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Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I357).

Background: There is no standardization within hand and upper-extremity surgery regarding which patient-reported outcome measures (PROMs) are collected and reported. This limits the ability to compare or combine cohorts that utilize different PROMs. The aim of this study was to develop a linkage model for the QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand) and PROMIS PF CAT (Patient-Reported Outcomes Measurement Information System Physical Function computerized adaptive testing) instruments to allow interconversion between these PROMs in a hand surgery population., Methods: A retrospective review was conducted to identify adults (≥18 years old) who had completed the QuickDASH and PROMIS PF CAT instruments at the same clinical encounter. Patients with shoulder pathology were excluded. The linear relationship between scores was evaluated with use of the Pearson correlation coefficient. Linking was performed with use of several common methods, and an optimal linkage model was recommended on the basis of a higher R2, strong intraclass correlation coefficient (ICC), and lower standard error (SE). The recommended model was further evaluated in subgroups based on age (<60 or ≥60 years), sex, etiology for presentation (traumatic versus atraumatic), and treatment type (operative versus nonoperative)., Results: A total of 15,019 patients (mean age, 49 years; 54% female; 86% White) were included. The mean QuickDASH score (and standard deviation) was 37 ± 22, and the mean PROMIS PF CAT score was 45 ± 10. There was a strong negative linear relationship between the QuickDASH and PROMIS PF CAT (r = -0.73). The circle-arc linkage model demonstrated good accuracy and reliability (R2 = 0.55; ICC = 0.71), and crosswalk tables were developed from this model. The subgroup analysis demonstrated age-related bias in the linkage model (root expected mean squared difference, 0.12). To address this, a separate crosswalk table was developed, which was dichotomized by age category., Conclusions: The QuickDASH and PROMIS PF CAT scores were successfully linked. Utilization of the developed crosswalks-one specific to patients <60 years old and another specific to patients ≥60 years old-will allow for score interconversion in future meta-analyses and multicenter hand surgery studies., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This investigation was supported by the University of Utah Population Health Research Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105, and UL1RR025764). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I345)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Weight optimization methods in morbidly obese patients with a body mass index (BMI) of ≥40 kg/m2 undergoing total knee arthroplasty (TKA) have shown mixed results. The purpose of this study was to evaluate the effect of perioperative use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with a BMI of ≥40 kg/m2 undergoing primary TKA., Methods: Using an administrative claims database, patients with morbid obesity undergoing primary TKA were stratified into GLP-1 RA use for 3 months before and after the surgical procedure (treatment group) and GLP-1 RA non-use (control group), and were matched on the basis of patient age, gender, diagnosis of type-2 diabetes mellitus, and Charlson Comorbidity Index (CCI). In addition, these groups were compared with a contemporaneous cohort of patients undergoing TKA with a BMI of 35.0 to 39.9 kg/m2. Outcomes including infection, complications, revision, and readmission were compared between the matched cohorts., Results: There were significant decreases in the rates of 90-day periprosthetic joint infection (PJI) (1.0% compared with 1.8%; p = 0.037), any medical complications (10.6% compared with 12.7%; p = 0.033), pulmonary embolism (<0.4% compared with 0.6%; p = 0.050), and readmissions (5.3% compared with 8.9%; p < 0.001) in patients with a BMI of ≥40 kg/m2 who were taking GLP-1 RA versus the control group who were not. There were no differences in the 2-year rates of surgical complications (p > 0.05) between these groups. Compared with obese patients (BMI of 35.0 to 39.9 kg/m2), patients who had a BMI of ≥40 kg/m2 and were taking a GLP-1 RA did not have increased rates of infection or 90-day or 2-year complications (p > 0.05)., Conclusions: GLP-1 RA administration for at least 90 days prior to and after primary TKA in patients with a BMI of ≥40 kg/m2 was associated with reductions in the risks of 90-day PJI, any medical complications, and readmission. Additionally, the reduced complication rate that was achieved was similar to that of obese patients with a BMI of 35.0 to 39.9 kg/m2 undergoing TKA. Randomized clinical trials are needed to define the true effect of these agents on clinical outcomes following TKA., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I355)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Studies investigating constitutional alignment across various grades of osteoarthritis (OA) are limited. This study explored the distribution of Coronal Plane Alignment of the Knee (CPAK) types and associated radiographic parameters with increasing OA severity., Methods: In this retrospective cross-sectional study, 17,365 knees were analyzed using deep learning software for radiographic measurements. Knees were categorized on the basis of the Kellgren and Lawrence (KL) grade and CPAK type. Radiographic measurements were the hip-knee-ankle angle (HKAA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), arithmetic HKAA (aHKA), joint line obliquity (JLO), and joint line convergence angle (JLCA). Age-stratified analysis was performed to differentiate the impact of age on OA severity., Results: A shift in the most common CPAK type from II to I was found with increasing KL grade (p < 0.05). Furthermore, there was a corresponding increase in LDFA and JLCA with increasing KL grade, while HKAA, MPTA, and aHKA decreased after KL grade 2. Age exhibited limited association with LDFA and MPTA, suggesting that OA severity is the dominant factor related to the CPAK distribution., Conclusions: The study found a shift in CPAK type with worsening OA. It is possible that constitutional varus types are more susceptible to OA, or that their increased OA prevalence is related to anatomical changes. This analysis offers new insights into alterations in CPAK type that occur with OA and underscores the importance of understanding pre-arthritic anatomy when performing joint reconstruction., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This research was supported by Korea Health Technology R&D Project grant HV23C1803 through the Patient-Doctor Shared Decision Making Research Center (PDSDM), funded by the Ministry of Health & Welfare, Republic of Korea. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I341)., (Copyright © 2024 The Author(s). Published by The Journal of Bone and Joint Surgery, Incorporated.)

