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Introduction The incidence of periprosthetic distal femur fractures (PDFF) is increasing as the number of total knee replacements becomes more common. This study compared the demographics, fracture characteristics, treatment, and outcomes of periprosthetic versus native distal femur fractures (NDFF). Materials and methods This was a retrospective cohort study of patients ≥ 18 who underwent surgical fixation of NDFF or PDFF from 2012 to 2020 at a level-1 trauma center. The main variables collected included demographics, AO/OTA fracture classification, fixation construct, concomitant fractures, polytrauma rates, bone density, and reduction quality. Primary outcomes were unexpected return to the operating room (UROR), hospital length of stay, and quality of reduction. T-tests, Fisher’s exact tests, and multivariate analyses were used for statistical analysis. Results 209 patients were identified, including 70 PDFF and 139 NDFF. PDFF patients were elderly females (81%) with isolated (80%) and comminuted (85%) 33 A.3 (71%) fractures. NDFF patients included 53% females, were commonly middle-aged, and displayed comminuted (92%) 33 C.2 fractures. 48% of NDFF patients had concomitant fractures. Intramedullary nailing was the primary fixation for both groups, followed by nail-plate combination (37%) for PDFF and lateral locking plates (21%) for NDFF. NDFF patients experienced significantly longer hospital stays, higher UROR rates, and worse quality of reduction ( p  < 0.05). PDFF patients had a significantly greater prevalence of low bone density ( p  < 0.05). Conclusion PDFF occur as isolated injuries with significant metaphyseal comminution in elderly females with low bone quality. NDFF commonly occurs in younger patients with less metaphyseal comminution and concomitant fractures. Intramedullary nailing was the most common treatment for both groups, although preference for nail-plate combination fixation is increasing. NDFF type 33 C fractures are at greater risk of UROR.

Objectives: The United States (US) healthcare sector contributes to 8.5% of the nation’s carbon emissions. Reducing the carbon footprint of resource-intensive environments, such as operating rooms (OR), is essential for achieving net-zero carbon emissions in healthcare. Arthroscopic partial meniscectomy (APM) is the most commonly performed orthopaedic procedure in the US. This study aimed to quantify the carbon dioxide equivalent emissions associated with a standard knee arthroscopy procedure. Methods: The carbon footprint, measured in kilograms of carbon dioxide equivalents (kgCO2e), was used to estimate environmental impact. Measurements and energy usage were derived from the outpatient surgery at our institution. The carbon footprint for a standard APM procedure was calculated based on an average surgery time of 45 minutes in an OR measured at 528sq ft. Calculating OR energy usage took into account the lighting, heating, ventilation, and air-conditioning (HVAC) systems, anesthesia gases and equipment, arthroscopy equipment and sterilization processes (assuming 1.5 hours processing time and 3 specialty trays per case). Waste generated after each case was weighed and averaged. Standard conversions outlined by the US Environmental Protection Agency were used - 0.417kgCO2 per kWh and 3.5kgCO2 per 1kg of US landfill waste. Results: The carbon footprint on average of one APM was 46.2kgCO2e, equivalent to driving a gasoline-powered car for 118 miles. The largest contributor, accounting for 81.3% (37.6kgCO2e) of the carbon footprint was the waste generated during the procedure, followed by anesthesia, HVAC, arthroscopy tower, lighting, and sterilization (Table 1). With over 500,000 APMs performed annually in the US, this amounts to 23,100 metric tons CO2e, equivalent to the annual electricity use of 4559 homes. Conclusions: Environmental sustainability in orthopaedic surgery is an increasing area of interest. Understanding the environmental impact of commonly performed procedures is the first step toward reducing the carbon footprint of our healthcare ecosystem. The substantial carbon emissions from waste during these procedures underscore the need for optimizing waste disposal processes, increasing recycling and switching to reusables, to reduce the overall carbon footprint.

