The Ovid-Embase, Web of Science, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), WeiPu (VIP), WanFang, and China Biology Medicine (CBM) databases were systematically screened from inception to March 2024 (PROSPERO study protocol registration: CRD42024507549). The quality assessment of the diagnostic accuracy studies tool assessed the risk of bias.

RESULTS

A total of 21 studies were included in the analysis. Of these, 10 studies identified and classified implant brands, 6 measured implant size and component alignment, 3 detected implant loosening, and 2 diagnosed prosthetic joint infections (PJI). For classifying and identifying implant brands, 5 studies demonstrated near-perfect prediction with an area under the curve (AUC) ranging from 0.98 to 1.0, and 10 achieved accuracy (ACC) between 96-100%. Regarding implant measurement, one study showed an AUC of 0.62, and two others exhibited over 80% ACC in determining component sizes. Moreover, Artificial intelligence showed good to excellent reliability across all angles in three separate studies (Intraclass Correlation Coefficient > 0.78). In predicting PJI, one study achieved an AUC of 0.91 with a corresponding ACC of 90.5%, while another reported a positive predictive value ranging from 75% to 85%. For detecting implant loosening, the AUC was found to be at least as high as 0.976 with ACC ranging from 85.8% to 97.5%.

CONCLUSIONS

These studies show that AI is promising in recognizing implants in knee arthroplasty. Future research should follow a rigorous approach to AI development, with comprehensive and transparent reporting of methods and the creation of open-source software programs and commercial tools that can provide clinicians with objective clinical decisions.

Nanoparticles in nuclear medicine: From diagnostics to therapeutics

The use of nanoparticles in nuclear medicine is paradoxical. While several nanoformulations, such as 99mTc colloids, have been used for diagnosis for decades, only a few new radionanomedicines have been able to reach the market, despite extensive preclinical efforts. This contradiction is dictated by the unique features of nanoparticles, such as (potential) prolonged circulation times, slow compartment exchanges, and large accumulations in the mononuclear phagocyte system, which allow for certain specific applications while preventing others. In this review, we discuss the development and clinical application of radiolabeled nanoparticles as imaging agents for disease diagnosis and patient stratification, as well as their promise and potential to be used as next-generation formulations to improve the efficacy of radiotherapy.

Causal association between smoke and the risk of chronic knee pain: A Mendelian randomization study

A plethora of research has identified a comorbid association between smoke and an elevated risk of knee pain. Despite these findings, the causal link between genetically influenced smoke and the risk of knee pain remains to be elucidated. Considering this knowledge gap, we undertook a Mendelian randomization (MR) study to delineate the potential causal relationship. The instrumental variables were derived from genome-wide association studies (GWAS). We procured summary statistics for ever smoked from a GWAS dataset (280,508 cases and 180,558 controls, dataset: ukb-b-20261) to represent the exposure. The outcome was determined by GWAS data for knee pain for 3+ months, encompassing 76,910 cases and 20,979 controls (dataset: ukb-b-8906). The primary MR method employed was the inverse-variance weighted approach. Assessments for pleiotropy and heterogeneity were conducted utilizing the MR pleiotropy residual sum and outlier test, the MR-Egger intercept test, the leave-one-out analysis, and the Cochran Q test. There was a statistically significant genetic causal effect of smoke on the increased risk of knee pain (odds ratio = 1.08, 95% confidence interval = 1.01-1.16, P = .014]. Cochran Q statistic showed no heterogeneity (Q P = .66). The leave-one-out analysis chart, the global test P value in MR-pleiotropy residual sum, and outlier revealed no significant pleiotropy (global test P = 0.53). The intercept P value in MR-Egger revealed no significant pleiotropy (intercept P = 0.66). Our MR study showed no pleiotropy or heterogeneity. The findings from our study point toward an association between genetic predisposition to smoke and the incidence of knee pain. This genetic association underscores the clinical relevance of our findings, indicating that interventions aimed at smoking cessation could be particularly beneficial for those individuals who are predisposed to smoking or are at risk of developing knee pain.

Long-term Follow-up of Patients with Acute Posterior Cruciate Ligament Injury Treated Non-operatively with a Physiotherapy-led Exercise and Support Brace Intervention

Background

Posterior Cruciate Ligament (PCL) injuries can be treated non-operatively with a structured rehabilitation program or by surgical reconstruction. However, while the outcomes of surgically treated PCL injuries are well described, there is a paucity of large prospective studies reporting long-term outcomes of exercise interventions.

Purpose

The primary aim was to investigate long-term (after five years) patient-reported outcomes of a physiotherapy-led exercise and support brace intervention in patients with an acute PCL injury. The secondary aim was to report conversion to surgical PCL reconstruction.

Study design

Case series study, prospective.

Methods

Fifty patients with acute isolated or multiligament PCL injuries (presenting within eight weeks of injury) completed a 16-week exercise intervention, including 12 weeks in a PCL support brace. Patients were followed prospectively, and patient-reported outcomes were assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC), the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Scale (TAS). In addition, conversion to surgery was retrospectively extracted from medical records.

Results

Thirty-six patients completed subjective questionnaires at the five-year follow-up. The mean IKDC score improved from 35 points at baseline to 79 points at the five-year follow-up. All mean KOOS subscale scores increased by a statistically significant amount from baseline to the five-year follow-up: Symptoms: 52/87 points; Pain 56/88 points; Activities of daily living 58/90 points; Sport/Recreation 17/75 points; Quality of life 23/73 points. The TAS improved from level 2 at baseline to level 5 at the five-year follow-up. Seven patients (14%) were converted to PCL surgical reconstruction. The median time from initiation of non-operative treatment to surgery was 13 months (range 10-14 months).

Conclusions

The physiotherapy-led exercise and brace intervention showed statistically significant improvements in patient-reported outcomes at long-term follow-up of five years, and the need for conversion to PCL reconstruction for isolated PCL injuries was low with a conversion rate of 7%.

Level of evidence

3b.

Mid-term Radiologic and Clinical Results of Pediatric-adolescent Lisfranc Injuries

INTRODUCTION

The incidence of Lisfranc injury in pediatric-adolescent children is lower compared with adults. There is limited research on adolescent patients in this age group, with only a few case reports of pediatric patients. Furthermore, studies with adequate follow-up are lacking in the literature. This study aims to provide insights into the causes and types of fractures and evaluate mid-term clinical and radiologic outcomes.

METHODS

A retrospective analysis was conducted on pediatric-adolescent patients diagnosed with a Lisfranc injury who underwent surgical treatment between June 2015 and January 2022. Patients underwent open reduction and internal fixation using Kirschner wires and/or screws, had satisfactory imaging, and were followed up for at least 2 years. Radiologic measurements included intermetatarsal distance, meary angle, and calcaneal height angle, done while the patient was standing. Assessments were made using the AOFAS midfoot score, the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C), Visual Analog Scale (VAS) scores, and physical activities.

RESULTS

The study included 14 surgically treated patients with a minimum 2-year follow-up. The average patient age was 12.6 years, with a mean follow-up of 52.4 months. In pediatric cases, crush injury was the predominant trauma type ( P = 0.009). There were no significant differences in calcaneal pitch angle or meary angle between healthy and injured feet ( P = 0.2 and 0.1), but a greater intermetatarsal distance was observed on the injured side ( P = 0.02). The mean Visual Analog Scale (VAS) score was 1.5, the AOFAS midfoot score averaged 91.5, and the OxAFQ-C score averaged 86.3%.

CONCLUSIONS

The mid-term outcomes for this age group were promising compared with adults. The use of Kirschner wires for fixation is more common in younger patients. Crush injuries and complications like compartment syndrome are more prevalent in the pediatric age group.

Imaging Review of Knee Ligament Reconstructions Other than the Anterior Cruciate Ligament

Assessment of knee ligament reconstructions other than the anterior cruciate ligament is challenging due to limited data and continuously developing techniques. Imaging is vital to assessment, demonstrating expected postoperative findings, allowing detection of complications, and enabling differentiation of techniques from one another-information that is critical if revision is being contemplated. Stress radiography is useful for evaluating joint stability in the setting of ligament insufficiency. The three-dimensional and multiplanar reconstruction capabilities of CT are highly useful in multiligament reconstruction, allowing unhindered evaluation of the many intersecting bone tunnels. Susceptibility artifacts in MRI can be remedied by use of metal artifact reduction sequences. Each technique, graft, and choice of specific ligaments to reconstruct must be decided on a case-to-case basis. Anatomic reconstruction reproduces the native ligament's anatomy but is more technically complex. Nonanatomic reconstruction is easier to perform but potentially provides less stability. As for graft selection, an autograft weakens another knee stabilizer, but an allograft is more expensive and less readily available. The decision to perform a single-ligament versus combined-ligament reconstruction ultimately rests on the degree of instability and the desire to return to sport. In contrast to single-ligament reconstruction, combined-ligament procedures are at higher risk of postoperative stiffness, arthrofibrosis, and tunnel convergence. Renewed attention to repair along with improvements in patient selection and rehabilitation protocols may change the future of operative treatment of ligament injury, and along with it, radiologic appraisal and reporting. ©RSNA, 2025 Supplemental material is available for this article.