Abstract: Despite the increasing utilization of total ankle replacement (TAR) for end-stage ankle arthritis, there remains a paucity of long-term follow-up data comparing arthroplasty to arthrodesis. The aim of the current paper was to provide the long-term clinical outcomes of TAR and ankle arthrodesis (AA), measured with use of validated scoring instruments, in a prospective multicenter cohort of patients with ankle arthritis. This cohort from the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database comprised patients who underwent TAR or AA between 2001 and 2007. Data collection included demographics, comorbidities, and Ankle Osteoarthritis Scale and Short Form-36 scores. A total of 211 patients were included in the present study, with a minimum follow-up of 10 years (range, 10 to 18 years) and a mean follow-up of 13.2 years. In this cohort, the baseline characteristics of those who underwent AA and those who underwent TAR differed with respect to mean age (53.8 versus 61.3 years; p < 0.001), smoking status (31% versus 50% with no smoking history; p < 0.001), and inflammatory arthritis diagnosis (2% versus 17%; p = 0.005). Patients in the AA group had a greater chance of having no further surgery following their index procedure compared with those in the TAR group (70% versus 58%; p = 0.02). The TAR and AA groups demonstrated similar functional outcomes. In conclusion, the long-term clinical outcomes of TAR and AA were similar in a diverse cohort in which the treatment was tailored to the condition of the patient., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: Direct or indirect research funding for this study was received from Integra LifeSciences and DePuy. An unrestricted research grant from DePuy supported data collection involving the Mobility prosthesis for each patient entered into the COFAS database. Some patients who underwent an ankle replacement with the Mobility prosthesis at the Dalhousie site were also part of an independent radiostereometric analysis study supported by an unrestricted research grant from DePuy. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I331)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Previous research has underscored the benefits of geriatrician consultation in improving outcomes for older patients undergoing hip fracture repair, highlighting enhanced functional outcomes and reduced morbidity. However, the impact of geriatrician care in outcomes for patients undergoing elective total joint arthroplasty (TJA) has yet to be described. We aimed to determine whether preoperative or postoperative geriatrician involvement was associated with differences in the length of hospital stay and emergency department (ED) visits after TJA., Methods: This retrospective cohort study screened the medical records of patients ≥65 years of age undergoing primary elective TJA in a network of tertiary hospitals. Geriatrician consultations occurring within a period spanning 90 days before to 90 days after TJA were recorded. Bivariate analysis and multivariable regression models were used to assess the relationship between receiving these consultations and changes in the length of stay and ED visits., Results: A total of 16,076 patients undergoing primary TJA were included. Of these surgical procedures, 9,677 (60.2%) were total knee arthroplasties and 6,087 (37.9%) were total hip arthroplasties; 1,416 (8.8%) of cases had geriatrician visits. Patients had lower odds of requiring postoperative ED visits when they had at least 1 geriatrician appointment within the week preceding an arthroplasty (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.68 to 0.99]; p = 0.005). This effect was most notable for 65-year-old patients (OR, 0.66 [95% CI, 0.45 to 0.98])., Conclusion: This study reports promising evidence supporting the benefits of perioperative geriatrician visits on TJA outcomes. Preoperative visits were shown to be associated with decreased odds of ED visits after TJA in patients for up to 90 days postoperatively. Thus, geriatrician involvement in elective TJAs has the potential to improve outcomes and reduce morbidity and costs for patients and reduce costs for surgeons and institutions., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I332)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Schatzker type-4 to 6 tibial plateau fractures most commonly occur when the distal femur is driven through the proximal tibial articular surface. This mechanism of injury can be equivalent to a knee dislocation and carries an increased risk of vascular injury. Our institution screens all Schatzker type-4 to 6 tibial plateau fractures with symmetric pulses for a vascular injury by measuring the ankle-brachial index (ABI). The purpose of this study was to describe our screening protocol and to determine its effectiveness at identifying vascular injuries., Methods: Our screening protocol consisted of measuring the ABI of the injured limb for all Schatzker type-4 to 6 tibial plateau fractures that presented with symmetric pulses. An ABI of ≤0.9 prompted a computed tomographic angiogram (CTA) of the injured extremity. We retrospectively reviewed all Schatzker type-4 to 6 tibial plateau fractures from 2006 to 2023 that presented to a single level-I academic trauma center. We collected demographic, fracture, ABI, and vascular injury data and examined the effectiveness of our screening protocol., Results: We identified 437 Schatzker type-4 to 6 tibial plateau fractures (mean age, 47 years; 59% male). There were 102 (23%) Schatzker type-4 fractures, 4 (1%) type-5 fractures, and 331 (76%) type-6 fractures. Eight fractures (2%) had a concomitant vascular injury; none of the vascular injuries were missed. An ABI of ≤0.9 had a positive predictive value of 0.250, and an ABI of >0.9 had a negative predictive value of 1.000. The sensitivity of the ABI was 1.000, whereas the specificity was 0.056. Thirty-seven fractures were in patients with an ABI of >0.9 at presentation who underwent a CTA of the injured limb for nonorthopaedic indications, with no vascular injuries identified., Conclusions: The ABI has frequently been cited as a valuable screening tool for vascular injury after a knee dislocation, but its application to Schatzker type-4 to 6 tibial plateau fractures had not yet been described. Our results indicate that this screening protocol is both safe and effective, with no missed vascular injuries over a 17-year period., Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I343)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The diagnosis of syndesmotic instability is challenging, and chronically unstable injuries can potentially lead to ankle arthritic degeneration. The objective of this cadaveric study was to utilize a 3-dimensional (3D) weight-bearing computed tomography (WBCT) distance mapping algorithm for the detection of subtle syndesmotic instability, induced by complete syndesmotic ligament sectioning and stressed by isolated axial load. We hypothesized that this algorithm would accurately detect subtle syndesmotic instability., Methods: Nineteen matched pairs of through-the-knee cadaveric specimens (38 legs) were utilized. Specimens were mounted in a frame that allowed simulated axial weight-bearing (356 N). Specimens were scanned using cone-beam WBCT in the normal pre-injury state and after complete syndesmotic ligament sectioning. The deltoid ligament was kept intact, and no external rotational stress was applied. Syndesmotic incisura and lateral gutter distances were assessed and compared between pre-injury ipsilateral, contralateral, and injured states using a 3D WBCT distance mapping algorithm. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were calculated for the comparison of syndesmotic distance measurements between injured specimens and controls. P values of <0.05 were considered significant., Results: Overall, significantly increased distances were observed in injured specimens when compared with controls, with average relative syndesmotic widening in injured specimens of 16.9% (p = 0.0003), 11.3% (p = 0.0015), 6.4% (p = 0.0027), and 2.9% (p = 0.037) at the first 1, 3, 5, and 10 cm (proximal to the apex of the distal tibial articular surface), respectively. Widening was more pronounced in the anterior aspect of the syndesmosis, where the diagnostic accuracy was found to be highest at the first 1 and 3 cm of the syndesmotic incisura, with AUC values ranging from 80.9% to 83.0% (p < 0.0001) and with threshold diagnostic values of relative syndesmotic widening as low as 0.43 mm., Conclusions: The newly proposed 3D WBCT distance mapping algorithm was able to accurately detect subtle syndesmotic instability in a cadaveric model of complete syndesmotic sectioning under isolated axial weight-bearing load. This algorithm needs to be further validated in patients with suspected traumatic syndesmotic instability., Clinical Relevance: This cadaveric study demonstrated high diagnostic accuracy of a 3D WBCT distance mapping algorithm to detect subtle syndesmotic instability when stressed with isolated axial loading and in the absence of deltoid injury. The future use of this algorithm in patients with suspected unilateral traumatic syndesmotic instability could hopefully optimize the diagnosis and treatment decision-making., Competing Interests: Disclosure: The cadaveric specimens utilized in this study were part of an industry grant from Paragon28. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I317)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/I320).

➢ Skeletal stem cells (SSCs) continually replenish mature cell populations to support skeletal homeostasis.➢ SSCs repopulate by self-renewal, have multilineage potential, and are long-lived in vivo.➢ SSCs express specific combinations of cell surface markers that reflect their lineage identity.➢ SSCs adapt to their anatomic environment to support regional differences in skeletal behavior and pathology., Competing Interests: Disclosure: Matthew B. Greenblatt is supported by the National Institutes of Health (NIH) under awards R01AR075585, R01HD115274, and R01CA282815, a Career Award for Medical Scientists from the Burroughs Welcome Foundation, a Marfan Foundation Innovator Award, the Mary Kay Ash Foundation, the Mathers Foundation, and a Pershing Square Foundation MIND Prize. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I321)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/I252).

