Clin. Orthop. Relat. Res. [JOURNAL]

BACKGROUND: Major complications that may result in the removal of osseointegrated implants in patients with limb loss include peri-implant fracture, severe bone resorption, and infection. It remains challenging to diagno... BACKGROUND: Major complications that may result in the removal of osseointegrated implants in patients with limb loss include peri-implant fracture, severe bone resorption, and infection. It remains challenging to diagnose and manage peri-implant infection in patients who have undergone osseointegration surgery. The Musculoskeletal Infection Society (MSIS) developed criteria to identify periprosthetic joint infection (PJI) after total joint arthroplasty during the 2018 MSIS/International Consensus Meeting; however, there is no such validated system for patients who have received osseointegrated implants, and some of the measures on the MSIS/International Consensus Meeting criteria are not applicable to osseointegrated implants. Nevertheless, establishing an adapted version of the MSIS criteria, or a comparable standardized system, would be valuable for enabling consistent diagnosis of osseointegration-associated peri-implant infections. QUESTIONS/PURPOSES: (1) Is there a difference in the serum parameters of the 2018 MSIS criteria between a cohort of patients without infection and a cohort with an infection? (2) Can the serum parameters of the 2018 MSIS criteria be validated in a population that has undergone osseointegration? (3) Can we develop a new, valid set of criteria to gauge the likelihood of infection from serum parameters for those who have undergone osseointegration? METHODS: We performed a secondary (retrospective) analysis using data from the Transfemoral Amputation Osseointegration Study, an FDA investigational device exemption study. We supplemented these data with additional participants from a separate, subsequent longitudinal study who had undergone transfemoral amputations. Both studies were conducted to determine the efficacy of an osseointegrated device in the context of patient-reported outcome measures and adverse events like infections and implant removals. The participants were drawn from both studies, which were performed at Walter Reed National Military Medical Center. Eligible patients were adults who underwent transfemoral osseointegration and who had available preoperative and/or postoperative laboratory data relevant to infection assessment. We excluded individuals with incomplete clinical records that precluded the determination of infection status. We collected serum parameters corresponding to the 2018 MSIS criteria from patients from both studies within 30 days of infection diagnosis, excluding joint aspirate data, as no joints are involved in transfemoral osseointegration. We compared the serum parameters (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], white blood cell count [WBC], and percentage of polymorphonuclear [PMN] cells) from the 2018 MSIS criteria in the 33% (18 of 55) of patients with infections to the 67% (37 of 55) of patients with no infections. A total of 93% (51 of 55) of patients were male, and the study population had a mean ± SD age of 39 ± 11 years. Most participants sustained traumatic amputations due to combat, whereas the remainder resulted from oncologic or infectious etiologies. All variables were assessed before undergoing any osseointegration surgery as part of routine care (preoperative baseline laboratory values) and during the occurrence of any suspected infection, and the study did not depend on longitudinal trajectories or repeated measures. We used the CDC definition of infection, which classified a superficial infection as an infection limited to the skin and a deep infection as an infection beneath the incision in the muscle and surrounding tissues. We used t-tests to compare serum parameters from the 2018 MSIS variables between the no infection cohort and the cohort that had an episode of an infection. To determine whether the original serum parameters from the 2018 MSIS criteria could be applied to a population undergoing osseointegration surgery, we performed a logistic regression using a generalized linear model with a binomial link. The dependent variable was the presence of any infection (superficial or deep) and the predictor was the serum parameters from the 2018 MSIS total score. Finally, we developed a novel list of criteria and tested them against this dataset to evaluate the sensitivity, specificity, and area under the receiver operating characteristic curve using the CDC definition of infection as the gold standard for the presence or absence of infection. Patient outcomes were followed for a minimum of 2 years after osseointegration surgery (Stage II). RESULTS: We found no difference between the no infection cohort and infection cohort values for the CRP (2.7 ± 4.0 mg/L versus 6.1 ± 8.4 mg/L; p = 0.14). Likewise, the ESR did not differ between the no infection and infection cohorts (20.0 ± 24.2 mm/hour versus 33.8 ± 27.8 mm/hour; p = 0.11). The WBC also did not differ between the no infection and infection cohorts (4.4 ± 2.4 ×103 cells/µL versus 9.3 ± 3.9 ×103 cells/µL; p = 0.08). However, the serum percentage of PMN was higher in the group with infections compared to the group with no infections (66.9% ± 12.2% versus 58.7% ± 10.7%; p = 0.02). We were unable to validate the serum parameters from the 2018 MSIS criteria in this osseointegration surgery population. Our generalized linear model showed that the MSIS total score was not associated with the presence of infection. Furthermore, the overall model was not different from the null model (likelihood ratio χ2 = 1.6; p = 0.21), suggesting that the serum parameters from the 2018 MSIS criteria did not discriminate between the participants without an infection and those who developed an infection. Finally, we developed a novel list of criteria to assess the presence or absence of infection in patients who had transfemoral osseointegration by assigning 1 point for each laboratory marker (CRP, ESR, WBC, and PMN) above its respective receiver operating characteristic (ROC)-derived threshold (range 0 to 4). The composite score showed excellent discrimination of infections (area under the curve [AUC] = 0.84). The optimal cutoff was ≥ 2, which produced a sensitivity of 0.88 and a specificity of 0.62. CONCLUSION: The serum parameters of the 2018 MSIS/International Consensus Meeting definition of infection did not differ between patients with and without infection after transfemoral osseointegration surgery, but a new approach that we developed appeared sensitive but not specific for this problem in a secondary analysis of patients from prior research trials. Based on these findings, surgeons should emphasize direct clinical examination, the characteristics of soft tissue changes, and patient-reported symptoms as there is no satisfactory approach using laboratory parameters alone. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Get PDF PubMed ↗

