Clin. Orthop. Relat. Res. [JOURNAL]

BACKGROUND: Benchmarking seeks to evaluate implant survivorship at certain follow-up time points against predetermined standards. The International Society of Arthroplasty Registries (ISAR) International Prosthesis Bench... BACKGROUND: Benchmarking seeks to evaluate implant survivorship at certain follow-up time points against predetermined standards. The International Society of Arthroplasty Registries (ISAR) International Prosthesis Benchmarking Working Group (IPBWG) developed a predefined set of standards in which receiving a benchmark indicates that an implant has acceptable revision-free survivorship, whereas not receiving a benchmark suggests that the revision rate exceeded these established standards. Although benchmarking of TKA implant systems has been performed in select international countries, applications of benchmarks to TKA systems used in a US-based cohort are lacking. QUESTIONS/PURPOSES: We sought to apply the ISAR IPBWG benchmarking standards to our US-based healthcare system's total joint replacement registry and identify TKA implant systems meeting (1) early 2- and 5-year benchmarks, (2) midpoint 10-year benchmarks, and (3) late 15-year benchmarks. As a secondary aim, we sought to evaluate the consistency of these benchmarks when stratified by patient gender and age. METHODS: Data from our US-based healthcare system's Total Joint Replacement Registry were used to conduct a retrospective cohort study. The registry is well suited for benchmarking analyses because it captures all primary and revision TKAs performed within a closed, longitudinal healthcare system, enabling near-complete outcome tracking and comprehensive implant tracking through barcode-based documentation, with routinely audited administrative and clinical coding. Patient follow-up was 96%, 91%, 85%, and 80% at 2, 5, 10, and 15 years, respectively. Surgeons complete intraoperative registry forms via the electronic health record (EHR) for all TKAs, which are crosschecked against implant information-including manufacturer, implant name, and catalog number-recorded in the EHR via barcode scan and extracted into the registry. Patients are longitudinally followed for revision surgery until healthcare plan termination or death, and all identified revisions are manually validated through chart review. We identified all primary TKAs for osteoarthritis performed from January 1, 2001, through December 31, 2024. The final sample included 288,584 primary TKAs performed by 605 surgeons at 68 facilities. The cohort had a mean ± SD age of 68 ± 9 years, mean ± SD BMI of 31.2 ± 5.5 kg/m2, was predominantly women (61% [176,641 of 288,584]), and largely comprised patients with ASA class I to II (59% [171,306 of 288,584]). Each unique implant system, defined as the femoral and tibial component brand, fixation for each component, insert stability, and tibial insert mobility, was evaluated separately; systems with < 250 TKAs recorded into the registry were excluded. All-cause revision incidence during follow-up was evaluated using 1 - the Kaplan-Meier estimate and reported as cumulative percent revision (CPR) and 95% confidence interval (CI). Benchmark standards proposed by the IPBWG were used to evaluate the 2-, 5-, 10-, and 15-year time points; at each time point, at least 250 TKAs had to remain at risk to receive a benchmark. Implant systems received an early benchmark at 2 and 5 years after the primary TKA when the lower bound of the CPR 95% CI was less than or equal to the revision rate benchmark standards of 2% and 3%, respectively. Superiority and noninferiority relative to the benchmark standard were determined for 10-year midpoint and 15-year late benchmarks; the noninferiority margin was set at a 20% higher relative