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The objective of this study was to assess the downsides of surgical treatment of scaphoid fracture nonunion in patients with minor preoperative symptoms. Patients were classified with minor symptoms based on the Patient-Rated Hand/Wrist Evaluation questionnaire. Of the 35 included patients, most patients encountered problems with patient-specific activities; 9% reported worse postoperative functional outcomes, 34% were not satisfied with the treatment and 9% were reoperated. The risk of a worse functional outcome after surgery with the need for further operations and the chance of developing wrist osteoarthritis, along with the possibility of poor patient satisfaction and ongoing daily functional impairment, should be considered during preoperative counselling. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Hydroxyapatite as a scaffold is capable of producing good bone regeneration formation. Incorporating secretome into scaffolds optimizes the bone healing process. The increase in proinflammatory, anti-inflammatory, and growth factors is one of the key factors in bone healing. In this study, we measured the levels of IL-6, IL-10, and FGF-2 to determine the effectiveness of bovine hydroxyapatite with secretome from normoxia and hypoxia on bone healing. This animal study employed a pure experimental research design, utilizing a post-test-only control group design. Bone marrow mesenchymal stem cells from rabbit thigh bones were used to derive secretomes under hypoxic and normoxic conditions. Bovine bone-derived hydroxyapatite (BHA) was treated with secretomes under both conditions. Rabbits' radius bones were implanted with BHA alone, BHA with normoxic secretome, and BHA with hypoxic secretome, then observed for 30 and 60 days. Levels of IL-6, IL-10, and FGF-2 were examined on days 30 and 60. On the 30th day, there was a significant increase in the levels of FGF-2, IL-6, and IL-10, with a dominance of strongly positive levels in BHA alone. However, on the 60th day, the levels of FGF-2, IL-6, and IL-10 started to decrease in all groups, with a dominance of moderately positive levels. Statistical tests showed significant results in all groups on days 30 and 60 ( p < .05). Among the three groups, the best levels of growth factors and pro-inflammatory factors, and the lowest levels of anti-inflammatory factors were found in the BHA alone group on evaluation day 30., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The aim of the present study was to evaluate biomechanical properties of tendon turnover repair in comparison to direct repair and Pulvertaft weave. A total of 48 sheep flexor tendons were assigned to eight groups comprising single or double tendon turnover repair, tendon turnover segment (without tenorrhaphy), direct repair or Pulvertaft weave. Tensile strength, stiffness and failure mechanisms were evaluated with a 500 N load cell. Turnover repair showed no significant difference in tensile strength to direct repair. Failure in turnover repair occurred largely at the site of tenorrhaphy due to suture pull-through or suture rupture. the increase in cross-sectional area after turnover repair was similar to that after direct repair, but less than after Pulvertaft weave. Tendon turnover offers tensile strength similar to direct repair with no associated increase in bulk. It provides a biomechanically secure and quicker alternative to tendon grafting for reconstructing tendon defects, without secondary donor site morbidity. Level of evidence: V., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Saws are a common source of upper extremity injury. There have been several commercial and government-mandated safety mechanisms designed to reduce the number of saw injuries. We aim to assess the trends in the incidence and impact of saw-related upper extremity injuries over the last 2 decades., Methods: The National Electronic Injury Surveillance System database was queried from January 2003 to December 2022 for upper extremity injuries caused by saws. Summary statistics for primary body part injured and diagnosis were calculated. Linear regression was performed to evaluate trends in the number of injuries over time., Results: An estimated 1.38 million injuries (weighted) presenting to emergency departments were reported from January 2003 to December 2022. Patients had a mean age of 50.5 ± 18.1. Digits (82.2%) accounted for most injuries, followed by hands (11.9%). The lower arm (3.4%), wrist (1.66%), shoulder (0.3%), elbow (0.2%), and upper arm (0.2%) accounted for fewer injuries. There was a downtrend in number of saw injuries over the study period (R = 0.83, R2 = 0.69, p  < .001). Subgroup analysis showed decreases in number of injuries to fingers (R = -0.82, R2 = 0.67, p  < .001) and wrists (R = -0.61, R2 = 0.37, p  = .004). The most common diagnoses were lacerations (69.7%), fractures (12.6%), and amputations (9.9%)., Conclusions: Upper extremity saw injuries have significantly decreased over the last 20 years. The fingers and hands account for the vast majority of saw injuries, resulting most commonly in lacerations, fractures, and amputations., Level of Evidence: IV., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Chronic pain remains a significant challenge for individuals following limb amputation, with incidence of painful neuromas, phantom limb pain (PLP), and residual limb pain (RLP). Targeted muscle reinnervation (TMR) is a surgical technique designed to restore motor control information lost during amputation by redirecting residual nerves to new muscle targets. This systematic review and meta-analysis aims to compare patient-reported and functional outcomes following amputation with either TMR or standard neurological treatment (SNT). The study also includes an examination of primary versus secondary TMR and explores outcomes in highly comorbid patient populations., Methods: A search of central databases was performed, and meta-analysis was completed on extracted data where possible., Results: Eleven studies were identified. Results indicate a significant reduction in PLP and RLP in patients undergoing TMR compared to SNT using various pain scores. TMR also demonstrates improved functional outcomes and decreased opioid use. Furthermore, results indicated patients who underwent TMR at the time of amputation (primary TMR) had improved pain scores compared with those who had TMR performed later (secondary TMR)., Conclusions: The review emphasizes the benefits of TMR as a valuable surgical adjunct for amputee patients, while also highlighting the need for further research, especially in comorbid populations., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Legal performance enhancing substance (PES) use is increasing in young athletes and may lead to banned PES use. This study examines legal PES use and consideration of banned PES use in young athletes with a season-ending injury (SEI) compared to young athletes with non-SEI/no previous injury., Hypothesis: Young athletes sustaining SEI or concussions have increased odds of reporting legal PES use and consideration of banned PES use compared with non-SEI or no injury., Study Design: Cross-sectional study., Level of Evidence: Level 4., Methods: Cross-sectional study from 2013 to 2020 of athletes aged 6 to 25 years., Results: No association was found between reporting legal PES use or consideration of banned PES use and young athletes with SEI or concussion compared with no injury/non-SEI. 14% of athletes reported legal PES use and 3% reported consideration of banned PES use. In adjusted analysis, athletes who were male (odds ratio [OR], 1.38; 95% CI, 1.16-1.73; P = 0.03), have history of depression (OR, 3.01; 95% CI, 1.26-7.18; P = 0.01), weight train (OR, 1.66; 95% CI, 1.04-2.65; P = 0.03), and believe that athletic ability is influenced by weight (OR, 1.75; 95% CI, 1.08-2.83; P = 0.02) had increased odds of reporting legal PES use. Older (OR, 1.18; 95% CI, 1.03-1.36; P = 0.02) and male (OR, 1.57; 95% CI, 1.02-1.81; P < 0.04) athletes had increased odds of consideration of banned PES use., Conclusion: This study found no increased odds of reported PES use in young athletes with sports-related injury or concussion regardless of injury type or severity. Factors associated with PES use were male sex, age, history of depression, weight training, and belief that weight affects athletic performance., Clinical Relevance: Risk factors associated with PES use in young athletes are essentially unknown. This study can inform pertinent clinical care, education, and policy implementation., Competing Interests: The authors report no potential conflicts of interest in the development and publication of this article.