Background: Robotic total knee arthroplasty (rTKA) has garnered increasing attention in recent years, both clinically and in the media. The purpose of this study was to compare the volume of and messaging in published randomized controlled trials (RCTs) versus media reports on the topic of rTKA., Methods: This was a systematic review of RCTs and media articles on rTKA. PubMed, Embase, and MEDLINE were searched for RCTs; Factiva was searched for media articles. The number of publications of each type per year was recorded. Media articles were classified on the basis of their primary information source, their general tone toward rTKA, and the benefits and drawbacks of rTKA discussed. The volume, tone, and specific messaging around rTKA were compared between media articles and RCTs., Results: Fifteen RCTs and 460 media articles, published between 1991 and 2023, were included. The rates of both publication types increased over time, with more rapid increases in recent years. Ninety-five percent of media publications highlighted at least 1 benefit of rTKA. The most commonly cited benefits were more precise implant positioning (82.6%) and faster recovery (28.7%). Fewer than 7% of media publications (n = 30) mentioned downsides to rTKA. Overall, 89.3% of media articles presented a favorable view of rTKA. Ninety percent of RCTs reported that rTKA significantly outperformed manual TKA in terms of component positioning. Four of 6 RCTs reported significantly longer operative times with rTKA. Most RCTs found no significant differences in functional outcomes, opioid use, or complication rates., Conclusions: The rate of publications on rTKA has increased substantially in media sources and peer-reviewed journals, with the volume of media articles far outpacing RCTs on the topic. More precise component positioning was the most consistently reported benefit of rTKA in RCTs. However, media sources also reported a range of other, less well-supported benefits, and employed overwhelmingly positive tones regarding rTKA, more so than is supported by mixed clinical results. Efforts to ensure that patients and health-care providers receive accurate and evidence-based information about new health technologies are critical., Clinical Relevance: This study demonstrates a clear disparity between news media coverage of rTKA and the best clinical evidence available. This information can help to guide discussions between patients and surgeons regarding the use of rTKA., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I199)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Developmental dysplasia of the hip (DDH) can cause pain and premature osteoarthritis. The risk factors and timing for disease progression in adolescents and young adults have not been fully defined. This study aimed to determine the prevalence of and risk factors for contralateral hip pain and surgery after periacetabular osteotomy (PAO) on a dysplastic hip., Methods: Patients undergoing unilateral PAO for DDH were followed for at least 2 years and categorized into contralateral pain and no-pain groups and contralateral surgery and no-surgery groups. Pain was defined with the modified Harris hip score. Univariate analysis tested group differences in demographics, radiographic measures, and range of motion. Kaplan-Meier survival analysis was used to assess pain development and surgery in the contralateral hip over time. Multivariable regression identified risk factors for contralateral pain and surgery. Contralateral pain and surgery predictors were secondarily assessed after categorization of the contralateral hips as dysplastic, borderline, and non-dysplastic and in subgroups based on the lateral center-edge angle (LCEA) and acetabular inclination (AI) in 5° increments., Results: One hundred and eighty-four patients were followed for a mean of 4.6 ± 1.6 years (range, 2.0 to 8.8 years), during which 51% (93) reported contralateral hip pain and 33% (60) underwent contralateral surgery. Kaplan-Meier analysis predicted 5-year survivorship of 49% with contralateral pain development as the end point and 66% with contralateral surgery as the end point. Painful hips exhibited more severe dysplasia compared with no-pain hips (LCEA = 16.5° versus 20.3°, p < 0.001; AI = 13.2° versus 10.0°, p < 0.001). AI was the sole predictor of pain, with every 1° increase in the AI raising the risk by 11%. Surgically treated hips also had more severe dysplasia (LCEA = 14.9° versus 20.0°, p < 0.001; AI = 14.7° versus 10.2°, p < 0.001) and were in younger patients (21.6 versus 24.1 years, p = 0.022). AI and a maximum alpha angle of ≥55° were predictors of contralateral surgery., Conclusions: At 5 years after hip PAO, approximately 50% of contralateral hips will have pain and approximately 35% can be expected to need surgery. More severe dysplasia, based on the LCEA and AI, increases the risk of contralateral hip pain and surgery, with AI being a predictor of both outcomes. Knowing these risks can inform patient counseling and treatment planning., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This work was supported in part by the Curing Hip Disease fund, the Jacqueline & W. Randolph Baker fund, The Foundation for Barnes-Jewish Hospital (Award Reference 5228), The Foundation for Barnes-Jewish Hospital (Award Reference 6421), and Daniel C. Viehmann (all to J.C.C.). Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award number R01AR081881. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I231)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/I239).

Background: This study aimed to determine the acetabular position to optimize hip biomechanics after transposition osteotomy of the acetabulum (TOA), a specific form of periacetabular osteotomy, in patients with hip dysplasia., Methods: We created patient-specific finite-element models of 46 patients with hip dysplasia to simulate 12 virtual TOA scenarios: lateral rotation to achieve a lateral center-edge angle (LCEA) of 30°, 35°, and 40° combined with anterior rotation of 0°, 5°, 10°, and 15°. Joint contact pressure (CP) on the acetabular cartilage during a single-leg stance and simulated hip range of motion without osseous impingement were calculated. The optimal acetabular position was defined as satisfying both normal joint CP and the required range of motion for activities of daily living. Multivariable logistic regression analysis was used to identify preoperative morphological predictors of osseous impingement after virtual TOA with adequate acetabular correction., Results: The prevalence of hips in the optimal position was highest (65.2%) at an LCEA of 30°, regardless of the amount of anterior rotation. While the acetabular position minimizing peak CP varied among patients, approximately 80% exhibited normalized peak CP at an LCEA of 30° and 35° with 15° of anterior rotation, which were the 2 most favorable configurations among the 12 simulated scenarios. In this context, the preoperative head-neck offset ratio (HNOR) at the 1:30 clock position (p = 0.018) was an independent predictor of postoperative osseous impingement within the required range of motion. Specifically, an HNOR of <0.14 at the 1:30 clock position predicted limitation of required range of motion after virtual TOA (sensitivity, 57%; specificity, 81%; and area under the receiver operating characteristic curve, 0.70)., Conclusions: Acetabular reorientation to an LCEA of between 30° and 35° with an additional 15° of anterior rotation may serve as a biomechanics-based target zone for surgeons performing TOA in most patients with hip dysplasia. However, patients with a reduced HNOR at the 1:30 clock position may experience limited range of motion in activities of daily living postoperatively., Clinical Relevance: This study provides a biomechanics-based target for refining acetabular reorientation strategies during TOA while considering morphological factors that may limit the required range of motion., Competing Interests: Disclosure: This work was supported by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (No. JP21K09281). The funder did not play a role in the investigation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I245 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The increased availability of dual-mobility acetabular constructs (DMCs) provides surgeons with a newer option to increase the effective femoral head size in revision total hip arthroplasty (rTHA). We sought to evaluate risks of re-revision and prosthetic dislocation following rTHA involving a DMC compared with other articulations., Methods: A cohort study was conducted using data from a U.S. integrated health-care system's Total Joint Replacement Registry. Adult patients who underwent primary THA and went on to undergo an aseptic rTHA in 2002 to 2022 were identified. Patients who received a DMC, a constrained liner, or a metal or ceramic unipolar femoral head on highly cross-linked polyethylene (XLPE) at the time of rTHA were the treatment groups. Subsequent aseptic re-revision and dislocation were the outcomes of interest. Multivariable Cox proportional-hazards regression was used to evaluate the risks of the outcomes, with adjustment for patient, operative, and surgeon confounders., Results: The analyzed rTHAs comprised 375 with a DMC, 268 with a constrained liner, 995 with a <36-mm head on XLPE, and 2,087 with a ≥36-mm head on XLPE. DMC utilization increased from 1.0% of rTHAs in 2011 to 21.6% in 2022. In adjusted analyses, a higher re-revision risk was observed for the constrained liner (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 1.29 to 4.59), <36 mm on XLPE (HR = 2.05, 95% CI = 1.13 to 3.75), and ≥36 mm on XLPE (HR = 2.03, 95% CI = 1.19 to 3.48) groups compared with the DMC group. A higher dislocation risk was observed in both XLPE groups (<36 mm: HR = 2.04, 95% CI = 1.33 to 3.14; ≥36 mm: HR = 2.46, 95% CI = 1.69 to 3.57) compared with the DMC group; a nonsignificant trend toward a higher dislocation rate in the group with a constrained liner than in the DMC group was also observed., Conclusions: In a large U.S.-based cohort, rTHAs using DMCs had the lowest re-revision risk and dislocation risk. Both outcomes were significantly lower than those using a unipolar femoral head on XLPE, re-revision risk was significantly lower than using a constrained liner, and dislocation risk trended toward a lower risk than using a constrained liner., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I250 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I238 ).

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I143 ).