revision rate than the benchmark standard. For the 10-year time point, the system was considered superior when the upper bound of the 95% CI was less than or equal to 5%; when the upper bound of the 95% CI was less than or equal to 6% (20% above the 5% benchmark standard, or a 1% noninferiority margin), the system was considered noninferior; when it was above 6%, the system did not receive a 10-year benchmark. For the 15-year time point, systems with the upper bound of the 95% CI less than or equal to 6.5% were considered superior, and those in which the upper bound was less than or equal to 7.8% were considered noninferior; systems in which the 95% CI was above the noninferiority margin did not receive a benchmark. RESULTS: Of the 45 TKA implant systems evaluated, 93% (42) received a benchmark at 2 years, representing 99% (284,929 of 288,584) of the TKAs included. The three implant systems not receiving a 2-year benchmark included the Smith & Nephew cemented, bicruciate-stabilized, fixed-bearing Journey™ (n = 889; CPR 3.1 [95% CI 2.1 to 4.5]); the Smith & Nephew cemented, bicruciate-stabilized, fixed-bearing Journey II/Journey (n = 2200; CPR 2.8 [95% CI 2.1 to 3.6]); and the Zimmer Biomet cemented, ultracongruent or anterior-stabilized, fixed-bearing Natural Knee®/Natural Knee II (n = 566; CPR 3.9 [95% CI 2.6 to 5.9]). Of the 42 implant systems evaluated for 5-year benchmarks, 88% (37) received a benchmark, representing 96% (274,056 of 286,020) of the cohort evaluated for this time point. Five implants did not receive a 5-year benchmark: the DePuy cemented, posterior-stabilized, rotating PFC Sigma®/MBT (n = 7899; CPR 3.6 [95% CI 3.2 to 4.0]); the Smith & Nephew cemented, bicruciate-stabilized, fixed-bearing Journey (n = 889; CPR 5.4 [95% CI 4.1 to 7.1]); the Smith & Nephew cemented, bicruciate-stabilized, fixed-bearing Journey II/Journey (n = 2200; CPR 5.1 [95% CI 4.1 to 6.4]); the Zimmer Biomet cemented, cruciate-retaining, fixed-bearing Natural Knee II (n = 410; CPR 4.9 [95% CI 3.2 to 7.7]); and the Zimmer Biomet cemented, ultracongruent or anterior-stabilized, fixed-bearing Natural Knee/Natural Knee II (n = 566; CPR 5.9 [95% CI 4.2 to 8.2]). Of 25 implant systems considered for the 10-year benchmark, 52% (13) of systems received a superior benchmark, and 16% (4) of systems received a noninferior benchmark. Eight implant systems did not receive any 10-year benchmark. Implant systems receiving a superior benchmark were used in 91% (204,633 of 224,619) of the eligible TKAs, whereas implants that did not receive any 10-year benchmark were used in only 3% (6385 of 224,619) of the eligible TKAs. At the 15-year time point, 50% (6 of 12) of the implant systems evaluated received a superior benchmark, representing 89% (119,871 of 135,060) of the cohort evaluated at this time point. Forty-two percent (5) of the implant systems received a noninferior benchmark, and 8% (1) of the systems did not receive a benchmark at the 15-year time point. The same implant systems consistently failed to receive benchmarks at various time points in gender- and age-stratified analyses. CONCLUSION: Applying IPBWG benchmarking to a large US-based arthroplasty registry identified TKA implant systems with consistently inferior, adequate, or superior revision performance at mid- and long-term follow-up. These findings support prioritizing implant systems that meet benchmark standards for primary TKA and reevaluating routine use of implants that fail to achieve benchmarks when alternatives with reliable mid- and long-term performance are available. Future studies integrating benchmarking with risk-adjusted analyses are needed to clarify factors driving implant performance and to strengthen postmarket surveillance. LEVEL OF EVIDENCE: Level III, therapeutic study.