Background: There is concern that physiologic knee hyperextension may be associated with inferior outcomes after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) autografts., Purpose: To assess whether there is an association between contralateral passive preoperative knee hyperextension (≤-5°) and postoperative anterior knee laxity, subjective knee function, or revision surgery after ACLR using HT autografts., Study Design: Cohort study; Level of evidence, 3., Methods: Patients without concomitant ligament injuries who underwent primary ACLR using an HT autograft at Capio Artro Clinic, Stockholm, Sweden, between January 1, 2005, and December 31, 2018, were identified. The cohort was dichotomized into the hyperextension group (≤-5°) and the no hyperextension group (>-5°) depending on preoperative contralateral passive knee extension degree. Anterior knee laxity (KT-1000 arthrometer; 134 N) was assessed preoperatively and at 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2, and 5 years postoperatively. Patients who underwent revision ACLR at any institution in Sweden within 5 years of the primary surgery were identified in the Swedish National Knee Ligament Registry., Results: A total of 6104 patients (53.5% male) for whom knee range of motion measurements were available were identified (hyperextension group [≤-5°]: 2350 [38.5%]; mean extension, -6.1°± 2.3° [range, -20° to -5°]; no hyperextension group [>-5°]: 3754 [61.5%]; mean extension, 0°± 1.4° [range, -4° to 15°]). There were no intergroup differences in anterior knee laxity preoperatively (hyperextension group, 3.6 ± 2.8 mm; no hyperextension group, 3.7 ± 2.7 mm; P = .24) or postoperatively (hyperextension group, 1.8 ± 2.3 mm; no hyperextension group, 1.8 ± 2.2 mm; P = .41). The only significant but nonclinically relevant intergroup differences were seen in the KOOS Symptoms subscale at the 1-year follow-up (hyperextension group, 81.4 ± 16.0; no hyperextension group, 80.3 ± 16.5; P = .03) and in the Sport and Recreation subscale at the 5-year follow-up (hyperextension group, 73.0 ± 25.6; no hyperextension group, 75.7 ± 24.3; P = .02). No other significant intergroup differences were noted preoperatively or at 1, 2, or 5 years postoperatively in any of the KOOS subscales. The overall revision ACLR rate at ≤5 years after the primary surgery was 4.9% (302 of 6104 patients). The hazard for revision ACLR in the no hyperextension group (4.5%; 170 of 3754 patients) was not significantly different from that in the hyperextension group (5.6%; 132 of 2350 patients) (hazard ratio, 0.89; 95% CI, 0.71 to -1.12; P = .34). A subsequent subanalysis showed that the hazard of revision ACLR in patients with no hyperextension was not significantly different from that of patients with ≤-10° of extension (5.8%; 27 of 467 patients) (hazard ratio, 0.91; 95% CI, 0.61 to 1.36; P = .65)., Conclusion: Preoperative passive contralateral knee hyperextension (≤-5°) was not associated with postoperative anterior knee laxity, subjective knee function, or revision surgery ≤5 years after ACLR using HT autografts. Therefore, the presence of knee hyperextension alone should not be considered a contraindication per se for the use of HT autografts in ACLR., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Masses in the forefoot and midfoot are common reasons for medical presentation and can be caused by various pathological conditions. The challenge in clinical practice is to distinguish the multitude of trivialities from the few malignant entities and to arrive at a reliable clinical diagnosis in a reasonable amount of time with a moderate use of diagnostic tools., Material and Methods: In a retrospective analysis, tumors, tumor-like lesions, and pseudotumors distal to the Chopart joint presented to our multidisciplinary university tumor board between January 2010 und June 2023 were analyzed concerning entity, location, age, and sex., Results: Of the 167 cases included, 18 were osseous and 149 were soft tissue lesions. Overall, the metatarsal region was most frequently affected, accounting for 42.5% of all cases. Osseous lesions showed a preference for the phalanges and soft-tissue lesions occurring more frequently in the metatarsal region. In total, 88.0% of all cases were benign. All 20 malignant cases derived from soft tissue, occurred in all sections of the forefoot and midfoot and comprised 13 entities. Most lesions affected middle-aged patients, but cases occurred in almost every age group., Conclusion: In the examined patient population of a German university hospital, most cases were benign soft tissue lesions with a substantial share of pseudotumors and tumor-like lesions. However, the malignancy rate of 12.0% highlights the importance of differential diagnostic considerations. In cases of uncertain results, it is crucial to refer individuals with unclear masses to a specialized center for musculoskeletal tumor care early on in their treatment process., Levels of Evidence: III ., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Overuse injuries in youth athletes are associated with risks, including sports specialization, biological maturation, female sex, and workload measures. As no assessment tool exists to evaluate risk accumulation, we developed a novel risk factor scoring system (Sport Training Assessment of Risk [STAR]) to assess participants' risk of overuse injury and explore association with return-to-play (RTP) time periods., Hypothesis: (1) STAR will reach an acceptable predictive threshold in the assessment of overuse injury in youth athletes. (2) Higher STAR scores will be associated with increased RTP time periods after injury., Study Design: Longitudinal cohort study., Level of Evidence: Level 3., Methods: Youth athletes with an injury sustained during competitive sport completed questionnaires. Association of questionnaire variables with injury risk type was evaluated via logistic regression analyses, and unweighted and weighted versions of a total risk score were developed. RTP was defined by physician clearance per electronic medical record review. Mantel-Haenszel chi-square tests and Kendall's rank correlation coefficients were used to assess the relationship between weighted total risk score and RTP time periods. The weighted STAR model was analyzed with receiver operating characteristic (ROC) curves., Results: The weighted STAR model trended toward an acceptable level of prediction for overuse (nonserious + serious) injury (area under the ROC curve [AUC], 0.66; 95% CI, 0.61-0.71), but was less predictive for serious overuse injury (AUC, 0.63; 95% CI, 0.55-0.71). Weighted total risk score was weakly associated with return to full play (ρ = 0.11; P < 0.01), and potentially with return to modified play (ρ = -0.08; P = 0.04)., Conclusion: STAR may be a feasible tool for assessing overuse injury risk and RTP time periods in youth athletes but requires further development, as it did not reach an acceptable predictive threshold in this preliminary study., Clinical Relevance: Clinicians can use STAR to assess overuse injury risk in youth athletes., Competing Interests: The authors report no potential conflicts of interest in the development and publication of this article.

Background: When implanting a cemented humeral stem, a reliable method to prevent inappropriate extension and enable pressurization of cement in the intramedullary canal is required. The aim was to assess the outcomes of a dedicated humeral diaphyseal cement restrictor., Methods: In total 218 shoulders (207 patients) were included in the study, all of whom underwent a cemented total shoulder arthroplasty and a retrospective review was performed. The primary outcomes of interest were device stability in the medullary canal, successful occlusion of the canal, cement extrusion and quality of cement mantle., Results: The majority of the cohort was female (63.3%) males and the average patient age was 71.7 years (SD 8.45). In 81.7% the device was deemed to be stable in the medullary canal. The device was significantly more stable in primary (84.2%) compared to revision cases (64.3%, p = 0.02). In 69.7% Barrack grade A mantle quality was achieved, this was higher in primary cases (74.2%) compared to revision cases (39.3%) (p = 0.00006)., Discussion: We noted excellent cementation outcomes using a cement restrictor specifically designed for the diaphyseal humerus anatomy. However, this humeral specific restrictor was noted to be more stable in primary as compared to revision cases., Competing Interests: Author GEG would like to declare the following potential conflicts of interest American Shoulder and Elbow Surgeons: Committee member, Arthroscopy Association of North America: Committee member, Academic Orthopaedic Consortium: Associate Chief medical officer, Enovis/DJO: IP royalties; Other financial or material support; Paid consultant; Paid presenter or speaker, Elsevier: Textbook royalties for “Skeletal Trauma of the Upper Extremity.”, Aevumed: Stock or stock options, Genesys: Stock or stock options, Sparta: Stock or stock options, CultivateMD: Stock or stock options, Patient IQ: Stock or stock options, Journal of Shoulder and Elbow Surgery: Editorial or governing board, Restor3d: Paid consultant; Stock, Mitek/DePuy: Paid consultant, Stryker/Tornier: IP royalties; Paid consultant, ROM 3: Stock or stock options. Author TEL would like to declare the following consultant for Lima and Tornier; IDE and author OAA would like to declare the following, consultant for Lima, Exactech, Responsive Arthroscopy and Smith & Nephew. The remaining authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Purpose: The purpose of this study was to review the current literature of intravascular ultrasound (IVUS) use in real world cohorts inclusive of chronic limb threatening ischemia (CLTI) patients and compare the outcomes to patients imaged by angiography alone., Methods: The systematic review was registered in Research Registry. A literature search