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Background: Despite broad calls to consider sex-specific effects in treatment/intervention studies, this remains a persistent gap. This study sought to identify presurgery factors associated with pain and physical function following hip and knee total joint arthroplasty (TJA) for osteoarthritis, specifically adopting a sex-stratified approach.

Methods: Questionnaires were patient-completed presurgery: sociodemographic and health-related characteristics, anxiety and depression symptoms, neuropathic-like pain symptoms, multijoint involvement, and opioid use. Pain and physical function were captured presurgery and 1 year postsurgery. Study outcomes: pain and function status scores at 1 year and their percentage change (presurgery to 1 year postsurgery). Associations between presurgery factors and outcomes were assessed by sex-stratified multivariable linear regressions. Findings were contrasted against a sex-adjusted approach (i.e. one analysis in combined male/female sample).

Results: Sample (45% hip, 55% knee): 787 female patients and 640 male patients. Among male patients only: Depressive symptoms were associated with worse pain and function status, and less pain improvement (β = -8.6% [-17.4%, 0.3%]), as were lower education and living alone. Among female patients only: Anxiety symptoms were associated with worse pain and function status and less pain (β = -7.7% [-14.3%, -1.0%) and functional improvement (β = -8.5% [-14.4%, -2.6%]), as was greater multijoint burden. The negative effect of neuropathic-like pain symptoms was greater in male patients than female patients. Sex-adjusted findings suggested sex had no consequence.

Conclusions: Several factors uniquely influenced TJA outcomes by sex. Simple sex-adjustment may miss important effects. This has broad implications, including for patient education, decision making, prognostic/comparative effectiveness study design, and development/improvement of prediction algorithms. Though TJA focused, we hypothesize that sex differences are likely relevant in other clinical populations.

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

Background: Venous thromboembolism (VTE) includes pulmonary embolism (PE), and deep vein thrombosis (DVT) and is a complication of total hip and knee (THR/TKR) joint replacement surgery. Guidelines historically recommended anticoagulation thromboprophylaxis for patients undergoing elective THR/TKR, and aspirin has emerged as an alternative for select patients. VTE risk stratification may identify patients who can safely receive aspirin. Limited evidence informs how to risk-stratify THR/TKR patients, then recommend risk-stratified thromboprophylaxis.

Methods: We derived and implemented "Standardized Thromboembolism Prophylaxis in Orthopedic Patients to prevent Venous ThromboEmbolism (STOP-VTE)," an evidence-based electronic heath record embedded VTE risk assessment model in our 23-hospital-integrated health system. The model classified patients as at high or standard risk of VTE and recommended anticoagulation (mostly apixaban 2.5 mg twice daily for 28 days) or aspirin (81 mg twice daily) prophylaxis, respectively. The primary implementation outcome for this prospective management study was adherence to STOP-VTE guidance, and the primary clinical outcome was VTE. Among 38,207 consecutive patients, we recorded surgeon adherence to STOP-VTE guidance and outcome rates of 90-day VTE, PE, DVT, mortality, and rates of 30-day major bleeding, emergency department visits, and hospitalization. Outcomes were recorded for 2 years preceding implementation of STOP-VTE (baseline) and for 6.8 years after STOP-VTE implementation (intervention).

Results: For the primary implementation outcome during the baseline period, 57.4% (1,467/2,554) received aspirin or anticoagulant prophylaxis consistent with risk classification, and during the intervention, this rate increased to 77.8% (27,744/35,653; p < 0.001). Clinical outcome rates at baseline vs. intervention were the following: for 90-day VTE, 0.9% vs. 0.65%; PE, 0.7% vs. 0.39%; DVT, 0.31% vs. 0.29%; and mortality, 0.16% vs. 016%. Thirty-day major bleeding was 0% vs. 0.04%; emergency department and rehospitalization rates were 6.97% vs. 5.31% and 2.45% vs. 1.71%, respectively. Pulmonary embolism, emergency department, and hospitalization visit rates significantly declined.

Conclusion: STOP-VTE guidance was implemented and broadly adopted. Adherent chemoprophylaxis was associated with low rates of 90-day VTE, major bleeding, decrease in anticoagulant chemoprophylaxis, increase in aspirin chemoprophylaxis, and cost savings.

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

Objectives: Correctly diagnosing periprosthetic joint infection (PJI) remains a major clinical challenge. While acute PJI is straightforward to identify because of its pronounced clinical presentation, chronic infections remain challenging to detect since clinical signs are subtle and standard criteria lack sensitivity. By analyzing a wide range of serum and synovial parameters in patients undergoing revision arthroplasty, we sought to identify the most accurate diagnostic PJI markers.

Methods: A retrospective analysis of 400 patients undergoing knee or hip revision arthroplasty, including 145 patients who had PJI and 255 patients who had aseptic failure, was conducted. Diagnosis of PJI was established using the 2018 International Consensus Meeting criteria. A comprehensive evaluation of medical records, serum, and synovial biomarkers was performed. For each marker, receiver operating characteristic curves, calculating the area under the curve and optimal cutoff values, were determined.

