This Week in Orthopedics — Jun 28, 2026

Welcome to This Week in Orthopedics. This week we are covering ten notable papers spanning advancements in knee and hip preservation, critical decision-making in shoulder arthroplasty, and optimized strategies for soft tissue repairs. Let us dive in.

We begin our first theme with knee preservation and ligament reconstruction. Intra-articular point-of-care cell-based therapy injections are increasingly discussed for knee osteoarthritis, but clear patient selection criteria have been lacking. To address this, a consensus from the European Society of Sports Traumatology, Knee Surgery and Arthroscopy and the International Cartilage Regeneration and Joint Preservation Society was published in Knee Surgery, Sports Traumatology, Arthroscopy [1]. Using the RAND/UCLA Appropriateness Method, European experts evaluated one hundred and forty-four scenarios based on five key clinical factors: cell source, age, joint involvement, osteoarthritis grade, and body mass index. Out of all scenarios, the experts deemed the therapy appropriate in only about twelve percent of cases, inappropriate in thirty-five percent, and remained uncertain in over half of the scenarios. The consensus concluded that cell-based therapy may be considered after other non-operative and injectable options have failed, specifically for patients sixty-five years of age or younger, with a body mass index of thirty-five or less, and Kellgren-Lawrence Grade two to three osteoarthritis. Interestingly, the panel noted that while bone marrow-derived cell-based therapy was restricted to younger patients, adipose-derived cell-based therapy was also appropriate for patients aged sixty-six to eighty with similar body mass and osteoarthritis grades. Conversely, these injections were deemed highly inappropriate for patients over eighty years of age and those with advanced Grade four osteoarthritis, providing clinicians with clear boundaries for patient selection.

When it comes to ligament reconstruction, selecting the optimal graft for primary anterior cruciate ligament reconstruction is a foundational decision. A systematic review and meta-analysis of fifteen randomized controlled trials published in Knee Surgery, Sports Traumatology, Arthroscopy compared quadriceps tendon autografts to bone-patellar tendon-bone and hamstring tendon autografts [8]. The analysis showed that up to twenty-four months post-surgery, the quadriceps tendon autograft provides comparable objective anterior stability, measured by KT-1000, and equivalent patient-reported outcomes to both of the traditional graft options. Most importantly, the quadriceps tendon autograft was associated with substantially lower donor-site morbidity compared to the bone-patellar tendon-bone graft and demonstrated no excess graft failure compared to hamstring autografts. This high-certainty evidence supports the quadriceps tendon as an excellent first-line autograft choice that balances joint stability with a more favorable recovery profile.

While graft selection is critical, the routine addition of lateral extra-articular tenodesis, or LET, to primary ACL reconstruction is another area of active debate. To evaluate its real-world impact on patient-reported outcomes, a matched-cohort study from the Swedish Knee Ligament Registry was published in The American Journal of Sports Medicine [3]. The researchers matched one hundred and seventy-four patients undergoing primary ACL reconstruction with concomitant LET to six hundred and ninety-six control patients undergoing ACL reconstruction alone, based on age, sex, body mass index, graft type, injury-to-surgery time, and concomitant meniscal or cartilage injuries. At both the one-year and two-year follow-ups, there were no significant differences in Knee injury and Osteoarthritis Outcome Scores between the two groups. Furthermore, the two-year revision rates were nearly identical, at just over two percent in both cohorts, and clinical failure rates were also highly comparable at around twenty-five percent. This registry data suggests that while randomized trials have shown reduced graft rupture rates in high-risk cohorts, the routine addition of LET does not translate to superior short-term patient-reported outcomes or lower revision rates in a broader, matched clinical population.

For patients with far more severe joint destruction, addressing extensive metaphyseal and metadiaphyseal bone loss during complex primary or revision total knee arthroplasty presents a major reconstructive challenge. A multicenter analysis published in The Journal of Bone and Joint Surgery evaluated eighty-four cases where stacked-metaphyseal cone constructs were utilized [10]. Over a five-year follow-up period, the stacked-cone constructs demonstrated excellent mechanical durability, with a five-year survivorship free from aseptic loosening of ninety-one point seven percent, with only a single tibial cone requiring revision for aseptic loosening. However, because of the highly complex nature of this patient population, the five-year survivorship free from all-cause reoperation was only fifty-six point five percent, and survivorship free from all-cause revision was sixty-five point two percent. Five other stacked cones had to be revised for reasons including periprosthetic joint infection and tibial implant fracture. These findings highlight that while stacked cones provide highly stable, durable fixation against aseptic loosening, clinicians must counsel these complex patients that the overall risk of subsequent complications and reoperations remains high.

Our second theme shifts to the shoulder, focusing on perioperative optimization, patient selection, and instability management. We start with a critical look at antibiotic prophylaxis in total shoulder arthroplasty. A retrospective study of over four thousand two hundred shoulder arthroplasties in the Journal of Shoulder and Elbow Surgery investigated how reported beta-lactam allergies affect perioperative antibiotic selection and subsequent revision rates [5]. The authors found that fifteen percent of patients had a reported beta-lactam allergy. This label severely compromised the use of standard cephalosporin prophylaxis, which dropped from ninety percent in patients with mild reported allergies to just forty-four percent in those with severe reported allergies, leading to a corresponding increase in clindamycin and vancomycin use. This deviation from first-line therapy had serious clinical consequences: the use of intraoperative cephalosporin prophylaxis was associated with roughly halving the odds of all-cause revision. Furthermore, having a reported beta-lactam allergy was associated with a higher likelihood of requiring a revision procedure for a presumed septic etiology. Strikingly, cephalosporins were administered to patients labeled as having anaphylactic reactions to penicillins or cephalosporins with zero adverse events reported. This study underscores that historical, unverified beta-lactam allergy labels unnecessarily expose patients to prosthetic joint infections, and highlights the urgent need for pre-operative allergy testing or test-dosing protocols to safely maximize first-line cephalosporin use.