[Chronic pain syndrome in musculoskeletal diseases-how different are fibromyalgia and long Covid?-Part 1]

Chronic pain is a common problem in rheumatology. Nociceptive pain is distinguished from neuropathic and nociplastic pain. Mechanistically, the former is explained by persistent inflammation, for example. Included in the second category is nerve damage of various causes. In contrast, nociplastic pain is not caused by tissue damage or a lesion in the somatosensory nerve system. It is caused by an altered sensation of pain through the modulation of stimulus processing. The concept of central sensitization, together with further neurobiological and psychosocial mechanisms, best explains such pain conditions. Fibromyalgia (FM) plays a big part in rheumatology - on the one hand, as a differential diagnosis, and on the other, because the management of inflammatory rheumatic conditions is made more difficult by the simultaneous occurrence of FM. In the context of the coronavirus pandemic, persistent pain syndromes with similarities to FM have been described after COVID-19 infection. There is an increasing scientific controversy whether the so-called long Covid syndrome is an actual entity or "only" a variant of FM. This discussion and the current state of knowledge on the problem are the subject of this review.

Improved physicochemical properties of structurally modified titanium coated with zein-mesoporous bioactive glass nanoparticles-Commiphora wightii for orthopaedic applications

Titanium (Ti) is an ideal implant material due to its strength, biocompatibility, and corrosion resistance. Ti is often structurally modified to overcome its inert nature. Nanostructures (pores, rods, tubes, etc.) formed on the surface of Ti followed by bioactive and antibacterial coatings can be exploited for many biomedical applications. A combination of zein (a biopolymer with low elastic modulus), mesoporous bioactive glass nanoparticles (MBGNs, a bioactive material) and Commiphora wightii (CW, an antibacterial herb) could result in a multi-functional coating for osteogenic purposes. Zein, not only reduces the stress shielding effect at the bone-implant interface but also acts as a binder for MBGNs and CW particles in the matrix and facilitates their uniform dispersion in the coating. In this work, zein nanoparticles (ZNPs), MBGNs, and CW were deposited on electrochemically synthesized titania nanotubes (TNTs) via electrophoretic deposition (EPD). A uniform and adherent composite coating named ZNPs/MBGNs/CW was obtained. The in-vitro bioactivity test in the simulated body fluid (SBF) revealed the formation of a biologically active calcium-deficient apatitic layer (cd-HA) on the coating surface. The electrophoretically deposited composite coating was also resistant to corrosion in SBF. Furthermore, the viability of MG-63 cells was tested in which coating displayed 100 % viability after 14 days of incubation. The presence of natural herb CW inhibited the growth of gram-positive (Staphylococcus aureus) and gram-negative (Escherichia coli) bacteria. Hence, the results demonstrate that the ZNPs/MBGNs/CW composite coating system may be a strong candidate for orthopaedic applications.

The use of an imageless robotic system in revision of unicompartmental knee arthroplasty

PURPOSE

The application of robotics in revision arthroplasty particularly from unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA), is underexplored. The purpose of this study is to describe the surgical technique of an imageless robotic system used in the revision of UKA to TKA and to evaluate short- to mid-term outcomes.

METHODS

This prospective study includes 35 patients treated from May 2020 to July 2023. Demographic data of the patients were gathered and the reasons for needing revision surgery were assessed. All patients were clinically evaluated preoperatively and at the final follow-up of 31.3 ± 12.1 months, using the Western Ontario and McMaster Universities Arthritis Index (WOMAC), Oxford Knee Score (OKS), Forgotten Joint Score (FJS-12), Numerical Rating Scale (NRS) and range of motion (ROM). Additionally, a radiographic evaluation was performed, and implant survival was assessed by analyzing complications at final follow-up.

RESULTS

In 88.6% of the patients, a primary Posterior Stabilized (PS) or Constrained Posterior Stabilized prosthetic implant was used, with 11.4% of patients requiring a varus-valgus constraint implant. In 71.4% of the cases, a thinnest size liner of 10 mm was used. The use of the robotic system was never aborted for any reason. At final follow-up, the implant survival rate was 97.14%. Average OKS increased from 31.4 ± 9.4 to 41.5 ± 4.3, FJS-12 from 47.3 ± 19.3 to 80.7 ± 8.9; WOMAC at final follow-up was 17.8 ± 8.7, from 53.5 ± 21.3 preoperatively. Analyzing ROM, NRS and patient-reported outcome measures, there were significant differences in each parameter between prerevision surgery and final follow-up.

CONCLUSIONS

This study highlights that in a cohort of patients undergoing robotic-assisted conversion from UKA to TKA, the use of an imageless procedure incorporating intraoperative bone morphing and alignment based on a functional philosophy has proven to be safe and has yielded excellent clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Asymptomatic Elevated Inflammatory Markers: Is There a Risk for Infection or Revision in Primary Total Knee Arthroplasty?

BACKGROUND

Total knee arthroplasty (TKA) is the treatment of choice for advanced knee osteoarthritis. Long-term studies report high patient satisfaction, while complications such as periprosthetic joint infection (PJI) can be devastating. Knowledge regarding risk factors for PJI is critical to minimize and ideally avoid complications. The purpose of this study was to investigate the risk of PJI and revision in patients who had preoperative asymptomatic high C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels in primary TKAs.

METHODS

Patients undergoing primary TKA between 2010 and 2022 were eligible. Inclusion criteria were patients who had preoperative complete biochemical parameters and a minimum follow-up of 12 months. Patients who died during the first year, and those who had a history of inflammatory arthritis, autoimmune disease, renal pathologies, or septic arthritis, were excluded. Patients who had elevated blood CRP and ESR levels taken within 48 hours before surgery underwent a thorough medical examination with a focus on infection symptoms. After screening and consultation, residual elevated CRP and ESR levels were classified as asymptomatic. After exclusions, 1,528 patients were included. The mean age was 66 years (range, 35 to 92), and the mean follow-up time was 6.4 years (range, 1.6 to 12.3).

RESULTS

The rate of revision within one year after surgery was 1.6%, whereas the rate of revision in the first 5 years was 3.8%. The PJI rates for the 1st and 5th postoperative years were 1.7 and 2.9%, respectively. Regression analysis did not show any of the potential variables to be a risk factor for revision or PJI.

CONCLUSIONS

Asymptomatic elevated acute-phase reactants are not a risk factor for periprosthetic joint infection or aseptic revision. At a mean follow-up of 6.4 years, overall survival was 96.7%, with only 2.2% of patients revised due to a PJI.

Common sports-related nerve injuries seen by the electrodiagnostic medical consultant

The high physiologic demands of sports create dynamic stress on joints, soft tissues, and nerves which may lead to injuries in the athlete. Electrodiagnostic (EDx) assessment is essential to identify the correct diagnosis, localization, and prognosis, to guide management of sports-related neuropathies. A comprehensive review was performed to provide the EDx medical consultant with a practical approach to the common peripheral nerve disorders seen in athletes. Sports-related neuropathies reviewed include transient traumatic irritation of the brachial plexus and/or cervical nerve roots ("Burners and stingers,") suprascapular and axillary neuropathies, ulnar neuropathy at the elbow (UNE) in throwers, ulnar neuropathy at the hand/wrist in cyclists, multi-ligamentous knee injury, and foot/ankle neuropathies including tarsal tunnel syndrome. A thorough understanding of peripheral anatomy, possible entrapment sites, mechanisms of injury, and key physical examination findings is essential for correct diagnosis. EDx assessments beyond routine studies are generally required for sports-related neuropathy, which may not necessarily follow typical entrapment patterns. Adjunct diagnostic imaging, such as point-of-care ultrasound and magnetic resonance imaging, are helpful tools to identify associated musculoskeletal pathology such as compressive cysts or nerve entrapment, which may be amenable to interventional or surgical treatment. When no clear reversible structural pathology exists, management of sports-related neuropathy is athlete-specific and generally multi-modal, involving a combination of physical rehabilitation techniques to address muscle imbalances, load management, protective equipment, and interventional pain procedures.

Retrospective analysis of external pin fixation of mandibular fractures: A 25-year single institution experience

External fixation of mandible fractures is an infrequently utilized fixation treatment modality in comparison to open reduction internal fixation (ORIF) or closed reduction techniques. However, external fixation still provides a necessary modality in the management of select mandibular fractures. Therefore, we aim to draw trends, outcomes, and treatment timelines through a retrospective analysis to better guide, advise and predict realistic treatment outcomes in the future for our patients. This abstract shows trends in indications, complications, airway management and timeline to definitive reconstruction through the experience of a single institution (University Hospital, Newark, NJ) over a period of 25 years. IRB approval was obtained from Rutgers University and University Hospital, Newark, NJ. Twenty-nine instances of external fixation of mandible fractures were found over 25 years. The charts, imaging, and notes were individually reviewed. The data points collected included age of the patient at time of injury, etiology of injury, duration of external fixation, numbers of Schanz screws, type of extraoral connecting bar, airway management, time to reconstruction, type of reconstruction, type of bone graft used, incidence of multiple space infections, and complications. The duration of study was from 1997 - 2023. The patients were found using CPT codes 21452 (percutaneous treatment of mandibular fracture, with external fixation) and 21454 (open treatment of mandibular fracture with external fixation). Twenty-nine instances of external fixation were found, 28 of the 29 had extensive documentation about the surgery and post operative period. The average age at the time of injury was 37 years old, 2 females and 26 males. 5 different types of etiologies were found. 14 gunshot wounds, 3 motor vehicle collisions (MVCs), 6 osteomyelitis with nonunion from a previous ORIF management of a mandible fracture, 4 pathologic fractures and 1 patient with a one-week-old unrepaired open fracture that developed a significant deep neck infection. The average duration of the external fixator was 88 days, ranging from 18 - 291 days. 10 patients were electively intubated and extubated for the external fixator surgery. 15 patients underwent tracheostomy due to airway compromise or expected prolonged intubation. The most common number of Schanz screws placed were 4, with a range of 4-6. The most common stabilizing system used to connect the screws were carbon fiber rods (61%). Prior to 2008, pre-adapted titanium was never used, after 2008 it was used in more than half of the cases. The most common complication was infection, occurring in 4 cases. With regards to secondary reconstruction, 55% of the cases required autologous harvesting of the anterior iliac crest. In summary, our research showed the average duration of external fixation duration to be dependent on the mechanism of injury. Failure of previous ORIF with non-union and concomitant osteomyelitis had an average external fixation duration of 107 days. Gunshot wounds had an average external fixation duration of 79 days. Motor vehicle accidents had an average external fixation duration of 18 days. Pathologic fractures had an average external fixation duration of 16 days. The most common complication was infection, occurring in 4 (14%) cases. For airway management, 100% of GSW injuries received tracheostomy, 66.7% of MVCs, 14% of osteomyelitis status-post prior ORIF, and no patients with pathologic fractures associated with malignancy received tracheostomy. This research aims to consolidate 25 years' worth of surgical experience and patterns for external fixation to better guide, advise and predict realistic treatment outcomes.