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S1P Modulation via S1P Lyase Inhibition Enhances Bone Regeneration in a Murine Critical-size Defect Model of Atrophic Nonunion.

Reinkemeier F, Korte R, Bakri A … +10 more , Wallner C, Drysch M, Schmidt SV, Fueth M, Puscz F, Steubing Y, Levkau B, Lehnhardt M, Behr B, Wagner JM

Clin Orthop Relat Res · 2026 Apr · PMID 42008819 · Publisher ↗

BACKGROUND: Atrophic nonunion is a challenging complication of fracture healing with few noninvasive therapeutic options. Given that sphingosine-1-phosphate (S1P) regulates bone remodeling and angiogenesis, systemic S1P... BACKGROUND: Atrophic nonunion is a challenging complication of fracture healing with few noninvasive therapeutic options. Given that sphingosine-1-phosphate (S1P) regulates bone remodeling and angiogenesis, systemic S1P modulation may offer a regenerative strategy; however, its efficacy in nonunion has not been established. QUESTIONS/PURPOSES: We therefore asked whether S1P lyase inhibition (1) enhances osteogenesis and consolidation in a murine critical-size bone defect model of atrophic nonunion, (2) modulates bone remodeling (osteoblast differentiation and osteoclast activity), and (3) augments cellular proliferation and endothelial activity, and (4) whether quantitative micro-CT corroborates histologically observed improvements. METHODS: In a validated murine critical-size bone defect model of atrophic nonunion, 12-week-old male and female C57BL/6J mice were treated by continuous systemic administration of the S1P lyase inhibitor 4-deoxypyridoxine (DOP) for 5 weeks, while a reference group remained untreated after nonunion induction. Bone regeneration was assessed by histology and immunohistochemistry to evaluate osteoblast differentiation, osteoclast activity, cellular proliferation, and angiogenesis (n = 7 per group) and by high-resolution micro-CT to quantify newly formed bone within the defect region (n = 6 per group). RESULTS: DOP treatment resulted in increased mineralized tissue and defect bridging on overview histology (aniline blue staining) compared with untreated controls (mean ± SD histologic bone formation score [pixels] DOP 80,000 ± 20,000 versus controls 52,000 ± 22,000, mean difference 28,000 [95% confidence interval (CI) 4200 to 53,000]; p = 0.03). Osteoblast differentiation was higher in DOP-treated animals (RUNX2 6200 ± 3200 versus 2200 ± 1400, mean difference 4000 [95% CI 1200 to 6900]; p = 0.01 and osteocalcin 60,000 ± 24,000 versus 28,000 ± 12,000, mean difference 32,000 [95% CI 9400 to 54,000]; p = 0.009), while osteoclast activity was also higher, indicating more active bone remodeling (TRAP 43,000 ± 15,400 versus 23,000 ± 7400, mean difference 20,000 [95% CI 6600 to 35,000]; p = 0.008). Cellular proliferation (PCNA 22,000 ± 7500 versus 14,000 ± 5700, mean difference 8000 [95% CI 470 to 16,000]; p = 0.04) and endothelial marker expression (PECAM-1 23,000 ± 6100 versus 13,700 ± 5500, mean difference 9300 [95% CI 2900 to 16,400]; p = 0.009) were both higher in the DOP group than in controls. Quantitative micro-CT confirmed greater newly formed bone volume within the defect region in DOP-treated mice compared with untreated controls (bone volume [%] 20.6 ± 8.2 versus 8.8 ± 3.3, mean difference 11.8 [95% CI 4.5 to 19.0]; p = 0.004). CONCLUSION: These results suggest that pharmacologic modulation of the S1P axis could represent a novel, noninvasive adjunct to surgical management of nonunions and delayed unions. CLINICAL RELEVANCE: Key unanswered questions include optimal dosing, treatment duration, and safety of systemic S1P modulation beyond murine models. Addressing these questions in translational large-animal studies and early clinical trials will be essential to advance this approach toward clinical application.

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Program Size and City Characteristics May Be Associated With Gender Diversity in Orthopaedic Surgery Residency Programs.

Park YL, Grossman M, Collier C … +3 more , Christiansen MJ, Musahl V, Mulcahey MK