was performed across 4 databases: PubMed, Medline/Embase, Cochrane Review, and Web of Science for eligible comparative studies. The primary outcomes examined were clinically driven target lesion revascularization (CD-TLR), amputation (including minor below the ankle and major above the ankle), all-cause mortality, limb salvage and mean balloon dilation. A random effects model was used when pooling outcomes to account for heterogeneity. Publication bias was determined using eggers test and illustrated on a funnel plot., Main Findings: Six studies were included in this review, with a total of 1883 subjects with Rutherford 1-6. Among the 1883 subjects, 940 had Rutherford 4-6. IVUS was used in 1294 subjects and angiography alone was used in 589 subjects. Pooled analysis determined no significant association in IVUS + angiography with CD-TLR (O.R = 1.43 [CI: 0.80, 2.58]), all-cause amputation (O.R = 0.63 [CI: 0.34, 1.17]), and all-cause mortality (O.R = 0.63 [CI: 0.34, 1.17]). Sub analysis of subjects with CLTI, Rutherford classes 4-6 showed an association between IVUS + angiography use with limb salvage at 1 year, O.R = 2.22 [1.24, 3.97]., Conclusion: The use of IVUS + angiography compared to angiography alone showed larger reference vessel diameter in both all-inclusive Rutherford classifications and the CLTI subset. The use of IVUS + angiography compared to angiography alone showed no difference in CD-TLR at 12 months, lower extremity amputation, and all-cause mortality for Rutherford 1-6. The use of IVUS + angiography compared to angiography alone in the CLTI subset analysis improved limb salvage., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Background: Etiology of osteochondral lesions of the talus (OLT) is multifactorial and may develop from trauma, genetics, or hypovascularity. The talar dome is supplied by the posterior tibial artery (PTA) and, to a lesser degree, the sinus tarsi artery (STA). The role of talar dome hypovascularity on OLT remains poorly studied. We aimed to determine any relationship between the diameter of PTA (dPTA) and STA (dSTA) and the incidence and characteristics of talus OLT., Methods: This retrospective study included 77 patients with OLT and 77 subjects as a matched control group (age range: 30-40 years). Using magnetic resonance imaging, the dPTA was measured 1 cm above the tibial plafond, at the plafond, and at the level of medial malleolar tip. Likewise, dSTA was measured at the level of the talar neck. The area, volume, depth, localization, and surgical intervention for OLT were recorded as well., Results: The study group had significantly smaller dPTA at all 3 levels (1.05 ± 0.22 mm, 0.99 ± 0.18 mm, 0.98 ± 0.31 mm, proximal to distal, respectively) compared with controls (1.25 ± 0.23 mm, 1.20 ± 0.22 mm, 1.14 ± 0.18 mm, respectively) ( P  < .001). The dSTA was also significantly smaller in the study group compared with the control group (0.5 ± 0.11 mm vs 0.57 ± 0.08 mm, respectively; P  = .001). The mean dPTA (of all 3 levels) cutoff value for predicting the occurrence of OLT was 1.1 mm with 74% sensitivity and 75% specificity. A significant inverse correlation was observed between OLT area and arterial diameters ( P  < .001)., Conclusion: Smaller luminal dPTA and dSTA appear to be associated with higher incidence of OLT, with defect size inversely correlated to arterial diameter., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Introduction: Anatomic hemiarthroplasty (aHA) is a treatment option for non-reconstructable constructable multifragment proximal humeral fractures that preserves range of motion. Our study aims to evaluate the radiographic and clinical outcomes of patients who received a modular aHA with anatomical sizing of the tubercle-bearing metaphyseal components., Materials and Methods: The medical records of thirty-nine consecutive patients were reviewed. Patients were treated at a single institution with aHA as first-line treatment following a non-reconstructable constructable proximal humeral fracture. Tubercle resorption and cranialization of the aHA were analyzed using radiographic controls. Patient clinical function was assessed using the Constant Murley Score (CS)., Results: Twenty-four patients (62%) were available for clinical follow-up, with a mean CS of 54 points after a mean 56-month follow-up period. There was no significant difference in functional outcome on average between patients with healed tubercles (CS = 57) and resorbed tubercles (CS = 51). Radiographic follow-up was available in 33 patients (85%), demonstrating healed tubercles in 33% of the patients. Patients with resorbed tubercles had significant smaller acromio-humeral distances (AHD) than patients with healed tubercles (p = 0.043). A positive correlation was observed between greater AHD and increased constant scores (p = 0.022)., Conclusions: The final patient outcome measures demonstrated a positive correlation with a greater acromio-humeral distance and tubercle healing rates. However, the modular stem design with sizing of the metaphyseal components did not result in superior outcomes when compared with the literature., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Evidence as to how patient thigh muscle strength and limb loading (LL) during a squatting task recovers throughout rehabilitation after anterior cruciate ligament reconstruction (ACLR) is lacking., Hypothesis: Patients will improve LL and strength throughout rehabilitation. Changes in LL and strength over time will be positively correlated., Study Design: Prospective cohort study., Level of Evidence: Level 3., Methods: A total of 60 participants (28 male/32 female; age, 22.5 ± 9.35 years) participated in 2 visits post-ACLR, assessing LL and strength. Using an instrumented pressure mat, patients completed 3 sets of 3 repetitions of bodyweight squats. Peak force (N), unilateral cumulative load (%), and quadriceps and hamstring isokinetic peak torque (N·m) were calculated and recorded bilaterally. LL and peak torque were compared over time and between limbs., Results: A significant limb-by-time interaction was observed for LL peak force (N), where patients underloaded the ACLR limb at visit 1 compared with the contralateral limb ( P < 0.01). Patients increased their ACLR LL across visits ( P = 0.04). A limb-by-time interaction for quadriceps peak torque (N·m) was observed where the ACLR limb increased peak torque across visits ( P < 0.01); however, strength deficits persisted at visit 2 ( P < 0.01) when compared with the nonoperative limb. Weak correlations were observed between all change scores metrics ( r , 0.20-0.25)., Conclusion: Patients recovering from ACLR exhibited more symmetric loading during a squatting task and improved their lower extremity strength over time. Changes in strength were not related to changes in LL during a squatting task over time., Clinical Relevance: Squatting tasks are safe and easily implemented throughout ACLR recovery. As changes in functional LL and strength recovery are not related, both should be considered in serial postoperative testing for more comprehensive function and strength assessments., Competing Interests: The following authors declared potential conflicts of interest: B.W. has received consulting fees from Arthrex and Zimmer Biomet, speaking fees from Zimmer Biomet, and research funding from Zimmer Biomet, Pacira, Exactech, and Lifenet. J.H. is cofounder and holds stock and stock options from Springbok Inc. R.Q. holds board positions with the Orthopaedic Research Society and the American Society of Biomechanics.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: funding from the Innovative, Developmental Exploratory Award (IDEA) research and development fund from the School of Education and Human Development at the University of Virginia; funding from the graduate student summer research fellowship from the American College of Sports Medicine Biomechanics Interest Group (BIG).

Background: Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied., Purpose: To perform (1) a systematic review of the current literature and (2) a Markov model-based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI., Study Design: Economic and decision analysis; Level of evidence, 3., Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER)., Results: The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases., Conclusion: ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.F.O. has received consulting fees from Kaliber.ai. A.J.K. has received research support from Aesculap/B.Braun and DJO; consulting fees from Arthrex, Joint Restoration Foundation, and Responsive Arthroscopy; royalties from Arthrex and Responsive Arthroscopy; and honoraria from Joint Restoration Foundation. D.C.T. has received financial or material support from Arthrex, Breg, DJOrtho, Mitek, and Smith & Nephew; and royalties from DePuy. C.L.C. has received consulting fees from Arthrex and research support from Major League Baseball. A.J.T. has received hospitality payments from Stryker, Arthrex, Medical Device Business Services, and Zimmer Biomet Holdings. