Amir Human Hoveidaei

Introduction and importance: Chronic intramedullary nail (IMN) migration with hardware protrusion following tibial fracture fixation is an exceptionally rare complication, with only four previously reported cases. Management is complicated in low-resource settings where delayed presentation and limited access to specialized care are common. Case presentation: A 44-year-old man in rural Kenya presented with approximately 15 cm of the IMN protruding through the medial ankle skin, 9 years following SIGN nail fixation of a distal tibial fracture. Hardware protrusion occurred after an ankle eversion injury 4 years post-fixation, with progressive migration over the subsequent 5 years. Financial hardship and geographic barriers prevented timely care. Radiographs demonstrated distal tibial malunion with rotational malalignment. He underwent IMN removal, irrigation and debridement, corrective osteotomies, and external fixation. Anterolateral thigh free-flap reconstruction failed due to arterial and venous thromboses. Salvage used a saphenous artery-based cross-leg fasciocutaneous flap with antibiotic-impregnated cement beads and staged division and inset. He absconded postoperatively but returned 8 months later with healed tibial union and an intact external fixator. At follow-up, he was ambulatory without assistance and had resumed work. Clinical discussion: Chronic tibial IMN protrusion is associated with infection and instability. Successful management requires a staged approach using debridement, deformity correction, external fixation, and soft-tissue reconstruction. Limb salvage can be achieved despite infection, soft-tissue loss, and interruptions in care. Conclusion: This case illustrates the consequences of prolonged hardware exposure and the feasibility of limb salvage through staged reconstruction in resource-limited settings. Structured postoperative surveillance following IMN fixation is critical, particularly in low- and middle-income countries. Graphical abstract available at: https://links.lww.com/IJSCR/A217.

Background: Orthopaedic infections require accurate microbiological diagnosis for effective treatment. This study aimed to evaluate the impact of an accelerated protocol for culture harvesting and incubation on culture positivity rates in orthopaedic surgeries, comparing it to the traditional protocol. Methods: A single-center, 1:1 matched case–control study was conducted at the Rubin Institute for Advanced Orthopaedics. Patients undergoing orthopaedic surgery with suspected infections were divided into two groups (108 patients): accelerated protocol (June–November 2024) and traditional protocol (January–June 2024). The time from operating room (OR) to incubation was significantly shorter in the accelerated group (89 min vs. 245 min, p < 0.001). Culture positivity rates and microorganism profiles were compared. The temporal dynamics of culture positivity were evaluated using Kaplan–Meier analysis across the entire cohort. A logistic regression analysis was carried out between the time from OR to incubation and culture positivity. Results: The accelerated protocol group had significantly higher culture positivity rates (70.4%) compared to the traditional group (48.1%) (p = 0.027). Microbial profiles were similar between groups. The probability of culture positivity across the entire cohort decreased by 6% for every 10-min delay after 100 min from OR. Regression analysis showed a significant inverse association between time and culture positivity (β = −0.005, p = 0.016). Conclusions: The accelerated protocol significantly improved culture positivity rates without compromising diagnostic performance. Reducing the time from sample collection to incubation enhances pathogen detection across all pathogen types, potentially improving outcomes in orthopaedic infection management.

Background: Primary bone sclerosing epithelioid fibrosarcoma (SEF) is a rare, yet aggressive, condition associated with considerable mortality and prone to misdiagnosis or delayed diagnosis, making precise radiologic identification essential. Materials and methods: The systematic review was conducted in accordance with PRISMA standards. PubMed, Scopus, Web of Science, and Embase were searched through March 2025. The inclusion criteria consisted of English-language human studies with radiologic descriptions of primary bone SEF. Two independent reviewers conducted screening and data extraction. The risk of bias was evaluated utilizing the Joanna Briggs Institute critical appraisal tools for case reports and series. Results: Out of 190 identified papers, 18 met the inclusion criteria, describing 26 patients. The predominant findings in X-rays and computed tomography scans were lysis and destruction (88.46%), well-defined margins (81.81%), and soft tissue involvement (53.84%). magnetic resonance imaging (MRI) data revealed T1-weighted images exhibiting hypo- to isointense signals, while mixed hyper- and hypointense signals mostly characterized T2 sequences. SEF predominantly affected irregular bones (46.2%), followed by long bones (38.5%), with sclerotic rims being most prevalent in long bones (60%). Bone SEF predominantly manifested as pain alone in 40% of cases, and only 33.3% of the patients were initially classified as SEF. Accurate initial diagnosis of SEF was more frequently reported in studies that performed MRI. Conclusion: This systematic review elucidates the varied imaging features of bone SEF across several bone types. When these characteristics elicit suspicion in primary imaging, it is probably wise to prioritize MRI, and early biopsy contemplated to guarantee a timely and precise diagnosis.

➢ Periprosthetic joint infection (PJI) remains a major complication of joint arthroplasty, associated with morbidity and health-care burden. Although room for progress remains, the management of PJI has evolved over the past 50 years from empiric, procedure-centered approaches to structured, evidence-based, and biologically informed strategies. ➢ This article summarizes key developments in the prevention, diagnosis, and treatment of PJI, driven by advances across multiple clinical and scientific subspecialties. ➢ Diagnostic approaches have advanced from reliance on clinical findings and culture to a multimodal framework integrating validated criteria, serological and synovial biomarkers, and molecular techniques. Surgical management has similarly evolved toward individualized strategies, including debridement with implant retention, 1-stage or 2-stage revision, and salvage surgery tailored to host, pathogen, and disease characteristics. ➢ Advances in microbiology, particularly the recognition of biofilm and the emerging role of the human microbiome, have further reshaped the understanding of PJI. Overall, this article examines how developments in prevention, diagnosis, surgical treatment, and microbiology have driven a transition toward precision-based, biology-informed, and individualized management of PJI.