Clin Orthop Relat Res · 2026 Apr · PMID 42008813 · Publisher ↗

BACKGROUND: Orthopaedic surgery remains one of the least gender-diverse specialties in medicine. Prior studies have identified factors that influence a woman applicant's rank list, such as surgical experience, women facu... BACKGROUND: Orthopaedic surgery remains one of the least gender-diverse specialties in medicine. Prior studies have identified factors that influence a woman applicant's rank list, such as surgical experience, women faculty, and resident satisfaction; however, little is known about how the geographic location of a program is associated with the gender composition of residency classes. QUESTIONS/PURPOSES: (1) Is the geographic location of an orthopaedic surgery residency program associated with the proportion of women in its residency class? (2) After adjusting for potential confounders like program size and type, what program- and city-level factors are associated with a higher percentage of women in orthopaedic residency programs? METHODS: Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic residency programs with updated resident lists for the 2025 to 2026 academic year were included; we included 204 such programs from a total of 212. Resident gender was determined using photographs, biographies, and preferred pronouns when available. The proportions of women residents were compared across US geographic divisions as defined by the Electronic Residency Application Service (ERAS®). Secondary analyses explored whether program characteristics (program type, women faculty proportion, gender of chair and program director) and city-level factors (population density, median household income, crime rate) were associated with gender distribution. An independent-samples Kruskal-Wallis test was used to compare the percentage of women between geographic divisions, and multivariable linear regression was used to adjust for covariates and identify factors associated with a higher proportion of women in a program. For interpretation of correlation strength, we classified coefficients as slight (|r| = 0.10 to 0.29), modest (|r| = 0.30 to 0.49), and substantial (|r| ≥ 0.50), which is consistent with commonly used conventions. Statistical significance was set at p < 0.05. RESULTS: Of the 204 programs included, the percentages of women residents were not different when comparing the nine locations as defined by ERAS. After controlling for potential confounding variables such as number of total residents, program type, and city education level (% of the population with at least a bachelor's degree), we found that larger programs were modestly associated with higher percentages of women in the programs (regression coefficient [β] 0.28 [95% confidence interval (CI) 0.07 to 0.49]; p = 0.01). Additionally, compared with university programs, community programs had a mean of 5% fewer women residents (95% CI -8% to -2%; p < 0.001). CONCLUSION: Our findings highlight differences in gender representation across orthopaedic surgery residency program types and sizes but do not identify causal factors or barriers. Programs seeking to increase gender diversity may wish to consider evaluating their size, recruitment strategies, and applicant outreach in light of these associations, while candidates interested in more gender-diverse environments might consider these program characteristics when applying. CLINICAL RELEVANCE: Addressing gaps in gender representation across orthopaedic surgery residency programs may not only improve gender balance in training but could also have downstream benefits for patient care and surgical team effectiveness. Future studies can build on this work by conducting a survey study to directly assess how program size and academic affiliation influence applicant decisions in orthopaedic residency.

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Reply to the Letter to the Editor: Total Arthroplasty Versus Trapeziectomy With Ligamentoplasty for Trapeziometacarpal Osteoarthritis: 5-year Outcomes.

