Surgical outcomes in patients with flexible adult-acquired flatfoot deformity (AAFD) have not been evaluated in large prospective register studies. Calcaneal osteotomy and hindfoot arthrodesis are commonly used. We aimed to compare the results of these 2 procedures using preoperative and 1-year postoperative patient-reported outcome data from the Swedish Quality Register for Foot and Ankle Surgery (Swefoot). We analyzed data regarding feet that had primary surgery for flexible (grade II) AAFD between 2017 and 2022 in Sweden. The primary outcome was the Self-Reported Foot and Ankle Score (SEFAS), range 0-48 (minimal important difference 5). Secondary outcomes were EQ-5D and satisfaction. 190 feet (63% women, median age 62 years, interquartile range 54-68) were surgically treated during the study period. Mean improvement in SEFAS score was 12 (95% confidence interval [CI] 10-13) in grade IIa and 10 (CI 8-12) in grade IIb, and in the EQ-5D index 0.27 (CI 0.20-0.34) and 0.23 (CI 0.15-0.31), respectively. Compared with preoperatively a higher percentage of patients were satisfied with postoperative foot appearance (77% vs 39%) and foot strength (66% vs 23%). The mean SEFAS score improvement was 11 (CI 10-13) in the osteotomy group and 10 (CI 5-15) in the arthrodesis group; adjusted mean difference was 2.7 (CI -1.2 to 6.5). Surgical treatment of flexible AAFD significantly improves function and quality of life at 1 year postoperatively. No differences in postoperative patient-reported outcomes were observed between patients who underwent calcaneal osteotomy compared with hindfoot arthrodesis.

Inducible displacement CT (ID-CT) is an emerging method for diagnosing implant loosening by (i) acquiring CT scans under different joint loading conditions, (ii) analyzing scans via segmentation and registration, and (iii) quantifying and visualizing relative implant-bone displacement. With multiple centers approaching these steps differently, this scoping review aimed to summarize current methodologies and key challenges. PubMed, Cochrane, and Embase were searched for clinical and experimental ID-CT studies on spinal and arthroplasty implants. Data was extracted using a table based on updated CT-radiostereometric analysis (RSA) guidelines, including study characteristics, CT acquisition parameters, image analysis methods, validation approaches, outcomes, and loading protocols. Diagnostic studies were assessed with QUADAS-2. 22 studies were included concerning the hip (10), knee (7), spine (4), and wrist (1), covering clinical and experimental (phantom and cadaveric) designs. Loading protocols varied widely, applying compressive, rotational, and angular forces with external stabilization or loading devices. CT acquisition ranged from µCT to conventional and weight-bearing CT, with variation in kVp, mAs, reconstruction spacing, and metal artefact reduction. Image-analysis workflows were broadly similar, though reporting of algorithms and displacement metrics was often incomplete. Diagnostic validation was limited by variable reference standards, non-prespecified loosening thresholds, and non-blinded assessments, undermining true performance. Technical validation, although often precise, did not cover the full ID-CT pipeline (i.e., complete loading protocol), leaving key sources of measurement variance untested. We showed that ID-CT is used with a wide variation in approach and limited reporting prevents the establishment of its true diagnostic accuracy.