Tear Location of Superficial Medial Collateral Ligament Tears: Validation of a Magnetic Resonance Imaging-Based Classification System

BACKGROUND

The superficial medial collateral ligament (sMCL) is commonly injured, with treatment varying based on associated injuries, tear grade, and location. However, the prevalence of different tear locations and the predictors of tear types have not been studied.

PURPOSE

To evaluate the interrater and intrarater reliability for a magnetic resonance imaging (MRI)-based sMCL classification system and assess the incidence of different tear types with its predictors.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective search in a single institution's MRI database identified patients with acute, complete sMCL tears (≤30 days between injury and MRI) between January 2018 and December 2022. Exclusion criteria included previous ligamentous knee trauma/surgery, >30 days between injury and MRI, and partial sMCL tears. MRI scans were assessed by 3 independent raters using a predefined sMCL tear location system: type I (proximal 25%), type Ib (proximal femoral bony avulsion), type II (midsubstance, 25%-75%), type III (distal 25%), type IIIb (distal tibial bony avulsion), and type IIIs (Stener-like lesion). The intraclass correlation coefficient (ICC) was used to assess interobserver and intraobserver reliability for continuous data, whereas Fleiss and Cohen kappas were used for categorical data. Univariate and multivariate logistic regression assessed predictors of tear location.

RESULTS

The study included 239 patients (49% female; mean age, 38 ± 14 years; range, 13-75 years). The MRI-based sMCL classification system showed excellent interobserver reliability (0.960; 95% CI, 0.951-0.969) and excellent intraobserver reliability (evaluator 1: 0.969 (95% CI, 0.960-0.976); evaluator 2: 0.952 (95% CI, 0.915-0.973)). Type I sMCL tears were most common (65.4%), followed by type III (14.6%), type II (14.5%), type Ib (3.4%), and type IIIs (1.7%). Binary logistic regression identified medial meniscal tears (odds ratio [OR] 7.987; P = .034) and younger age (OR 0.916; P = .0001) as predictors for distal sMCL tears and older age as a predictor for proximal tears (OR 1.048; P = .001).

CONCLUSION

This study validates an MRI-based sMCL classification system for locating high-grade sMCL tears with excellent reliability. Proximal tears were the most common (69%) and were significantly more prevalent with increasing age, whereas distal tears were more commonly seen with younger age and midbody medial meniscal tears. These findings may guide individualized treatment strategies and refine diagnostic protocols for patients with acute sMCL tears.

Patient involvement in the development of patient-reported outcome measures used following hip or knee arthroplasty: a scoping review

PURPOSE

Involving patients in developing patient-reported outcome measures (PROMs) is essential for accurately capturing their perspectives. However, understanding how patients were involved in developing PROMs used after hip or knee arthroplasty is limited. This scoping review aimed to evaluate whether patients were involved in the development of these PROMs and how they were involved.

METHODS

Two independent reviewers documented patient involvement in item development and comprehensibility testing for 50 PROMs used after hip or knee arthroplasty. Trends in patient involvement over time were analyzed using binary logistic regression.

RESULTS

There was no documentation of patient involvement in a collaborative role during the PROM development processes. Regarding the consultative role, of these 26 PROMs, they contributed to item development in 13 PROMs (26%) and comprehensibility testing in four PROMs (8%) and both item development and comprehensibility testing in nine PROMs (18%). Patients who underwent arthroplasty were involved in one or both phases in ten PROMs (20%), while patients with other lower extremity conditions were involved in 16 PROMs (32%). Patients who underwent arthroplasty contributed to both phases in five PROMs: Oxford Knee Score-Activity and Participation Questionnaire, Patient's Knee Implant Performance Questionnaire, Patient-Reported Outcomes Measurement Information System R-Plus-Osteoarthritis of the Knee, Oxford Arthroplasty Early Recovery Score and Oxford Arthroplasty Early Change Score. In addition, our analysis revealed no significant change in patient involvement in a consultative role during either item development or comprehensibility evaluation over time since 1982, when the first PROM included in this review was developed (p = 0.21).

CONCLUSIONS

Almost half of PROMs used after arthroplasty did not involve patients in their development, highlighting the need to address this gap in development of PROMs. There is also a need to analyze PROMs to ensure they accurately reflect the outcomes that matter to patients.

Hemophilic pseudotumor in the bilateral forearms: a unique case report

Hemophilic pseudotumor (HP) is a rarely encountered cystic mass that forms as a result of repeated bleeding from extra-articular soft tissues. HP cases have been previously documented in several locations in the body, most commonly in the femur and pelvis. To date, no upper extremity case involving the bilateral forearms has been reported. The current case involves an adult male with uncontrolled hemophilia who presented with diffuse enlargement of the bilateral forearms with associated pain. Radiographs and magnetic resonance imaging (MRI) were subsequently performed revealing variable aged hemorrhagic, expansile, lytic intramedullary lesions. In keeping with the history, a subsequent radiologic diagnosis of HP was favored, among other differentials, including benign and malignant processes with biopsy confirming the diagnosis. The hemorrhagic masses were surgically excised after initial management with factor VIII replacement. This case details a unique presentation of this pathology in the bilateral forearms and highlights the diagnostic value of radiographs and MRI in diagnosis and management.

Effect of BMI on the risk of postoperative complications following total hip arthroplasty

Aims

While obesity is associated with an increased risk of complications after total hip arthroplasty (THA), the relationship between BMI and the risk of early postoperative complications has not been fully characterized. This study sought to describe the relationship between BMI and the risk of early postoperative complications, including periprosthetic joint infection (PJI), and composite surgical and composite medical complications.

Methods

Primary, elective THAs performed from 1 October 2015 to 31 December 2021 were identified using the Premier Healthcare Database. The study's primary outcome was the diagnosis of PJI within 90 days of THA. Using BMI as a continuous variable, logistic regression was used to develop restricted cubic splines (RCSs) to determine the impact of BMI on PJI risk. Bootstrap simulation was used to identify an inflection point in the final RCS model. The same technique was used to characterize the effects of BMI on composite medical and surgical complications.

Results

We found that PJI risk increased exponentially beyond a BMI threshold of 37.4 kg/m2. Relative to this threshold, patients with a BMI of 40 or 50 kg/m2 were at a 1.22-fold and 2.55-fold increased risk of developing PJI, respectively. Surgical complications increased at a BMI of 32 kg/m2 and medical complications increased at a BMI of 39 kg/m2. Relative to these cut points, patients with a BMI of 50 kg/m2 were at a 1.36-fold and 2.07-fold increased risk of developing medical and surgical complications, respectively.

Conclusion

The results of this study indicate a non-linear relationship between patient BMI and early postoperative risk of PJI, composite medical complications, and composite surgical complications following THA. The identified cut points with associated odds ratios can serve as tools to help risk-stratify and counsel patients seeking primary THA.

Measurement of periarticular subcutaneous fat on CT images and adverse outcomes following total knee arthroplasty

Background

Obesity is associated with a higher rate of wound complications following primary total knee arthroplasty (TKA). With readily available computer tomography (CT) images from robotic-assisted TKA, we analyzed measurement of fat content on preoperative CT images as a possible predictor of wound complications following primary TKA.

Methods

Patients who underwent robotic-assisted TKA at one institution in 2018 were included in this retrospective cohort study. Two independent reviewers measured three SCF areas at different axial CT cuts and normalized them by dividing the area of the distal femur. These areas were distributed into 4 groups. Any wound complication that required clinical or surgical intervention was reviewed and analyzed. For further comparison, prepatellar SCF thickness ratio measured on CT scan and BMI were grouped and analyzed similarly for wound complications. We also analyzed any association of SCF measurement with secondary outcomes such as operative time, length of stay, readmission, and reoperation.

Results

One hundred fifty patients with diagnosis of osteoarthritis, mean age of 64 years and BMI of 34.3 kg/m2 were included in this study. Ninety-one patients (61 %) were female. Normalized SCF measurements at 2 cm above the patella, mid-patella, and tibial tubercle had excellent intraclass correlation coefficient at 0.987, 0.989, and 0.989, respectively. When SCF at 2 cm above patella was analyzed, Group 1 (smallest amount of SCF) had a significantly higher wound complication rate compared with Groups 2 and 3 combined (18.9 vs 5.3 %, p = 0.036). Group 4 (largest amount of SCF) also had a significantly higher wound complication rate compared with Groups 2 and 3 combined (18.9 vs 5.3 %, p = 0.036).