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Tendon injuries in the lower extremities are common in physically active individuals, although spontaneous Achilles tendon ruptures are linked to oral corticosteroid or fluoroquinolone use. Such ruptures are typically due to degenerative changes within the tendon and frequently occur during sudden dorsiflexion of a plantar-flexed foot. Bilateral spontaneous ruptures are especially prevalent in patients undergoing long-term corticosteroid therapy. Here, we present a rare case of bilateral spontaneous calcaneal avulsion in an otherwise healthy woman, ultimately diagnosed with alkaptonuria. This case underscores the importance of considering metabolic disorders in atraumatic tendon ruptures and highlights the diagnostic value of intraoperative findings., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: The main goal of this study was to evaluate postoperative changes in the length of the first metatarsal (M1) and the proximal phalanx of the hallux (P1) after acellular dermal allograft interpositional arthroplasty (ADA-IPA). We hypothesized that there would be a shortening of the first ray at the first metatarsal, the proximal phalanx, or both., Methods: In this retrospective study, we assessed patients who underwent ADA-IPA between 2019 and 2022. On standing anteroposterior (AP) foot radiographs, we measured first metatarsal (M1), second metatarsal (M2), proximal phalanx (P1), and the entire hallux (HX) lengths. M1/M2 and P1/HX ratios were calculated. The first metatarsophalangeal joint space was calculated. All measurements were recorded preoperatively, at 6 weeks postoperatively, and at final follow-up., Results: The pilot study included 11 patients. At final follow-up, we found shortening of M1 and P1 in comparison to the preoperative length, as evidenced by lower M1/M2 (82.6 ± 2.3 vs 75.4 ± 5.1; P  = .001) and P1/HX ratios (53.4 ± 2.3 vs 48.9 ± 7.9; P  = .001). Follow-up length was negatively correlated with M1/M2 ( r  = -0.76, P  = .003)., Conclusion: ADA-IPA might be associated with shortening of both first metatarsal and proximal phalanx, with the former showing progressive shortening., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Introduction: Surgical treatment of distal femoral fractures (DFFs) in osteoporotic bone is challenging despite improvements in hardware and surgical techniques. The occurrence and degree of secondary displacement during healing after bridging plate fixation are still unknown. This study aimed to assess the occurrence and degree of secondary displacement in healing DFFs in elderly patients and correlate the secondary displacement to body mass index, bone density, and weight-bearing regimen., Patients and Methods: The study involved 32 patients, 65 years or older, with a DFF of AO/OTA types 33 A2-3, B1-2, C1-2, and 32(c) A-C,1-3, including peri-prosthetic fractures with stable implants. Twenty-seven patients had at least 8 weeks of follow-up, and 21 patients had a complete 1-year follow-up. Minimally invasive surgery was performed using a distal anatomical femoral plate as a long bridge-plating construct. Secondary displacement was assessed with computed tomography of the entire femur postoperatively and at 8, 16, and 52 weeks. Femoral length, coronal angulation (varus/valgus), and subsidence as the change in distance between the distal joint surface and a specified locking screw were measured., Results: There was a statistically significant mean femoral shortening at 52 weeks of 4.7 mm (SD 3.9, (95% CI 2.9-6.5), P < 0.001) mainly by subsidence of the distal fragment. Most patients experienced limited coronal angulation. There was no correlation between body mass index or bone density and secondary displacement. At the 1-year follow-up, no patient needed revision surgery for non-union or plate breakage. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or adverse events such as cut-outs., Conclusion: Modern dynamic plate osteosynthesis could not prevent commonly occurring fracture subsidence in DFF in an elderly cohort. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or mechanical adverse events., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Objective: The aim of this study was to identify prognostic factors pertaining to neck pain from systematic reviews., Data Sources: A search on PubMed, Scopus, and CINAHL was performed on June 27, 2024. Additional grey literature searches were performed., Review Methods: We conducted an umbrella review and included systematic reviews reporting the prognostic factors associated with non-specific or trauma-related neck pain and cervical radiculopathy. Prognostic factors were sorted according to the outcome predicted, the direction of the predicted outcome (worse, better, inconsistent), and the grade of evidence (Oxford Center of Evidence). The predicted outcomes were regrouped into five categories: pain, disability, work-related outcomes, quality of life, and poor outcomes (as "recovery"). Risk of bias analysis was performed with the ROBIS tool., Results: We retrieved 884 citations from three databases, read 39 full texts, and included 16 studies that met all selection criteria. From these studies, we extracted 44 prognostic factors restricted to non-specific neck pain, 47 for trauma-related neck pain, and one for cervical radiculopathy. We observed that among the prognostic factors, most were associated with characteristics of the condition, cognitive-emotional factors, or socio-environmental and lifestyle factors., Conclusion: This study identified over 40 prognostic factors associated mainly with non-specific neck pain or trauma-related neck pain. We found that a majority were associated with worse outcomes and pertained to domains mainly involving cognitive-emotional factors, socio-environmental and lifestyle factors, and the characteristics of the condition to predict outcomes and potentially guide clinicians to tailor their interventions for people living with neck pain., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Studies to date of superior capsular reconstruction (SCR) comparing outcomes of healed grafts versus torn grafts do not separate graft tears based on location of the tear, rather they combine and report all tears as a single group., Purpose/hypothesis: The purpose of this study was to correlate functional outcome with graft integrity and graft tear location after SCR with a dermal allograft. It was hypothesized that the functional outcomes of patients with an intact graft would be equivalent to those with graft tears leaving the tuberosity covered., Study Design: Cohort study; Level of evidence, 3., Methods: Patients who underwent SCR with an acellular dermal allograft at a single institution were included. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score, visual analog scale (VAS) for pain, and postoperative Single Assessment Numeric Evaluation (SANE) scores were recorded. A magnetic resonance imaging scan was performed postoperatively to assess graft integrity., Results: A total of 39 patients met inclusion criteria. Mean age of patients was 60.4 ± 8.7 years; mean follow-up was 53.3 ± 25 months (range, 14-98 months). Magnetic resonance imaging performed at a mean of 17.5 months (range, 6-66 months) demonstrated an intact graft in 14 (36%); tear from the glenoid in 11 (28%), from midsubstance in 4 (10%), and from the tuberosity in 8 (21%); and complete graft absence in 2 (5%). Patients were divided into group 1 (intact graft), group 2 (tuberosity covered: tears from glenoid and midsubstance tears), and group 3 (tuberosity bare: tears from the tuberosity and dissolved or absent grafts). In group 1, there was significant improvement in ASES (37.9 to 88.5; P < .001), Oxford (25.2 to 46.2; P < .001), and VAS (6.8 to 0.9; P < .001). In group 2, there was significant improvement in ASES (32.2 to 86.1; P < .001), Oxford (23.4 to 44.2; P < .001), and VAS (7.3 to 1.3; P < .001). In group 3, there was no significant improvement in ASES (40.3 to 45.8; P = .50) or Oxford (33.5 to 31.4; P = .81), but there was a significant reduction in VAS (7.1 to 5.4; P = .03). There was no significant difference between group 1 and 2 in postoperative ASES (88.5 vs 86.1; P = .59), Oxford (46.2 vs 44.2; P = .07), VAS (0.9 vs 1.3, P = .42) and SANE (85.4 vs 83.2; P = .92) scores. However, group 3 had significantly lower ASES (45.8; P < .001), lower Oxford (31.4; P < .001), lower SANE (45.4; P < .001), and higher VAS (5.4; P < .001) scores than groups 1 and 2. There were no differences in outcomes based on sex ( P = .72), previous surgery ( P = .06), preoperative acromiohumeral distance ( P = .57), and preoperative Goutallier stage of the supraspinatus ( P = .16)., Conclusion: Patients who underwent SCR with a dermal allograft and developed a graft tear leaving the tuberosity covered had equivalent functional outcomes to those with an intact graft., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: R.M. has received honoraria from Arthrex not related to this manuscript, consulting fees from Arthrex, and speaking fees from Empire Medical. A.S. has received compensation from Arthrex for services other than consulting, support for education from Arthrex, and support for education from ImpactOrtho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. This study was approved by the Kaiser Permanente Southern California institutional review board (No. 11147).

Objective: To evaluate the effectiveness of retrograde tibial intramedullary nail (RTN) in addressing nonunion in the distal one-fourth of the tibia., Methods: This retrospective study included consecutive patients who were treated with RTN for nonunion in the distal one-fourth of the tibia between December 2020 and August 2023. Data regarding age, sex, injury mechanism, fracture type, initial fixation method, nonunion duration and type, risk factors, surgical duration, hospital stay, time to bone union, ankle function at final follow-up, and any complications were extracted from hospital records and analysed., Results: Five patients in total were included, with previous treatments comprising locking plates and/or external fixation. The mean duration of RTN surgery was 94.0 ± 13.7 min, and mean duration of hospital stay was 9.8 ± 1.9 days. Patients were monitored for 10-18 months post RTN, achieving complete bone healing within a mean of 4.8 months. At the latest follow-up, the mean American Orthopedic Foot and Ankle Society (AOFAS) score was 84.4 ± 6.8 (range, 77-95). No complications, such as infection, reoperation, implant issues, rotational deformity, or shortening were reported., Conclusion: RTN emerges as a dependable, minimally invasive, and safe treatment modality for managing nonunion in the distal one-fourth of the tibia., Competing Interests: Declaration of conflicting interestThe authors declare that there are no conflicts of interest.

