JBJS Open Access最新文献

Background: Surgery in patients with hip fracture on direct oral anticoagulants (DOACs) is frequently delayed because of concerns about bleeding risk. However, evidence supporting such delays remains limited, and institutional practices vary widely. This study aims to determine whether early surgery within 24 hours is associated with a greater perioperative hemoglobin decrease compared with delayed surgery after 24 hours or more in patients with hip fracture on DOACs.

Methods: This multicenter retrospective cohort study included patients with hip fracture aged ≥70 years on DOACs at admission across 5 hospitals from 2018 to 2023. Patients were stratified by time to surgery: <24 hours (early surgery) versus ≥24 hours (delayed surgery). The primary outcome was hemoglobin decrease in mmol/L. Secondary outcomes included a hemoglobin decrease of more than 2 mmol/L, preoperative and postoperative blood transfusion, packed red blood cells administered, postoperative anemia, hospital length of stay, and in-hospital and 30-day mortality. Multiple linear regression and multiple imputation were applied.

Results: Among the 875 patients included, 504 underwent early surgery and 371 underwent delayed surgery. Early surgery was associated with a lower median decrease in hemoglobin levels (0.6 vs. 0.9 mmol/L, p < 0.001); with an adjusted mean difference of -0.25 mmol/L (95% CI, -0.37 to -0.13, p < 0.001). No significant differences were observed in a hemoglobin decrease of more than 2 mmol/L, blood transfusion rates, postoperative anemia, or in-hospital and 30-day mortality. Early surgery was associated with a shorter hospital length of stay median 2 days (95% CI, 2-3; p < 0.001).

Conclusions: Early surgery within 24 hours was associated with a modestly smaller hemoglobin decrease and a shorter hospital length of stay, without an increased blood transfusion rate or mortality rates compared with delayed surgery. These findings suggest that early surgery in patients with hip fracture on DOACs may be safe and potentially beneficial in reducing hospital length of stay.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

» Conventional treatment of shoulder periprosthetic joint infection (PJI) consists of prolonged intravenous (IV) antibiotics injected into a PICC line. This method can be associated with adverse events such as catheter-related infections, extended hospitalizations, and higher medical costs. » The OVIVA trial demonstrated that oral antibiotics are no less effective than IV antibiotics as previously thought for complex orthopedic infections. These findings have sparked interest in the use of oral antibiotics for shoulder PJI. » Current data on the use of oral antibiotics in shoulder PJI is limited but growing. A number of studies assess the effects of oral antibiotic therapy on the shoulder, with most being small and retrospective. » Early evidence in shoulder PJI suggests that oral antibiotic therapy may provide satisfactory outcomes in select cases, though confirmation in high-quality, multicenter trials is essential.

Background: Managing medial compartment knee osteoarthritis (OA) with anterior cruciate ligament (ACL) deficiency, particularly in younger, active patients, remains challenging. Medial unicompartmental knee arthroplasty (UKA) combined with ACL reconstruction (ACLR) (UKACL) has gained interest, yet outcomes remain incompletely defined. This systematic review aims to evaluate the clinical effectiveness, implant survivorship, complications, and patient-reported outcomes after combined UKA and ACLR in end-stage medial OA with ACL deficiency.

Methods: We systematically searched PubMed, Embase, Scopus, and Web of Science. Studies reporting outcomes of UKA performed with ACLR were included; case reports, technical notes, and biomechanical studies were excluded. Risk of bias was assessed with ROBINS-I V2. We extracted clinical outcomes, implant survival, complications, radiographic findings, and validated functional scores.

Results: Fourteen studies comprising 353 patients met the inclusion criteria. Reported survivorship consistently exceeded 90% at 10 years. Ten revisions were reported, most commonly for lateral OA progression. Overall complication rate was 9.06% with no difference between mobile-bearing and fixed-bearing designs. Mobile-bearing implants had a slightly higher bearing dislocation risk, whereas fixed-bearing designs showed marginally higher polyethylene wear. Functional outcomes improved across studies.