Background: Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival., Methods: The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization., Results: Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72])., Conclusions: One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed., Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The HIP ATTACK-1 trial was supported by the Canadian Institutes of Health Research, the Ontario Strategy for Patient Oriented Research Support Unit, the Ontario Ministry of Health and Long-Term Care, the Hamilton Health Sciences Foundation, the Physicians’ Services Incorporated Foundation, the Michael G. DeGroote Institute for Pain Research and Care, Smith & Nephew (to recruit patients in Spain), and Indiegogo Crowdfunding. This substudy received funding from a McMaster General Internal Medicine Research Grant. Funders had no role in the study design, conduct, analyses, or manuscript preparation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I117 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I88 ).

Background: We investigated the normal development of the secondary ossification centers of the acetabulum, focusing on their location and the amount of acetabular coverage increased by them., Methods: We enrolled 132 patients who were 7 to 16 years of age and had no pelvic deformity but did have ≥1 os ischium, os ilium, and/or os pubis on abdominal or pelvic computed tomographic (CT) scans. The locations of the ossification centers were evaluated by adopting an orientation using 0° for the superior acetabulum, 90° for the anterior acetabulum, 180° for the inferior acetabulum, and 270° for the posterior acetabulum, on a reconstructed 3-dimensional (3D) CT image. The acetabular coverage increase by the os ischium, os ilium, or os pubis was defined as the difference in the posterior acetabular sector angle (ΔPASA), posterosuperior acetabular sector angle (ΔPSASA), superior acetabular sector angle (ΔSASA), anterosuperior acetabular sector angle (ΔASASA), or anterior acetabular sector angle (ΔAASA) measured with and without each secondary ossification center. Patients were grouped into 3 age ranges: late childhood, preadolescence, and early adolescence. The location of each ossification center and the increase in acetabular coverage were compared between these groups., Results: In the late-childhood group, the median start-to-end positions in right hips were 269° to 316° for the os ischium, 345° to 356° for the os ilium, and 81° to 99° for the os pubis. These positions tended to be wider in the early-adolescence group at 252° to 328° for the os ischium (p < 0.001), 338° to 39° for the os ilium (p = 0.005), and 73° to 107° for the os pubis (p = 0.049) in right hips. In right hips in the late-childhood group, the median values were 8.1° for ΔPASA, 14.0° for ΔPSASA, 9.9° for ΔSASA, 11.1° for ΔASASA, and 3.9° for ΔAASA; and in the early-adolescence group, the median values in right hips were 10.7° for ΔPASA, 12.9° for ΔPSASA, 8.4° for ΔSASA, 7.4° for ΔASASA, and 5.6° for ΔAASA. Only the median ΔPASA was larger in the early-adolescence group than in the late-childhood group (p = 0.026). Similar results were observed in left hips., Conclusions: In early adolescence, the secondary ossification centers appeared at more extended areas along the acetabular rim, and the increase in acetabular coverage by the secondary ossification centers tended to be larger in the posterior area but not in the anterior or superior area., Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I125 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS)., Methods: Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression., Results: In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all)., Conclusions: Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I243)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and its abbreviated version, QuickDASH, are commonly used patient-reported outcome measures (PROMs) for the assessment of an upper-extremity disability. Theoretically, they can be used to compare the treatment outcomes of different upper-extremity conditions. Despite increasingly widespread use for some shoulder conditions, these questionnaires have not been rigorously validated for use to assess the outcomes of patients undergoing anatomic total shoulder arthroplasty (aTSA). The objective of this study was to validate the DASH and QuickDASH scores for a longitudinal outcome assessment of patients undergoing aTSA to treat advanced glenohumeral osteoarthritis (GHOA)., Methods: In this study, 450 patients with a median age of 70.3 years (interquartile range [IQR] width, 11.7 years) were included; 52.4% of the patients were female. The DASH and QuickDASH questionnaires, the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and the EuroQol-5 Dimensions (EQ-5D) questionnaire were completed preoperatively and at follow-ups of 3 months, 6 to 12 months, and a minimum of 2 years by patients undergoing aTSA. The criterion validity, construct validity, reliability, and responsiveness of the DASH and QuickDASH were assessed., Results: The DASH and QuickDASH scores demonstrated moderate to very strong correlations with the ASES scores (ρ = -0.83 to -0.62), SST scores (ρ = -0.73 to -0.55), and EQ-5D scores (ρ = -0.72 to -0.57); minimal floor or ceiling effects; internal consistency (Cronbach alpha > 0.80); and large Cohen d and standardized response means (<1.6) at all time points. Very strong positive correlations were observed between the DASH and QuickDASH scores at all time points (ρ = 0.96 to 0.97)., Conclusions: The DASH and QuickDASH scores, which are region-specific rather than shoulder-specific, are valid, reliable, and responsive PROMs for the evaluation of patients with advanced GHOA treated with aTSA. Therefore, the DASH and QuickDASH scores can be used to compare the outcomes of aTSA for the treatment of advanced GHOA with the outcomes of treatment of other upper-extremity disorders, potentially facilitating comparative cost-effectiveness and value analysis studies., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I220)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

➢ Shoulder periprosthetic joint infection (PJI) is a potentially devastating complication after arthroplasty and is projected to rise with increasing numbers of performed arthroplasties, particularly reverse shoulder arthroplasties.➢ Important considerations for the diagnosis and treatment of shoulder PJI include age, sex, implant type, primary compared with revision shoulder surgery, comorbidities, and medications (i.e., corticosteroids and disease-modifying antirheumatic drugs). ➢ Diagnosis and management are unique compared with lower-extremity PJI due to the role of lower-virulence organisms in shoulder PJI, specifically Cutibacterium acnes.➢ Treatment pathways depend on chronicity of infection, culture data, and implant type, and exist on a spectrum from irrigation and debridement to multistage revision with temporary antibiotic spacer placement followed by definitive revision arthroplasty., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I242 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Scoliosis is a deformation of the spine and trunk that, in its more severe forms, creates a life-long burden of disease and requires intensive treatment. For its most prevalent form, adolescent idiopathic scoliosis, no underlying condition can be defined, and the pathomechanism appears to be multifactorial; however, it has been suggested that the biomechanics of the spine play a role. For nonidiopathic scoliosis, underlying conditions can be recognized, but what drives the deformity remains unclear. In this study, we examined the early sagittal shape of the spine before the onset of scoliosis in a population with 22q11.2 deletion syndrome (22q11.2DS). This cohort was chosen since children with this syndrome have an approximately 50% chance of developing scoliosis that shares certain characteristics with idiopathic scoliosis, namely, age of onset, curve morphology, and rate of progression., Methods: This prospective cohort study included patients with 22q11.2DS who were followed with the use of spinal radiographs during adolescent growth. All of the children, who initially had no scoliosis while still skeletally immature (Risser stages 0 and 1), were followed at 2-year intervals until they reached skeletal maturity (Risser stages 3 to 5). We assessed the segment of the spine that has previously been shown to be rotationally unstable, the posteriorly inclined segment, to determine if it was predictive of later scoliosis development. For quantification, the area of the "posteriorly inclined triangle" (PIT), a previously described parameter that integrates both the inclination and length of the at-risk segment, was measured., Results: Of the 50 children who initially had no scoliosis (mean age at inclusion, 10.7 ± 1.7 years; mean follow-up, 4.8 ± 1.6 years), 24 (48%) developed scoliosis. Patients with an above-average PIT area (>60 cm 2 ) at inclusion showed a relative risk of 2.55 for scoliosis development (95% confidence interval [CI]:1.22 to 5.34). PIT inclination was correlated with curve type: a taller and steeper hypotenuse predicted later thoracic scoliosis, while a shorter and less steep inclination predicted the development of (thoraco)lumbar scoliosis., Conclusions: This prospective study identified the pre-scoliotic sagittal shape of the spine as a risk factor for the later development of scoliosis in the population of children with 22q11.2DS., Level of Evidence: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Article Processing Charge for open access publication was funded by Utrecht University. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I235 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure : No external funding was received for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article ( http://links.lww.com/JBJS/I251 ).