Objectives: There are no consensus guidelines for perioperative pain management in anterior cruciate ligament reconstruction (ACLR) surgery. The adductor canal block (ACB) is a motor-sparing alternative to femoral nerve block, with studies showing no difference in postoperative opioid consumption or pain. Few randomized studies have assessed its efficacy beyond the immediate postoperative period. The aim of this study was to compare the efficacy of a single preoperative ACB versus no block on postoperative pain control following ACLR. We hypothesized that ACB would reduce pain and opioid use without affecting functional outcomes. Methods: This was a prospective, randomized controlled trial of all adult patients undergoing primary ACLR at a single academic institution from 2018-2024. Patients were randomized to receive either ACB or no block (NB) preoperatively. All patients received a standardized preoperative regimen (400mg celecoxib, 300mg gabapentin, and 1000mg acetaminophen). The surgical team was blinded to the treatment intervention. Patients given hydromorphone were excluded from the study. All patients completed the Brief Resilience Scale (BRS) the day of surgery and scores were stratified into low, normal, or high resilience groups. Intraoperative fentanyl morphine equivalent doses (MED), postoperative visual analogue scale (VAS) pain level and MEDs were assessed in the post-anesthesia care unit (PACU) after 15 minutes and daily through 10 days postoperatively. Knee Injury and Osteoarthritis Outcomes Scores (KOOS) were completed at 6 and 12 weeks postoperatively. Results: 50 patients were analyzed (ACB, n=25; NB, n=25), with no differences in demographics or surgical characteristics. The cohort consisted of a young patient population (ACB mean age = 24.6, NB mean age = 23.6, p=0.39). The ACB group had a lower mean BRS (3.70 vs 4.11, p=0.02), though both groups remained within the “normal resilience” range. Intraoperative fentanyl MEDs were similar (2.48 vs 2.45, p=0.91). PACU VAS scores were significantly lower in the ACB group at 15 minutes postoperatively (3.40 vs 5.62, p<0.01), but no difference was noted from the time of discharge onwards (3.64 vs 4.24, p=0.24). VAS scores remained comparably low at 5 days (3.49 vs 3.70, p=0.70) and 10 days (3.06 vs 3.22, p=0.80) in both groups. No differences were seen in MED requirements in the PACU (18.08 vs 28.70, p=0.04), at 24 hours (33.28 vs 43.18, p=0.20), 5 days (58.16 vs 87.86, p=0.08), or 10 days (64.25 vs 84.10, p=0.28) postoperatively. No differences were observed in KOOS at 6 or 12 weeks. Conclusions: The addition of a preoperative ACB to a multimodal, non-opioid pain medication regimen improved immediate postoperative pain in ACLR patients, but these effects dissipated by 24 hours, offering no long-term benefit for pain control or opioid consumption.

Introduction : Effective postoperative pain management is imperative in total hip arthroplasty (THA) to enable early mobilization and accelerate recovery pathways. This study investigated the patterns of inpatient opioid consumption following THA and identified the factors associated with increased opioid usage. Methods : In this large-scale, single-institution study, we analyzed data from 1,867 primary THAs between April 2019 and July 2023. We collected data on demographics, length of stay (LOS), type of anaesthesia, Post Anaesthesia Care Unit (PACU) admissions, 30-day readmissions, total opioid consumption (MME; morphine milligram equivalents), implant fixation techniques, surgical characteristics and pre- and postoperative haemoglobin (Hb) levels. Factors associated with increased opioid consumption (patients in the ≥ 75th percentile of inpatient opioid consumption; MME ≥ 211.9 mg) were identified through univariate and multivariate logistic regression models. Results : The cohort included 1150 women (61.6%) and 717 men (38.4%). The median inpatient opioid use was 88 mg (IQR = 39.3–211.9). In the univariate model, significant predictors included age, American Society of Anaesthesiologists (ASA) score, manual THA technique, general anaesthesia, pre- and postoperative Hb levels, need for PACU admission and year of surgery. After adjusting for baseline demographics in the hierarchical multivariate logistic regression model, significant predictors of higher opioid utilization were age (OR 0.989 [95% CI 0.981–0.997], p  = 0.01), general anaesthesia (OR 2.386 [95% CI 1.865–3.054], p  < 0.001), PACU admission (OR 2.098 [95% CI 1.310–3.358], p  = 0.002), ASA score (OR 1.492 [95% CI 1.193–1.866], p  < 0.001), postoperative Hb levels (OR 0.981 [95% CI 0.970–0.992], p  < 0.001), and year of surgery (OR 0.638 [95% CI 0.579–0.703], p  < 0.001) indicating that later years were associated with lower odds of high opioid consumption). Discussion : Younger age, higher ASA scores, lower postoperative haemoglobin, the need for PACU admission and general anaesthesia were significantly associated with increased opioid consumption following THA. Recognizing these factors can facilitate the development of tailored postoperative pain management protocols, enabling targeted interventions that minimize opioid reliance while enhancing recovery.