CORR Insights®: Can a Targeted Dissemination Strategy of the PREPARE Trial Results Change Surgical Antiseptic Practice?

Ring DC

Clin Orthop Relat Res · 2026 Jun · PMID 42297380 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

CORR Insights®: What Is the Association Between Adding Genicular Nerve Block to Adductor Canal Block and Infiltration Between the Popliteal Artery and Capsule of the Knee and Perioperative Outcomes After Primary TKA?

Webb ML

Clin Orthop Relat Res · 2026 Jun · PMID 42297356 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

Is a Resorbable Citrate-based Bioceramic Device Associated With Osseous Integration? An Early Retrospective MRI Analysis.

Berberian WS, Day J, Schon L

Clin Orthop Relat Res · 2026 Jun · PMID 42297353 · Publisher ↗

BACKGROUND: Bioresorbable fixation devices may be advantageous because they eliminate the question of whether they ought to be removed, have biomimetic qualities, and minimize artifacts seen on MRI. Most bioresorbable de... BACKGROUND: Bioresorbable fixation devices may be advantageous because they eliminate the question of whether they ought to be removed, have biomimetic qualities, and minimize artifacts seen on MRI. Most bioresorbable devices utilized during orthopaedic surgery consist of thermoplastic polymers derived from lactic and glycolic acids. These devices are linked to implant-related osteolysis, inflammation, and bone tunnel enlargement, and their integration with surrounding bone is inconsistent. Citregen®, a resorbable composite of a citrate-based thermoset polymer and hydroxyapatite, recently has been approved for use in the United States; yet to date, there are no published studies documenting device-related MRI findings. QUESTIONS/PURPOSES: (1) Was there observable bone tunnel enlargement on MRI at a minimum of 2 years after implantation of a resorbable citrate-based bioceramic device? (2) Were there other observable adverse findings (such as bone marrow edema or device breakage) on MRI at a minimum of 2 years after implantation of a resorbable citrate-based bioceramic device? (3) Did citrate-based bioceramic devices demonstrate integration with surrounding bone on MRI at a minimum of 2 years after implantation? (4) What was the frequency of early clinical complications after soft tissue fixation with citrate-based bioceramic interference devices? METHODS: All 15 patients who underwent tendon transfer or ligament reconstruction in the foot and ankle during a 21-month time period were treated with citrate-based bioceramic interference devices. This group of patients had a median (range) age of 55 years (21 to 75), and 10 were male. Most presented with degenerative or work-related conditions; two had athletic injuries. Two patients were lost to follow-up, and MRI scans performed on 13 patients (25 devices) more than 2 years after surgery were reviewed separately in retrospective, blinded fashion by two investigators. For each device, surrounding bone was assessed for bone tunnel enlargement, which was quantified in millimeters by measuring the width of any gap between the inner surface of the bone tunnel and the outer diameter of the device threads. An intraclass correlation coefficient of 1.0 was achieved, indicating absolute agreement between raters with regard to width of gap measured to the nearest millimeter. The proportion of bone marrow edema abutting the total cross-sectional circumference of each device was quantified using a five-point interval scale (0%, 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%). Percentage intervals assessed on the five-point scale demonstrated high interrater reliability (prevalence-adjusted, bias-adjusted kappa [PABAK] = 0.92). Qualitative assessment for other adverse findings, such as cysts, sinus tracts, peridevice fluid, and device breakage, was also performed. The proportion of osseous integration along the long axis of each device was also quantified using a five-point interval scale (0%, 0% to 25%, 26% to 50%, 51% to 75%, and 76% to 100%). Percentage intervals assessed on the five-point scale demonstrated high interrater reliability (PABAK = 0.92). Retrospective chart analysis was used to document the number of complications at the most recent follow-up. RESULTS: There was no measurable bone tunnel enlargement around any of the devices. Two devices showed bone marrow edema limited to 25% or less of device circumference. Osseous integration occurred around all devices, with 21 of 25 implants showing near-complete (76% to 100%) integration along their long axes. Clinically, there were no device-related complications at median follow-up of 36 months in the 13 patients who were accounted for at a minimum of 2 years (range 2 to 4 years). CONCLUSION: In our study of a citrate-based thermoset polymer with hydroxyapatite, common problems associated with other resorbable devices were not seen. Although these findings are promising, our series was very small and had multiple limitations. Therefore, this study should not serve as a basis to recommend widespread use of this material without publication of larger and more rigorous studies that independently replicate our findings. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Get PDF PubMed ↗