Results: Synovial biomarkers such as alpha-defensin and C-reactive protein did not demonstrate superior diagnostic performance compared with polymorphonuclear neutrophil (PMN) count and percentage. Importantly, low synovial lymphocyte percentage (<34.7%) emerged as the most accurate marker for PJI diagnosis (area under the receiver operating characteristic curve [AUC] = 0.96, sensitivity = 0.85, specificity = 0.96), independent of location or infection subtype (acute and chronic). This was further supported by a conditional inference tree model for diagnosing chronic PJI, which identified synovial lymphocyte percentage and PMN count as key decision nodes and demonstrated excellent diagnostic performance (AUC = 0.95; sensitivity = 0.93; specificity = 0.91).

Conclusions: Our study provides evidence that low synovial lymphocyte percentage is a reliable diagnostic marker of PJI. Integrating the assessment of synovial lymphocytes into clinical practice could enable more timely diagnosis and, therefore, effective treatment, ultimately improving patient outcomes. However, as this was a single-center study limited to hip and knee revision, external validation is warranted to confirm the generalizability of our findings.

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

Background: The healthcare sector significantly affects the environment, with hospitals consuming more energy and producing more waste than other nonresidential buildings. The shift toward outpatient total shoulder arthroplasty (TSA) is driven by increasing demand and cost reduction, yet the environmental implications of this remain poorly understood. We hypothesize that the inpatient stay accounts for 20% of TSA's environmental impact. This study aims to quantify the environmental impact of TSA using life cycle analysis (LCA) and waste audit, and to identify opportunities for sustainability.

Methods: Patients eligible for outpatient TSA between June 2023 and March 2024 were included. LCA evaluated 4 phases of care: preoperative (preop), operative (OR), postanesthesia care unit (PACU), and a 23-hour inpatient stay. Waste audits quantified surgical and inpatient waste. Patient demographics were collected through chart review.

Results: Twenty-one patients (average age 62 years) were included. Average surgical and inpatient waste was 19.6 kg (12.3 kgCO₂e) and 4 kg (2.73 kgCO₂e), respectively. Average total TSA emissions were 148.2 kgCO₂e, equivalent to driving 379 miles in a gasoline-powered vehicle. Emissions by phase: OR (61%), anesthesia (27%), inpatient (9%), preop (2%), and PACU (1%). Major contributors included anesthetic supplies, surgical packs, and anesthetic medications.

Conclusion: TSA's environmental impact may be mitigated by performing outpatient procedures, minimizing inhaled anesthetics, adopting reusable devices, and customizing surgical packs. Recognizing the environmental implications of surgical practices is essential to balancing patient care, public health, and environmental sustainability.

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

Background: Obesity (body mass index ≥30 kg/m²) is a global health challenge and a known risk factor of knee osteoarthritis (KOA), increasing the need for total knee arthroplasty (TKA). Obese patients face higher risks of early implant failure and revision, often linked to malalignment. Navigation-assisted surgery (NAS) improves precision in achieving mechanical alignment, but its impact in obese patients remains underexplored. This randomized, controlled, open-label, multicenter trial evaluated short-term radiographic outcomes, focusing on coronal alignment, in obese patients undergoing TKA with NAS versus conventional instrumentation. The primary hypothesis was that NAS would result in a higher rate of mechanical axis alignment within a predefined target (180° ± 3°).

Methods: A total of 159 obese patients with symptomatic KOA were randomized 1:1 at 2 hospitals to undergo TKA with either NAS or conventional guides. Mechanical axis alignment was assessed 1 year postoperatively using long-standing radiographs. Secondary end points included femoral and tibial component alignment, surgical time, complications, range of motion, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, visual analog scale, and EuroQol-5D.

Results: In total, 154 patients were analyzed. Proper mechanical axis alignment (180° ± 3°) was achieved in 69% of NAS cases vs. 47% in controls (p = 0.006; OR = 2.5; 95% confidence interval: 1.29-4.83). The mean deviation was -1.59° (SD 3.02) in NAS vs. -2.15° (SD 3.56) in controls. Tibial alignment outliers occurred in 16% (12/73) of NAS vs. 32% (23/71) in controls (p = 0.026). Surgical time was longer with NAS (70 min [interquartile range (IQR) 63-76] vs. 59 min [IQR 55-67], p < 0.001). No differences were found in complications or hospital stay. Functional outcomes improved similarly in both groups at 1 year.

Conclusion: NAS significantly improves precision in achieving mechanical alignment in obese patients undergoing TKA. Despite similar clinical outcomes, NAS offers superior radiographic accuracy. Longer term studies are needed to assess effects on implant survival and patient-reported outcomes.

