Prior fragility fractures are associated with a higher risk of 8-year complications following total shoulder arthroplasty.

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications. PURPOSE: As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture. METHODS: Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery. RESULTS: The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001). CONCLUSIONS: Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications. LEVEL OF EVIDENCE: III.

Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases.

BACKGROUND: Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents. METHODS: A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms. RESULTS: Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019. CONCLUSIONS: Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries. LEVEL OF EVIDENCE: This is a level III retrospective study.

A General Approach to O-Sulfation by a Sulfur(VI) Fluoride Exchange Reaction.

O-sulfation is an important chemical code widely existing in bioactive molecules, but the scalable and facile synthesis of complex bioactive molecules carrying O-sulfates remains challenging. Reported here is a general approach to O-sulfation by the sulfur(VI) fluoride exchange (SuFEx) reaction between aryl fluorosulfates and silylated hydroxy groups. Efficient sulfate diester formation was achieved through systematic optimization of the electronic properties of aryl fluorosulfates. The versatility of this O-sulfation strategy was demonstrated in the scalable syntheses of a variety of complex molecules carrying sulfate diesters at various positions, including monosaccharides, disaccharides, an amino acid, and a steroid. Selective hydrolytic and hydrogenolytic removal of the aryl masking groups from sulfate diesters yielded the corresponding O-sulfate products in excellent yields. This strategy provides a powerful tool for the synthesis of O-sulfate bioactive compounds.

Equity in the Developmental Dysplasia of the Hip (DDH) Diagnosis and Treatment: A Retrospective Cohort Study to Unravel the Effect of Area Deprivation and the Insurance Type.

Background Timely diagnosis of developmental dysplasia of the hip (DDH) is crucial for implementing less invasive treatment. However, socioeconomic barriers may lead to late diagnoses. The Area Deprivation Index (ADI) is an indicator of the socioeconomic challenges experienced by patients and their families. The primary objective is to investigate if the age at which DDH is diagnosed and the treatment protocol are influenced by the ADI or the insurance type. Materials and methods Using International Classification of Diseases-Tenth Edition (ICD-10) codes, newly diagnosed DDH patients (age under 10 years) from 2020 to 2023 were retrospectively identified at our pediatric tertiary center. Patients were categorized into four groups based on ADI percentile: (1) 1-10th percentile, (2) 11-20th percentile, (3) 21-40th percentile, and (4) 41-100th percentile. They were also stratified by insurance type. Age at diagnosis and treatment protocol (non-operative vs. operative) were collected and compared between the different ADI groups and insurance groups. Operative treatment was defined as open reduction with or without femoral/pelvic osteotomy. Results A total of 327 patients satisfied the inclusion criteria and had available ADI scores for analysis. The average age at diagnosis was notably lower in ADI group 1 compared to all other ADI groups (p < 0.05) and considerably lower for patients with commercial insurance compared to those with public (p = 0.0002). The rate of surgical treatment was markedly lower in ADI group 1 compared to ADI groups 2 and 3 (both p < 0.05) and notably lower for those with commercial insurance compared to public (p = 0.0005). ADI groups 2-4 showed no significant differences in average age at diagnosis or surgical treatment rate. Conclusion The study demonstrates that socioeconomic factors affect the diagnosis and, consequently, the treatment course of DDH. Specifically, patients residing in areas with lower levels of deprivation tend to be diagnosed at a younger age and undergo surgical treatment less frequently.

A National Observational Study From 2010 to 2021 of the Trends in the Timing of Hip Surgery in Children With Cerebral Palsy: Is Surgery Being Performed Earlier?

Background Hip instability is a concern in pediatric cerebral palsy (CP) patients, with approximately one-third developing hip displacement. This may lead to pain, functional limitations, and decreased quality of life. Due to the progressive nature of hip displacement in CP, earlier surgical interventions may be beneficial. However, any shifts in practice to earlier surgical intervention, on a national scale, is not well described. The purpose of this study was to determine the recent trends in the surgical timing of hip interventions in children with CP. Methods A retrospective study was conducted using the PearlDiver Mariner all-payer claims database (PearlDiver Technologies, Colorado Springs, Colorado, United States). CP patients aged 10 years and younger were identified between 2010 and 2021. Hip surgeries including open reduction, adductor tenotomy, and pelvic osteotomy were identified. Patients were stratified by their age on the date of surgery and the year of the procedure. Linear regression analysis was conducted for temporal trends. Further, the compounded annual growth rate (CAGR) was calculated. Results A total of 309,677 CP patients were identified. For those aged one to four years old, the percentage undergoing hip surgery increased from 10.2% in 2010 to 19.4% in 2021. In the five- to 10-year-old age group, the surgery rate peaked at 14.9% in 2016 and steadily declined to 11.5% in 2021. The overall CAGR from 2010 to 2021 was +6.03% for the one- to four-year-old group and +0.88% for the five- to 10-year-old group. Linear regression demonstrated a significant association between year and the percentage of operations for patients ages one to four (R2=0.792, p<0.001), but not ages five-10 (R2=0.019, p=0.704). Conclusions Rates of surgical hip procedures in one- to four-year-old CP patients have been increasing since 2010, whereas the rate in five- to 10-year-old CP patients has been decreasing since 2016. Recently, CP patients may be undergoing hip surgery at younger ages.