Background: Excessive glenoid retroversion is a known risk factor for posterior shoulder instability and failure after soft tissue stabilization procedures. Whether excessive glenoid retroversion is a risk factor for failure after posterior glenoid bone grafting is unknown., Purpose: To evaluate the biomechanical effectiveness of posterior iliac crest bone grafting (ICBG) for posterior shoulder instability with increasing glenoid retroversion., Study Design: Controlled laboratory study., Methods: Six fresh-frozen cadaveric shoulders had a posterior glenoid osteotomy allowing the glenoid retroversion to be set at 0°, 10°, and 20°. At these 3 preset angles, 4 conditions were simulated consecutively on the same specimen: (1) intact glenohumeral joint, (2) posterior Bankart lesion, (3) 20% posterior glenoid bone defect, and (4) posterior ICBG. Stability was evaluated in the jerk position (60° of glenohumeral anteflexion, 60° of internal rotation) by measuring (A) posterior humeral head (HH) translation (in mm) and (B) peak translational force (in N) necessary for translation of the HH over 25% of glenoid width., Results: At 0° of retroversion, the ICBG restored posterior HH translation and peak translational force to values comparable with those of the intact condition ( P = .649 and P = .979, respectively). At 10° of retroversion, the ICBG restored the peak translational force to a value comparable with that of the intact condition (22.3 vs 24.7 N, respectively; P = .418) but showed a significant difference in posterior HH translation in comparison to the intact condition (4.5 vs 2.0 mm, respectively; P = .026). There was a significant increase in posterior HH translation and significant decrease in peak translational force with the ICBG at 20° of glenoid retroversion compared with the intact condition (posterior HH translation: 7.9 vs 2.0 mm, respectively; P < .006; peak translational force: 15.3 vs 24.7 N, respectively; P = .014)., Conclusion: In this cadaveric study, posterior ICBG was able to restore stability to a level comparable to that of the native condition at 0° and to some extent at 10° of retroversion. However, posterior ICBG was not able to provide adequate stability at 20° of glenoid retroversion., Clinical Relevance: Posterior glenoid bone grafting with ICBG should be used with caution when performed in isolation in the setting of posterior instability associated with glenoid bone loss and combined glenoid retroversion of >10°., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Tibial tuberosity-trochlear groove distance (TT-TG) is often used as a primary metric for surgical decision-making in the treatment of patellofemoral instability (PFI), particularly when considering tibial tubercle transfer. Although TT-TG has high interrater reliability, it is prone to measurement differences caused by the alignment of the patient's leg in a scanner gantry, potentially influencing surgical decision-making. Quantification of this error within the clinical literature remains limited., Purpose: To quantify and specify the error in TT-TG caused by leg-scanner alignment by using detailed topographical landmarks and 3-dimensional (3D) analysis of computed tomography scans of patients with PFI., Study Design: Controlled laboratory study., Methods: Three-dimensional models of knees with PFI were created from computed tomography scans and used to identify TT-TG landmarks. TT-TG was measured using the established 2-dimensional (2D) and 3D methods. A model to estimate the differences between these 2 methods was created, and the orientation of the patients' legs in relation to scanner longitudinal axis was measured to validate this model via linear regression. Interrater reliability was calculated via intraclass correlation coefficients (ICC)., Results: A total of 44 knees of patients with PFI were analyzed. Differences between the 2D and 3D methods ranged from -4.0 to 14.7 mm (mean ± SD, 2.7 ± 4.1 mm) with a root mean square difference of 4.8 mm. The TT-TG distance of the 2D method (19.8 ± 7.2 mm) was significantly ( P = .045) longer than that of the 3D method (17.1 ± 4.9 mm). The variance of the 2D method was significantly larger than that of the 3D method. In total, 13 (29.5%) of the knees had a difference of >5 mm between 2D and 3D TT-TG. The estimation model had an adjusted r value of 1.00 and a resulting root mean square difference of 0.21 mm. 3D TT-TGs interrater reliability was good to excellent (ICC, 0.94 [95 CI%, 0.81-0.98]).2 value of 1.00 and a resulting root mean square difference of 0.21 mm. 3D TT-TGs interrater reliability was good to excellent (ICC, 0.94 [95 CI%, 0.81-0.98])., Conclusion: 3D TT-TG can be used to correct scanner-leg alignment errors, some of which are substantial when using only 2D TT-TG measurements., Clinical Relevance: The findings in this study suggest a need for caution and awareness of the potential effects of differences in alignment of the axes of the leg and scanner when using purely 2D TT-TG as a basis for surgical planning., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: D.H.W. has received support for education from Zimmer Biomet, Smith & Nephew, Intellijoint Surgical, and Stryker and consulting fees from Globus Medical. J.P.F. has received consulting fees from Linvatec Corp and a grant from Encore Medical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Many adolescents experience knee pain, and only some undergo detailed imaging. In this population, the prevalence of abnormalities and normal variants on magnetic resonance imaging (MRI) scans is unknown., Purpose: To investigate the prevalence of abnormalities and normal variants of the knee on MRI scans and their relationship with participant characteristics in the general young adolescent population., Study Design: Cross-sectional study; Level of evidence, 3., Methods: This study was part of an open population-based cohort study that focuses on health, growth, and development from fetal life until adulthood. Between 2017 and 2020, adolescents aged 12 to 15 years underwent MRI of both knees. These MRI scans were assessed in a standardized way for abnormalities and normal variants to determine their prevalence. Logistic regression was used to analyze the presence of abnormalities and normal variants in relation to sex, height, weight, body mass index-standard deviation (BMI-SD), and ethnicity., Results: A total of 1910 participants (median age, 13.5 years; interquartile range, 13.4-13.7 years; 52% girls) were included in this study. Of them, 370 (19.4%) participants had at least 1 abnormality or normal variant. Bone marrow edema around the knee was the most prevalent finding, affecting 140 (7.3%) participants. In 107 (5.6%) participants, nonossifying fibromas were found. A total of 43 (2.3%) participants had characteristics of Osgood-Schlatter disease, 16 (0.8%) showed characteristics of Sinding-Larsen-Johansson syndrome, and osteochondritis dissecans was found in 13 (0.7%) participants. Variants such as discoid menisci were found in 40 (2.1%) participants and a bipartite patella in 21 (1.1%) participants. There were multiple associations between abnormalities or variants and participant characteristics, including bone marrow edema being more often present in boys (odds ratio [OR], 2.44; 95% CI, 1.69-3.52) and those with a lower BMI-SD (OR, 0.85; 95% CI, 0.73-0.98). Osgood-Schlatter and osteochondritis dissecans were more often present in boys (OR, 4.21 [95% CI, 2.01-8.85] and OR, 13.18 [95% CI, 1.71-101.58], respectively). Discoid menisci were associated with a non-Western ethnicity (OR, 2.06; 95% CI, 1.07-3.96) and higher BMI-SD (OR, 2.34; 95% CI, 1.76-3.11)., Conclusion: Abnormalities and normal variants on MRI scans of the knees are common in adolescents. Physicians who are involved in the treatment of adolescents with knee pain need to be aware of this prevalence so that these children will not be overtreated or misdiagnosed., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: The Generation R Study is made possible by financial support from Erasmus Medical Center, Rotterdam; Erasmus University Rotterdam; ZonMw; the Netherlands Organisation for Scientific Research (NWO); and the Ministry of Health, Welfare and Sport of the Netherlands. The Anna Foundation (Nederlands Orthopedisch Research en Educatie Fonds) supports the work of L.A.M.K. through a research grant. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Previous studies suggest that Dupuytren's disease is associated with increased mortality, but most studies failed to account for important confounders. In this population-based cohort study, general practitioners' (GP) data were linked to Statistics Netherlands to register all-cause and disease-specific mortality. Patients with Dupuytren's disease were identified using the corresponding diagnosis code and assessing free-text fields from GP consultations. Multiple imputations were performed to estimate missing values of covariates, followed by 1:7 propensity score matching to balance cases with controls on confounding factors. A frailty proportional hazard model was used to compare mortality between both groups. Out of 209,966 individuals, 2561 patients with Dupuytren's disease were identified and matched to at least four controls. After a median follow-up of 5 years, mortality was found to be actually reduced in patients with Dupuytren's disease. There was no difference in mortality secondary to cancer or cardiovascular disease. Future studies with longer average follow-up using longitudinal data should clarify these associations in the longer term. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors disclosed the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: PW was a SERB member and is a DMC member for Fidia Ltd, Milan, Italy. Revenues are used for research purposes. PW and DB are both members of the scientific advisory board of the Dutch Dupuytren Society and PW is a member of the scientific advisory board of the International Dupuytren Society. DF is a trustee of the British Dupuytren Society. This is not related to the submitted work. BB, FG, RK and EH declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain., Methods: This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors ( P  < .05)., Results: In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P  = .009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P  = .007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P  < .001) as being associated with the decision for surgery., Conclusion: Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

The design and construction of a new and excellent synthetic graft is of great significance in the field of bone defect repair and reconstruction. In this study, a dopamine modified chitosan hydrogel doped with Cu ions with a mild photothermal effect was designed to provide a better microenvironment to advance the bone repair via promote the angiogenesis and osteogenesis. Characterizations showed the successful synthesis of the material while it also presented excellent biocompatibility and mild photothermal effect under the irradiation of near-infrared light. Further, it could enhance the angiogenesis of HUVECs cells through promoting the ability of migration and tube formation and enhance the osteogenic differentiation of MC3T3-E1 cells via increasing the content of vital osteogenic factors including Runx2, Col-1, OPN, OCN, OSX, etc. The in vivo experiment also testified that it could promote the bone defect repair in rat models. These results indicate the multifunctional hydrogel is an ideal material for the treatment of bone defects and has good clinical application potential., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study compared lower extremity (LE) muscular strength by 3 groups of female athletes using chronological age and consideration of age of peak height velocity (PHV). Isometric quadriceps, hamstrings, and hip abductors strength were assessed from physically active, pediatric females. The body mass normalized isometric strength (N m/kg) was compared by the 3 age groups. There were 388 young female athletes (<10 years [14.2%], 11-14 years [48.7%], and 15-18 years [37.1%]). The body mass normalized LE strength was lower in 11-14 years compared with <10 years (quadriceps [ P = .001], hamstrings [ P = .001], and hip abductors [ P = .037]) as well as in 15-18 years relative to <10 years in quadriceps ( P = .001) and hamstrings ( P = .001). The analysis results were consistent with both chronological