Long-term Oncologic Outcomes After Unplanned Soft Tissue Sarcoma Surgery: Implications for Surveillance Strategies.

Jahn J, Dean KK, Travis LM … +7 more , Daftari M, Costello JP, Shloush M, Brutti J, Shae J, Temple HT, Pretell-Mazzini J

Clin Orthop Relat Res · 2026 Jun · PMID 42284494 · Publisher ↗

BACKGROUND: Unplanned excision refers to the resection of soft tissue sarcomas without appropriate preoperative imaging, histologic confirmation, or oncologic planning. Although the short-term oncologic risks of unplanne... BACKGROUND: Unplanned excision refers to the resection of soft tissue sarcomas without appropriate preoperative imaging, histologic confirmation, or oncologic planning. Although the short-term oncologic risks of unplanned excisions are well described, data on long-term outcomes remain limited. QUESTIONS/PURPOSES: After controlling for tumor grade, clinical stage, Charlson comorbidity index (CCI), and surgical margin status, is unplanned excision independently associated with (1) worse overall survival, (2) local recurrence-free survival, and (3) metastatic disease-free survival compared with planned excision? METHODS: In this study of 1100 patient records initially identified by Current Procedural Terminology code query, 403 were identified as duplicate records, 253 were excluded for insufficient baseline data or lack of cancer center entry, and 48 were excluded for insufficient follow-up or not undergoing surgery at the institution, yielding 396 patients, 279 who underwent planned excision and 117 who underwent unplanned excision. We defined an unplanned excision as resection of a soft tissue mass performed without appropriate preoperative advanced imaging (such as MRI) or histologic tissue diagnosis (such as core needle biopsy), or when imaging and biopsy findings were misinterpreted as benign, leading to resection without oncologic planning. The mean ± SD age was similar between groups (planned excision 59 ± 17 years versus unplanned excision 56 ± 18 years); however, groups differed in sex distribution, CCI, clinical stage, and histologic subtype distribution, underscoring the importance of multivariable adjustment. Overall survival, local recurrence-free survival, and metastatic disease-free survival were compared using Kaplan-Meier analysis, log-rank testing, and multivariable Cox regression at 5-, 10-, and 15-year intervals. RESULTS: Overall survival did not differ at 5 years between patients with unplanned excisions and planned excisions (79% [95% confidence interval (CI) 68% to 87%] versus 87% [95% CI 81% to 91%]; p = 0.21), but it was lower after unplanned versus planned excision at 10 years (65% [95% CI 49% to 77%] versus 81% [95% CI 71% to 87%]; p < 0.01) and 15 years (43% [95% CI 11% to 73%] versus 74% [95% CI 58% to 85%]; p = 0.02; log-rank, p = 0.02). Metastatic disease-free survival was lower after unplanned excision at 5, 10, and 15 years, and local recurrence-free survival was worse at 10 years (unplanned excision 67% [95% CI 47% to 81%] versus planned excision 69% [95% CI 57% to 79%]; p = 0.047) and 15 years (40% [95% CI 12% to 67%] versus 69% [95% CI 57% to 79%]; p = 0.01). On multivariable analysis, unplanned excisions independently were associated with worse overall survival (HR 1.77 [95% CI 1.06 to 2.97]; p = 0.03) and local recurrence-free survival (HR 1.74 [95% CI 1.10 to 2.75]; p = 0.02). CONCLUSION: Unplanned excision of soft tissue sarcoma is associated with worse long-term overall, local recurrence-free, and metastatic disease-free survival, with differences emerging after 10 years. These findings suggest a potential role for extended oncologic surveillance beyond 5 years, particularly in patients at high risk. Further prospective studies are needed to define appropriate surveillance strategies and determine whether earlier detection improves outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

Get PDF PubMed ↗

Letter to the Editor: Editorial: AAOS Orthobiologics Registry-Sometimes, More is Less.