Simón-Pérez C, Frutos-Reoyo EJ, Martín-Ferrero MÁ

Clin Orthop Relat Res · 2026 Jun · PMID 42008803 · Publisher ↗

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Bilateral Open Adductor Longus Tenotomy Is Associated With Predictable Return to Play in Professional Soccer Players: A Case Series of 100 Patients.

Cugat R, Montaña F, Barastegui D … +5 more , Barrueto D, Vázquez M, Ferré-Aniorte A, Láiz P, Seijas R

Clin Orthop Relat Res · 2026 Apr · PMID 42008802 · Publisher ↗

BACKGROUND: Dynamic pubic osteopathy is a clinical diagnosis characterized by chronic localized pain at the pubic insertion of the adductor longus that can limit high-level athletic performance in professional soccer pla... BACKGROUND: Dynamic pubic osteopathy is a clinical diagnosis characterized by chronic localized pain at the pubic insertion of the adductor longus that can limit high-level athletic performance in professional soccer players. Although open adductor longus tenotomy has been used for decades in selected athletes, little is known about return-to-play (RTP) timelines and outcomes in professional soccer players undergoing modern bilateral open release. QUESTIONS/PURPOSES: We asked: (1) How long after bilateral open adductor longus tenotomy did professional soccer players return to unrestricted match participation? (2) What proportion returned to their preinjury competitive level? (3) Was player age associated with RTP duration? (4) What complications and reoperations occurred after surgery? METHODS: We performed a retrospective case series of 100 professional men's soccer players (Tegner activity level 9 to 10) who underwent bilateral open adductor longus tenotomy between 2011 and 2024. All patients were diagnosed clinically with dynamic pubic osteopathy based on localized pubic insertion pain reproduced with resisted adduction. Radiographs were used to exclude fractures, stress fractures, tumors, or avulsion injuries. MRI was performed to evaluate associated findings such as bone edema or degenerative changes of the pubic symphysis; however, imaging findings were frequently within normal limits or reflected chronic adaptive changes unrelated to current symptoms. All athletes had persistent symptoms despite structured nonoperative management including flexibility work and training-load modification. During the study period, these 100 players represented all surgically treated patients with this diagnosis at our institution, and no patients were lost to follow-up. The primary endpoint was days from surgery to medical clearance for unrestricted match play. Secondary endpoints included return to preinjury level, complications, and reoperations. Major complications were defined as events that substantially altered recovery (such as infection, clinically important bleeding, or thromboembolic events). Correlation between age and RTP was assessed using Spearman coefficient. RESULTS: All 100 players returned to competitive soccer. The median (IQR) RTP time was 87 days (62 to 128). Ninety-eight percent (98 of 100) resumed competition at their preinjury level; one returned at a lower competitive level, and one retired for reasons unrelated to surgery. Age was not associated with time to RTP (ρ = 0.04; p = 0.84). Two percent (2 of 100) underwent revision surgery. No major complications occurred. CONCLUSION: In this study of professional men's soccer players with clinically diagnosed dynamic pubic osteopathy, bilateral open adductor longus tenotomy was associated with return to unrestricted match play at a median of 87 days, with 98% resuming their preinjury competitive level. No major complications occurred, and 2% of players underwent revision surgery. Within the limits of this retrospective design, the procedure may be considered a surgical option in high-performance athletes with persistent symptoms despite structured nonoperative management. LEVEL OF EVIDENCE: Level IV, therapeutic study.