AIDS but not asymptomatic HIV is associated with lower 2-10-year implant survivorship following total knee arthroplasty.

INTRODUCTION: Prior studies have demonstrated HIV does not increase the risk of 2-year complications following TKA; however, the literature is sparse regarding the impact of HIV and AIDS on long-term implant survivorship. The purpose of this study was to compare the 10-year cumulative incidence and risk of revision TKA in patients with and without asymptomatic HIV, and with and without AIDS. METHODS: Patients with HIV who underwent elective TKA were identified using a national database and divided into subgroups of asymptomatic HIV (AHIV) and acquired immunodeficiency syndrome (AIDS). These patients with HIV were propensity matched based on age, sex, and Charlson Comorbidity Index (CCI) to a control group of elective TKA patients without HIV in a 1:2 ratio. Patients were also compared to an unmatched control group. RESULTS: The 10-year risk for all-cause revision TKA was higher in the HIV group compared to unmatched controls (HR 1.40, 95% CI 1.02-1.93, p = 0.038) but not matched controls (HR 1.13, 95% CI 0.77-1.63, p = 0.594). When compared to both control groups (unmatched; matched), the AIDS group had a higher risk of 10-year all-cause revision (HR 2.74, 95% CI 1.51-4.99, p < 0.001; HR 2.19, 95% CI 1.17-4.11, p = 0.014), dislocation/instability (HR 4.89, 95% CI 1.54-15.51, p = 0.007; HR 3.86, 95% CI 1.12-13.34, p = 0.033), and periprosthetic fracture [PPF] (HR 0.67, 95% CI 0.16-2.74, p = 0.002; HR 3.82, 95% CI 1.08-13.45, p = 0.037). However, patients with AIDS were not at increased risk of PJI or mechanical loosening compared to unmatched controls or matched controls. DISCUSSION: This study expands on current literature by following a nationwide cohort of HIV/AIDS patients for 10 years after TKA. Although a diagnosis of asymptomatic HIV was not associated with increased risk of 10-year revision rates following TKA, a diagnosis of AIDS was. Surgeons should ensure patients' serum CD4 level is sufficient, ideally in the normal range of 500-1500 cells per mm3, before undergoing TKA.

A National Database Analysis: Does Cold Weather Affect the Surgical Intervention Rate for Developmental Dysplasia of the Hip in Children Under Five Years?

Background Cold weather in the first few months of life may increase the risk of a late diagnosis of developmental dysplasia of the hip (DDH). Early detection of DDH can often be treated non-surgically. The purpose of this study is to observe whether the rates of surgical intervention for DDH differ based on average outdoor temperatures in the winter months. Methods A retrospective observational study of DDH patients diagnosed from 2010 to 2021 was conducted using a national administrative database. Five geographic regions were defined based on the average temperatures in the coldest quarter of the year. The rates of DDH-related surgeries were compared across these temperature regions. Results A total of 55,911 patients ≤5 years old with a DDH diagnosis from 2010 to 2021 were identified in the database. When compared to the warmest region (Group 5), the coldest region (Group 1) had higher rates of open reduction (4.59% vs. 2.06%, p<0.001), adductor tenotomy (6.95% vs. 2.91%, p<0.001), femoral osteotomy (5.75% vs. 2.04%, p<0.001), pelvic osteotomy (5.27% vs. 2.04%, p<0.001), and total DDH surgeries (11.42% vs. 5.03%, p<0.001). Conclusion Children living in states with an average winter temperature of -6.17°C had an increased likelihood of requiring surgical intervention for DDH within the first five years of life.

Treatment of Symptomatic Residual Deformity in Legg-Calvé-Perthes Disease: Mid-Term Outcomes and Predictors of Failure After Surgical Hip Dislocation with Femoral-Head Reshaping and Relative Neck Lengthening.