Wang X, Shen W

Clin Orthop Relat Res · 2026 Jun · PMID 42284481 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

Does Liposomal Bupivacaine Provide Superior Postoperative Analgesia Compared With Ropivacaine With Dexamethasone in Suprainguinal Fascia Iliaca Compartment Block for THA? A Randomized Controlled Trial.

Wu W, Hu X, Yang C … +3 more , Sun Y, Li J, Wang L

Clin Orthop Relat Res · 2026 Mar · PMID 42284069 · Publisher ↗

BACKGROUND: Choosing the most effective pain management is important for enhancing functional recovery after surgery. The fascia iliaca compartment block (FICB) is recommended for analgesia after THA, but whether liposom... BACKGROUND: Choosing the most effective pain management is important for enhancing functional recovery after surgery. The fascia iliaca compartment block (FICB) is recommended for analgesia after THA, but whether liposomal bupivacaine is more effective for this application remains uncertain. QUESTIONS/PURPOSES: (1) Did a single-injection suprainguinal FICB using liposomal bupivacaine provide superior pain control by a clinically important margin? (2) What was the effect of liposomal bupivacaine on perioperative opioid consumption? (3) How did liposomal bupivacaine affect the duration of the sensory block and quadriceps motor weakness in the operated limb? METHODS: This was a prospective, parallel-group, assessor-blinded, single-center, randomized controlled clinical trial. Patients who underwent unilateral primary THA via the posterolateral approach were included in the study. Exclusion criteria included a BMI of > 32.5 kg/m2 (which is the diagnostic criterion for moderate obesity in China), contraindications to peripheral nerve block, known allergy to study medications, psychiatric or cognitive disorders that could interfere with pain assessment, severe hepatic or renal dysfunction, and chronic pain necessitating long-term opioid therapy. According to these criteria, 76% (60 of 79) of screened patients met eligibility requirements and were subsequently randomized into either the liposomal bupivacaine group or the control group. All patients received an ultrasound-guided, single-injection, suprainguinal FICB. The patients in the liposomal bupivacaine group were administered a solution consisting of 10 mL of 1.33% liposomal bupivacaine combined with 20 mL of 0.25% bupivacaine hydrochloride, whereas the control group received 30 mL of 0.5% ropivacaine with the addition of 5 mg dexamethasone. There were no dropouts, and all patients were analyzed in the groups to which they were assigned. The groups did not differ in important ways with respect to baseline characteristics or relevant surgical and anesthesia parameters. The outcomes were (1) static (at rest) and dynamic (during passive hip flexion to 45°) numeric rating scale (NRS) scores measured at 6, 12, 24, 48, and 72 hours postoperatively, (2) cumulative opioid consumption expressed as intravenous morphine equivalents intraoperatively and within 72 hours postoperatively, and (3) sensory block duration and quadriceps motor weakness in the operated limb assessed at 24 and 48 hours postoperatively. Postoperative rebound pain, rescue analgesia, and adverse events were also recorded. The minimum clinically important difference was predefined as 1.5 for static NRS scores, 1.8 for dynamic NRS scores, and 10 mg of intravenous morphine equivalents for opioid consumption. RESULTS: Although we found no clinically important between-group differences in either static or dynamic NRS scores at any time point, we found that the group treated with liposomal bupivacaine consumed fewer morphine equivalents in the first 72 hours after surgery than did patients treated without liposomal bupivacaine in the block (median [IQR] 10 mg [7 to 16] versus 24 mg [20 to 28], difference of medians -12; p < 0.001). Likewise, the sensory block lasted longer in the liposomal bupivacaine group (median [IQR] 71 hours [66 to 77] versus 12 hours [10 to 17], difference of medians 58; p < 0.001). However, there were no differences in the number of patients with quadriceps motor weakness at 24 hours and 48 hours after surgery between the two groups. Postoperative rebound pain, rescue analgesia, and adverse events likewise did not differ between the groups. CONCLUSION: In this randomized trial, we found a clinically relevant reduction in opioid consumption within the first 72 hours after posterolateral THA with the use of liposomal bupivacaine in a single-injection suprainguinal FICB. Furthermore, the prolonged block duration with liposomal bupivacaine was not associated with an increased risk of quadriceps motor weakness. Based on these findings, we recommend the routine use of liposomal bupivacaine for this application. Future trials should focus on the use of liposomal bupivacaine in combined regional anesthesia methods. LEVEL OF EVIDENCE: Level I, therapeutic study.