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Can a Targeted Dissemination Strategy of the PREPARE Trial Results Change Surgical Antiseptic Practice?

Nesbit SE, Hong I, O'Hara NN … +3 more , Sprague S, Slobogean GP, Levack AE

Clin Orthop Relat Res · 2026 Apr · PMID 42008801 · Publisher ↗

BACKGROUND: The PREPARE trial (Pragmatic Randomized trial Evaluating Pre-operative Alcohol skin solutions in Fractured Extremities), published in February 2024, demonstrated that 0.7% iodine povacrylex in 74% isopropyl a... BACKGROUND: The PREPARE trial (Pragmatic Randomized trial Evaluating Pre-operative Alcohol skin solutions in Fractured Extremities), published in February 2024, demonstrated that 0.7% iodine povacrylex in 74% isopropyl alcohol reduced surgical site infections in patients with closed fractures compared with chlorhexidine gluconate in 70% isopropyl alcohol. Prior studies have shown that the translation of clinical trial findings into routine clinical practice and surgical procedures frequently takes longer than a decade, and strategies to accelerate implementation in orthopaedic surgery remain poorly defined. Engaging in a multifaceted implementation strategy with minimal barriers to entry for providers may be able to reduce this time to widespread adoption. QUESTIONS/PURPOSES: (1) Can the low-cost single-center dissemination efforts of the PREPARE trial results change antiseptic usage? (2) If a true practice change occurs, can the change be sustained over time without additional dissemination efforts? (3) Does the adoption of new evidence vary between fellowship-trained orthopaedic trauma surgeons and orthopaedic trauma surgeons who are not fellowship-trained? (4) What is the economic impact of a practice change to iodine povacrylex on hospital purchasing costs? METHODS: This was a retrospective, historically controlled comparative study of patients who underwent operative treatment of an extremity fracture at a single, urban, Level I academic trauma center before and after a dissemination effort aimed at increasing PREPARE trial awareness. A multifaceted dissemination strategy consisting of surgeon and nursing education, posted reminders, and supply chain support was implemented at the study site in February 2024. Patients were analyzed across three time periods: before dissemination (January 2020 to January 2024), during the transition (February 2024), and after dissemination (March 2024 to July 2025). An electronic medical record query identified patients with operative fracture management procedural codes who had a recorded antiseptic skin prep in the surgical flow sheet between January 2020 and July 2025. A total of 4822 patients were identified, and 222 duplicate entries were excluded, leaving 4600 patients for analysis (3351 before dissemination, 49 transitional, and 1200 after dissemination). To validate the completeness of our electronic health record query, we performed manual random sampling of monthly operative case logs, confirming that this query strategy successfully identified all patients with the relevant Current Procedural Terminology codes (that is, there were no exclusions for lack of antiseptic documentation). There were no differences in patient demographics, including sex, ethnicity, open fractures, or the distribution of upper and lower extremity fractures. Choice of surgical skin antiseptic was compared before and after dissemination using a log-binomial model. RESULTS: Dissemination efforts changed antiseptic use patterns with an immediate increase in iodine povacrylex use from 0.8% (27 of 3351) before intervention to 86% (1033 of 1200) after intervention (OR 765 [95% confidence interval 488 to 1197]; p < 0.001). This high level of use remained stable throughout the 17-month postintervention period without any additional dissemination efforts (p = 0.20 for trend). Adoption was higher among fellowship-trained trauma surgeons (94.8% increase) compared with surgeons without trauma fellowship training (34.7% increase). Hospital antiseptic product purchasing data, which reflect usage and restocking and were used as a secondary metric of practice change, also demonstrated an increase in iodine povacrylex demand and decline in chlorhexidine demand. CONCLUSION: A targeted and multifaceted dissemination strategy led to rapid adoption of iodine povacrylex for use as the preferred surgical skin antisepsis in fracture surgery at our institution, which was sustained over the 17-month postintervention period. This finding contrasts with a historically slow uptake of surgical trial evidence into clinical practice. Pragmatic, low-cost approaches such as surgeon leadership, team-based multidisciplinary education, workflow reminders, and supply chain readiness may help to accelerate translation of evidence into orthopaedic practice. Future studies should evaluate the long-term sustainability of practice changes, surgical site infection outcomes, and generalizability across institutions. LEVEL OF EVIDENCE: Level III, therapeutic study.