BACKGROUND: Treating patients with symptomatic hips after healed Legg-Calvé-Perthes disease (LCPD) is challenging, mainly because of the complexity of the deformity. We performed a retrospective study to evaluate clinical and radiographic outcomes, measure the survival rate, and identify predictors of failure following a surgical hip dislocation (SHD) with femoral-head reshaping and relative femoral-neck lengthening for the treatment of symptomatic residual hip deformity after healed LCPD. METHODS: We identified 60 patients undergoing SHD for the treatment of symptomatic residual LCPD deformity. Fifty-one (85%) of the patients (mean age, 16.3 ± 4.7 years; 21 male patients [41%]), were followed ≥4 years after surgery. We defined surgical failure as conversion to, or recommendation for, total hip arthroplasty (THA) or a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of ≥10 at the most recent follow-up. We used a multivariable Cox proportional hazards model to identify factors that were predictive of failure. The rate of survival free from failure was estimated using a Kaplan-Meier curve. RESULTS: Twenty (39%) of the patients met 1 of the end-point criteria for surgical failure, while the hips of the remaining 31 (61%) of the patients were successfully preserved at a median follow-up of 10.2 years (interquartile range, 5.7 to 12.9 years). The estimated survival was 80% (95% confidence interval [CI] = 70% to 92%) at 5 years and 66% (95% CI = 53% to 81%) at 10 years. Independent factors associated with surgical failure were the severity of preoperative pain as assessed by the WOMAC pain score (hazard ratio [HR] = 1.16; 95% CI = 1.03 to 1.30; p = 0.01) and the severity of the deformity as assessed by the anteroposterior alpha angle (HR = 1.06; 95% CI = 1.01 to 1.11; p = 0.01). CONCLUSIONS: We found that SHD with relative femoral-neck lengthening and osteochondroplasty of the femoral head-neck junction was associated with improved deformity as assessed radiographically and decreased pain and symptoms of stiffness among patients with symptomatic residual LCPD deformity. Preoperative pain and deformity were identified as predictors of surgical failure. Further research is needed to establish the role of SHD and other procedures in preserving the hip over the long term. LEVEL OF EVIDENCE: Therapeutic L evel IV . See Instructions for Authors for a complete description of levels of evidence.

Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia in Patients ≥40 Years Old: Intermediate and Long-Term Outcomes and Predictors of Failure.

BACKGROUND: The Bernese periacetabular osteotomy (PAO) is controversial as a treatment for symptomatic acetabular dysplasia in patients ≥40 years of age. We conducted a retrospective study to evaluate the outcomes, measure the survival rate, and identify factors associated with PAO failure in patients ≥40 years of age. METHODS: We performed a retrospective study of patients ≥40 years of age undergoing PAO. Study eligibility criteria were met by 166 patients (149 women; mean age, 44 ± 3 years), and 145 (87%) were followed for ≥4 years after PAO. We used a Kaplan-Meier curve with right-censoring to calculate survivorship, with "failure" defined as either conversion to or recommendation for total hip arthroplasty or a Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score of ≥10 at the most recent follow-up. We used simple logistic regression models to determine whether any preoperative characteristics were significantly associated with PAO failure. RESULTS: The median follow-up time was 9.6 years (range, 4.2 to 22.5 years). Sixty-one of 145 hips (42%, 95% confidence interval [CI] = 34% to 51%) experienced PAO failure during follow-up. The median survival time was 15.5 years (95% CI = 13.4 to 22.1 years). The median survival time was longer for hips with no or mild preoperative osteoarthritis: 17.0 years for Tönnis grade 0, 14.6 years for grade 1, and 12.9 years for grade 2. Higher preoperative Tönnis arthritis grades (p = 0.03) and worse WOMAC function scores (p < 0.001) were associated with an increased likelihood of failure. CONCLUSIONS: PAO is usually effective at improving function and is effective at preserving the hip in patients ≥40 years of age provided that they have good preoperative function and no or mild preoperative osteoarthritis (Tönnis grade 0 or 1). Patients who are ≥40 years old with advanced preoperative osteoarthritis (Tönnis grade 2) and those with poor preoperative dysfunction have a high risk of therapeutic failure after PAO. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

A qualitative study of the impact of a periacetabular osteotomy on patients' lives.

AIMS: The aim of this study was to understand the experience of mature patients who undergo a periacetabular osteotomy (PAO), a major hip-preserving surgical procedure that treats symptomatic hip dysplasia by realigning the acetabulum. Our aim was to improve our understanding of how the operation affected the lives of patients and their families, with a long-term goal of improving their experience. METHODS: We used a phenomenological approach with in-depth, semi-structured interviews to investigate the experience of seven female patients, aged between 25 and 40 years, who underwent a PAO. A modified homogeneity sampling approach coupled with criterion sampling was used. Inclusion criteria involved having at least one child at home and being in a committed relationship with a spouse or partner. RESULTS: Analysis of interview transcripts revealed five major themes: feelings of frustration before having a treatment plan; fear of the operation; the importance of understanding the procedure in order to feel in control of their care; feelings of helplessness, dependence, and depression during recovery; and the need for support during recovery. CONCLUSION: Our findings suggest that both the physical and psychosocial burdens of undergoing a PAO are great, with a major impact on the patient and their family. Many important issues lie outside the scope of what healthcare teams currently address. Cite this article: Bone Joint J 2022;104-B(7):781-785.