Get PDF PubMed ↗

Is Neighborhood Socioeconomic Deprivation Associated With Outcomes Following Primary THA and TKA? A Systematic Review Utilizing the Area Deprivation Index.

Furyes AR, Elmenawi KA, Hackett L … +2 more , Deren ME, Piuzzi NS

Clin Orthop Relat Res · 2026 Jun · PMID 42275670 · Publisher ↗

BACKGROUND: Socioeconomic disadvantage is increasingly recognized as an important factor associated with outcomes after total joint arthroplasty (TJA). The Area Deprivation Index (ADI) has emerged as a validated measure... BACKGROUND: Socioeconomic disadvantage is increasingly recognized as an important factor associated with outcomes after total joint arthroplasty (TJA). The Area Deprivation Index (ADI) has emerged as a validated measure of socioeconomic disadvantage that specifically captures individual neighborhood levels of structural and material deprivation based on income, education, employment, and housing characteristics. Prior research has demonstrated ADI to be associated with surgical outcomes; however, its relationship to postoperative outcomes after THA and TKA, procedures in which outcomes depend highly on institutional and structural support, home environment, and accessible postacute care resources, has not been well synthesized. Prior studies provide a broad overview of heterogeneous measures of socioeconomic disadvantage that are not directly comparable. QUESTIONS/PURPOSES: (1) Is a higher ADI associated with increased postoperative healthcare utilization after primary THA and TKA? (2) Is a higher ADI associated with differences in patient-reported outcome measures (PROMs)? (3) Is a higher ADI associated with increased postoperative complications? (4) Is ADI associated with differences in implant survivorship after TJA? METHODS: A systematic review of four databases-Ovid Medline, Embase, Cochrane Library, and Web of Science Core Collection-was performed from their inception to March 27, 2025. Each database was last searched on March 27, 2025. In all, 128 records were available. Studies were included if they evaluated patients receiving primary THA or TKA and examined ADI in the Results section of the manuscript in terms of any of the following: 90-day outcomes, healthcare utilization, complications, reoperations, revisions, cost, or PROMs. Studies were excluded if they examined revision hip or knee arthroplasty, hemiarthroplasty, or arthroplasty of any other joint; did not evaluate outcomes in association with ADI; or were case reports, systematic reviews, conference abstracts, editorials, or narrative reviews. Sixteen studies were included for final review. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Newcastle-Ottawa Scale (NOS), which has a maximum quality score of nine stars. Included studies had a median (range) NOS score of 8 stars (7 to 9), suggesting that most were of good quality with a low risk of bias. Results were synthesized qualitatively; meta-analyses were not performed because of the heterogeneity of included studies. RESULTS: A higher ADI was consistently associated with greater healthcare utilization, including prolonged length of stay, increased likelihood of nonhome discharge, and increased odds of emergency department visits. PROMs demonstrated worse absolute postoperative scores and lower likelihood of achieving patient acceptable symptom states among patients who live in high ADI neighborhoods despite comparable levels of improvement across all groups. Overall, ADI was not associated with reaching the standard minimum clinically important difference (MCID). All groups achieved the MCID on all domains of the Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score, and Patient-Reported Outcomes Measurement Information System short forms regardless of ADI. A higher ADI was associated with increased odds of medical complications such as infection, venous thromboembolism, cardiopulmonary events, and acute kidney injury. Evidence on implant survivorship was limited but suggested increased odds of reoperation and periprosthetic joint infection within 90 days and increased odds of aseptic revision beyond 90 days in populations with more severe levels of deprivation as measured by the ADI. CONCLUSION: Higher neighborhood socioeconomic deprivation was independently associated with worse postoperative outcomes, greater resource utilization, and signals of inferior early implant survivorship after THA and TKA. The ADI provides meaningful insight into neighborhood-level social risk beyond traditional clinical factors and individual patient demographics and may help identify patients who may benefit from interventions such as more intensive preoperative medical management of comorbidities, tailored perioperative support, easily accessible rehabilitation, or closer postoperative follow-up. Incorporating the ADI into risk-adjustment models and care pathways may help clinicians better anticipate possible barriers to recovery and may help ensure that patients from less affluent communities achieve the results they seek after lower extremity arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study.