Conclusions

Accurate and consistent measurement of periarticular fat around the knee based on axial CT images demonstrated that moderate amount of fat is associated with better clinical outcomes following primary TKA. Our study did not find any clinical significance of gender difference in fat distribution. Therefore, more studies should be undertaken to evaluate for any clinical association of gender-specific fat distribution and to confirm our finding that a certain amount of fatty tissue is necessary for improved outcomes following TKA.

How do surgically treated multiligamentous knee injuries affect overall complication rate and especially stiffness? A systematic review

BACKGROUND

Multiligamentous knee injuries (MLKIs), defined as injuries involving at least two of the four primary knee ligaments, are rare but severe, with potentially limb- or life-threatening complications. Despite numerous publications, the low incidence and heterogeneity of injury patterns limit high-level evidence for optimal surgical timing, technique, and management of complications. This systematic review aims to consolidate the available evidence on MLKI surgery complications, with a particular focus on arthrofibrosis as the underlying cause of stiffness, infection, and graft failure.

METHODS

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO) (no. CRD42024618025). A comprehensive search of PubMed, EMBASE, and MEDLINE from January 2013 to November 2024 identified studies reporting complications in surgically treated MLKIs with at least a 12-month follow-up. The studies were screened independently by two reviewers. Data on demographics, injury mechanisms, surgical techniques, and complication outcomes were extracted. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

A total of 33 studies with 2863 patients met the inclusion criteria. The mean age was 32.4 years (standard deviation, SD ± 5.37), with males constituting 69.4% of the sample. Arthrofibrosis was the most common complication, requiring surgical management in 8.4% of cases. Graft failure was reported in 5%, while infection, the third most common complication, occurred in 2.86% of cases. Management of lack of range of motion varied, with manipulation under anesthesia and arthroscopic arthrolysis utilized. Surgical timing also influenced outcomes; 54.2% of patients underwent acute surgery (< 21 days), which seems to be associated with increased stiffness rates.

CONCLUSIONS

This systematic review highlights the complexity of managing MLKIs, with a 19.2% overall complication rate. Stiffness demanding reoperation remains a rare but a significant challenge, underscoring the need for standardized treatment protocols. However, the included studies demonstrate heterogeneity and lack high methodological rigor, highlighting the need to account for these limitations.

Posterolateral corner ligament reconstruction in knee arthroscopy: Complications and complication management

The posterolateral corner (PLC), composed of three static stabilizers including the fibular collateral ligament, popliteus tendon, and popliteofibular ligament, collectively provide posterolateral knee stability (varus and external rotation). Disruption of this complex typically occurs in the setting of concomitant multi-ligament knee injuries (MLKI), typically requiring surgical management for restoration of knee stability. Anatomic surgical reconstructions have been shown to outperform non-anatomic reconstructions or repairs, yet are technically challenging and are not exempt of complications. The present review will address the anatomy and biomechanics of the involved structures, detail the senior author's anatomic three ligament tibiofemoral based reconstruction technique, and provide tips and tricks for avoiding the most frequently associated intraoperative and postoperative complications.

Efficacy and Safety of Recombinant Factor VIII in Previously Untreated and Previously Treated Children with Hemophilia A: A Systematic Review

INTRODUCTION

Inhibitor development is a primary concern for pediatric patients with hemophilia A (HA) undergoing recombinant factor VIII (rFVIII) therapy, yet relevant research is lacking. We aimed to compare the efficacy and safety of standard (SHL) and extended half-life (EHL) rFVIII products in previously treated (PTPs) and untreated (PUPs) pediatric patients with HA.

METHODS

Following PRISMA guidelines, we searched clinical studies from PubMed, Embase, and Cochrane Library. Data were extracted and a single-arm meta-analysis was performed.

RESULTS

This systematic review included 16 studies involving 1145 patients. Three studies reported changes in annual bleeding rate (ABR); their results displayed no statistically significant difference in ABR changes in pediatric patients with HA after rFVIII treatment. Ten studies reported inhibitor development, nine focused on PUPs. Here, EHL rFVIII showed a proportion of inhibitors at 27.5% (95% confidence interval [CI] 22.6%; 32.6%), and third-generation SHL rFVIII showed a proportion of inhibitors at 36.4% (27.2%; 46.2%), with a high-titer proportion of 20.9% (12.9%; 30.3%) for the latter. Both SHL rFVIII (octocog alfa) and EHL rFVIII (rurioctocog alfa pegol) presented low proportions of inhibitor development. Octocog alfa exhibited the lowest high-titer inhibitor incidence, marked at 12.7% (5.3%; 24.5%). Eleven studies addressed adverse events (AEs), with octocog alfa showing low reported treatment-related AEs at a proportion of 14.5% (6.5%; 26.7%).

CONCLUSION

Our analysis revealed that both octocog alfa and rurioctocog alfa pegol showed low inhibitor development, with octocog alfa having few treatment-related AEs. Regular monitoring for inhibitors during rFVIII therapy is important.

Periprosthetic Joint Infection Mortality After Total Hip Arthroplasty is Comparable to 5-Year Rates of Common Cancers: A Meta-Analysis

BACKGROUND

Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a rare, but devastating complication with elevated morbidity and mortality. While associated with increased mortality, the reported range is broad and most often reported after 2-stage exchange arthroplasty. This study aimed to report the overall mortality after PJI following primary THA, PJI mortality at one, three, and 12 months, and mortality after common PJI treatments. We hypothesized that mortality after THA PJI would be high, increase over time, and be highest after a 2-stage exchange.

METHODS

A meta-analysis of articles from six databases, queried from inception to December 2023, was performed. Full-length articles reporting mortality following PJI after primary THA were included. Articles with oncologic, infectious, or traumatic THA indications were excluded. Articles investigating high-risk patient populations, including those who had solid organ transplants, active cancer diagnoses, and synchronous PJI, were excluded. There were two independent reviewers who reviewed articles. Mortality over time and after treatment (debridement, antibiotics, and implant retention [DAIR], 1- and 2-stage exchange arthroplasty) was collected. A meta-analysis of proportions with inverse-variance proportion models was constructed for overall mortality.

RESULTS

A total of 19,917 patients who had PJI after THA from 20 studies were included. Overall mortality was 11.0% (95% CI [confidence interval]: 5 to 18.8) at a mean follow-up of 40.3 months (range, one to 240). Pooled mortality at one, three, and 12 months was 1.1, 3.7, and 10.0%, respectively. Mortality following treatment with DAIR, 1-stage, and 2-stage exchange was 7.8% (95% CI: 2.3 to 15.9), 1.6% (95% CI: 0 to 14), and 9.2% (95% CI: 5.4 to 13.9), respectively. Considerable heterogeneity was present.

CONCLUSIONS

Mortality after THA PJI is high (11.0%) within three years of arthroplasty and comparable to 5-year rates of cancers such as breast (11%) and prostate (1%) cancers. A multidisciplinary approach, like those adopted in the treatment of cancer, is warranted to reduce the burden of this devastating complication.

Poly-ε-caprolactone/chitosan/whitlockite electrospun bionic membrane conjugated with an E7 peptide for bone regeneration

BACKGROUND

Periosteum plays an important role in bone defect repair due to its rich vascular network and cells. However, natural periosteum is difficult to meet clinical requirements due to its low availability. Therefore, it is necessary to develop a tissue engineering strategy of biomimetic periosteum for bone defect repair.

METHODS

Poly-ε-caprolactone/chitosan/Whitlockite electrospun bionic membrane (PCL/CS/WH) was prepared using electrospinning technology, then it was conjugated with an E7 peptide as PCL/CS/WH/E7 bionic membrane. The physical properties of the membranes were evaluated by TEM, FTIR and tensile strength testing. In vitro, LIVE/DEAD staining and Cell Counting Kit-8 assay of bone marrow mesenchymal stem cells (BMSCs) and Endothelial progenitor cells (EPCs) are used to assess the biocompatibility of bionic membranes. Matrigel was applied to evaluate the ability of the different composite nanofibers samples to promote angiogenesis. Mineralized nodule and collagen formation in the BMSCs was detected by alizarin red staining and sirius red staining respectively. The expression of osteogenesis related genes and angiogenesis associated genes were detected using quantitative real-time polymerase chain reaction (qRT-PCR). In vivo, the ability of PCL/CS/WH/E7 membrane to promote bone regeneration and angiogenesis was assessed by Micro-CT and associated staining.

RESULT

The addition of chitosan (CS) and E7 peptide (E7) enhanced the hydrophilicity and cytocompatibility of pure PCL membranes. Additionally, CS, E7 and Mg2+ released from Whitlockite (WH) had a synergistic effect to promote angiogenesis and osteogenic differentiation. Three weeks after implantation, the membrane successfully bridged the bone defect and significantly promoted the formation of new bone and blood vessels.

CONCLUSION

The PCL/CS/WH/E7 membrane to achieve efficient repair of bone tissue and enriches clinical solutions for the treatment of critical bone defects.

Assessment of Clinical Characteristics and Sociocontextual Factors on Medication Adherence in Children and Adolescents With Hemophilia

INTRODUCTION

Sociocontextual factors, including social determinants of health (SDOH), affect health outcomes and clinical progression in chronic blood diseases such as hemophilia. Continuous prophylaxis with intravenous clotting factor concentrates or subcutaneous factor VIII mimetic agents reduces bleeding and improves quality of life. However, adherence to prophylaxis is challenging.

AIM

To investigate the impact of clinical and sociocontextual factors, including SDOH, on adherence to prophylaxis in children and adolescents with hemophilia.