Background: Tranexamic acid (TXA) is commonly utilized to reduce blood loss in adult spinal deformity (ASD) surgery. Despite its widespread use, there is a lack of consensus regarding the optimal dosing regimen. The aim of this study was to assess differences in blood loss and complications between high, medium, and low-dose TXA regimens among patients undergoing surgery for complex ASD., Methods: A multicenter database was retrospectively analyzed to identify 265 patients with complex ASD. Patients were separated into 3 groups by TXA regimen: (1) low dose (<20-mg/kg loading dose with ≤2-mg/kg/hr maintenance dose), (2) medium dose (20 to 50-mg/kg loading dose with 2 to 5-mg/kg/hr maintenance dose), and (3) high dose (>50-mg/kg loading dose with ≥5-mg/kg/hr maintenance dose). The measured outcomes included blood loss, complications, and red blood cell (RBC) units transfused intraoperatively and perioperatively. The multivariable analysis controlled for TXA dosing regimen, levels fused, operating room time, preoperative hemoglobin, 3-column osteotomy, and posterior interbody fusion., Results: The cohort was predominantly White (91.3%) and female (69.1%) and had a mean age of 61.6 years. Of the 265 patients, 54 (20.4%) received low-dose, 131 (49.4%) received medium-dose, and 80 (30.2%) received high-dose TXA. The median blood loss was 1,200 mL (interquartile range [IQR], 750 to 2,000). The median RBC units transfused intraoperatively was 1.0 (IQR, 0.0 to 2.0), and the median RBC units transfused perioperatively was 2.0 (IQR, 1.0 to 4.0). Compared with the high-dose group, the low-dose group had increased blood loss (by 513.0 mL; p = 0.022) as well as increased RBC units transfused intraoperatively (by 0.6 units; p < 0.001) and perioperatively (by 0.3 units; p = 0.024). The medium-dose group had increased blood loss (by 491.8 mL; p = 0.006) as well as increased RBC units transfused intraoperatively (by 0.7 units; p < 0.001) and perioperatively (by 0.5 units; p < 0.001) compared with the high-dose group., Conclusions: Patients with ASD who received high-dose intraoperative TXA had fewer RBC transfusions intraoperatively, fewer RBC transfusions perioperatively, and less blood loss than those who received low or medium-dose TXA, with no differences in the rates of seizure or thromboembolic complications., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This publication was made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part through a grant (UL1TR003098) from the National Center for Advancing Translational Sciences (NCATS), which is a component of the National Institutes of Health (NIH), and the NIH Roadmap for Medical Research. V. Lafage received grant funding from the International Spine Study Group pertaining to the submitted manuscript (paid directly to the institution). J. Smith received grant funding from DePuy Synthes and ISSG pertaining to the submitted manuscript (paid directly to the institution). S. Bess received grant funding from Medtronic, Stryker, Globus, Carlsmed, and SI-BONE pertaining to the submitted manuscript (paid directly to the institution). L. Lenke received funding from Scoliosis Research Society pertaining to the submitted manuscript (paid directly to the institution) and nonfinancial assistance from the Harms Study Group (paid directly to the institution). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I227 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Telehealth visits (THVs) have made it essential to adopt innovative ways to evaluate patients virtually. This study validates a novel THV approach that uses educational videos and an instructional datasheet, enabling parents to use smartphones to measure their child's scoliosis at home or in telehealth settings., Methods: We identified a prospective cohort of patients with adolescent idiopathic scoliosis (AIS) scheduled for follow-up care from March to July 2021. The angle of trunk rotation (ATR) was first measured at home by patients' guardians using instructional video guidance and a smartphone application with internal accelerometer software. The second measurement was made during a THV examination performed by caregivers with supervision by trained associates via a telehealth appointment. Lastly, the clinician measured the child's ATR during an in-person clinic visit. Intraclass correlation coefficients (ICCs) and interrater reliability were compared between in-person clinic measurements and (1) at-home and (2) THV measurements. Shoulder, lower back, and pelvic asymmetry were observed and quantified at home and virtually, and then were compared with in-person clinic evaluations using kappa values. Surveys were used to evaluate the experience of the patient/caregiver with the at-home and telehealth assessment tools., Results: Seventy-three patients were included (mean age, 14.1 years; 25% male). There was excellent agreement in the ATR measurements between THVs and in-person visits (ICC = 0.88; 95% confidence interval [CI] = 0.83 to 0.92). ATR agreement between at-home and in-person visits was also excellent, but slightly diminished (ICC = 0.76; 95% CI = 0.64 to 0.83). Agreement between THV and in-person measurements was significantly higher compared with that between at-home and in-person measurements (p = 0.04). There was poor agreement in lower back asymmetry between THV and in-person assessments (kappa = 0.37; 95% CI = 0.14 to 0.60); however, there was no significant agreement between at-home and in-person assessments (kappa = 0.06; 95% CI = -0.17 to 0.29). Patient/caregiver satisfaction surveys (n = 70) reported a median score of 4 ("good") for comfort with use of the technology, and a score of 3 ("neutral") for equivalence of THV and in-person evaluation., Conclusions: There was a high level of agreement between telehealth and in-person spine measurements, suggesting that THVs may be reliably used to evaluate AIS, thus improving access to specialized care., Level of Evidence: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I224 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Tibial tubercle fractures (TTFs) are uncommon injuries, comprising <3% of all proximal tibial fractures. These fractures occasionally occur in conjunction with a patellar tendon injury (PTI). We aimed to identify risk factors associated with combined TTF and PTI., Methods: A retrospective review was performed of patients presenting to a single, tertiary children's hospital with TTF between 2012 and 2023. Demographic data, operative details, radiographs, and injury patterns were analyzed. Radiographs were assessed for the epiphyseal union stage (EUS), Ogden classification, and fracture patterns. Multiple logistic regression models were used to assess the impact of body mass index, comminution, fracture fragment rotation, EUS, bilateral injury, and Ogden classification on injury type., Results: We identified 262 fractures in 252 patients (mean age, 13.9 ± 1.31 years). Of the patients, 6% were female and 48% were Black. Of the 262 fractures, 228 (87%) were isolated TTFs and 34 (13%) were TTFs with PTI. Multivariable analysis demonstrated fragment rotation on lateral radiographs (p < 0.0001) and Ogden Type-I classification (p < 0.0001) to be the most predictive risk factors for a combined injury. Rotation was associated with a substantial increase in the odds of a combined injury, with an odds ratio of 22.1 (95% confidence interval [CI], 6.1 to 80.1). Ogden Type-I fracture was another significant risk factor, with an odds ratio of 10.2 (95% CI, 3.4 to 30.4)., Conclusions: The Ogden classification and fragment rotation are the most useful features for distinguishing between isolated TTF and combined TTF with PTI. This is the first study to identify risk factors for TTF combined with PTI. Surgeons may use this information to aid in preoperative planning., Level of Evidence: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I213 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Our understanding of the relationship between sagittal alignment and mechanical complications is evolving. In normal spines, the L1-pelvic angle (L1PA) accounts for the magnitude and distribution of lordosis and is strongly associated with pelvic incidence (PI), and the T4-pelvic angle (T4PA) is within 4° of the L1PA. We aimed to examine the clinical implications of realignment to a normal L1PA and T4-L1PA mismatch., Methods: A prospective multicenter adult spinal deformity registry was queried for patients who underwent fixation from the T1-T5 region to the sacrum and had 2-year radiographic follow-up. Normal sagittal alignment was defined as previously described for normal spines: L1PA = PI × 0.5 - 21°, and T4-L1PA mismatch = 0°. Mechanical failure was defined as severe proximal junctional kyphosis (PJK), displaced rod fracture, or reoperation for junctional failure, pseudarthrosis, or rod fracture within 2 years. Multivariable nonlinear logistic regression was used to define target ranges for L1PA and T4-L1PA mismatch that minimized the risk of mechanical failure. The relationship between changes in T4PA and changes in global sagittal alignment according to the C2-pelvic angle (C2PA) was determined using linear regression. Lastly, multivariable regression was used to assess associations between initial postoperative C2PA and patient-reported outcomes at 1 year, adjusting for preoperative scores and age., Results: The median age of the 247 included patients was 64 years (interquartile range, 57 to 69 years), and 202 (82%) were female. Deviation from a normal L1PA or T4-L1PA mismatch in either direction was associated with a significantly higher risk of mechanical failure, independent of age. Risk was minimized with an L1PA of PI × 0.5 - (19° ± 2°) and T4-L1PA mismatch between -3° and +1°. Changes in T4PA and in C2PA at the time of final follow-up were strongly associated (r 2 = 0.96). Higher postoperative C2PA was independently associated with more disability, more pain, and worse self-image at 1 year., Conclusions: We defined sagittal alignment targets using L1PA (relative to PI) and the T4-L1PA mismatch, which are both directly modifiable during surgery. In patients undergoing long fusion to the sacrum, realignment based on these targets may lead to fewer mechanical failures., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The International Spine Study Group (ISSG) is funded through research grants from NuVasive, SI-Bone, DePuy Synthes Spine, K2M, Stryker, Biomet, AlloSource, and Orthofix, and individual donations. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I191 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Vice chairs (VCs) of research play an integral role in orthopaedic departments at academic medical centers; they strategically lead research efforts and support the research careers of faculty and trainees. To our knowledge, no analysis of orthopaedic VCs of research exists in the literature, and no similar analyses have been completed in other medical specialties. We aimed to investigate the academic and demographic characteristics of orthopaedic VCs of research., Methods: Doximity was used to identify orthopaedic residencies in the U.S. Personal and program websites were queried to identify VCs of research and collect academic and demographic characteristics. The Scopus database, the National Institutes of Health (NIH) RePORTER, and Google Scholar were used to obtain each investigator's Hirsch index (h-index) and the number and type of NIH grants awarded, respectively., Results: Of the 207 orthopaedic residency programs identified, 71 (34%) had a named VC of research in the orthopaedic department. Of the top 50 medical schools, 42 were affiliated with such programs. Most VCs were men (89%). The racial and/or ethnic background of the majority of VCs was White (85%), followed by Asian (14%), and Black (1%). Most held the rank of professor (78%), followed by associate professor (18%), and assistant professor (4%). Over half were PhDs (55%), followed by MDs (37%) and MD/PhDs (8%). On average, the VCs had an h-index of 40.5. Furthermore, 65% had been awarded at least 1 NIH grant for their research, with 43% awarded at least 1 R01 grant., Conclusions: VCs of research develop research opportunities and shape the brand recognition of academic orthopaedic programs. Most orthopaedic VCs of research are men (89%); 85% each are White and have a rank of professor. Nearly half have been awarded at least 1 R01 grant from the NIH., Clinical Relevance: This study outlines important academic and demographic characteristics among orthopaedic surgery VCs of research. Considering the mentorship aspect of their role, VCs of research have an opportunity to influence the diversity of incoming trainees in the field of academic orthopaedics., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I134 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Abstract: In 1992, the American Orthopaedic Association-Japanese Orthopaedic Association (AOA-JOA) Traveling Fellowship was created to develop and enhance collaboration between the Japanese and American orthopaedic communities. The fellowship is geared to early-career surgeons and fosters clinical and cultural exchange between members of the 2 countries. In 2024, the fellows hailed from around the United States: Kelly K. Hynes, Lucas S. McDonald, Joshua A. Parry, Joseph H. Schwab, and Byron F. Stephens all participated in the program. During the 3-week fellowship, the fellows visited 8 academic centers across Japan and attended the JOA Annual Meeting in Fukuoka. This experience was incredibly rewarding, both clinically and professionally, and all the fellows returned home with novel ideas for their clinical practices., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I311)., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I310).

