This week in Orthopedics

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Welcome to This Week in Orthopedics. This week we're covering 10 notable papers spanning hip and knee arthroplasty outcomes, sports and shoulder surgery, and paediatric deformity care. Let's dive in.

We start with periprosthetic femoral fracture, where two Bone and Joint Journal papers connect implant choice to its human cost. Børsheim and colleagues analysed just over two hundred thousand primary hip arthroplasties from the Norwegian Arthroplasty and Hip Fracture Registers. They compared four stem types for the risk of reoperation for periprosthetic fracture: cemented composite beam, cemented polished taper-slip, uncemented collarless, and uncemented collared. In men, polished taper-slip and collarless uncemented stems carried roughly nine times the risk of the composite beam stem, and collared uncemented stems about four times the risk [1]. The age pattern matters. In men, the excess risk with collarless stems appeared beyond 65, and with collared stems beyond 75. Polished taper-slip stems carried higher risk at all ages. In women, the excess emerged beyond 70 for taper-slip and collared stems, and beyond 60 for collarless stems. The authors conclude that composite beam stems should be preferred at least in men over 75 and women over 70. They also found collared stems the best uncemented option, and taper-slip stems a concern in men of any age. This is registry evidence and open to residual confounding, but the sample is large and the effect sizes are big. Why the stakes are high is shown by Ablett and colleagues, who followed 140 patients treated operatively for periprosthetic fracture around a primary hip replacement, at a median of about three years [2]. Compared with matched general population controls, close to two thirds of patients reported a clinically meaningful drop in quality of life. About one in ten patients described health states the scoring system rates as worse than death. Trajectory analysis suggested the fracture wiped out roughly two fifths of the quality-of-life gain from the original arthroplasty. This is a single-centre retrospective cohort with a small recall-validation subgroup, but together these papers add weight to fracture prevention as a reason for stem selection.

Staying with joint replacement, three papers address thromboprophylaxis, tibial fixation, and oncologic reconstruction. In the Bone and Joint Journal, Mohammad and colleagues pooled 22 randomized trials with over twenty-eight thousand patients undergoing elective hip replacement [3]. Direct oral anticoagulants lowered venous thromboembolism risk by a bit more than a third compared with low molecular weight heparin, driven by fewer deep vein thromboses. Overall bleeding was modestly higher with the oral agents. That bleeding difference disappeared when the analysis was restricted to agents and doses licensed in the United Kingdom, and reoperation and mortality did not differ. The authors estimate a switch could save the National Health Service about 8.6 million pounds a year. They acknowledge that many of the trials predate modern rehabilitation pathways and call for new trials. For knees, Firth and colleagues, writing in Knee Surgery Sports Traumatology Arthroscopy, reviewed nearly twelve thousand consecutive cemented total knee replacements from one centre [4]. Tibial baseplates with recessed cement pockets showed no difference in all-cause revision. They were, however, associated with significantly fewer revisions for aseptic tibial loosening, an effect confined to fixed-bearing designs and absent in mobile-bearing designs. This is observational, level three evidence spanning multiple implant designs, so the finding is hypothesis-strengthening rather than settled. Finally, Downie and colleagues, again in the Bone and Joint Journal, reported 205 patients with metastatic disease around the hip reconstructed with a long modular uncemented femoral stem [5]. Accounting for death as a competing risk, the probability of reintervention for femoral implant failure was about one percent at both two and five years, while roughly half of patients had died by two years. There were three femoral implant failures, all periprosthetic fractures, and no revisions for loosening. The overall rate of complications needing further surgery was 8 percent. As a single-series report without a comparator, it supports the uncemented approach as a reasonable option in selected patients, avoiding cement-related risks, rather than proving superiority over cemented reconstruction.

Turning to sports and shoulder surgery, three papers weigh graft harvest morbidity, added procedures, and operative versus nonoperative care. In Knee Surgery Sports Traumatology Arthroscopy, Davies and colleagues reported an MRI subgroup of 38 patients from the DOSTAR randomized trial. The trial compared a semitendinosus-only graft with adjustable button fixation against a combined semitendinosus and gracilis graft for ACL reconstruction [6]. Between six and twelve months, the gracilis muscle lost volume after harvest but grew in the semitendinosus-only group. Adductor longus showed a similar pattern, with hypertrophy in about seven in ten single-tendon patients versus three in ten dual-tendon patients. Other thigh muscles did not differ. These are volumetric imaging outcomes in a small subgroup, with no functional endpoint reported here, so they add mechanistic support for sparing the gracilis rather than proof of clinical benefit. In the Journal of Shoulder and Elbow Surgery, Berreta and colleagues built a five-year decision model comparing rotator cuff repair alone with repair plus biceps tenodesis [7]. Adding tenodesis cost about eight hundred dollars more but yielded slightly more quality-adjusted life years. That works out to roughly thirteen thousand dollars per quality-adjusted life year, well under the fifty thousand dollar threshold. Tenodesis was preferred in close to nine in ten simulations, and remained cost-effective with implant costs up to about three thousand dollars. The inputs come from published literature rather than a trial, so the conclusion is only as strong as those assumptions. And in Arthroscopy, Sun and Liu meta-analysed six randomized trials with 705 patients comparing arthroscopic capsular release with nonoperative care for frozen shoulder [8]. Release produced a clinically meaningful range-of-motion gain within the first six months, but the advantage faded over time. Pain improvement at six months was statistically significant but not clinically meaningful, and safety was comparable. With evidence certainty rated very low to moderate, this supports a short-term mobility advantage for surgery but leaves the longer-term case unproven.

Our final theme is paediatric deformity, with two Bone and Joint Journal papers asking whether adjuncts change the natural course. Zhang and colleagues randomized braced adolescents with idiopathic scoliosis, curves of 25 to 45 degrees and Risser grade 0 to 2, to supervised Schroth-based exercises or self-directed general exercise [9]. At 24 months, supervised therapy reduced the major Cobb angle by about three degrees more. That was statistically significant but short of the prespecified five-degree threshold for clinical importance. The proportion of patients classed as improved, stable, or worsened did not differ, and there was no meaningful quality-of-life benefit. This single-centre trial therefore points to limited added value of supervised exercise over bracing with home exercise. In cerebral palsy, Bakhtiyar and colleagues used Danish national surveillance data on 259 nonambulant children, contributing 406 hips with migration percentages between 30 and 49 percent [10]. At ten years, about a fifth of hips that had a tenotomy progressed to severe displacement or osteotomy, compared with about a third of hips without one. That corresponds to roughly halving the adjusted risk. The association was clear in GMFCS level IV but did not reach significance in level V, where progression remained substantial regardless. Higher spasticity independently raised risk. As observational data, this supports soft-tissue release in level IV children while underscoring careful selection and continued surveillance in level V.

If you only have time for one paper this week, make it the Norwegian registry study by Børsheim and colleagues [1]. Drawing on more than two hundred thousand hips, it reopens the question of stem choice by age and sex, and it quantifies a fracture risk that, as the companion quality-of-life data show, carries a lasting cost for patients.

That's your roundup for This Week in Orthopedics. The full transcript and references are available on the episode page. See you next week.

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