METHODS

In this cross-sectional study, parent and adolescent participants were enrolled from 2018 to 2023. Adherence to prophylaxis was measured by Hemophilia Regimen Treatment Adherence Scale-Prophylaxis as overall adherence as well as "time," "dose," "plan," "remember," "skip," and "communicate" subscales. Sociocontextual factors were assessed by self-reported validated surveys. Linear regression analysis was performed.

RESULTS

Of 41 parent participants, 56% were Hispanic. There was no difference in adherence scores between Hispanic and non-Hispanic parents (p = 0.97). Older age of child (p = 0.002), prophylaxis via peripheral intravenous route (vs. central line, p = 0.004), and use of Spanish language for medical communication (vs. English, p = 0.002) were associated with lower adherence. Higher trust in provider was associated with higher adherence (p = 0.051).

CONCLUSION

Our findings may help guide tailored interventions to improve adherence, including targeting older children/adolescents as they become independent in their care, language-concordant education, and measures to improve social support and enhance trust in healthcare providers.

Bilateral total knee replacement for hemophilic arthropathy: a case report

Von Willebrand disease (vWD) and hemophilia present unique challenges in orthopedic surgery due to their inherent bleeding risks and potential complications. While joint bleedings are well-documented in hemophilia, they are less understood in vWD, especially regarding their impact on daily activities and the development of arthropathy. We present a case of a young female patient aged 25 years with vWD Type 3 who underwent bilateral total knee replacement (TKR) due to end-stage knee osteoarthritis. Following two previous operations of the right knee at the age of 14, the patient had high degree of extra-articular valgus and intra-articular deformity, ankylosed knee in 30o flexion, osteopenia, and chronic patellar dislocation. Bilateral TKR was performed using patient-specific templating (PST) technology, which includes preoperative planning using a CT scan followed by surgical execution. Financial constraints and limited prosthetic resources necessitated a sequential approach to TKR, addressing the more affected right knee first. Despite many challenges, successful outcomes were achieved, with significant improvements in pain, mobility, overall satisfaction, and no complications at two-year follow-up. Our case highlights the importance of individualized treatment strategies, meticulous surgical planning, and postoperative care in managing knee arthropathy patients with bleeding disorders.

Safety of strength training with blood flow restriction in patients with hemophilic arthropathy; a randomized pilot study

INTRODUCTION

Hemophilic arthropathy is characterized by chronic pain, decreased joint range and periarticular muscle atrophy. In the absence of suitable prophylactic treatment, these sequelae cause severe disability from early ages. The aim of this study was to evaluate the safety of applying blood flow restriction in patients with hemophilia and to observe changes in pain intensity, range of motion and muscle strength.

METHODS

A randomized, single-blind pilot study. Twenty-three patients were recruited and randomized to the two study groups: experimental (training with blood flow restriction) and control (no intervention). The intervention, which lasted for 3 weeks with two weekly sessions, included strengthening exercises of the quadriceps muscle and the plantiflexor and dorsiflexor muscles. The study variables were: safety (number of bleeds), pain intensity (Visual Analog Scale), range of motion (goniometry) and muscle strength (dynamometry).

RESULTS

None of the patients with hemophilia who received the intervention developed muscle or joint bleeds during the study phase. There were statistically significant intergroup differences (p < .001) in the intensity of knee pain (F = 17.97; ŋ2p = 0.29) and ankle pain (F = 24.84; ŋ2p = 0.36), and quadriceps muscle strength (F = 23.49; ŋ2p = 0.34).

CONCLUSIONS

Strength training with blood flow restriction is safe and does not cause joint or muscle bleeding in hemophilia patients in this group. Low-load and flow-restriction exercises can improve the intensity of joint pain and periarticular muscle strength in patients with bilateral hemophilic knee and ankle arthropathy.

Metaphyseal Fixation in Revision Total Knee Arthroplasty

➢ Bone defect management is challenging, but essential, in revision total knee arthroplasty.➢ Appropriate metaphyseal fixation is crucial for stability and implant support.➢ Allografts have been traditionally used to address large defects, but the advent of highly porous metaphyseal cones and sleeves has attracted attention during the past years.➢ Metaphyseal implants are now available in a variety of shapes and sizes to meet various clinical needs.➢ These devices can successfully fill large defects, can better support revision implants, and can achieve long-term biologic fixation.➢ Very good intermediate-term outcomes have been reported with the available metaphyseal implants, using fully cemented or press-fit stems.➢ More research is warranted to further assess surgical indications and the strengths and weaknesses of the various implants used for metaphyseal fixation.

Physical Activity Awareness and Understanding of Treatment Protection Among People With Haemophilia and Their Caregivers in Central Europe

BACKGROUND

Physical activity is now considered generally beneficial for persons with haemophilia (PWH). However, the specific type and extent of activity and its impact on quality of life (QoL) and bleed protection during exercise is under-researched. This knowledge gap should significantly impact PWH's ability to manage their condition optimally.

OBJECTIVE

To explore levels of physical activity and understand bleed protection during exercise among PWH as part of the Liberate Life project.

METHODS

A web-based survey was conducted across eight European countries between August and September 2023. The online survey was developed by haemophilia treatment experts and patient association representatives according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) method. The 24-question survey, distributed to PWH or their parents/caregivers, covered topics such as demographics, the impact of haemophilia on daily life, bleed protection understanding and involvement in physical activities. An activity index was used to categorize PWH as 'more' or 'less' active.

RESULTS

Of 374 respondents analysed, PWH engagement in physical activities, mainly low-impact activities like walking, swimming or cycling, was high (90.9%). Most respondents (74.9%) were 'less active' according to the activity index. There was a significant knowledge gap in respondents' understanding of bleed protection provided by factor and non-factor therapies. Joint health (68.7%), disease severity (69.3%) and capability for physical activity (62.3%) were indicated as key variables influencing PWH QoL.

CONCLUSION

These findings underscore the need for educational programs to improve PWH's understanding of protective factor levels and the role of non-factor therapies in managing haemophilia.

Hemosiderin quantification in hemophilic arthropathy using quantitative magnetic resonance imaging

The goal of this study is to quantify hemosiderin deposition in the knee joint tissues of hemophilic arthropathy (HA) patients using quantitative susceptibility mapping on MRI. Knee synovial tissues from HA patients and controls without hemophilia were included. The tissues underwent ultrashort echo time quantitative susceptibility mapping (UTE-QSM) and clinical MRI. HA tissues were processed histologically with Perl's Prussian Blue (PPB) staining to identify iron contents. Seven regions of interest were drawn in each tissue, and the susceptibility values were tested. Moreover, the association between the estimated magnetic susceptibility and the iron contents quantified by histology was investigated. Nine synovial tissues were procured from total knee arthroplasty of hemophilia patients (males, 40.8 ± 9.0 years), and three synovial tissues were harvested from cadaveric knee joints of donors without hemophilia as controls (males, 72.0 ± 12.8 years). The estimated susceptibility values (ESVs) showed significant differences between HA and control samples. Accordingly, HA tissues presented a mean ESV of 0.48 ± 1.08 ppm and control tissues of -0.13 ± 0.12 ppm (p < 0.05). A significant linear correlation was found between the iron level quantified by histology (PPB stain) and the ESV estimated by UTE-QSM (R = 0.908, p < 0.01). There was a significant difference in the susceptibility in high load (HL) tissues compared to low load (LL) tissues (ESV = 5.57 ± 1.23 ppm for HL vs. 0.57 ± 0.85 ppm for LL, p < 0.001). Reliable hemosiderin quantification in joint tissues of HA patients can be achieved using MRI based on quantitative susceptibility mapping.

Extracorporeal Shockwave Therapy for Tendinopathies Around the Hip and Pelvis: A Systematic Review

Background: Tendinopathies affecting the hip and pelvis include proximal hamstring tendinopathy (PHT), gluteal tendinopathy (greater trochanteric pain syndrome [GTPS]), and calcific tendinopathy (CT). Extracorporeal shockwave therapy (ESWT) is a noninvasive treatment described for the management of lower-extremity tendinopathies. Purpose: We sought to synthesize the evidence on ESWT used in the treatment of hip/pelvis tendinopathies, including protocols, outcomes, and safety. Methods: A comprehensive search of PubMed/Medline, EMBASE, and Cochrane Library databases was performed on November 1, 2024, for studies reporting ESWT data for hip/pelvis tendinopathies. Study design, population, and ESWT-related data (protocols, outcomes, and safety) were extracted. Results: Eighteen studies were included; 9 reported on GTPS, 7 on CT, and 5 on PHT. Most ESWT protocols (72% [n = 13]) implemented 3 to 4 weekly sessions and delivered 2000 to 3000 pulses/session (83% [n = 15]). Eleven studies used radial ESWT and 7 used focused ESWT. ESWT significantly improved pain and functional outcomes for GTPS, CT, and PHT in 17 level-I to level-V studies; only 1 level-V study showed no improvement. Six studies showed superior outcomes post-ESWT vs conservative treatment (PHT/GTPS), sham ESWT (GTPS), ultrasound therapy (GTPS/CT), or corticosteroid injection (GTPS). One study showed comparable outcomes between ESWT and eccentric exercise (GTPS). Two studies reported no outcome differences between radial ESWT and "minimal-dose" ESWT (GTPS) or combined ESWT (PHT). All studies assessing pain showed improvement from 0.5 to 27 months post-ESWT. Six of 18 studies reported adverse events, including increased pain and skin irritation (overall rate: 12% [n = 65/557]). Conclusions: The results of this systematic review suggest that ESWT may be safe and effective for hip/pelvis tendinopathies. Future research using validated outcome measures and ESWT parameters will aid in treatment optimization.