Background: Clinicians must be knowledgeable about osteoporosis so that they can convey information regarding the prevention of fragility fractures to their patients. The purposes of this study were to develop objective and subjective knowledge instruments for osteoporosis and fragility fractures and then test their reliability and validity among Chinese orthopaedic surgeons., Methods: A 2-round procedure was used to develop the objective and subjective knowledge instruments. A cross-sectional online survey was distributed to 293 orthopaedic surgeons; 189 surgeons returned the questionnaires. We examined internal consistency, test-retest reliability, criterion validity, and discriminant validity; we also compared the subjective knowledge level with the objective knowledge level among surgeons., Results: Our results showed that the Subjective Knowledge Scale (SKS) regarding Osteoporosis and Fragility Fractures had a high Cronbach alpha coefficient (0.915), and the objective Osteoporosis Knowledge Test for Clinicians (OKTC) had an adequate Kuder-Richardson 20 coefficient (0.64). Item analyses were conducted, and a short version of the OKTC (the OKTC-SF) was developed. The SKS, the OKTC, and the OKTC-SF all showed good test-retest reliability, criterion validity, and discriminant validity. The percentage of surgeons with a high subjective knowledge level was higher than the percentage of surgeons who selected the correct answer for several corresponding questions related to objective knowledge., Conclusions: The SKS, the OKTC, and the OKTC-SF all demonstrated good reliability and validity. However, the orthopaedic surgeons may have overestimated their knowledge level regarding osteoporosis. Targeted continuing medical education that is based on individual knowledge level is needed to improve the undertreatment of osteoporosis among patients with fragility fractures., Competing Interests: Disclosure: This study was funded by the National Natural Science Foundation of China (72004241), Guangzhou Basic and Applied Basic Research Foundation (2023A04J1745), and Philosophy and Social Science Planning Project of Guangzhou (2020GZQN56). The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I273)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The purpose of this study was to (1) perform the first analysis of bone-derived DNA methylation, (2) compare DNA methylation clocks derived from bone with those derived from whole blood, and (3) establish a relationship between DNA methylation age and 1-year mortality within the geriatric hip fracture population., Methods: Patients ≥65 years old who presented to a Level-I trauma center with a hip fracture were prospectively enrolled from 2020 to 2021. Preoperative whole blood and intraoperative bone samples were collected. Following DNA extraction, RRBS (reduced representation bisulfite sequencing) libraries for methylation clock analysis were prepared. Sequencing data were analyzed using computational algorithms previously described by Horvath et al. to build a regression model of methylation (biological) age for each tissue type. Student t tests were used to analyze differences (Δ) in methylation age versus chronological age. Correlation between blood and bone methylation ages was expressed using the Pearson R coefficient., Results: Blood and bone samples were collected from 47 patients. DNA extraction, sequencing, and methylation analysis were performed on 24 specimens from 12 subjects. Mean age at presentation was 85.4 ± 8.65 years. There was no difference in DNA extraction yield between the blood and bone samples (p = 0.935). The mean follow-up duration was 12.4 ± 4.3 months. The mortality cohort (4 patients, 33%) showed a mean ΔAgeBone of 18.33 ± 6.47 years and mean ΔAgeBlood of 16.93 ± 4.02 years. In comparison, the survival cohort showed a significantly lower mean ΔAgeBone and ΔAgeBlood (7.86 ± 6.7 and 7.31 ± 7.71 years; p = 0.026 and 0.039, respectively). Bone-derived methylation age was strongly correlated with blood-derived methylation age (R = 0.81; p = 0.0016)., Conclusions: Bone-derived DNA methylation clocks were found to be both feasible and strongly correlated with those derived from whole blood within a geriatric hip fracture population. Mortality was independently associated with the DNA methylation age, and that age was approximately 17 years greater than chronological age in the mortality cohort. The results of the present study suggest that prevention of advanced DNA methylation may play a key role in decreasing mortality following hip fracture., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This study was funded by an Orthopaedic Trauma Association Resident Research Grant (5181) via the AirCast Foundation, and from an AO Trauma North America Young Investigator's Award. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I259)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The health-care sector and particularly the surgical sector are major contributors to the exacerbation of the global climate crisis. Little is known about the carbon emissions caused by surgical procedures. Therefore, the aim of this study was to estimate the carbon footprint associated with common orthopaedic surgical procedures., Methods: Eight surgical procedures (total hip arthroplasty, total knee arthroplasty, knee arthroscopy, anterior cruciate ligament reconstruction, shoulder arthroscopy, elective foot surgery, revision hip arthroplasty, and revision knee arthroplasty) were selected for analysis. The inventory process was performed according to the Greenhouse Gas Protocol for all activity occurring in the operating room., Results: The carbon footprint (in CO2 equivalents, CO2e) ranged between 53.5 kg for knee arthroscopy and 125.9 kg for revision knee arthroplasty. Energy consumption accounted for 57.5% of all emissions, followed by other indirect emissions (38.8%) and direct emissions (3.7%). The largest single contributors were the supply chain (34.6%) and energy consumption for ventilation, heating, and air conditioning (32.7%)., Conclusions: Orthopaedic surgical procedures produce considerable amounts of CO2. Reduction in and greening of energy consumption, as well as the decarbonization of the supply chain, would have the greatest impact in reducing the carbon footprint of orthopaedic surgical procedures., Clinical Relevance: Orthopaedic surgical procedures contribute to the climate crisis by emitting relevant amounts of CO2. It should therefore be imperative for all orthopaedic surgeons to endeavor to find solutions to mitigate the environmental impact of their practice., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I193)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/I216).