Conclusion: Combined UKA and ACLR appears effective for younger, active patients with isolated medial OA and ACL deficiency, yielding high survivorship and consistent functional gains. Given heterogeneity among studies, high-quality, long-term randomized trials are needed to refine patient and implant selection.

Level of evidence: Level IV, systematic review of nonrandomized studies. See Instructions for Authors for a complete description of levels of evidence.

Background: Although arthroscopic rotator cuff repair (ARCR) is widely performed for rotator cuff tears, the extent to which manual laborers can return to their original occupations remains unclear. This study aimed to evaluate the proportion of manual workers who change or discontinue their professional activity following ARCR.

Methods: A retrospective review was conducted of patients who underwent ARCR by a single surgeon between December 2010 and June 2014. Inclusion criteria were a minimum follow-up of 9 years and employment in a manual labor occupation before surgery. Patients completed a long-term follow-up assessment, which included a professional activity questionnaire (primary outcome) and shoulder function evaluations (secondary outcome).

Results: A total of 165 patients (55 women, 110 men; mean age 53 ± 5 years at the time of surgery) were followed for an average of 11 ± 1 years. Of these, 128 patients (77%) resumed the same occupation postoperatively, while 37 patients (23%) changed or discontinued their work. There was no group difference for the subjective shoulder value at the final follow-up between physical workers and repetitive workers (p = 0.75). A significant association was found between occupational change and poorer shoulder function, as reflected by lower Constant scores (p = 0.008). The median time to occupational change was 12 months (interquartile range: 6-60 months). The mean was 29.7 ± 33.8 months. Change in professional activity was not associated with the presence of a full-thickness retear (p = 0.70), initial tear type (p = 0.23), or sex (p = 0.09). However, salaried employees were more likely to change their occupation than self-employed individuals (p = 0.02).

Conclusions: Most manual workers can maintain their original occupation following ARCR. However, approximately 1 in 4 patients changes or abandons their job, potentially due to suboptimal shoulder function. Self-employed individuals appear less likely to modify their professional activity.

Clinical relevance: Manual laborers undergoing ARCR can generally expect to resume their professional duties. Nevertheless, persistent shoulder symptoms may necessitate a career transition in some cases.

Level of evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Orthopedic infections, including fracture-related infection and periprosthetic joint infection (PJI), remain difficult to eradicate because bacteria within biofilms exhibit high tolerance to systemic antibiotics. Conventional antibacterial strategies based on minimum inhibitory concentration often fail in the biofilm environment, where substantially higher antimicrobial concentrations are required. Continuous local antibiotic perfusion (CLAP) has emerged as a technique that enables sustained delivery of high local antibiotic concentrations directly to the infected site while providing continuous drainage using negative pressure wound therapy.

Methods: This narrative review summarizes the principles, technical aspects, clinical indications, and reported outcomes of CLAP. A literature search of the MEDLINE database was conducted up to July 2025 using the term "continuous local antibiotic perfusion." Clinical studies describing the use of CLAP in orthopedic infections, including case reports, case series, and retrospective studies, were reviewed. Perfusion strategies (iMAP, iSAP, iJAP, and TRAP), antibiotic regimens, safety considerations, and current limitations were analyzed.

Results: CLAP enabled delivery of high local antibiotic concentrations exceeding the minimum biofilm eradication concentration while maintaining relatively low systemic exposure. Favorable outcomes for infection control, implant retention, and fracture union, were reported across various intractable infections, including fungal PJI. Complications such as transient elevations in serum antibiotic levels and renal dysfunction were reported but appeared to be infrequent. Although CLAP has shown potential utility in refractory infections, further high-quality studies with rigorous safety evaluations are required to strengthen the evidence base.

Conclusion: CLAP is a promising adjunctive strategy for challenging orthopedic infections, offering targeted high-concentration antibiotic delivery with effective drainage. However, current evidence is limited to low-level studies. Prospective trials, standardized protocols, and long-term safety evaluations are needed to define its role in clinical practice.