Background: Talus fracture-dislocations with talar body extrusion (TBE) are a rare subtype of talus fracture that have been reported to occur in 1.2% of talus fractures. There is limited evidence on the outcomes of these injuries. The purpose of this study was to characterize injury patterns, operative management, and radiographic and reoperation outcomes of TBE. Methods: A retrospective review of talus fractures treated at a level 1 trauma center from 2016 to 2024 was performed. Radiographs and computed tomography scans were screened for TBE. Demographics, injury characteristics, operative details, reoperations, and radiographic complications were recorded. Outcomes were reported descriptively for patients with at least 6 months of follow-up, with a nested subanalysis of those with at least 12 months. Uneventful outcome was defined as no reoperation, no avascular necrosis (AVN) or nonunion, and no greater than grade 2 posttraumatic arthritis (PTA) at final follow-up. Results: Among 178 talus fractures, 18 TBEs were identified. Seventeen patients had at least 6 months of follow-up and 15 had at least 12 months. In the 6-month cohort, mean follow-up was 1.72 years; 15 patients (88%) underwent temporizing reduction with external fixation and/or percutaneous fixation, 16 underwent definitive ORIF, and 1 underwent primary TTC fusion. Reoperation occurred in 7 (41%), AVN in 6 (35%), nonunion in 4 (24%), and grade 3 or 4 PTA in 10 (59%); 4 (24%) had an uneventful outcome. In the 12-month subgroup, reoperation occurred in 7 (47%), AVN in 5 (33%), nonunion in 4 (27%), and grade 3 or 4 PTA in 10 (67%); 3 (20%) had an uneventful outcome. Conclusion: Complications and reoperations were common after open reduction and internal fixation for TBE, although a minority of patients achieved uneventful radiographic and surgical outcomes. Follow-up stratified reporting showed persistently high complication burden at 12 months, although a small subset maintained uneventful radiographic and surgical outcomes, including 3 of 15 patients with at least 12 months of follow-up. Level of Evidence: Level IV, case series.

Study Design A narrative review of the current literature on the application of Computer-Assisted Navigation (CAN) in cervical spine surgeries. Objective To analyze the perioperative integration, types of CAN systems, technical considerations, and clinical applications of CAN in cervical spine surgeries, as well as to assess the associated complications and potential strategies to minimize these risks. Methods A comprehensive review of published studies between 2015 and 2024 was conducted to evaluate the usage, benefits, and challenges of CAN in cervical spine surgeries. The review covered perioperative integration, system types, complications, and emerging technologies, including augmented reality (AR) and robotics. Results The use of CAN in cervical spine surgeries provides improved accuracy in screw placement and reduced neurovascular complications. However, the review identified several limitations, such as a steep learning curve, cost considerations, and potential inaccuracies related to cervical spine mobility. Conclusions CAN offers significant benefits in cervical spine surgeries, including enhanced precision and reduced complications. Despite the current limitations, advancements in AR and robotics hold promise for improving the safety and effectiveness of CAN in cervical procedures. The future focus should be on overcoming the existing challenges to increase the adoption of CAN in cervical spine surgeries.

Background: While magnetic resonance imaging (MRI) is commonly used to identify meniscal tears, intraoperative assessment typically dictates repairability. This study evaluated whether a simplified MRI-based scoring system could reliably predict meniscal repair versus meniscectomy. Methods: Patients who underwent meniscectomy or meniscal repair between 2010 and 2018 were retrospectively identified. Preoperative MRIs were independently reviewed in a blinded fashion by two radiologists and one orthopedic sports surgeon. Reviewers scored images based on four arthroscopic criteria for tear repairability, with one point awarded for each of the following criteria—(1) proximity within 4 mm of the meniscosynovial junction, (2) length > 10 mm, (3) presence of intact inner meniscal segment, and (4) >50% meniscal thickness. Tears scoring four points were considered repairable. Accuracy, sensitivity, and positive and negative predictive values were calculated against the actual procedure performed. Inter- and intraobserver reliability were evaluated using kappa statistics. The predictive performance of each individual criterion was also analyzed. Results: A total of 202 meniscal tears were included (134 meniscectomies and 68 repairs). Reviewer accuracy in predicting repairability ranged from 48% to 76%. Intraobserver reliability was moderate to substantial (κ = 0.42–0.66), whereas interobserver reliability was poor to moderate (pairwise κ = 0.07–0.43; Fleiss’ κ = 0.11). Analysis of individual MRI criteria demonstrated limited predictive value, with most criteria achieving less than 50% accuracy across reviewers. Conclusions: MRI-based prediction of meniscal repairability using arthroscopic criteria demonstrated limited accuracy and poor interobserver reliability. Overall predictive reliability remains insufficient for clinical decision-making. Further investigation, integrating advanced imaging techniques and artificial intelligence, may improve the preoperative assessment of meniscal repairability.