The evolution of three-dimensional knee kinematics after ACL reconstruction within one year

Introduction

This study aims to explore the dynamic changes in the six degrees of freedom (6DOF) kinematics of the knee joint in patients within one year after anterior cruciate ligament reconstruction (ACLR), combined with clinical scoring systems to analyze functional recovery characteristics, providing scientific evidence for optimizing postoperative rehabilitation strategies.

Methods

The study enrolled 49 patients followed up at 3 months postoperatively, 33 patients at 6 months, and 35 patients at 12 months. Twenty-nine healthy controls were recruited. A three-dimensional motion capture system was used to collect 6DOF knee kinematic data at 3, 6, and 12 months after surgery, including flexion-extension, internal-external rotation, adduction-abduction angles, and anterior-posterior, distal-proximal, medial-lateral translation data. Clinical function was assessed using the IKDC and KOOS scores. One Way ANOVA of one-dimensional statistical parametric mapping (SPM1D) was used to assess the changes in gait kinematics and differences compared to healthy controls.

Results

After ACLR, the IKDC and KOOS scores of patients significantly improved between 3 and 12 months postoperatively, showing good subjective functional recovery. Over the course of one year, the knee kinematic data of gait has gradually recovered. However, abnormalities in knee joint kinematics still exist. In the coronal plane, the adduction angle of the knee joint during motion is relatively large (p < 0.05); In the sagittal plane, the flexion angle increased during the standing phase (p < 0.05); In the transverse plane, the internal rotation angle of the knee joint increased compared to the controls (p < 0.05). The range of motion of flexion and rotational angles decreased compared to the controls (p < 0.05).

Discussion

The kinematic recovery of the knee joint in ACLR patients presents multidimensional characteristics and dynamic changes. The recovery rates and patterns differ significantly across dimensions, with some abnormalities not fully corrected within one-year post-urgery. These findings provide scientific evidence for individualized rehabilitation strategies, emphasizing the need for strengthening joint stability and range of motion recovery in the early postoperative phase (0-6 months) and focusing on correcting rotational and flexion-extension function during the later phase (6-12 months) to further improve knee function and prevent long-term adverse outcomes.

Efficacy of corticosteroids addition to multimodal cocktail periarticular injection in total knee arthroplasty with hemophilic arthropathy

Hemophilic arthropathy (HA) patients frequently have perioperative pain after total knee arthroplasty (TKA). Although periarticular local infiltration analgesia by using a cocktail has been utilized in various surgeries, the efficacy of cocktail administration in HA patients undergoing TKA remains unclear. This study aims to determine whether cocktail therapy can relieve perioperative pain and improve postoperative rehabilitation activities after TKA in HA patients, and whether the addition of corticosteroids to the cocktail is both effective and necessary. We conducted a retrospective analysis of clinical data from 98 HA patients who underwent TKA at our institution between January 2015 and January 2024. All surgeries were performed by two senior orthopedic surgeons and two assistants from our team, using posterior-stabilized prostheses. The patients were divided into two groups: the experimental group (ropivacaine 100 mg + morphine 10 mg + dexamethasone 35 mg + normal saline 50 ml, n = 45) and the control group (ropivacaine 100 mg + morphine 10 mg + normal saline 50 ml, n = 53). A three-month follow-up study was conducted to compare the postoperative outcomes in the above groups, including Visual Analogue Scale (VAS) scores, knee range of motion (ROM), Knee Society Score (KSS), inflammatory markers (C-reactive protein, CRP, and Interleukin- 6, IL- 6), and hospitalization parameters (body temperature, length of hospital stay, hospitalization costs, and perioperative usage of coagulation factor VIII). Both groups improved knee joint function and reduced post-operative pain at the last follow-up. With knee ROM increasing from 47.22° to 95.36° and KSS increasing from 35.42 to 82.02, the experimental group's VAS ratings dropped from 4.31 to 1.47. Besides, the control group's VAS scores dropped from 4.71 to 2.09, knee ROM increased from 45.95° to 91.60°, and KSS from 36.87 to 80.40 (all with P < 0.05). Throughout the follow-up, the experimental group showed better pain reduction (P < 0.05), with greater knee ROM and KSS within the first month compared to the control group. This difference diminished by the third month, but the experimental group still showed higher knee ROM and KSS. Additionally, the experimental group exhibited lower inflammation markers and a shorter hospital stay (P < 0.05). In people with hemophilia undergoing TKA the cocktail of ropivacaine 100 mg + morphine 10 mg + nomal saline 50 mL + 35 mg dexamethasone seemed to be more effective in relieving postoperative pain than the cocktail of ropivacaine 100 mg + morphine 10 mg + nomal saline 50 mL at 3-month follow-up.

Reducing Walking Speed Decreases Surgical Knee Loading but Not Between-Limb Symmetry in Individuals With Anterior Cruciate Ligament Reconstruction

A higher risk of knee osteoarthritis (OA) has been identified in patients with slower walking speeds following anterior cruciate ligament reconstruction (ACLR). Given that altered loading of the surgical knee has been the most proposed mechanism for early knee OA post-ACLR, understanding how modulating walking speed may modify knee joint loading is essential for developing strategies to reduce the risk of knee OA in ACLR patients. The purpose of this study was to determine how modulation of walking speed affects knee joint loading during overground walking post-ACLR. Lower extremity kinematics and kinetics were recorded during overground walking at a self-selected, slower, and faster speed from 16 patients with unilateral ACLR. The results showed that ACLR patients demonstrated lesser peak knee flexion and adduction moments of the surgical knees when walking at slower speeds. However, modulating walking speed did not alter between-limb knee loading asymmetry. The ACLR limbs had lower peak knee flexion moments than the uninjured limbs across all 3 walking speeds. Although interventions that increase walking speed may deter the onset of knee OA by elevating the mechanical stimulation at the surgical knee, additional gait training strategies may be needed to restore the between-limb loading symmetry in ACLR patients.

The application of antibiotic-loaded bone cement in preventing periprosthetic joint infection: an umbrella review

OBJECTIVES

The purpose of this study was to provide thorough, understandable and precise evidence for the clinical use of antibiotic-loaded bone cement (ALBC) in preventing periprosthetic joint infection (PJI).

METHODS

We evaluated the effectiveness of ALBC in preventing PJI by conducting an umbrella review of existing meta-analysis. Four databases, PubMed/MEDLINE, Cochrane Library, Embase and Web of Science, were searched until May 2024. Two reviewers were reviewers for literature screening, and data were extracted independently. AMSTAR 2 guideline and GRADE were also used for quality evaluation. The clinical outcomes were evaluated for effectiveness by several indicators, including surface infection rate (SIR), deep infection rate (DIR), total infection rate (TIR), unadjusted/adjusted all-cause revision rate, and revision rate for PJI.

RESULTS

We synthesized the results of ten meta-analyses. Two meta-analyses had high AMSTAR 2 scores, two had moderate AMSTAR 2 ratings, three had critically low AMSTAR 2 scores, and the remaining meta-analyses had low AMSTAR 2 ratings. In terms of postoperative surgical site infection and revision rate, SIR (OR 1.50, 95% CI 1.14, 1.99, P = 0.004, I2 = 0%), unadjusted all-cause revision rate (RR 1.44, 95% CI 1.08, 1.90, P = 0.011, I2 = 91.8%) and adjusted all-cause revision rate (HR 1.21, 95% CI 1.12, 1.31, P < 0.001, I2 = 0%) in ALBC group were significantly higher than those in non-antibiotic-loaded bone cement (NALBC) group. ALBC group was significantly lower than NALBC group in DIR (OR 0.53, 95% CI 0.39, 0.70, P < 0.0001, I2 = 57%), (RR 0.506, 95% CI 0.341, 0.751, P = 0.001, I2 = 0%) and revision for PJI (RR 0.721, 95% CI 0.628, 0.828, P = 0, I2 = 53%). There was no statistical difference in total infection rate (TIR) between the ALBC group and the NALBC group (OR 0.81, 95% CI 0.51, 1.28, P = 0.37, I2 = 73%).

CONCLUSIONS

On the basis of the results of our analysis, we do not believe that ALBC is more effective than NALBC in preventing PJI after primary total joint arthroplasty (PTJA). No statistically significant difference was found on TIR between the two groups, although it was lower in the ALBC group. In addition, the DIR and revision for PJI are significantly lower in the ALBC group, but the results are of low quality, which calls for high-quality and large-sample studies in the future.

Global trends in hemophilic arthropathy research: a bibliometric and visualization analysis

Background

Hemophilic arthropathy (HA), a common complication of hemophilia caused by recurrent hemarthrosis, significantly impacts patients' quality of life. Despite ongoing research, a comprehensive overview of research trends for HA is lacking. Therefore, this study utilizes bibliometrics and knowledge mapping techniques to visually analyze the current status and developmental trends of HA-related research, and analyzed and predicted future research hotspots.

Methods

A bibliometric analysis was conducted using the Web of Science Core Collection database. Data on publications, author names, countries, research institutions, journals, and keywords were extracted and visualized using Bibliometrix, VOSviewer, and CiteSpaces.

Results

The number of HA-related publications has increased steadily over time. United States was found to be the leading country in terms of publications and international collaborations. HEMOPHILIA was found to be the most influential journal and Hospital Universitario La Paz to be the leading institution conducting HA-related research. Rodriguez-Merchan EC was identified as the most prominent researcher in the field. Keyword analysis identified five main research clusters, namely, quality of life and management, pathogenesis, classification and functional assessment, replacement surgery, and ankle arthritis treatment.