Background: Hyperextension varus tibial plateau fracture (HVTPF) is known to present with concomitant injuries to the posterolateral corner (PLC). However, the exact rate and characteristics of these injuries remain unclear. The primary objective of this study was to explore the rate and characteristics of PLC injuries in HVTPFs. The secondary objective was to investigate the relationship between the fracture morphological features and the associated PLC injuries., Methods: Patients with HVTPFs were subdivided into 2 groups: group I (without fracture of the posterior column cortex) and group II (with fracture of the posterior column cortex). Fracture characteristics were summarized qualitatively based on fracture maps and quantitatively based on the counts of morphological parameters. Knee ligamentous and meniscal injuries were assessed using magnetic resonance imaging. The association between fracture characteristics and PLC injuries was analyzed., Results: We included a total of 50 patients with HVTPFs in our study: 28 in group I and 22 in group II. The rate of PLC injuries was 28.6% in group I and 27.3% in group II. In group I, patients with PLC injuries showed fracture lines closer to the anterior rim of the medial plateau and had smaller fracture areas. Furthermore, 6 of the 8 patients with PLC injuries in group I also had posterior cruciate ligament injuries., Conclusions: The rate of PLC injuries is relatively high in HVTPFs. In HVTPFs without fracture of the posterior column cortex, a small fracture area strongly suggests an accompanying PLC injury, and PLC injury is frequently combined with posterior cruciate ligament injury., Level of Evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure : This work was sponsored by the National Natural Science Foundation of China (No. 82172521) and the Youth Program of National Natural Science Foundation of China (No. 82002287). The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I208 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: Funding for this study was received from Sophies Minde Ortopedi AS, The South-East Health Authority Norway, and The Research Council of Norway. The funding sources did not play a role in the investigation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I188 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Liposomal bupivacaine (LB) is a long-lasting local anesthetic agent that was developed for use in the surgical setting to help manage postoperative pain. The objective of this study was to evaluate the effect of LB on postoperative pain, function, and overall hospital course in patients with intracapsular hip fractures who were treated with hip hemiarthroplasty., Methods: This was a single-center, randomized prospective double-blinded study of 50 patients with an isolated intracapsular femoral neck fracture who were treated with hip hemiarthroplasty from 2018 to 2022. The study group consisted of 25 patients who were treated with intraoperative LB and bupivacaine hydrochloride injections, while the control group consisted of 25 patients who were treated with intraoperative bupivacaine hydrochloride injections only. Primary outcomes were a visual analog scale (VAS) score for pain, total morphine milligram equivalents (MME), delirium, and time to ambulation with physical therapy., Results: No significant differences between the study and control groups were found in any of the outcomes measured. Most notably, there were no differences in the average postoperative pain score (VAS, 2.26 versus 2.7; p = 0.34), total MME used postoperatively (11.73 versus 9.98 MME; p = 0.71), and postoperative day of discharge (4.00 versus 3.88 days; p = 0.82)., Conclusions: The results of our study suggest that use of LB is not associated with substantially improved postoperative pain or function or with a shorter hospital course following hip hemiarthroplasty for a femoral neck fracture. Given the higher cost of LB compared with standard postoperative pain modalities, it is worth questioning its use in the setting of geriatric hip fractures., Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I173 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Focal cartilage lesions (FCLs) are frequently found during knee arthroscopies and may impair quality of life (QoL) significantly. Several treatment options with good short-term results are available, but the natural history without any treatment is largely unknown. The aim of this study was to evaluate patient-reported outcome measures (PROMs), the need for subsequent cartilage surgery, and the risk of treatment failure 20 years after diagnosis of an FCL in the knee., Methods: Patients undergoing any knee arthroscopy for an FCL between 1999 and 2012 in 6 major Norwegian hospitals were identified. Inclusion criteria were an arthroscopically classified FCL in the knee, patient age of ≥18 years at surgery, and any preoperative PROM. Exclusion criteria were lesions representing knee osteoarthritis or "kissing lesions" at surgery. Demographic data, later knee surgery, and PROMs were collected by questionnaire. Regression models were used to adjust for and evaluate the factors impacting the long-term PROMs and risk factors for treatment failure (defined as knee arthroplasty, osteotomy, or a Knee injury and Osteoarthritis Outcome Score-Quality of Life [KOOS QoL] subscore of <50)., Results: Of the 553 eligible patients, 322 evaluated patients (328 knees) were included and analyzed. The mean follow-up was 19.1 years, and the mean age at index FCL surgery was 36.8 years (95% confidence interval [CI], 35.6 to 38.0 years). The patients without knee arthroplasty or osteotomy had significantly better mean PROMs (pain, Lysholm, and KOOS) at the time of final follow-up than preoperatively. At the time of follow-up, 17.7% of the knees had undergone subsequent cartilage surgery. Nearly 50% of the patients had treatment failure, and the main risk factors were a body mass index of ≥25 kg/m 2 (odds ratio [OR] for overweight patients, 2.0 [95% CI, 1.1 to 3.6]), >1 FCL (OR, 1.9 [CI, 1.1 to 3.3]), a full-thickness lesion (OR, 2.5 [95% CI, 1.3 to 5.0]), and a lower level of education (OR, 1.8 [95% Cl, 1.1 to 2.8]). Autologous chondrocyte implantation (ACI) was associated with significantly higher KOOS QoL, by 17.5 (95% CI, 3.2 to 31.7) points, and a lower risk of treatment failure compared with no cartilage treatment, microfracture, or mosaicplasty., Conclusions: After a mean follow-up of 19 years, patients with an FCL who did not require a subsequent knee arthroplasty had significantly higher PROM scores than preoperatively. Nonsurgical treatment of FCLs had results equal to those of the surgical FCL treatments except for ACI, which was associated with a better KOOS and lower risk of treatment failure. Full-thickness lesions, >1 FCL, a lower level of education, and a greater BMI were the main risk factors associated with poorer results., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The present study was funded by the Norwegian Research Council (2015107) through the Norwegian Cartilage Project. The funder did not play any role in the investigation. The Article Processing Charge for open access publication was funded by the University of Bergen. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I180 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I71 ).