Background and purposeThe 2 most common surgical approaches in hemiarthroplasty for hip fracture treatment are the posterolateral and the direct lateral approach. We aimed to estimate the relative cost-effectiveness of these approaches.MethodsWe conducted an economic evaluation alongside a randomized controlled superiority trial for 6 months. The trial included 555 patients over 18 years of age with an acute femoral neck fracture. The effectiveness outcome used was quality-adjusted life years (QALYs), assessed using the EQ-5D-5L. Costs were measured through self-reported questionnaires administered at baseline, after 3 months, and after 6 months. We dealt with missing data through multiple imputation and analyzed the imputed datasets by comparing group means in costs and QALYs. A secondary analysis included adjustment for baseline imbalances through linear regression.ResultsThe estimated average treatment effect on the QALYs was 0.02 (95% confidence interval [CI] –0.006 to 0.046). From the healthcare and societal perspective, we found a non-significant average treatment effect on costs of 1,508 (CI –1,744 to 4,760) and 1,583 (CI –1,972 to 5,137), respectively. The probability of cost-effectiveness was 10% at a willingness-to-pay of zero, and then slowly increased to around 50% for higher willingness-to-pay values.ConclusionWe found no conclusive evidence of any differences between the surgical approaches with respect to costs, QALYs, and cost-effectiveness. We therefore suggest that, from an economic viewpoint, the 2 surgical approaches should be treated as interchangeable.

Background and purposePatient-specific instrumentation (PSI) in total knee arthroplasty (TKA) aims to improve implant alignment and clinical outcomes, but its effectiveness remains uncertain. We aimed to compare whether PSI was superior to conventional instrumentation (CVI) in TKA. The primary outcome was the Oxford Knee Score (OKS) at 2 years with assessments of additional clinical outcomes up to 5 years after surgery.MethodsThis study included 70 knees with primary osteoarthritis randomized (1:1) to undergo TKA using either PSI or CVI. Outcomes were evaluated using patient-reported outcome measures (PROMs), radiographic alignment, and radiostereometric analysis (RSA) of migration over the full follow-up period of 5 years.Results68 knees underwent surgery as per protocol. At 2 years, 29 knees in the PSI group and 36 in the CVI group were assessed with the OKS, which improved significantly by 21.2 in the PSI group and 18.2 in the CVI group (mean difference [MD] 2.1; 95% confidence interval [CI] –1.5 to 5.7). PSI resulted in slightly increased tibial varus alignment (MD –1.4°; CI –2.3° to –0.4°), migrated slightly more into varus (mean difference at 2 years: –0.28 mm, CI –0.54 to –0.03 mm), and showed higher maximum total point motion (MTPM) during the period 1 to 2 years (mean difference: 0.13 mm; CI 0.01–0.25). At 5 years, 3 knees had been revised (PSI: 2; CVI: 1).ConclusionPSI did not demonstrate superior outcomes compared with CVI. These findings suggest that PSI may not provide significant benefits over conventional techniques in routine TKA.

Why the randomized controlled trial is still at the apex and the gold standard for evaluating new medical and surgical interventions

Background and purposeWe examined the association between preoperative self-rated health (SRH) and opioid use 12 months after total hip arthroplasty (THA) for osteoarthritis.MethodsWe identified 381,323 people who answered a question on SRH in the Danish National Health Surveys 2010, 2013, or 2017. Among these, 4,174 people age > 35 years subsequently underwent THA for osteoarthritis. SRH was categorized as poor (“poor” or “fair” health) or good (“good,” “very good,” or “excellent” health). Opioid use was defined as ≥ 2 prescriptions 1–12 months after THA. We calculated prevalences and prevalence ratios (PR) with 95% confidence intervals (CI) through log-binomial regression, overall and by preoperative opioid use status adjusting for potential confounders. The total morphine milligram equivalent (MME) dose after THA with interquartile range (IQR) was further calculated.Results876 (21%) patients rated their health as poor and 3,292 (79%) as good. The prevalence of opioid use among patients with poor SRH was higher than among those with good SRH (PR 2.33, CI 2.05–2.65) (315 [36%] vs 132 [14%]). Similarly, among preoperative non-users, the prevalence was 62 (15%) for patients with poor SRH and 140 (6%) for patients with good SRH (PR 2.20, CI 1.65–2.93), and among preoperative users, the prevalence was 252 (54%) for patients with poor SRH and 299 (31%) for patients with good SRH (PR 1.64, CI 1.44–1.86). The overall median MME dose was higher among patients with poor SRH (2,940, IQR 800–9,610) than among those with good SRH (1,000, IQR 400–3,175) with a median difference of 1,940 (IQR 1,227–2,653).ConclusionCompared with good preoperative SRH, poor preoperative SRH was associated with higher opioid use 12 months after THA for osteoarthritis.