age alone and incorporating effects of age of PHV. In short, body mass normalized LE strength (quadriceps, hamstrings, and hip abductors) of 11-14 years females was lower than <10 years females., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/- C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: There have been a large number of patient-reported outcome measures (PROMs) used to assess outcomes after anterior cruciate ligament (ACL) reconstruction (ACLR)., Purpose/hypothesis: The purpose was to determine which PROMs are being commonly used in randomized clinical trials (RCTs) to assess patients undergoing ACLR and to compare the responsiveness between them. It was hypothesized that the International Knee Documentation Committee (IKDC) score would be the most commonly used and responsive PROM among patients undergoing ACLR., Study Design: Meta-analysis. Level of evidence, 2., Methods: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, and relevant studies were extracted from the PubMed/MEDLINE and Web of Science databases. The inclusion criteria were English-language RCTs reporting on PROMs after ACLR. For articles meeting our inclusion criteria for responsiveness analysis (≥2 PROMs reported, 1 year minimum follow-up, and reported pre- and postoperative PROM means and standard deviations), the responsiveness between PROMs was compared using effect size (ES) and relative efficiency (RE)., Results: A total of 108 articles met the inclusion criteria, comprising 9034 patients (mean age, 29.9 years; mean body mass index, 24.3; mean follow-up time, 36.1 months). There were 34 PROMs identified. The top 3 most commonly reported PROMs were the IKDC (n = 68; 63.0%), Lysholm (n = 65; 60.2%), and Tegner (n = 47; 43.5%) scores. The 2 PROMs with the highest ES were the ACL-Quality of Life (QoL) (3.37) and Knee Injury and Osteoarthritis Outcome Score (KOOS) QoL (2.07) scores. Compared with other PROMs, Lysholm and KOOS QoL scores had the greatest RE values. The Lysholm score had a greater RE than the KOOS Pain (RE, 1.17), KOOS Symptoms (RE, 1.22), KOOS Activities of Daily Living (ADL) (RE, 1.42), KOOS Sport/Recreation (RE, 1.55), KOOS QoL (RE, 1.41), and Tegner (RE, 2.89) scores. KOOS QoL had a greater RE than the IKDC (RE, 1.32), KOOS Pain (RE, 1.60), KOOS Symptoms (RE, 2.12), KOOS ADL (RE, 3.03), KOOS Sport/Recreation (RE, 1.27), and Tegner (RE, 2.06) scores., Conclusion: The IKDC score is the most commonly reported PROM in RCTs after ACLR; however, the Lysholm and KOOS QoL scores demonstrated the highest responsiveness in patients undergoing ACLR compared with other PROMs., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.P.C. has received support for education from Pinnacle. D.C.L. has received support for education from Medwest Associates and hospitality payments from Exatech; he is an associate editor for AJSM. A.V.S. has received consulting fees from Bioventus; speaking fees from Smith & Nephew; support for education from Smith & Nephew, Legacy Ortho, Arthrex, Medwest Associates, and Stryker; research support from Arthrex; and hospitality payments from Wright Medical Technologies. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Treatment strategies for a symptomatic accessory navicular include both operative and nonoperative approaches. The primary aim of this study is to define health utility values for 7 health states experienced by those with a symptomatic accessory navicular who undergo operative and/or nonoperative treatment. Secondarily, the study incorporates the health utility values with treatment costs, probabilities of various outcomes, and duration of health states into a cost-effectiveness model comparing the nonoperative treatment protocol at our institution vs surgical excision., Methods: Institutional review board approval was obtained to call parents of patients 10-20 years old at the time of interview who were evaluated for a symptomatic accessory navicular from February 1, 2016, to March 2, 2023, at a single institution by one of 4 pediatric orthopaedic surgeons. Participants were asked to rate 7 health states from 0 to 100, with 0 representing death (if 18 years or older) or the worst health imaginable (if under 18 years) and 100 representing perfect health. Using published values for the probabilities of various treatment outcomes, time spent in various health states, and Medicare costs from the perspective of the payor and society, a decision analysis was constructed., Results: Health utility values for 7 health states were obtained. Operative treatment was preferred to nonoperative treatment in the base case model. Surgery was more expensive ($16 825) than nonoperative treatment ($7486). Using a willingness-to-pay threshold of <$50 000 per quality-adjusted life year (QALY), surgery was cost-effective compared to nonoperative treatment with an incremental cost-effectiveness ratio of $20 303/QALY. Sensitivity analysis revealed that the only variable that indicated a preference for nonoperative treatment is a 71% likelihood of nonoperative treatment resolving the condition., Conclusion: Unless a physician suspects at least a 71% chance of a symptomatic accessory navicular resolving without operative treatment, surgical excision is recommended from a cost-effectiveness perspective., Competing Interests: Ethical ApprovalEthical approval for this study was obtained from Hospital for Special Surgery Institutional Review Board: Utilities Acquisition in Orthopedics (2014–404). Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Background: Based in part on the results of randomized controlled trials (RCTs) that suggest a beneficial effect over alternative treatment options, the use of platelet-rich plasma (PRP) for the management of knee osteoarthritis (OA) is widespread and increasing. However, the extent to which these studies are vulnerable to slight variations in the outcomes of patients remains unknown., Purpose: To evaluate the statistical fragility of conclusions from RCTs that reported outcomes of patients with knee OA who were treated with PRP versus alternative nonoperative management strategies., Study Design: Systematic review and meta-analysis; Level of evidence, 2., Methods: All RCTs comparing PRP with alternative nonoperative treatment options for knee OA were identified. The fragility index (FI) and reverse FI were applied to assess the robustness of conclusions regarding the efficacy of PRP for knee OA. Meta-analyses were performed to determine the minimum number of patients from ≥1 trials included in the meta-analysis for which a modification on the event status would change the statistical significance of the pooled treatment effect., Results: In total, this analysis included outcomes from 1993 patients with a mean ± SD age of 58.0 ± 3.8 years. The mean number of events required to reverse significance of individual RCTs (FI) was 4.57 ± 5.85. Based on random-effects meta-analyses, PRP demonstrated a significantly higher rate of successful outcomes when compared with hyaluronic acid ( P = .002; odds ratio [OR], 2.19; 95% CI, 1.33-3.62), as well as higher rates of patient-reported symptom relief ( P = .019; OR, 1.55; 95% CI, 1.07-2.24), not requiring a reintervention after the initial injection treatment ( P = .002; OR, 2.17; 95% CI, 1.33-3.53), and achieving the minimal clinically important difference (MCID) for pain improvement ( P = .007; OR, 6.19; 95% CI, 1.63-23.42) when compared with all alternative nonoperative treatments. Overall, the mean number of events per meta-analysis required to change the statistical significance of the pooled treatment effect was 8.67 ± 4.50., Conclusion: Conclusions drawn from individual RCTs evaluating PRP for knee OA demonstrated slight robustness. On meta-analysis, PRP demonstrated a significant advantage over hyaluronic acid as well as improved symptom relief, lower rates of reintervention, and more frequent achievement of the MCID for pain improvement when compared with alternative nonoperative treatment options. Statistically significant pooled treatment effects evaluating PRP for knee OA are more robust than approximately half of all comparable meta-analyses in medicine and health care. Future RCTs and meta-analyses should consider reporting FIs and fragility quotients to facilitate interpretation of results in their proper context., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: J.F.O. has received consulting fees from Kaliber.ai. A.P. has received support for education from Smith & Nephew and hospitality payments from Medical Device Business Services. S.M.S. has received consulting fees from Moximed, Smith & Nephew, Miach Orthopaedics, Vericel, and Flexion Therapeutics; research support from Vericel and JRF; speaking fees from Organogenesis and Vericel; and royalties from Organogenesis; and holds stock or stock options in Engage and Stryker. B.U.N. has received consulting fees from Stryker, Wright Medical, and Zimmer Biomet; support for education from Arthrex and Smith & Nephew; consulting fees from Figur8; and a grant from Arthrex; and holds stock or stock options in BICMD. C.L.C. has received consulting fees from Arthrex; research support from Major League Baseball; and publishing royalties from Springer. A.J.K. has received consulting fees from Joint Restoration Foundation, Arthrex, and Responsive Arthroscopy; honoraria from Joint Restoration Foundation; royalties from Arthrex and Responsive Arthroscopy; a grant from DJO; and research support from Aesculap/B.Braun; and serves on the medical board of trustees for the Musculoskeletal Transplant Foundation. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

The aim of this study was to develop an automated approach model to define in vivo kinematics of the trapeziometacarpal (TMC) joint using four-dimensional computed tomography. A total of 15 healthy volunteers were included and their TMC joint kinematics were studied during a retropulsion-opposition-retropulsion movement. We used cardan angles estimated from transformation matrices using a ZYX-decomposition and analysed the motion of the thumb metacarpal relative to the trapezium, the thumb metacarpal relative to the index metacarpal, and the trapezium relative to the index metacarpal. The study also included an analysis of the joint hysteresis effect and a joint proximity model that estimated the joint contact area during a retropulsion-opposition-retropulsion movement. The automated approach significantly decreased the time needed to analyse each case and makes this model applicable for further research on TMC kinematics., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: This study aims to investigate the characteristics of concomitant distal radius and scaphoid fractures and determine outcome differences of operative and nonoperative management., Methods: A retrospective search of a level-1 trauma center's database over a 15-year period (2007-2022) for concomitant distal radius and scaphoid fractures in adult patients was completed. In all, 31 cases were reviewed for mechanism of injury, method of fracture management, distal radius fracture AO Foundation/Orthopaedic Trauma Association classification, scaphoid fracture classification, time to radiographic scaphoid union, time to motion, and other demographics. A multivariate statistical analysis was completed comparing outcomes in operative versus conservative management of the scaphoid fracture in these patients. Outcomes were defined as time to radiographic union and time to motion., Results: In all, 22 cases of operative fixation of the scaphoid and 9 cases of nonoperative management of the scaphoid were reviewed. One case of nonunion was identified in the operative group. Operative management of scaphoid fractures resulted in a statistically significant reduction in time to motion (2-week reduction) and time to radiographic union (8-week reduction)., Conclusions: This study demonstrates that operative management of scaphoid fractures in the setting of a concomitant distal radius fracture reduces the time to radiographic union and time to clinical motion. This suggests that operative management is ideal in patients who are good candidates for surgery and desire earlier return of motion. However, conservative management should be considered, as nonoperative care showed no statistical difference regarding union rates of scaphoid or distal radius fractures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: R.R. is a consultant for Medartis. All other authors have no conflicts of interests to disclose.