Get PDF PubMed ↗

Editor's Spotlight/Take 5: How Does Traumatic Hand Injury Impact Patients in a Safety-net Healthcare System? A Mixed Methods Study.

Wongworawat MD

Clin Orthop Relat Res · 2026 Jun · PMID 42275649 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

Letter to the Editor: Guest Editorial: Recalling a Recall.

Doyle TR, Hennessy O, Keogh CJ … +4 more , Hughes AJ, Kenny PJ, Sheridan GA, Murphy CG

Clin Orthop Relat Res · 2026 Jun · PMID 42269720 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

CORR Insights®: Is Higher Surgeon Volume Associated With Lower Complication and Revision Risk After Distal Radius Fracture Surgery? A Population-based Cohort Study of 13,389 Patients.

O'Shaughnessy MA

Clin Orthop Relat Res · 2026 Jul · PMID 42267699 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

Is Higher Surgeon Volume Associated With Lower Complication and Revision Risk After Distal Radius Fracture Surgery? A Population-based Cohort Study of 13,389 Patients.

Persitz J, Zagorski B, Baltzer H … +7 more , Calzavara A, Wolfstadt J, Avisar E, Zuo KJ, Chan A, Paul R, Urbach DR

Clin Orthop Relat Res · 2026 Jul · PMID 42267690 · Publisher ↗

BACKGROUND: Surgeon case volume has been linked with outcomes across many orthopaedic procedures, but its influence on distal radius fracture fixation remains uncertain. QUESTIONS/PURPOSES: (1) For distal radius fracture... BACKGROUND: Surgeon case volume has been linked with outcomes across many orthopaedic procedures, but its influence on distal radius fracture fixation remains uncertain. QUESTIONS/PURPOSES: (1) For distal radius fracture surgery, at what surgeon annual case volume does the risk of complications plateau? (2) For distal radius fracture surgery, at what surgeon annual case volume does the risk of revision surgery plateau? METHODS: A retrospective, population-based study was performed using administrative health databases in Ontario, Canada, accessed through the Institute for Clinical Evaluative Sciences, an independent, nonprofit research institute that houses linkable, individual-level health administrative data for Ontario's publicly funded healthcare system. Between 2010 and 2020, a total of 27,945 adult patients (≥ 18 years of age) underwent surgical fixation for acute isolated distal radius fracture. After applying prespecified inclusion and exclusion criteria, including exclusion of patients with open fractures, polytrauma, compartment syndrome, neurovascular injury, emergent presentations, incomplete administrative records, or prior distal radius surgery, a final cohort of 13,389 patients (48% of the initial cohort) was included (71% [9533] females; mean ± SD age 56 ± 15 years). Surgeon annual case volume, defined as the number of distal radius fracture fixations performed in the preceding year, was the primary exposure. The primary outcome was a composite of complications, including postoperative complications or revision surgery up to 10 years after the index procedure; revision surgery was also analyzed separately. Cox proportional hazards models were adjusted for demographics, comorbidities, fracture type (intraarticular versus extraarticular), fixation method, and hospital type (teaching versus nonteaching). Restricted cubic spline models were used to assess nonlinearity and identify potential volume thresholds. RESULTS: Surgeons performing < 5 distal radius fracture fixations annually had the highest hazards of both composite complications and revision surgery. Complication hazards declined with increasing surgeon volume and stabilized after approximately 20 procedures per year; consistent with this threshold, surgeons performing 20 to 24 procedures annually demonstrated a 37% lower hazard of complications compared with surgeons performing < 5 procedures per year (HR 0.63 [95% confidence interval (CI) 0.49 to 0.81]; p = 0.004). Revision surgery hazards likewise declined with increasing surgeon volume but plateaued at a lower threshold of approximately 10 procedures per year; surgeons performing 10 to 14 procedures annually had a 56% lower hazard of revision surgery compared with surgeons performing < 5 procedures per year (HR 0.44 [95% CI 0.33 to 0.60]; p < 0.001). CONCLUSION: Surgeons who perform distal radius fracture fixation infrequently may benefit from focused strategies to support maintenance of procedural proficiency including continuing professional development and enhanced surgical training. At a systems level, the lower risk of complications observed among surgeons performing at least 20 procedures per year have implications for training programs, ongoing competence frameworks, and health-system planning, particularly in settings where referral options may be limited. LEVEL OF EVIDENCE: Level III, prognostic study.