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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?

Giannakis P, Yu S, Illescas A … +8 more , Rowe JE, Liu J, Marx RG, Della Valle AG, Memtsoudis SG, Poeran J, Sideris A, Maalouf D

Clin Orthop Relat Res · 2026 Apr · PMID 41996683 · Publisher ↗

BACKGROUND: Limited evidence exists on the functional and analgesic efficacy of adding a genicular nerve block to an adductor canal block (ACB) plus infiltration between the popliteal artery and posterior knee capsule (I... BACKGROUND: Limited evidence exists on the functional and analgesic efficacy of adding a genicular nerve block to an adductor canal block (ACB) plus infiltration between the popliteal artery and posterior knee capsule (IPACK) for TKA. Filling this knowledge gap would be important because if this approach were to be effective, patients could benefit from an additional opioid-free, motor-sparing analgesic modality. QUESTIONS/PURPOSES: (1) Is the addition of a genicular nerve block to an ACB/IPACK associated with better pain management during hospitalization? (2) Is the addition of a genicular nerve block to an ACB/IPACK associated with better pain management in the postanesthesia care unit (PACU)? (3) Is the addition of a genicular nerve block to an ACB/IPACK associated with earlier time to physical therapy (PT) clearance? (4) Is the addition of a genicular nerve block to an ACB/IPACK associated with lower incidence of opioid refills within 90 days postoperatively? METHODS: This was a retrospective, propensity score-matched cohort study including patients undergoing TKA from January 2021 to December 2024 at a high-volume academic institution specializing in inpatient and outpatient arthroplasty. All adults undergoing primary elective unilateral TKA for primary osteoarthritis with administration of an ACB/IPACK, with or without a genicular nerve block, were assessed for eligibility (n = 20,648). After excluding patients with American Society of Anesthesiologists physical status of > III; patients receiving general anesthesia, additional peripheral nerve blocks, or acupuncture; and patients discharged to a facility, a total of 10,156 patients undergoing inpatient TKA and 2814 patients undergoing outpatient TKA were considered eligible for propensity score matching. After a 1:1 propensity score match on baseline demographic characteristics, psychosocial factors, active opioid prior to admission, perioperative and anesthesia details, and first PT visit pass or fail, 2803 and 1102 patients from each group were analyzed for inpatient and outpatient TKAs. The median (IQR) age was 71 years (64 to 76) for inpatient TKAs and 65 years (60 to 71) for outpatient TKAs; 64% and 48% were female, respectively, and no differences among groups within the same setting were observed after matching. Aside for the comparison of interest, the same standardized perioperative pain management protocol was followed for all patients. For our first aim and second aim, we evaluated median and highest pain scores and opioid consumption. For our third aim, we assessed PT clearance, and for our fourth aim, we assessed incidence of opioid refills within 90 days. A difference in pain of ≥ 2 on the numeric rating scale (NRS) and a difference in opioid consumption of ≥ 10 oral morphine milligram equivalents (OMEs) were considered clinically meaningful. For the inpatient setting, a 4-hour median difference in time to PT clearance was considered clinically meaningful, and for the outpatient setting, any statistically significant difference with a median time to PT clearance of < 12 hours for either group was considered clinically meaningful. RESULTS: During hospitalization, we found no difference between the intervention and control group in terms of highest pain and median pain. In terms of total opioid consumption, we found no clinically important difference between the intervention group and control group (median [IQR] NRS score 55 [30 to 82] versus 52 [30 to 80]; p = 0.001) in the inpatient setting and no difference in the outpatient setting. In the PACU, we found no difference in terms of highest pain and median pain in the inpatient setting and no clinically important difference for highest pain (median [IQR] NRS score 7 [5 to 8] versus 7 [6 to 8]; p = 0.03) in the outpatient setting. In the inpatient setting, no clinically important difference was observed between the intervention and control group for opioid consumption (median [IQR] OMEs 53 [30 to 82] versus 48 [25 to 75]; p < 0.001); no difference was observed in the outpatient setting. We found no clinically meaningful difference between the intervention group and control group in terms of time to PT clearance in the inpatient setting (median [IQR] 21 hours [18 to 25] versus 22 hours [19 to 41]; p < 0.001) and the outpatient setting (median [IQR] 13 hours [4 to 16] versus 14 hours [4 to 16]; p = 0.001). We found no difference in terms of incidence of opioid refills within 90 days. CONCLUSION: The associations we found do not justify the addition of a genicular nerve block in patients undergoing inpatient and outpatient TKA with a comprehensive multimodal analgesia protocol given the modest, at best, effect size observed, its potential financial cost and time cost, and risk for adverse events. Our study suggested that there are subpopulations in the general TKA population that could potentially benefit from the addition of genicular nerve block, but until future evidence identifies these subpopulations, our data suggest that the addition of a genicular nerve block was not associated with any clinically meaningful benefit in the general TKA population. LEVEL OF EVIDENCE: Level III, therapeutic study.