Background: Orthopedic oncology research is hindered by the scarcity of musculoskeletal tumors and research administrative inefficiencies. This paper introduces observational research through an innovative institution-specific methodology—termed an umbrella protocol. This protocol outlines a comprehensive standard procedure to expedite ethical approval for future aligned studies, reducing administrative barriers to research. Methods: We developed an umbrella protocol at an academic center, involving meticulous methodological identification and coordination with the institutional review board (IRB) to adhere to local guidelines. The protocol encompasses identifying investigators, research objectives, study goals, and data and safety monitoring frameworks necessary for typical standards. Results: Implementation of the umbrella protocol took 110 days to achieve exemption status, following multiple discussions with the IRB and extensive revisions. At the authors institution, this protocol significantly reduces protocol review times from an average of six-to-eight weeks to nearly instantaneous, facilitating a streamlined research process. Additionally, we established a dedicated orthopedic oncology patient registry to enhance future research endeavors. Conclusions: The adoption of umbrella protocols represents a pioneering strategy in orthopedic oncology. This approach mitigates research administrative burdens and broadens research scope in the field. It underscores the necessity of IRB collaboration, methodological precision, and stringent data management. The article also reflects on the ethical implications and potential biases introduced by emerging technologies like artificial intelligence, advocating for diligent ethical oversight. The establishment of an umbrella protocol marks a significant step towards more efficient research methodologies, ultimately aiming to improve patient care and outcomes for individuals with rare musculoskeletal conditions.

Comprehensively mapping the genetic basis of human disease across diverse individuals is a long-standing goal for the field of human genetics 1 – 4 . The All of Us Research Program is a longitudinal cohort study aiming to enrol a diverse group of at least one million individuals across the USA to accelerate biomedical research and improve human health 5 , 6 . Here we describe the programme’s genomics data release of 245,388 clinical-grade genome sequences. This resource is unique in its diversity as 77% of participants are from communities that are historically under-represented in biomedical research and 46% are individuals from under-represented racial and ethnic minorities. All of Us identified more than 1 billion genetic variants, including more than 275 million previously unreported genetic variants, more than 3.9 million of which had coding consequences. Leveraging linkage between genomic data and the longitudinal electronic health record, we evaluated 3,724 genetic variants associated with 117 diseases and found high replication rates across both participants of European ancestry and participants of African ancestry. Summary-level data are publicly available, and individual-level data can be accessed by researchers through the All of Us Researcher Workbench using a unique data passport model with a median time from initial researcher registration to data access of 29 hours. We anticipate that this diverse dataset will advance the promise of genomic medicine for all. A study describes the release of clinical-grade whole-genome sequence data for 245,388 diverse participants by the All of Us Research Program and characterizes the properties of the dataset.

Type 2 diabetes mellitus (T2D) is a growing health problem, but little is known about its early disease stages, its effects on biological processes or the transition to clinical T2D. To understand the earliest stages of T2D better, we obtained samples from 106 healthy individuals and individuals with prediabetes over approximately four years and performed deep profiling of transcriptomes, metabolomes, cytokines, and proteomes, as well as changes in the microbiome. This rich longitudinal data set revealed many insights: first, healthy profiles are distinct among individuals while displaying diverse patterns of intra- and/or inter-personal variability. Second, extensive host and microbial changes occur during respiratory viral infections and immunization, and immunization triggers potentially protective responses that are distinct from responses to respiratory viral infections. Moreover, during respiratory viral infections, insulin-resistant participants respond differently than insulin-sensitive participants. Third, global co-association analyses among the thousands of profiled molecules reveal specific host–microbe interactions that differ between insulin-resistant and insulin-sensitive individuals. Last, we identified early personal molecular signatures in one individual that preceded the onset of T2D, including the inflammation markers interleukin-1 receptor agonist (IL-1RA) and high-sensitivity C-reactive protein (CRP) paired with xenobiotic-induced immune signalling. Our study reveals insights into pathways and responses that differ between glucose-dysregulated and healthy individuals during health and disease and provides an open-access data resource to enable further research into healthy, prediabetic and T2D states. Deep profiling of transcriptomes, metabolomes, cytokines, and proteomes, alongside changes in the microbiome, in samples from individuals with and without prediabetes reveal insights into inter-individual variability and associations between changes in the microbiome and other factors.