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

» The coronal plane alignment of the knee (CPAK) classification is a practical and straightforward framework to define a patient's constitutional coronal knee limb alignment and joint line obliquity. » Patients are assigned to one of nine phenotypes using two straightforward calculations; the arithmetic hip-knee-ankle angle (aHKA) and the arithmetic joint line obliquity (aJLO). » CPAK allows clear understanding of the geographical and gender variations in knee alignment, as well as the differing outcomes of knee reconstructive surgery, based on phenotype. » CPAK enables surgeons to tailor their alignment strategy to best fit a patient's constitutional phenotype and avoid the drawbacks of a "one-size fits all" approach.

Background: Cephalomedullary nailing systems, such as the trochanteric femoral nail advanced (TFNa), are standard of care for trochanteric fractures. The TFNa system allows for the use of either a helical blade or a lag screw for femoral neck fixation, but there is ongoing debate regarding which component provides superior outcomes. The aim of this study was to compare the performance of these two components in maintaining fracture reduction and preventing mechanical complications.

Methods: A prospective cohort study enrolled 201 patients aged 50 years or older with type 31A1-31A2 (pertrochanteric) and 31A3 (intertrochanteric) fractures, as classified by the Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA), all treated with the short TFNa. Patients were allocated to helical blade (n = 101) or lag screw (n = 100) cohorts. Radiographic outcomes-changes in the tip-apex distance (TAD), femoral neck shortening, and changes in the neck-shaft angle (NSA)-were assessed at 3 months. Secondary outcomes included mechanical complications, patient-reported outcome measures (PROMs), and number of patients deceased at 1-year follow-up.

Results: Radiographic outcomes among pertrochanteric fractures-femoral neck shortening, NSA, and TAD changes-were comparable between cohorts. Owing to limited power, no conclusions could be drawn for intertrochanteric fractures. Mechanical complication rates were similar between groups (blades: 4.0%, screws: 6.0%), with no significant association between femoral neck component and complications. A postoperative TAD greater than 20 mm was significantly associated with increased mechanical complications (odds ratio = 4.4, p = 0.023). PROMs improved similarly in both groups over time, and the number of patients deceased within 1 year after the operation was identical in both cohorts.

Conclusions: The findings indicate that helical blades and lag screws offer comparable stability in pertrochanteric fracture fixation within the TFNa system. Femoral neck component choice does not significantly affect mechanical complication rates or clinical outcomes. Rather, optimal implant placement and a postoperative TAD under 20 mm are key to successful outcomes. These results support prioritizing surgical precision over component selection in managing pertrochanteric fractures.

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

Background: Selecting an orthopaedic surgery practice setting is a career-altering decision, yet guidance is often anecdotal. Despite existing resources, no consolidated data compare surgeon experiences across practice models. This study surveys orthopaedic surgeons across Texas and California, to quantify perceived strengths and weaknesses of academic, private, hospital-employed, and privademic practice environments.

Methods: An anonymous survey was distributed through professional networks and organizations between May 2024 and May 2025. Respondents identified their current and prior practice settings, subspecialties, and employment ZIP codes. They rated each practice setting in categories including autonomy, salary, ancillary income opportunities, education, research, administrative burden, reputation, community respect, and work-life balance. Responses were aggregated into a heatmap, with subgroup analysis conducted based on employment history and location.

Results: A total of 100 orthopaedic surgeons responded 45% academic, 30% private, 16% hospital-employed, and 8% privademic. Subspecialty distribution was balanced. Academic surgeons rated research opportunities, professional reputation, and continued education highly (p < 0.001), and ancillary income was rated poorly (p < 0.001). Private practitioners valued autonomy, salary, and ancillary income (p < 0.001), but rated research opportunities and continued education poorly (p < 0.001). Hospital-employed surgeons had no categories rated highly. Privademic surgeons had favorable views on autonomy, salary, and income opportunities (p < 0.001), and no categories were rated poorly. Regional comparison showed California surgeons perceived lower academic autonomy (p = 0.048) and work-life balance (p = 0.037), along with less favorable views on salary and income (p = 0.007).

Conclusions: This survey highlights distinct tradeoffs across orthopaedic practice models and locations. Academic models offer professional and educational benefits but are limited in financial upside, whereas private and privademic settings offer enhanced autonomy and compensation. California surgeons reported less favorable perceptions, especially with compensation, highlighting potential regional influences on employment satisfaction. These findings may inform future decisions in orthopaedic career planning and workforce policy.

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

Pragmatic trials have gained popularity in recent years because of their applicability to practical clinical situations. In contrast to traditional explanatory trials, which are tightly controlled and designed to define the effects of treatments under ideal circumstances, pragmatic trials are intended to reveal differences between established treatments in real-world situations. Although the intention-to-treat principle remains the cornerstone of explanatory trials, it may not reliably identify the treatment effect of greatest relevance in pragmatic trials. The estimand approach to trial design and analysis provides for specification and handling of various important intercurrent events that characterize pragmatic trials and arguably allows clearer definition of the treatment effects of interest for assorted real-world populations. Since pragmatic trials have considerable relevance to orthopaedics, we share the rationale for design and upcoming analysis of the Pulmonary Embolism Prevention after Hip and Knee Replacement Trial using an estimand framework.