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Letter to the Editor: Is Displacement of the Lesser Trochanter Associated With Functional Outcome in Older Adults With Intertrochanteric Fractures?

Qin K, Xu Y, Liang W

Clin Orthop Relat Res · 2026 Apr · PMID 41995326 · Publisher ↗

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What Is the Fate of Retained Antibiotic Spacers After First-stage Revision for Periprosthetic Joint Infection?

Sarfraz A, Khury F, McCormick K … +5 more , Aziz HH, Koljaka S, Rozell JC, Schwarzkopf R, Aggarwal VK

Clin Orthop Relat Res · 2026 Apr · PMID 41995314 · Publisher ↗

BACKGROUND: Prolonged retention of antibiotic-loaded articulating spacers after the first stage of a two-stage revision for periprosthetic joint infection (PJI) can occur because of patient preference, surgeon preference... BACKGROUND: Prolonged retention of antibiotic-loaded articulating spacers after the first stage of a two-stage revision for periprosthetic joint infection (PJI) can occur because of patient preference, surgeon preference, or medical reasons that prevent the planned second stage. Little is known about the frequency of persistent infections, mechanical complications, and functional results in patients with retained spacers. QUESTIONS/PURPOSES: At a minimum follow-up of 2 years after spacer placement, among patients who do not undergo the second stage revision (replacement of the spacer with a definitive prosthesis of the hip or knee): (1) What was the survival of the spacer free from unplanned reoperation or removal, the cumulative incidence of symptomatic infection, and the overall (Kaplan-Meier) survivorship of the patients? (2) What is the cumulative incidence of mechanical complications (spacer fracture or dislocation)? (3) What is the ambulatory status of patients who have retained their spacers? METHODS: Between March 2011 and July 2023, a total of 111 and 152 patients underwent first-stage revision with an articulating spacer placement as part of a planned two-stage procedure for chronic PJI after THA and TKA at our institution, respectively. Of these, 21% (23 of 111) in the THA group and 24% (37 of 152) in the TKA group did not undergo the anticipated second-stage reimplantation at our institution at least 1 year after spacer placement. Among the original cohorts, 2% (2 of 111) of patients who underwent THA and 3% (4 of 152) of patients who underwent TKA subsequently underwent second-stage reimplantation at outside institutions when reviewed, leaving 19% (21 of 111) in the THA group and 22% (33 of 152) in the TKA group with retained spacers. Of the original cohorts, 7% (8 of 111) in the THA group and 5% (8 of 152) in the TKA group did not have a 2-year follow-up, leaving 12% (13 of 111) of patients with THA and 16% (25 of 152) of patients with TKA available for analysis with a minimum of 2 years of follow-up or death in this retrospective study. The median (range) follow-up from spacer placement to the latest follow-up was 5 years (2 to 11) for patients with THA and 4 years (2 to 8) for patients with TKA. In the THA cohort, the median (range) age was 72 years (59 to 86), and eight patients were female; the median BMI was 32 kg/m2, and the median Charlson comorbidity index (CCI) was 3.5. In the TKA cohort, the median (range) age was 69 years (45 to 83), 13 patients were female, the median BMI was 31 kg/m2, and the median CCI was 4. Complication data following spacer placement were obtained from the electronic medical record and by telephone follow-up when needed. Clinical symptoms (swelling, erythema, warmth, fever, drainage, sinus tract, and pain), inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), available radiographic findings, and laboratory test results (including synovial fluid analysis when obtained) were reviewed for evidence of infection or spacer-related mechanical failure. Infection after the spacer placement was defined as failure when the treating surgeon determined that an unplanned return to the operating room or spacer removal was warranted, acknowledging that postoperative evaluation thresholds varied among surgeons. Spacer-related mechanical failure was defined as spacer fracture or dislocation leading to reoperation or spacer removal. Patients were classified based on whether they underwent an unplanned reoperation or spacer removal. Patients who did not undergo unplanned reoperation or spacer removal were further categorized based on use of chronic suppressive antibiotics (decisions regarding chronic antibiotic therapy were made by the treating surgeon and/or infectious disease team). Patients who underwent reoperation were those who returned to the operating room because of concerning clinical, imaging, and/or laboratory findings of infection or mechanical complications, and the treating surgeon decided to proceed with revision surgery. All reoperation decisions were made by fellowship-trained arthroplasty surgeons with high-volume experience in two-stage revision. We used a competing-risks model to estimate survival of the spacer free from unplanned reoperation or removal attributable to infection or mechanical complications (calculated as 1 minus the corresponding cumulative incidence), with death treated as a competing event. Kaplan-Meier analysis was used to estimate patient survivorship, with death as the endpoint. Mortality data were obtained from medical records and hospital databases and were confirmed by telephone follow-up with family members and public records when needed. Ambulatory status before and after spacer placement was summarized descriptively and reported only for patients with both prespacer and postspacer data available (10 THAs and 25 TKAs); no formal hypothesis testing was performed for ambulatory or functional measures. RESULTS: At 2 years of follow-up, the survival of the spacer free from unplanned reoperation or removal was 89% (95% confidence interval [CI] 80% to 99%) for patients with THA and TKA combined, the cumulative incidence of infection was 5% (95% CI 0% to 12%), and the Kaplan-Meier survivorship of the patients was 92% (95% CI 84% to 100%). The cumulative incidence of mechanical complications (spacer fracture or dislocation) was 5% (95% CI 0% to 13%). In the THA cohort (10 patients), ambulatory status before the first stage included two patients using a wheelchair, two using a walker, one using crutches, two using a cane, and three walking without assistive devices. At latest follow-up, four patients used a wheelchair, two used a walker, two used a cane, and two walked without assistive devices. In the knee cohort (25 patients), ambulatory status before the first stage included two patients using a wheelchair, five using a walker, 13 using a cane, and five walking without assistive devices. At latest follow-up, two patients used a wheelchair, five used a walker, 13 used a cane, and five walked without assistive devices. CONCLUSION: Retained articulating spacers can provide infection control in selected patients who do not proceed to reimplantation after first-stage spacer placement for PJI. Although infection-free spacer survival is achievable, these patients remain at risk for mechanical complications, including dislocation and fracture, as well as progressive functional decline. These risks should be clearly discussed during preoperative counseling to align expectations and support informed decision-making. Further studies are needed to refine patient selection, improve spacer durability, and standardize definitions of treatment success in PJI. LEVEL OF EVIDENCE: Level III, case series.

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