Conclusion

This bibliometric analysis provides a comprehensive overview of the research trends for HA. Future studies must focus on elucidating the underlying mechanisms of HA, developing early diagnostic biomarkers, and exploring personalized treatment strategies to improve patient outcomes. Our study offers valuable insights to researchers to facilitate the identification of emerging trends and prioritization of future research directions.

The proportion of young male hemophilia patients who underwent ultrasound examinations: an observational study using a nationwide claims database

BACKGROUND

Advances in hemophilia treatment have reduced bleeding episodes in patients with hemophilia (PWH) and improved their musculoskeletal prognosis; however, complete prevention of musculoskeletal disorders has not been achieved. Recently, the usefulness of ultrasound (US) examinations in the musculoskeletal assessment of PWH has been reported, but the actual use of US has been suggested to be limited. The aim of this study was to clarify the extent to which US is being performed on young male PWH at medical institutions in Japan.

METHODS

This was an observational study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. We identified almost all male PWH aged under 30 years who were prescribed hemostatic agents between 2015 and 2021 in Japan. For each year, we calculated the proportion of PWH who underwent US and, as a sensitivity analysis, the proportion of PWH who underwent US examinations for musculoskeletal disease. The Cochran‒Armitage trend test was used to examine changes in the number of PWH who underwent US examinations over the observation period. The Lorenz curves and Gini coefficients were calculated from the proportion of US examinations performed at each medical institution annually.

RESULTS

A total of 2137-2483 male PWH younger than 30 years were identified annually. The annual proportion of PWH who underwent US ranged from 6.1 to 12.9%. By age group, the annual proportions of US were 6.7-14.4%, 8.1-16.6%, and 2.0-8.7% for 0-9, 10-19, and 20-29 years, respectively. The annual proportions of musculoskeletal US were 2.9-7.7%. The proportion of PWH who underwent US increased significantly over the seven-year period; however, it varied by medical institution (Gini coefficients 0.85-0.92).

CONCLUSIONS

The use of US for young PWH is becoming more widespread in Japan. However, US is performed at different rates among medical institutions.

Exploring the Multifactorial Predictors of Pain in Chronic Musculoskeletal Pain: A Regression-Based Study

Objective

This study aimed to assess differences in pain neurophysiology knowledge between individuals with chronic musculoskeletal pain (CMP) and those without CMP, and to explore associations between pain knowledge, pain intensity, and demographic and lifestyle factors.

Methods

A cross-sectional study was conducted with 171 participants, including 120 with CMP and 51 without CMP. Sociodemographic, pain-related, and lifestyle data were collected. Pain knowledge was assessed using the Revised Neurophysiology of Pain Questionnaire (R-NPQ). Statistical analyses included t-tests, chi-squared tests, Pearson's correlation, and stepwise regression models to identify predictors of pain intensity and CMP presence.

Results

Significant differences were found between participants with and without CMP in BMI (p<0.001), physical activity (p=0.023), education level (p=0.002), and alcohol consumption (p=0.017). Participants with CMP scored lower on the R-NPQ (mean 4.40 ± 2.1) than those without CMP (mean 6.31 ± 2.03; p<0.001). Pain intensity was negatively associated with R-NPQ scores (r=-0.315; p<0.001), physical activity (r=-0.199; p=0.030), and education level (rho=0.236; p=0.010). Stepwise regression analysis revealed that R-NPQ scores (20.7%), BMI (6.7%), education level (3.9%), and physical activity (2.6%) collectively explained 33.9% of the variance in pain intensity (adjusted R²=0.339). Binary logistic regression identified BMI, R-NPQ scores, and education level as significant predictors of CMP presence, with higher BMI and lower R-NPQ scores increasing the odds of CMP, while higher education levels and physical activity were predictive factors.

Conclusion

Individuals with CMP exhibited lower knowledge of pain neurophysiology, higher BMI, reduced physical activity levels, and lower educational attainment, all of which were associated with increased pain intensity and a greater likelihood of CMP presence.

Extracorporeal Shock Wave Therapy versus laser therapy in treating musculoskeletal disorders: a systematic review and meta-analysis

This systematic review aimed to compare the effectiveness of Extracorporeal Shock Wave Therapy (ESWT) versus Laser therapy (Low-Level Laser Therapy (LLLT) and High-Intensity Laser Therapy (HILT) in treating musculoskeletal disorders (MSKDs). Systematic searches of randomized clinical trials (RCTs) were performed in six databases from inception till February 2025. Two researchers independently screened titles, abstracts, and full-text articles. Eligible studies had to report at least one of the following outcomes: pain, functionality, strength, range of motion (ROM), and quality of life (Qol). Risk of bias was assessed using the revised Cochrane Collaboration tool (RoB 2.0). Meta-analysis was conducted using Review Manager software version 5.4.1, and quality of evidence was evaluated using the GRADE approach. Twenty-eight RCTs involving 1,460 patients were included. The findings indicated that neither LLLT nor HILT showed a significant difference from ESWT in pain, strength, ROM, or quality of life. However, ESWT demonstrated a marginal statistically significant functional advantage over LLLT, but not over HILT. The GRADE certainty rating was rated as very low to moderate. According to GRDAE certainty rating, ESWT and laser therapies (LLLT and/or HILT) had equivalent effect in improving pain, strength, ROM, and Qol in patients with MSKDs, while ESWT had some short-term effects in improving functions more than LLLT but not than HILT. Large RCTs with higher methodological quality are needed to draw more incisive conclusions.

Outcomes of Selectively Unresurfaced Patellae with a Partial Lateral Facetectomy in Primary Total Knee Arthroplasty

BACKGROUND

Not resurfacing the patella during primary total knee arthroplasty (TKA) has steadily increased as implants and techniques have improved. However, limited data exist on the acceptable arthritis severity to leave the patella unresurfaced and the subsequent effect on patient-reported outcome measures (PROMs). This study evaluated PROMs in matched cohorts of unresurfaced and resurfaced patellae, accounting for patellar osteoarthritis severity and lateral patellar facetectomies.

METHODS

A consecutive series of primary TKAs was retrospectively reviewed. There were 871 patellae selectively unresurfaced, of which 667 (76%) had an aggressive lateral facetectomy. The remaining 1,064 patellae were resurfaced. The TKAs with unresurfaced patellae were matched to TKAs with resurfaced patellae based on demographics and patellar osteoarthritis severity. There were 140 TKAs in each matched group, which did not differ by demographics (P ≥ 0.334) or osteoarthritis severity (P ≥ 0.999). The PROMs were compared between groups at a mean of 2.7 years (range, 1 to 10) at a significance level of 0.05.

RESULTS

The matched groups did not differ by postoperative knee-specific PROMs (P ≥ 0.225), nor improvement from the preoperative baseline score (P ≥ 0.193). A greater percentage of patients who had unresurfaced patellae and a lateral facetectomy achieved minimal clinically important differences (MCIDs) for the Knee Injury and Osteoarthritis Outcome Score (94, 89, 86%) and pain with stairs (88, 85, 81%) compared to patella groups without a lateral facetectomy, despite lacking statistical significance (P ≥ 0.295). The change in PROMs for patients who had moderate to severe patellofemoral arthritis grade ≥ 2 was not different between patella groups (P ≥ 0.382).

CONCLUSION

Study results show that patients who had unresurfaced and resurfaced patellae have similar PROMs after TKA regardless of patello-femoral osteoarthritis severity. An aggressive lateral facetectomy when leaving the patella unresurfaced may help achieve PROM MCIDs more frequently.

Leisure time exercise and depressive symptoms in sedentary workers: exploring the effects of exercise volume and social context

Background

Workers in sedentary occupations often engage in prolonged periods of low physical activity, which may be associated with depressive symptoms. Leisure-time exercise plays a significant role in alleviating these symptoms. Previous studies have shown that adults who engage in physical exercise report fewer depressive symptoms than those who do not. However, the relationship between exercise volume and mental health remains inconsistent. Leisure-time exercise can be categorized into individual and group exercise. Despite its potential importance, little is known about the differential effects of individual and group exercise on depressive symptoms in sedentary occupational populations. The objective of this study was to analyze the association between leisure-time exercise volume and depressive symptoms in sedentary workers, as well as to evaluate the disparities in the effects of individual and group exercise on depressive symptoms.

Methods

From September to October 2024, a cross-sectional survey was conducted to collect data from sedentary workers. The participants' sociodemographic characteristics, exercise patterns, exercise volume, and depressive symptoms were gathered. Chi-square tests and hierarchical logistic regression were employed to analyze the obtained data.

Results

Of the 1,277 respondents, 13.16% reported depressive symptoms. The prevalence of depressive symptoms was higher in those with low exercise volume than in those with medium or high exercise volume. Medium and high exercise volumes were associated with a lower risk of depressive symptoms, with odds ratios (OR) of 0.517 and 0.559, respectively. Group exercisers reported fewer depressive symptoms than individual exercisers, with an OR of 0.624.

Conclusion

The benefits of leisure-time exercise on depressive symptoms in sedentary workers do not always increase with higher exercise volume. Additionally, sedentary workers who participated in group exercise exhibited a lower risk of depressive symptoms than those who participated in individual exercise.

Impact of intra-articular injection on infection risk and therapeutic effect after unicompartmental knee arthroplasty: a retrospective cohort study

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is an effective treatment for single-compartment knee osteoarthritis. However, some patients experience lateral compartment pain after UKA. The impact of lateral compartment intra-articular injection on infection risk of the medial prosthesis and therapeutic outcomes in these patients remains controversial.