As the volume of shoulder arthroplasty continues to grow, we must also evaluate the safety of these procedures in our oldest patients. A National Joint Registry study of nearly seven thousand patients aged eighty and older undergoing elective reverse shoulder arthroplasty was published in the Journal of Shoulder and Elbow Surgery [7]. The registry data revealed that revision surgery was remarkably uncommon in this elderly cohort, with revision rates of just one point four percent at one year, rising to only three point three-five percent at nine years. Interestingly, increasing age was actually associated with a slightly reduced risk of revision, likely reflecting a higher clinical threshold for reoperation and competing mortality. However, medical complications and mortality rose significantly with advancing age and higher American Society of Anesthesiologists grades. Medical complications occurred in nearly nine percent of patients aged eighty and older, but this rate nearly doubled to over sixteen percent in patients aged ninety and older. Additionally, one-year mortality increased from three point three percent in octogenarians to eight point two percent in nonagenarians. These findings suggest that while chronological age alone should not disqualify a patient from receiving a reverse shoulder arthroplasty, preoperative counseling must focus heavily on these elevated systemic medical risks rather than the risk of implant failure.

In the same journal, Torrens and colleagues published a randomized controlled trial comparing three weeks of post-operative immobilization to no immobilization following primary reverse shoulder arthroplasty [6]. While specific outcomes from this trial require close individual review, optimizing post-operative rehabilitation remains a key pillar of modern shoulder surgery.

For younger, active patients, managing traumatic anterior shoulder instability requires a highly individualized approach. Part two of the 2024 ESSKA-ESA formal consensus, published in Knee Surgery, Sports Traumatology, Arthroscopy, delivers age- and time-specific recommendations for treatment and return to sport based on a structured review and expert validation [9]. The consensus emphasizes that bone loss and soft tissue lesions are the primary drivers of surgical decision-making. The panel recommends bone augmentation procedures not only for critical defects where bone loss exceeds twenty percent, but also for subcritical defects of ten to fifteen percent, especially in cases of bipolar bone loss. When planning a return to sports, the consensus advises against relying solely on time-based milestones. Instead, return-to-sport criteria must include objective measures such as a pain-free full range of motion, restored shoulder stability, objective strength assessments, and sport-specific readiness. These criteria are typically met between four and six months post-injury or surgery, depending on the specific procedure and the physical demands of the patient's sport.

Our final theme explores soft tissue injuries and joint instability in the lower extremity, starting with the management of proximal hamstring tendon ruptures. A systematic review and meta-analysis of twelve studies, encompassing nearly one thousand early repairs and over seven hundred delayed repairs, was published in The American Journal of Sports Medicine [2]. The authors defined early repair as surgery performed within four to six weeks of the injury. While both groups achieved mostly similar long-term patient-reported outcomes, early surgical repair was associated with a substantial, four-fold lower risk of postoperative sciatica and roughly half the risk of tendon retear compared to delayed repair. Other complications, such as peri-incisional numbness, infection, and revision rates, did not differ significantly between the groups. This study provides clear evidence that while delayed repair remains a viable option, intervening within the first four to six weeks of injury offers significant protective benefits against neurological complications and construct failure.

Lastly, we look at the hip joint and the significance of central acetabular osteophytes. A case-control study of one hundred and fifty-seven patients with borderline developmental dysplasia of the hip undergoing hip arthroscopy was published in The American Journal of Sports Medicine [4]. The researchers compared patients with and without central acetabular osteophytes to determine their relationship with joint instability. The study revealed that patients with central acetabular osteophytes had significantly higher rates of intraoperative microinstability and ligamentum teres tears, as well as increased femoral neck, acetabular, and combined anteversion. Logistic regression confirmed that microinstability, ligamentum teres tears, and combined anteversion were strongly associated with the presence of these osteophytes. This suggests that central acetabular osteophytes are not merely incidental degenerative findings, but serve as a valuable radiographic marker of microinstability and early osteoarthritis in patients with borderline hip dysplasia.

If you only have time for one paper this week, make it the retrospective cohort study on beta-lactam allergies in total shoulder arthroplasty from the Journal of Shoulder and Elbow Surgery [5]. This paper provides powerful, actionable evidence that historical, unverified penicillin and cephalosporin allergy labels lead to suboptimal antibiotic prophylaxis, which in turn doubles the risk of all-cause revision. It challenges us to actively implement pre-operative allergy delabeling protocols in our clinics to safeguard our patients from devastating joint infections.

Here are the key takeaways from this week in Orthopedics.

First, intraoperative cephalosporin prophylaxis is associated with roughly halving the risk of revision in shoulder arthroplasty; we must aggressively challenge unverified beta-lactam allergy labels to ensure patients receive first-line prophylaxis.

Second, for proximal hamstring tendon ruptures, performing surgical repair within four to six weeks of injury significantly reduces the risk of postoperative sciatica and tendon retear compared to delayed reconstruction.

Third, quadriceps tendon autografts represent a highly reliable alternative for primary ACL reconstruction, offering equivalent stability and patient-reported outcomes to patellar and hamstring grafts but with significantly lower donor-site morbidity than patellar tendon harvests.

Fourth, reverse shoulder arthroplasty remains highly successful with low revision rates in patients over eighty, but clinicians must prepare for a substantial rise in medical complications and mortality in patients approaching or exceeding age ninety.

And finally, the presence of central acetabular osteophytes in patients with borderline hip dysplasia is a strong indicator of joint microinstability and ligamentum teres pathology.

That's your roundup for This Week in Orthopedics. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.