Background and purposeThere are still strong beliefs in medicine concerning things that bring “bad luck.” It is unclear whether a suspicious component size or surgery date is related to “bad luck” in orthopedic surgery. We aimed to examine: (i) if a potentially unlucky femoral stem size 13 in total hip arthroplasty (THA), and (ii) if a possible unlucky surgery date, Friday 13th, in THA and total knee arthroplasty (TKA) have a higher revision rate.MethodsWe analyzed 611,050 THAs and TKAs, performed in the past 13 years using Dutch Arthroplasty Register data. The revision rate of uncemented femoral stem size 13 (Corail and Taperloc) in THA was compared with all other stem sizes of the same type. Furthermore, the revision rate of THA and TKA implanted on Friday 13th was compared with all other days and with other Fridays. Both were performed using competing risk analyses with death as competing risk and cause-specific multivariable Cox proportional hazard regression analyses.ResultsThe use of an uncemented Corail or Taperloc femoral stem size 13 in THA was associated with a lower revision rate (3.0%, 95% confidence interval [CI] 2.3–4.0) compared with the revision rate of other femoral stem sizes (3.5%, CI 3.3–3.8) (hazard ratio [HR] 0.76, CI 0.65–0.87). TKA procedures on Friday 13th were not associated with increased revision rate (5.2%, CI 4.1–6.7) compared with procedures on other days (6.0%, CI 5.9–6.2) or on other Fridays (5.8%, CI 5.4–6.2) (HR 1.03, CI 0.80–1.32 and HR 1.01, CI 0.79–1.30, respectively). For THA, procedures on Friday 13th were associated with a higher revision rate (5.1%, CI 3.9–6.6) compared with procedures on other days (4.6%, CI 4.5-4.8) (HR 1.32, CI 1.04–1.67) but not compared with procedures on other Fridays (4.8%, CI 4.4–5.1) (HR 1.24, CI 0.97–1.58).ConclusionBased on national arthroplasty registry data, femoral stem size 13 in THA was associated with a lower revision rate. TKA procedures on Friday 13th were not associated with increased revision rate; however, in THA there seems to be an increased risk of revision in THA procedures performed on Friday 13th compared with other days, but not when compared with other Fridays.

With more knee arthroplasties (KAs) performed in working-age patients, interest in return to work (RTW) increases. We aimed to investigate the association between body mass index (BMI) and RTW after primary KA and whether the association varies by sex, age, comorbidity, and socioeconomic position. From Danish national registries, we included 6,128 patients aged 18 to 60 years undergoing KA from 2008-2018. Exposure was BMI in categories < 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, and ≥ 40.0. Outcome was RTW after KA. We estimated cumulative incidence proportions (CIP) of RTW. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CI). Median time to RTW was 70 days. Overall CIP for RTW was 63% (CI 62-65) at 3 months. With BMI < 25 as reference, CIP was 65% (n = 1,401) for BMI 25.0-29.9, 64% (n = 1,130) for BMI 30.0-34.9, 60% (n = 528) for BMI 35.0-39.9, and 60% (n = 260) for BMI ≥ 40.0, corresponding to an adjusted HR of 1.06 (CI 0.98-1.15), 1.02 (CI 0.94-1.11), 0.97 (CI 0.88-1.06), and 0.96 (CI 0.85-1.08). Men with BMI 35.0-39.9 and ≥ 40 had an adjusted HR of 0.89 (CI 0.76-1.05) and 0.87 (CI 0.70-1.10). None of the associations were statistically significant. Age, comorbidity, and socioeconomic position did not modify the association between BMI and RTW. More than 60% of patients RTW within 3 months but we found no association between BMI and RTW after primary KA.