Background: Particulated autograft cartilage implantation is a surgical technique that has been previously described for the repair of osteochondral lesions of the talus (OLT). It uses cartilage fragments harvested from the OLT that are minced into 1-2-mm 3 fragments and then immediately reimplanted back into the chondral defect and sealed with fibrin glue during a single-stage surgery. The purpose of this study was to characterize the suitability of these minced cartilage fragments as immediate autograft for the treatment of OLTs., Methods: Thirty-one patients undergoing primary arthroscopic surgery for their OLT consented to have their loose or damaged cartilage fragments removed and analyzed in the laboratory. Harvested specimens were minced into 1- to 2-mm 3 fragments and cell count, cell density, and cell viability were determined. In addition, physical characteristics of the OLT lesion were recorded intraoperatively and analyzed including size, location, Outerbridge chondromalacia grade of the surrounding cartilage, density of underlying bone, and whether the surgeon thought the OLT was primarily hyaline or fibrocartilage., Results: An average of 419 000 cells was able to be obtained from the harvested OLT fragments. The cells were 71.2% viable after mincing. Specimens from younger patients and from lesions with worse chondromalacia adjacent to the OLT had significantly higher cell numbers. Those from lateral lesions and with worse neighboring chondromalacia had a significantly higher cell density. None of the remaining physical OLT characteristics studied seemed to significantly affect cell number or viability., Conclusion: A large number of viable cells are available for immediate autografting by removing the loose or damaged cartilage from an OLT and mincing it into 1- to 2-mm 3 fragments. These can be reimplanted into the chondral defect in a single-stage surgery. Future clinical studies are needed to determine if the addition of these live autologous cells either alone or in conjunction with other techniques significantly improves the quality of the repair tissue and clinical outcomes., Level of Evidence: Level IV, case series., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: John T. Campbell, MD, reports research grant from Paragon28; OMEGA educational grant; AOFAS fellowship grant; editorial board, Foot & Ankle International; and chair, AOFAS Fellowship Match & Accreditation Committee. Rebecca A. Cerrato, MD, reports consultancy fees from Stryker and Acumed. Patrick J. Maloney, MD, reports consultancy fees from Arthrex and Paragon28; institutional research support from Arthrex, Paragon28, and Stryker. Clifford L. Jeng, MD, reports consultancy fees from Smith & Nephew. Disclosure forms for all authors are available online., (© The Author(s) 2024.)

Study Design: Cross-sectional survey., Objectives: Injury classifications are important tools to identify fracture patterns, guide treatment-decisions and aid to identify optimal treatment plans. The AO Spine-DGOU Osteoporotic Fracture (OF) classification system was developed, and the aim of this study was to assess the reliability of this new classification system., Methods: 23 Members of the AO Spine Knowledge Forum Trauma participated in the validation process. Participants were asked to rate 33 cases according to the OF classification at 2 time points, 4 weeks apart (assessment 1 and 2). The kappa statistic (κ) was calculated to assess inter-observer reliability and intra-rater reproducibility. The gold master key for each case was determined by approval of at least 5 out of 7 members of the DGOU., Results: A total of 1386 ratings (21 raters) were performed. The overall inter-rater agreement was moderate with a combined kappa statistic for the OF classification of 0.496 in assessment 1 and 0.482 in assessment 2. The combined percentage of correct ratings (compared to gold-standard) in assessment 1 was 71.4% and 67.4% in assessment 2. The average intra-rater reproducibility was substantial (κ = 0.74, median 0.76, range 0.55 to 1.00, SD 0.13) for the assessed fracture types., Conclusions: The assessed overall inter-rater reliability was moderate and substantial in some instances. The average intra-rater reproducibility is substantial. It seems that appropriate training of the classification system can enhance inter- and intra-rater reliability., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The AO Spine-DGOU Injury Classification System was developed and funded by AO Spine through the AO Spine Knowledge Forum Trauma, a focused group of international spine trauma experts. AO Spine is a clinical division of the AO Foundation, which is an independent medically-guided not-for-profit organization. Individual authors of this manuscript have no disclosures to declare regarding the proposed article.

The 3D printing of porous titanium scaffolds reduces the elastic modulus of titanium alloys and promotes osteogenic integration. However, due to the biological inertness of titanium alloy materials, the implant-bone tissue interface is weakly bonded. A calcium silicate (CS) coating doped with polymetallic ions can impart various biological properties to titanium alloy materials. In this study, CuO and SrO binary-doped CS coatings were prepared on the surface of 3D-printed porous titanium alloy scaffolds using atmospheric plasma spraying and characterized by SEM, EDS, and XRD. Both CuO and SrO were successfully incorporated into the CS coating. The in vivo osseointegration evaluation of the composite coating-modified 3D-printed porous titanium alloy scaffolds was conducted using a rabbit bone defect model, showing that the in vivo osseointegration of 2% CuO-10% SrO-CS-modified 3D-printed porous titanium alloy was improved. The in vitro antimicrobial properties of the 2% CuO-10% SrO-CS-modified 3D-printed porous titanium alloy were evaluated through bacterial platform coating, co-culture liquid absorbance detection, and crystal violet staining experiments, demonstrating that the composite coating exhibited good antimicrobial properties. In conclusion, the composite scaffold possesses both osteointegration-promoting and antimicrobial properties, indicating a broad potential for clinical applications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury., Methods: The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test., Results: Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified., Conclusion: Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Hans Polzer, MD, reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Arthrex GmbH. Sebastian F. Baumbach, MD, reports collaborative research, paid lectures, and support for attending meetings and/or travel from Arthrex. Disclosure forms for all authors are available online.

Introduction: The objective of the present study is to assess the impact of the triglyceride-glucose index (TyG index) on the prognosis and explore the correlation between the TyG index and all-cause mortality in femoral neck fracture patients., Materials and Methods: In this retrospective cohort study, we analyzed the TyG index in the follow-up of femoral neck fracture patients who underwent partial hip prosthesis. The formula of ln [fasting triglycerides (mg/dL) x fasting blood glucose concentration (mg/dL)/2] was used in the calculation of the TyG index. The patients were separated into three categories based on the TyG index., Results: It was found that there was a significant correlation between prolonged hospital stay and elevated admission and postoperative TyG index ( P = 0.011, P < 0.001, respectively). The Kaplan-Meier survival analysis curves revealed a higher risk of 30-day, 90-day and overall mortality in patients with higher postoperative TyG index levels, categorized by postoperative TyG tertiles (log-rank P < 0.001, P < 0.001 and P = 0.001, respectively). In the multivariate Cox proportional hazard models, higher postoperative TyG index was a significant risk factor for mortality ( P = 0.01). The receiver operating characteristic analysis indicated that a postoperative TyG index of 9.01 and above was critical for 30-day mortality (69% sensitivity, 82% specificity and 0.78 area under curve; P < 0.001)., Conclusions: In our study demonstrate that the TyG index may be useful in identifying individuals at high risk of mortality in patients with femoral neck fractures., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Study Design: Retrospective Cohort Study., Objective: To identify risk factors for sacroiliac (SI) joint fusion after instrumented spinal fusion., Methods: Patients were identified from the PearlDiver BiscayneBay database. Patients who underwent 1 level (CPT: 22840), 3-6 vertebral segment (22842), and 7+ vertebral segment spinal fusions (22843 and 22844) were identified. Patients were separated based on whether they received an SI joint fusion (27280 and 27279) after their spinal fusion. A univariate analysis and multivariate logistic regression was performed to evaluate the associations between patient factors and incidence of SI joint fusion., Results: 549,625 patients who underwent posterior spinal fusions were identified, 6068 of whom underwent subsequent SI joint fusion (1.1%). Factors associated with future SI joint fusion included female gender, patients with obesity, fibromyalgia, diabetes, tobacco use, increased construct length, and prior SI joint injection. Prior SI joint injection had the highest odds ratio (OR: 8.70; 95% CI: 8.25-9.16; P < 0.001), followed by 7+ vertebral segment (OR: 2.17; 95% CI: 2.03-2.33; P < 0.001) and 3-6 vertebral segment fusion (OR: 1.49; 95% CI: 1.42-1.57; P < 0.001)., Conclusions: The highest predictor of requiring subsequent SI joint fusion is a prior SI joint injection. We also found that longer fusion constructs are associated with increased risk for future SI joint fusion., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Clifford Lin: Grants/Contracts: AO Spine North America, Medtronic. Consulting: Depuy. Meeting/Travel Support: North American Spine Society Biologics Committee. Jung U Yoo: Royalties/Licenses: Osiris Therapeutics.