Abstract: Despite progress with the development of joint replacement registries in the United States, surgeons may have limited opportunities to determine the cumulative outcome of their own patients or understand how those outcomes compare with their peers; this information is important for quality improvement. In order to provide surgeons with accurate data, it is first necessary to have a registry with complete coverage and patient matching. Some international registries have accomplished this. Building on a comprehensive statewide registry in the United States, a surgeon-specific report has been developed to provide surgeons with survivorship and complication data, which allows comparisons with other surgeons in the state. This article describes funnel plots, cumulative sum reports, complication-specific data, and patient-reported outcome measure data, which are provided to hip and knee arthroplasty surgeons with the goal of improving quality, decreasing variability in the delivery of care, and leading to improved value and outcomes for hip and knee arthroplasty in the state of Michigan., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I52 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The current literature investigating surgical treatments for lumbar spondylolisthesis in adolescent patients is limited by small sample sizes. There are high reoperation rates, and posterior interbody fusion has not been reported to help. The current study aimed to utilize a nationwide database to investigate outcomes of spinal fusion for spondylolisthesis in young patients., Methods: The PearlDiver database was queried for patients <21 years old who had undergone lumbar spinal fusion for spondylolisthesis between 2010 and 2020. Patients were divided into 4 cohorts based on surgical approach: (1) posterior spinal fusion with posterior instrumentation (PSF), (2) posterior spinal fusion with posterior instrumentation plus interbody (PSF+I), (3) anterior spinal fusion without posterior instrumentation (ASF), and (4) anterior spinal fusion plus posterior instrumentation (A+PSF). Patients with <2 years of follow-up were excluded. The primary outcome was reoperation., Results: Of 33,945 patients with spondylolisthesis, 578 (1.7%) underwent lumbar spinal fusion: 236 (40.8%) had PSF, 219 (37.9%) had PSF+I, 66 (11.4%) had ASF, and 57 (9.9%) had A+PSF. The mean age was 16.5 ± 1.1 years, and the mean follow-up was 5.4 ± 2.9 years. A higher percentage of girls underwent surgery compared with boys (2.0% versus 1.4%). Survival analysis using all-cause reoperation as the end point demonstrated an overall 5-year reoperation-free survival rate of 85.5% (95% confidence interval [CI]: 82.5% to 88.6%). The overall reoperation rate within 5 years was significantly different depending on the approach, with A+PSF being the lowest at 7.0% (PSF = 11.9%, PSF+I = 10.5%, and ASF = 31.8%)., Conclusions: This is the largest reported series of spondylolisthesis surgery in young people. The lowest rate of revisions within 5 years was for a combined approach of A+PSF. The 5-year risk of reoperation of 31.8% for a stand-alone ASF appeared to be unacceptably high compared with other approaches, and was over 4 times higher than A+PSF (7.0%). Consistent with previous clinical series, the addition of an interbody fusion to a PSF did not decrease the reoperation rate and did not appear to offer any advantages to a PSF alone., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I258)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Superior translation of the humeral head is often identified in large and massive rotator cuff (RC) tears. However, the ability of the remaining RC muscles to compensate for the forces causing such superior translation in RC tears remains unclear. The purpose of this study was to investigate the impact of compensatory forces exerted by the remaining RC muscles on humeral head translation using a progressive RC tear model., Methods: Eight fresh-frozen cadaveric shoulders (mean donor age, 57 years) were tested using a custom shoulder testing system. In addition to an intact RC model, 3 RC tear models were created: a supraspinatus tear (Tear I); combined supraspinatus and infraspinatus tears (Tear II); and combined tears of the supraspinatus, infraspinatus, and superior one-third of the subscapularis (Tear III). Compensatory conditions were simulated by increasing the loading of the remaining RC muscles in each RC tear model. Humeral head translation was measured at different abduction and neutral rotation angles in each condition with normal and high deltoid muscle loading., Results: Significant superior translation of the humeral head was observed in Tears II and III (but not Tear I), compared with the intact state, under high loading of the deltoid during abduction and during rotation. In Tear II, compensatory conditions involving increased loading of the teres minor and subscapularis muscles effectively reduced superior translation, so that no significant differences were observed compared with the intact state, even under high deltoid muscle loading. However, in Tear III, significant superior translation was still observed, regardless of the compensatory conditions., Conclusions: ompensation by the remaining RC muscles, particularly the teres minor and subscapularis, effectively reduced superior translation of the humeral head in the posterosuperior RC tear model, whereas this compensatory strategy was insufficient if tears also involved the superior one-third of the subscapularis., Clinical Relevance: Patients with posterosuperior RC tears may find conservative treatment focusing on strengthening the remaining RC muscles, especially the subscapularis and teres minor, to be beneficial. Conversely, patients with repairable massive RC tears also involving the subscapularis tendon may benefit from surgical interventions aimed at primarily repairing the subscapularis tendon to restore the transverse force couple. Massive tears deemed not to be repairable should be evaluated for arthroplasty or other procedures., Competing Interests: Disclosure: This study was in part supported by the University of Texas at San Antonio and the San Antonio Medical Foundation. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I254)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/I240).

➢ The alpha angle was originally defined on magnetic resonance imaging (MRI) scans, using a plane, parallel to the axis of the femoral neck. However, much of the literature on the alpha angle has used radiographs or other imaging modalities to quantify the alpha angle.➢ The measurement of the alpha angle can be unreliable, particularly on radiographs and ultrasound.➢ If radiographs are used to measure the alpha angle, the circle of best-fit method should be used on multiple different views to capture various locations of the cam lesion, and "eyeballing" or estimating the alpha angle should be avoided.➢ The cam lesion is a dynamic and 3-dimensional (3D) problem and is unlikely to be adequately defined or captured by a single angle.➢ Modern technology, including readily available 3D imaging modalities, as well as intraoperative and dynamic imaging options, provides novel, and potentially more clinically relevant, ways to quantify the alpha angle., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I170 )., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated.)

Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article ( http://links.lww.com/JBJS/H993 ).

Background: Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel., Methods: We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it., Results: An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques., Conclusions: As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs) 1 , 2 . It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs) 3 . Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources 4-6 . In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account 7 , 8 ., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I22 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Vertebral body tethering (VBT) is a well-recognized, non-fusion alternative for idiopathic scoliosis in children with growth remaining. To date, there have been almost no published outcome studies with postoperative follow-up of >2 years. We aimed to fill this gap by evaluating mid-term outcomes in our first 31 consecutive patients., Methods: We retrospectively assessed additional clinical and radiographic data (mean, 5.7 ± 0.7 years) from our first 31 consecutive patients. Assessments included standard deformity measures, skeletal maturity status, and any additional complications (e.g., suspected broken tethers or surgical revisions). Using the same definition of success (i.e., all residual deformities, instrumented or uninstrumented, ≤30° at maturity; no posterior spinal fusion), we revisited the success rate, revision rate, and suspected broken tether rate., Results: Of our first 31 patients treated with VBT, 29 (of whom 28 were non-Hispanic White and 1 was non-Hispanic Asian; 27 were female and 2 were male) returned for additional follow-up. The success rate dropped to 64% with longer follow-up as deformity measures increased, and the revision rate increased to 24% following 2 additional surgical revisions. Four additional suspected broken tethers were identified, for a rate of 55%, with only 1 occurring beyond 4 years. No additional patients had conversion to a posterior spinal fusion. We observed a mean increase of 4° (range, 2° to 8°) in main thoracic deformity measures and 8° (range, 6° to 12°) in thoracolumbar deformity measures., Conclusions: With >5 years of follow-up, we observed a decrease in postoperative success, as progression of the deformity was observed in most subgroups, and an increase in the revision and suspected broken tether rates. No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I95 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)