Get PDF PubMed ↗

On Patient Safety: Worsening Healthcare Costs Threaten Americans' Safety.

Rickert J

Clin Orthop Relat Res · 2026 Jul · PMID 42267660 · Publisher ↗

Abstract loading — click title to view on PubMed.

Get PDF PubMed ↗

Preoperative Shoulder Stiffness Was Accompanied by Distinct Supraspinatus Tendon Inflammatory Signatures but Not Inferior Long-term Outcomes After Rotator Cuff Repair.

Liu M, Cai H, Tang C … +7 more , Luo J, Wang X, Liu H, Ruan D, Wang C, Chen X, Shen W

Clin Orthop Relat Res · 2026 Jun · PMID 42248213 · Publisher ↗

BACKGROUND: Rotator cuff tears with concomitant preoperative shoulder stiffness present a clinical challenge because the rehabilitation needed to restore motion may conflict with the protection typically used to support... BACKGROUND: Rotator cuff tears with concomitant preoperative shoulder stiffness present a clinical challenge because the rehabilitation needed to restore motion may conflict with the protection typically used to support tendon healing after rotator cuff repair. Although recent studies suggest that preoperative stiffness may not be associated with inferior long-term outcomes, whether it is associated with a different pattern of postoperative improvement and distinct inflammatory features in the torn tendon remains unclear. QUESTIONS/PURPOSES: (1) Do a greater proportion of patients with preoperative shoulder stiffness achieve improvements in functional outcomes that exceed the minimum clinically important difference (MCID) at 3, 6, 12, and 24 months? (2) Do supraspinatus tendons from patients with shoulder stiffness show molecular and histologic features consistent with greater inflammation than tendons from patients without stiffness? METHODS: This prospective, observational cohort study included patients scheduled to undergo arthroscopic rotator cuff repair for unilateral rotator cuff tears with medium-sized, full-thickness supraspinatus tears, with or without concomitant preoperative shoulder stiffness. A medium-sized tear was defined as a supraspinatus tendon tear measuring 3 cm or less on preoperative coronal MRI. Preoperative shoulder stiffness was defined as passive shoulder ROM of less than 120° in forward flexion, less than 30° in external rotation at the side, or internal rotation lower than the L3 spinal level. Patients who met any one of these three criteria were assigned to the stiffness group. Between March 2020 and December 2023, 474 patients from both urban and rural areas who were scheduled to undergo repair for rotator cuff tears were evaluated at our shoulder pain specialty clinic. The inclusion criteria were: (1) full-thickness unilateral supraspinatus tendon tears measuring 3 cm or less in the AP dimension, confirmed on T2-weighted MRI, and (2) radiographs and MRI demonstrating no other shoulder pathology, including fracture, arthritis, dislocation, or glenoid labral tear. After strict eligibility assessment, 39% (186 of 474) of patients met all inclusion criteria and were enrolled into either the stiffness group (92 patients) or the without stiffness group (94 patients) based on predefined criteria. Specifically, 28% (135 of 474) of patients were excluded because symptom duration exceeded 12 months, 1% (2 of 474) were excluded because of missing MRI data, and 4% (20 of 474) were excluded because they had received more than three glucocorticoid injections. In addition, 18% (84 of 474) of patients were excluded because of systemic comorbidities or a history of surgery on the affected shoulder: rheumatoid arthritis in 1% (2 of 474), thyroid disorders in 3% (12 of 474), diabetes in 9% (43 of 474), gout in 1% (1 of 474), osteoporosis in 1% (5 of 474), hyperlipidemia in 4% (17 of 474), previous shoulder surgery in 1% (3 of 474), and concomitant upper limb fracture in 1% (1 of 474). A preoperative MRI evaluation resulted in the exclusion of patients with labral lesions (1% [5 of 474]), calcific tendinitis (1% [3 of 474]), massive tears (4% [21 of 474]), and partial-thickness tears (4% [18 of 474]). The enrolled cohort comprised 186 patients, with a mean age of 62 ± 7 years and a mean BMI of 24.1 ± 2.8 kg/m2. Women accounted for 68% (127 of 186) of the cohort. Of the 186 enrolled patients, 4% (8 of 186) were lost to follow-up by 12 months and an additional 15% (27 of 186) by 24 months, leaving 81% (151 of 186) for the final analysis; there were 75 patients with stiffness and 76 without stiffness. Clinical outcomes, including ROM, the VAS, Oxford shoulder score (OSS), and Constant-Murley Score (CMS), were assessed preoperatively and