Background: Rock climbing participation in the United States has grown markedly, yet recent epidemiologic data are limited. This study characterizes national trends, injury patterns, and risk factors for severe injuries among climbers treated in US emergency departments from 2014 to 2023.

Methods: Rock climbing-related injuries were identified in the National Electronic Injury Surveillance System database. Injuries were analyzed by type, body region, mechanism, and demographic group. Weighted logistic regression assessed fracture and hospitalization risk by age and fall height.

Results: From 2014 to 2023, an estimated 47,251 injuries occurred. Fractures (26.8%) were most common, followed by sprains/strains (20.4%), soft tissue (10.2%), and lacerations (8.0%). Lower extremities were most frequently injured (50.6%), followed by upper extremities (26.7%) and torso (14.9%). Falls (58.8%) were the leading mechanism; falls >20 ft carried 52% higher fracture risk (odds ratio = 1.52, [1.41-1.63]). Adults 21 to 45 years accounted for 63.1% of cases. Climbers >45 years had 45% higher fracture odds compared with those 7 to 20 years. Hospitalization occurred in 9% of cases.

Conclusion: Fractures and lower extremity injuries are the most common presentations in US rock climbing Emergency Department visits. Older age and higher fall height were associated with increased severity of the injury.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: For intercalary defects after resection of pediatric sarcoma, an isolated vascularized free fibular graft (VFFG) offers a living bone option with the potential for durability but is underutilized due to concerns about mechanical sufficiency. By contrast, structural allograft is initially strong but is associated with a high complication profile with or without a composite VFFG (Capanna). Our aim was to compare the complications associated with allograft/VFFG composites to isolated VFFG.

Methods: This is a retrospective comparison of 32 pediatric patients with primary femoral or tibial sarcoma. Reconstructions were categorized into 2 groups: allografts + VFFG (Capanna) (Group 1, n = 9) and "single barrel" isolated VFFG (Group 2, n = 23). Descriptive and inferential statistical analyses were performed.

Results: No significant differences between the 2 groups were observed in age, sex, diagnosis, length of reconstruction, or follow-up (56 months (SD 29) for Group 1 and 53 months (SD 24) for Group 2). Group 1 participants exhibited a higher number of complications including the need for unplanned surgery (mean 2.9) compared with those in Group 2 (mean 1.6, p < 0.01). Disparities in bone healing were notable. At the final follow-up, 46% in Group 1 had achieved full consolidation compared with 96% in Group 2 (p = 0.002). Graft fractures and hardware failures were not different between the groups despite full weight-bearing among all subjects, suggesting mechanical equivalency within the follow-up period. The mean numbers of unplanned surgeries per participant were 4.2 ± SD 4.4 and 2.3 ± SD 2.5 for Groups 1 and 2, respectively (p = 0.149).

Conclusions: Isolated single barrel VFFG reconstructions are structurally sound and had fewer complications and faster union than composite allograft/VFFG composites.

Level of evidence: Retrospective cohort study Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Competency-based medical education relies on assessment to evaluate performance and guide learning. This study compared the validity evidence and psychometric performance of the Objective Structured Assessment of Technical Skills (OSATS), adapted for distal radius fracture fixation, with a procedure-specific instrument-the Distal Radius Fracture Assessment of Technical Expertise (DRF-RATE)-for assessing technical performance during volar locking plate (VLP) fixation of distal radius fractures (DRFs).

Methods: First-year orthopaedic residents (n = 12) and practicing trauma or hand surgeons (n = 13) performed standardized VLP fixation on a cadaveric DRF model. Anonymous video recordings were independently assessed by 2 orthopaedic trauma surgeons and 2 hand surgeons using either OSATS or DRF-RATE. Validity evidence was gathered in accordance with the Messick contemporary validity framework.