OBJECTIVE

This study aims to evaluate the impact of lateral compartment intra-articular injection after UKA on the risk of medial prosthetic joint infection, as well as its therapeutic effect on lateral compartment pain and inflammation. We hypothesized that lateral compartment intra-articular injection in patients with post-UKA lateral pain could provide better pain relief and functional outcomes without increasing the risk of medial prosthetic infection.

METHODS

This retrospective cohort study included patients who experienced lateral compartment pain after UKA at Jinshan Branch of Shanghai Sixth People's Hospital between January 2018 and December 2020. Patients were divided into two groups: those who received lateral compartment intra-articular injection for pain management (injection group) and those who received only oral medication (control group). The primary outcome was medial prosthetic infection rate within 6 months post-injection. Secondary outcomes included pain scores, knee function, and quality of life.

RESULTS

A total of 249 patients with post-UKA lateral compartment pain were included (144 in the injection group, 105 in the control group). There was no significant difference in medial prosthetic infection rates between the two groups (2.1% vs. 2.9%, p = 0.812). The injection group showed significantly better pain relief (VAS score) and knee function (KSS score) at 1 week and 1 month post-injection (p < 0.05). Quality of life measures (SF- 36) also showed improvements in the injection group at these early time points.

CONCLUSION

Intra-articular injection after UKA does not increase the risk of infection and may provide better short-term pain relief and functional outcomes. These findings support the safety and potential efficacy of this approach in managing apparent lateral knee post-operative pain and enhancing early recovery after UKA. However, larger prospective studies are needed to confirm these results and further explore the long-term impact of this intervention.

Survivorship in robotic total knee arthroplasty compared with conventional total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

Total knee arthroplasty (TKA) is the gold standard surgical management for end-stage knee osteoarthritis (OA). Robotic TKA (rTKA) was developed to improve bone preparation accuracy and increase reproducibility. In many settings internationally, rTKA systems have significantly higher costs for patients, and survivorship outcomes are unclear. There are several prior meta-analyses, but these focused on clinical and radiologic outcomes, and to our knowledge, none have evaluated survival. Differences in survival between semi-active or active robotic systems are also not well investigated.

STUDY DESIGN

Meta-analysis.

METHODS

A random-effects meta-analysis was conducted on comparative studies between robotic-assisted TKAs and conventional TKAs (cTKAs) in patients undergoing TKA for primary knee OA. We searched MEDLINE, Embase, Cochrane Library, and SCOPUS from inception to 19 December 2024. Outcomes assessed were the implant survival in robotic-assisted TKA compared to conventional methods in standard primary knee OA cases, with subgrouping between active and semi-active systems performed. Secondary outcomes included associated complications, post-operative pain scores, and functional outcomes.

RESULTS

A total of 20 comparative studies were included in the meta-analysis. Among them, 2,804 patients underwent cTKA, while 2,599 underwent rTKA. At two years, the pooled survivorship rate was 97.9% (95% CI: 96-99) in the conventional group and 98.3% (95% CI: 96.2-99.2) in the robotic group. There were no significant differences between the groups (P = 0.7). There were no significant differences between the robotic (semi-active) group and the conventional group (P = 0.5) on further unpaired T-Testing. Between 2 and 5 years, pooled survivorship rates in the conventional group were 96.8% (95% CI: 90.3-99) and 97.1% (95% CI: 91.3-99) in the robotic group. There were no significant differences between groups (P = 0.9). At ten years postoperatively, pooled survivorship rates in the conventional group were 96.9% (95% CI: 95-98) and 97.8% (95% CI: 96.7-98.5) in the robotic group. There were no significant differences between the groups (P = 0.3).

CONCLUSION

Conventional TKA is non-inferior to rTKA at short and long-term follow-up with regard to implant survival, complications, and postoperative pain scores, while rTKA shows subtle improvements in functional outcome measures.

TRIAL REGISTRATION

CRD42024540997.

Clinical analysis of Ganz approach in the treatment of Pipkin type IV fracture: a retrospective review

PURPOSE

This study aimed to evaluate the early clinical outcomes of the Ganz approach in treating Pipkin IV fractures.

METHODS

From January 2016 to January 2021, 22 patients with Pipkin IV fracture were treated in our department with Ganz approach. The operation time, intraoperative blood loss, fracture healing time, the incidence of postoperative complications such as heterotopic ossification of hip joint and avascular necrosis of femoral head were recorded. Radiological assessment of fracture reduction was achieved using Matta's evaluation criteria. The functional recovery of the hip joint was assessed using the Harris Hip Score at one year and before the current study, as well as the modified Merle d'Aubigné and Postel score during the final evaluation.

RESULTS

21 patients were available for follow up. The average intraoperative blood loss was 145.5 ± 39.3 ml and the average operation time was 150.4 ± 40.6 min. The average follow-up time was 39.2 ± 11.2 months. X-ray confirmed bony healing of the femoral head, acetabular fractures, and greater trochanter osteotomy, with an average healing time of 7.22 ± 3 months. The difference between the Harris hip score of hip joint at one year and at the last follow-up was not statistically significant (p = 0.06). At final follow up with the modified Merle D'Aubigne Postel score, nine had excellent functional outcome; ten presented very good to good result while two patients had average (one) to poor (one) result. Two (9.5%) patient developed osteonecrosis (avascular necrosis) of the femoral head.

CONCLUSION

The Ganz approach effectively preserves the blood supply to the femoral head, moreover, it also fully expose the operative fields such as hip joint and femoral head, achieving satisfactory clinical outcomes, making it a valuable option for clinical application.

Impact of Adequate Disinfection Techniques for Ultrasound-Guided Injections in Musculoskeletal Rehabilitation: A Scoping Review

Background: Interventional physiatry is a branch of medicine that uses minimally invasive ultrasound-guided techniques for diagnosis and treatment in the musculoskeletal system. The aim of this scoping review is to investigate the sterilisation techniques used and the rate of infection with ultrasound-guided injections. Methods: PubMed was searched up to 30 September 2024 using the following search terms ("Ultrasound, Interventional"[mesh]) AND "Injections, Intra-Articular"[mesh]; "Ultrasound-guided intra-articular injection". The inclusion criteria were randomised clinical trials, written in English, involving US-guided mini-invaexercissive procedures. Results: The search identified a total of 256 potentially relevant publications. After screening for duplication, inclusion, and exclusion criteria, 105 articles were eligible for data extraction. In 51 studies, the method of skin disinfection was not specified, 18 RCT reported a 'sterile condition', 9 studies used povidone-iodine solution, 5 used alcohol, and 2 used chlorhexidine 0.5%. In 64 trials, the method of probe preparation was not specified, 11 trials described the use of sterile gel, 10 trials reported the use of a probe cover, sterile pad, or barrier, and 2 trials reported the use of chlorhexidine 0.5%; 41 studies reported mild adverse events and 4 serious adverse events. Conclusions: Taken together, the findings of this scoping review did not show a clear relationship between current sterilisation protocols and the prevention of the microbial contamination of the probes or the patient's skin. The variation in protocols highlights the need for standardised guidelines and more rigorous studies to accurately determine the most effective disinfection practices.

Bleeding Complications, Transfusion, and Acute Care Costs After Major Arthroplasty in Patients With Hereditary Bleeding Disorders: A National Healthcare Database Analysis

BACKGROUND

Advances in blood conservation have reduced the need for allogeneic transfusions in total knee and hip arthroplasty (TKA/THA). This study aimed to assess whether perioperative bleeding complications, including hemorrhage/hematoma, allogeneic transfusions, and postoperative anemia, occurred at similar rates between patients with hereditary bleeding disorders (BDs) and controls. Using a national health care database, we assessed the use of clotting factor concentrates (CFCs), perioperative outcomes, and resource utilization.

METHODS

A retrospective cohort study was conducted using the Premier Health Database (2017-2021) to analyze differences in outcomes and costs between 1528 patients with hereditary BDs and 20,509 non-BD controls undergoing elective TKA and THA. Summary statistics, bivariate analyses, and odds ratios (ORs) were used to evaluate perioperative outcomes and resource use.

RESULTS

Patients with hereditary BDs were slightly younger, predominantly female, and more often treated at larger, urban hospitals compared to controls. Bleeding complications, including hemorrhage and hematoma, were infrequent but higher in the BD group (1.1% vs 0.2%; P < .0001). Transfusion rates were higher in THA than TKA, with significantly increased odds for patients with hereditary BD: for THA, OR 2.7 (95% confidence interval [CI], 2.0-3.7; P < .0001); and for TKA, OR 2.6 (95% CI, 1.9-3.8; P < .0001). CFC exposures occurred in 16.4% of patients with hereditary BD compared to 0.03% in controls. Of 270 reported CFC exposures, factor VIII (FVIII) and von Willebrand factor (VWF) were most commonly used (49.6% and 23.0%, respectively), followed by FIX concentrate (12.6%) and bypassing agents, including FVIIa (8.5%) and anti-inhibitor coagulant complex (AICC; 3.7%). Antifibrinolytic therapy was administered in most cases. Pharmacy costs for patients with hereditary BD were significantly higher, with a mean of $23,792 (95% CI, $8722-$39,312), being over 30 times the mean cost in controls ($750; 95% CI, $739-$762). Other outcomes were not different, except for a higher incidence of venous thromboembolism in the BD group (OR 3.9, 95% CI, 2.4-6.1; P < .0001).

CONCLUSIONS

THA and TKA in patients with hereditary BDs are relatively safe, with most outcomes comparable to controls. However, higher rates of bleeding, transfusion, and VTE underscore the need for optimizing anemia management and targeted use of CFCs along with antifibrinolytic therapy.