at 3, 6, 12, and 24 months postoperatively. MRI was performed preoperatively and at 24 months. Retears were assessed using the Sugaya classification at 24-month follow-up, with Types IV and V defined as postoperative retears. Intraoperative supraspinatus tendon samples were collected and analyzed using histology and bulk RNA sequencing. To address our first study question, we evaluated postoperative recovery at two levels. First, we applied anchor-based MCID thresholds reported in previous studies: 10 points for the CMS, 6 points for the OSS, and 1.4 points for the VAS. We then compared the proportions of patients in the two groups who achieved clinically meaningful improvement at each postoperative follow-up time point (3, 6, 12, and 24 months) to determine whether patients with preoperative stiffness were more likely to achieve meaningful improvement at scheduled follow-up visits. Second, we used repeated-measures ANOVA and mixed-effects models to analyze the longitudinal trajectories of the CMS and OSS across follow-up and to evaluate whether the postoperative pattern of improvement differed between groups. To address our second study question, supraspinatus tendon tissue was collected intraoperatively for histologic and bulk RNA sequencing. Histologic differences were assessed using the revised Bonar scoring system, and transcriptomic differences were evaluated using differential gene expression and functional enrichment analyses. RESULTS: At 3 months, a greater proportion of patients in the stiffness group achieved the MCID in the CMS (43% [32 of 75] versus 13% [10 of 76], OR 4.9 [95% CI 2.2 to 11.0]; p < 0.001), OSS (59% [44 of 75] versus 21% [16 of 76], OR 5.3 [95% CI 2.6 to 10.9]; p < 0.001), and VAS-movement (33% [25 of 75] versus 17% [13 of 76], OR 2.4 [95% CI 1.1 to 5.2]; p = 0.02). Similar patterns were observed at 6 and 12 months, with higher proportions of patients in the stiffness group achieving clinically meaningful improvement across the CMS, OSS, and VAS-movement. By 24 months, the patients with stiffness still had higher MCID achievement proportions for the CMS (100% [75 of 75] versus 83% [63 of 76], OR 32.1 [95% CI 1.9 to 550.8]; p < 0.001), OSS (99% [74 of 75] versus 88% [67 of 76], OR 9.9 [95% CI 1.2 to 80.6]; p = 0.02), and VAS-movement (83% [62 of 75] versus 68% [52 of 76], OR 2.2 [95% CI 1.0 to 4.7]; p = 0.04), whereas we found no differences between groups for VAS-rest or VAS-sleep at any follow-up timepoint. Longitudinal analyses showed different postoperative improvement patterns for the CMS and OSS between groups (group-by-time interaction: CMS, ges = 0.121; p < 0.001; OSS, ges = 0.075; p < 0.001), although these differences were no longer observed after adjustment for baseline score (CMS: β 0.1 [95% CI -0.1 to 0.2]; p = 0.63). With respect to tendon biology, patients with and without preoperative stiffness showed different molecular and histologic features. The patients with stiffness had 254 upregulated genes and 554 downregulated genes, were enriched in the inflammatory tendinopathy subtype (NES 2.6; adjusted p < 0.01), and showed more inflammatory cell infiltration and higher revised Bonar inflammation scores. By contrast, the patients without stiffness were enriched in the hypoxia-white subtype (NES -2.8; adjusted p < 0.01) and in metabolic, muscle-development, and neurodevelopment pathways. Immune deconvolution also supported a more immune-activated tendon microenvironment in the patients with stiffness. CONCLUSION: In patients with medium-sized rotator cuff tears, preoperative shoulder stiffness was not associated with worse long-term outcomes after arthroscopic rotator cuff repair. Although patients with stiffness started with worse shoulder function, they were more likely to achieve clinically meaningful improvement during the early postoperative period, a pattern that likely reflects lower baseline function and greater room for improvement rather than superior final recovery. In addition, inflammatory tendon features from patients with shoulder stiffness reflected a distinct biologic context. For surgeons, these findings may help when counseling patients with rotator cuff tears that satisfactory recovery is achievable even with concomitant preoperative shoulder stiffness. Future work should focus on whether this inflammatory tendon feature can be validated in broader patient populations and can be used to refine biologic classification and postoperative management. LEVEL OF EVIDENCE: Level II, therapeutic study.

Get PDF PubMed ↗

Clin. Orthop. Relat. Res. [JOURNAL]

About