Results: Internal consistency reliability was good-to-excellent for OSATS (α = 0.82-0.98) and DRF-RATE (α = 0.95). Interrater reliability was weaker for OSATS (r = 0.59-0.69) than for DRF-RATE (r = 0.78), though both demonstrated systematic rater bias. OSATS discriminated between novices and experienced surgeons (p = 0.02), whereas DRF-RATE demonstrated even stronger discrimination (p < 0.001). Contrasting-groups analysis revealed higher misclassification rates with OSATS (21%-40%) than DRF-RATE (11%-13%), indicating superior accuracy for the latter.

Conclusions: The DRF-RATE demonstrated stronger and more comprehensive validity evidence than the modified OSATS, with better reliability, higher discrimination and classification accuracy, and overall superior psychometric performance compared with OSATS. Its procedural granularity and structured design address key limitations of OSATS and support detailed, high-quality formative feedback for distal radius fracture fixation.

Background: This 5-year longitudinal study evaluated changes in occupational radiation exposure and radiation-induced skin injury among orthopaedic surgeons, focusing on the effects of educational campaigns.

Methods: Orthopaedic surgeons at Hirosaki University were surveyed in 2019 and 2024. Self-reported weekly fluoroscopy ("beam-on") time and dermatologist-graded hand skin findings were compared. Educational campaigns (2020-2023) emphasized As Low As Reasonably Achievable principles and personal protective equipment. We hypothesized that repeated education would improve radiation-safety attitude, reduce self-reported fluoroscopy time, and mitigate dermatologic injury.

Results: The proportion of surgeons cautious about radiation increased from 5.8% to 70.9%. The median weekly self-reported fluoroscopy time decreased from 9.5 to 8.0 minutes (p = 0.045). The prevalence of radiation-induced skin injury declined from 34.9% to 25.6%. Inter-rater reliability was excellent (weighted κ = 0.910). Nonspine surgeon status predicted improvement in skin condition.

Conclusions: During the 5-year period in which repeated radiation-safety education was conducted, surgeons demonstrated improved safety attitudes, decreased self-reported fluoroscopy time, and improved dermatologist-graded skin findings. These observations indicate an association between educational activities, self-reported exposure, and skin findings, but do not establish causality because exposure was self-reported and the study lacked a control group.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder primarily managed with transphyseal screw fixation. Opioid pain medication is often used postoperatively, but there is little evidence to guide prescribing practices. The purpose of this study was to describe opioid utilization and prescribing practices for patients after screw fixation of SCFE.

Methods: This was a prospective observational study of patients with SCFE who underwent transphyseal screw fixation. Patients and guardians were contacted on postoperative days 1, 3, and 5 for data collection. Postdischarge analgesic use, pain severity using a parental proxy, and pain control satisfaction were recorded. Patients who underwent surgical osteotomy or open reduction, patients with cognitive disability, or patients who had other injuries impeding accurate pain assessments were excluded.

Results: Of the 34 patients recruited for the study, 91.2% (31/34) of patients were prescribed opioid medications. Of these 31 patients, 4 were lost to follow-up (87% follow-up). In total, 266 opioid doses were prescribed and 28 were used (p < 0.0001). On average, patients were prescribed 9.85 ± 3.8 opioid doses but used an average of 0.77 ± 1.27 opioid doses (p < 0.0001). Sixty percent of patients did not use any of their prescribed opioid medication, and 90% were satisfied with their pain postoperatively. In addition, 90% of prescribed opioid doses went unused. There was no significant difference in pain control between patients who took opioids and those who did not for each postoperative day. Analysis of opioid use distribution demonstrated that a prescription of 3 doses postoperatively would be sufficient for greater than 95% of all patients.

Conclusions: Overprescription of opioids occurs following screw fixation of SCFE, introducing oversupply into the population. Most patients do excellently with minimal opioid use and have low levels of pain. With adequate nonopioid analgesia counseling and use, outpatient opioid prescriptions following screw fixation of SCFE should be limited. If providers elect to prescribe opioids, we recommend prescribing no more than 3 doses following screw fixation of SCFE.

Level of evidence: Level II. See Instructions for Authors for a complete description of levels of evidence.