The combination of double antegrade intramedullary pinning with proximal interphalangeal joint transfixation offers an effective and minimally invasive approach to reduce the complications of joint stiffness and functional disability. Level of evidence: V.

This study aimed to analyse and contrast changes in health-related quality of life (HR-QoL) and hand symptoms in the first 6 months after surgical treatment for primary cubital tunnel syndrome. Data originated from the United Kingdom Hand Registry. HR-QoL was assessed using the generic EuroQol five-dimensional assessment tool (EQ-5D-5L) and hand symptoms using the Patient Evaluation Measure (PEM). In total, 281 patients were included in the statistical analysis. Cubital tunnel release resulted in clinically relevant relief of hand symptoms. However, no improvement in HR-QoL was detected by the EQ-5D-5L. As a result, current health economic models, such as those used by the National Institute for Health Care Excellence (NICE) in the UK, might conclude that cubital tunnel release is not cost-effective. This discrepancy requires exploration, and hand-specific preference-based measures might be needed for value-based healthcare in hand surgery. Level of evidence: III., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Study Design: Retrospective cohort study., Objectives: Atypical hangman's fractures are associated with increased risk for neurologic injury due to involvement of the posterior cortex of the axis body. We present the largest single-center cohort of atypical hangman's fractures with the goal of guiding treatment decisions and outcomes based on fracture classification., Methods: We performed a retrospective analysis of all patients with atypical hangman's fractures treated at a single Level I trauma center between January 2010 and September 2023. 51 patients met inclusion criteria and demographic, treatment, and radiographic data were recorded and compared across the Type I and II fracture groups., Results: Final treatment modalities varied significantly between the groups ( P < 0.01), with hard cervical collar and invasive halo immobilization being the most prevalent treatments for fracture Types I and II respectively. One Type I fracture patient and four Type II fracture patients failed non-operative treatment, requiring surgery. Across both groups, posterior cervical fusion (73%) was the most common surgical approach. Median length of stay varied significantly between the two fracture groups (2.0 (1.0-7.0) vs 5.0 (3.0-8.0) days; P = 0.01). Irrespective of fracture type, longer hospital length of stay was associated with increased patient age (IRR = 1.02; P < 0.01), non-white race (IRR = 2.47; P = 0.01), injury caused by MVC (IRR = 1.93; P < 0.01), and the presence of non-spine orthopedic injuries (IRR = 1.72; P = 0.03)., Conclusions: While atypical Type I hangman's fractures may be managed effectively non-operatively with a hard cervical collar, atypical Type II fractures managed with a hard cervical collar are at greater risk of requiring subsequent surgical intervention., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Broad narrative review., Objectives: To review and summarize the evolution of spinopelvic fixation (SPF) and its implications on clinical care., Methods: A thorough review of peer-reviewed literature was performed on the historical evolution of sacropelvic fixation techniques and their respective advantages and disadvantages., Results: The sacropelvic junction has been a long-standing challenge due to a combination of anatomic idiosyncrasies and very high biomechanical forces. While first approaches of fusion were determinated by many material and surgical technique-related limitations, the modern idea of stabilization of the lumbosacral junction was largely initiated by the inclusion of the ilium into lumbosacral fusion. While there is a wide spectrum of indications for SPF the chosen technique remains is defined by the individual pathology and surgeons' preference., Conclusion: By a constant evolution of both instrumentation hardware and surgical technique better fusion rates paired with improved clinical results could be achieved., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Our survey of 38 surgeons shows that Ecological Momentary Computerized Adaptive Testing (EMCAT), a platform to remotely collect patient-reported outcome measures (PROMs) is acceptable to surgeons, and 36 of 38 are willing to participate in future randomized control trials comparing EMCAT versus routine follow-up. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Each author certifies that he has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: This study investigates the effectiveness of tibia periosteum distraction (TPD) applied to the tibial periosteum, an innovative approach grounded in Ilizarov's tension-stress theory, for the treatment of ischemic diabetic foot and vasculitic foot conditions., Methods: A retrospective analysis was conducted on 33 patients (36 limbs) who underwent TPD between June 2019 and May 2022. The study comprised 21 males (23 limbs) and 12 females (13 limbs), aged 41 to 80 years (mean age: 63.4 years). Diabetic foot accounted for 27 cases, thromboangiitis obliterans for 2 cases, and arterial occlusive disease for 4 cases. The distribution of affected limbs included 15 left feet and 21 right feet. Periosteum traction commenced on the third postoperative day at a rate of approximately 0.75 mm/day, adjusted biweekly. The traction device was removed after two weeks. Evaluation included capillary refill and wound healing assessment, along with pre- and postoperative analysis of foot skin temperature, ankle-brachial index (ABI), visual analogue scale (VAS) pain scores, and peripheral blood oxygen saturation. CT angiography (CTA) was utilized to assess vascular conditions in both lower limbs., Results: All 33 patients were successfully followed up for a duration ranging from 4 to 24 weeks (mean: 11.03 weeks). VAS pain scores significantly decreased from preoperative (5.09 ± 1.70, range: 2-8) to postoperative two weeks (2.24 ± 0.90, range: 1-4) (t = 9.44, p < .001). Oxygen saturation levels increased from 83.88% ± 11.82% (range: 58%-97%) preoperatively to 91.36% ± 5.69% (range: 76%-98%) at two weeks postoperatively (t = -4.21, p < .001). Foot skin temperature also showed a significant increase (t = -3.98, p < .001). Capillary refill test at two weeks postoperatively demonstrated notable improvement. CTA revealed evident neovascularization in the operated limbs compared to preoperative conditions. Wound improvement was significant in all 33 patients within two months postoperatively., Conclusion: TPD emerges as a promising technique for chronic ischemic lower limb diseases, demonstrating favorable preliminary outcomes in wound healing promotion and amputation rate reduction. Nevertheless, large-scale randomized controlled trials are essential to further validate its efficacy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The uric acid-to-high-density lipoprotein cholesterol ratio (UHR) has emerged as a novel indicator of inflammatory and metabolic status. This study aims to examine the association between UHR and bone mineral density (BMD), as well as the risk of osteoporosis, in individuals aged ≥50 years. Methods: This cross-sectional study used data from the National Health and Nutrition Examination Survey, focusing on participants aged ≥50 years. Femoral neck BMD (FN-BMD) was measured using dual-energy X-ray absorptiometry. Linear regression models were employed to examine the association between UHR and FN-BMD. Additionally, generalised additive models were used to assess the nonlinear relationship between UHR and FN-BMD. Logistic regression models were employed to evaluate the association between UHR and the risk of osteoporosis. Results: Finally, the study included 2963 adults with a mean age of 64.16 ± 8.92 years. Linear regression analyses revealed a positive association between UHR and FN-BMD, regardless of covariate adjustments. Logistic regression analyses indicated that elevated UHR was associated with a reduced risk of osteoporosis with or without covariate adjustments. Subgroup analyses revealed that the positive association between UHR and BMD was significant in individuals aged ≥65 years but not in those aged 50 to 64 years. Interaction analyses by age showed significant differences after adjusting for all covariates. Conclusions: Clinicians should be vigilant regarding the potential risk of osteoporosis in individuals with a low UHR. UHR might serve as a risk indicator for osteoporosis., Competing Interests: Declaration of conflicting interestsThe author(s) declare that there are no potential conflicts of interest related to the research, authorship, and/or publication of this article.