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are rarely performed in children and adolescents but may be required for end-stage joint disease. Evidence regarding safety, survivorship, and patient-reported outcomes in patients younger than 25 years remains limited. The aim of this study was to systematically evaluate postoperative complications, functional outcomes, quality of life, and revision rates following THA and TKA in this age group. Methods: A systematic review and meta-analysis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. MEDLINE, Embase, Scopus, and Web of Science were searched through October 2025 for studies reporting outcomes of THA or TKA in patients aged younger than 25 years. Random-effects models were used to pool complication rates, functional outcomes, quality of life, and all-cause revision separately for THA and TKA. Meta-regression explored the influence of age, sex, year of patient inclusion, arthroplasty indications, and bearing surface types. Results: A total of 44 studies involving 3,317 patients and 5,632 joints were included. Following THA, pooled rates of periprosthetic joint infection (PJI), aseptic loosening, and periprosthetic fracture were 1.6%, 5.4%, and 1.4%, respectively, and all-cause revision rate was 8.7%. Functional scores (standardized mean difference [SMD] = 4.9) and quality-of-life measures (SMD = 1.8) improved substantially after THA. For TKA, pooled PJI and aseptic loosening rates were 2.9% and 9.9%, with an all-cause revision rate of 12.4%. Subgroup analyses demonstrated that more recent years of patient inclusion were associated with lower revision and infection rates following THA. Conclusion: THA and TKA in patients younger than 25 years can improve function and quality of life, although the risks of revision and infection remain higher than those in older adults. Outcomes have improved in more recent cohorts with advances in implant design and surgical technique. Further prospective studies with standardized reporting are needed to define optimal implant selection and long-term outcomes in this population. PROSPERO Registration Code: CRD420261303010. Level of Evidence: Therapeutic Level III (systematic review of retrospective cohort studies). See Instructions for Authors for a complete description of levels of evidence.

Background: Preoperative templating in total hip arthroplasty (THA) optimizes implant sizing and positioning accuracy. Standard practice relies on two-dimensional (2D) templating, while three-dimensional (3D) and AI-assisted planning are evolving alternatives. This study aimed to evaluate the implant size prediction accuracy and its impact on intraoperative and postoperative outcomes. Methods: We conducted a systematic review and meta-analysis in April 2025 across MEDLINE (PubMed), Scopus, and Web of Science to identify studies comparing advanced preoperative planning (AI-based or 3D) with 2D planning in THA. Data on femoral stem and acetabular cup sizing accuracy and key clinical outcomes were extracted. Study quality was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist. Overall, 32 studies were identified. Results: Meta-analysis showed that 3D planning had significantly higher exact implant size agreement than 2D (femoral OR = 2.00, 95% CI 1.34–2.97; acetabular OR = 5.32, 95% CI 1.89–14.94), and significantly lower major deviation (femoral OR = 0.37, 95% CI 0.24–0.58; acetabular OR = 0.18, 95% CI 0.06–0.50). AI-assisted planning showed significantly higher exact implant size agreement (femoral OR = 3.27, 95% CI 2.52–4.24; acetabular OR = 3.96, 95% CI 2.95–5.32) and significantly lower major deviation (femoral OR = 0.22, 95% CI 0.16–0.31; acetabular OR = 0.29, 95% CI 0.15–0.56). Significantly reduced blood loss (MD = − 36.21, 95% CI − 46.58 to − 25.85), operative time (MD = − 15.54, 95% CI − 24.25 to − 6.83), LLD (MD = − 1.58, 95% CI − 2.22 to − 0.93), and higher abduction angle (MD: 1.64; 95% CI 0.37–2.92) were associated with AI-based planning. Postoperative Harris Hip Score was marginally higher with AI-assisted planning (MD = 0.73 points), but this difference was below the minimal clinically important threshold and not robust to sensitivity analysis. Conclusion: Advanced planning improved implant sizing accuracy. AI-assisted planning was additionally associated with more favorable intraoperative and postoperative outcomes; however, heterogeneity, limited long-term data, and restricted external validity due to the geographic concentration of AI-assisted studies and limited diversity of AI software platforms warrant further standardized comparative studies.

Background: Outcomes after total joint arthroplasty are influenced by various biopsychosocial factors, among which preoperative psychological status and personality traits play a crucial role. Given that personality traits – such as extroversion, psychoticism, anxiety, and neuroticism – represent a wider, enduring framework compared to transient mental states like depression and stress, their impact on surgical outcomes is significant. This systematic review aims to evaluate the influence of personality traits on clinical outcomes after total joint arthroplasty. Methods: PubMed, Web of Science, Scopus, and Embase were explored from initiation until May 2025. The inclusion terms were “personality traits,” “total knee arthroplasty,” and “total hip arthroplasty,” along with related MeSH terms, with no boundaries for language. Backward reference citation searches were also conducted. Results: Finally, a total of 15 studies were included. Anxiety is one of the most substantial factors impacting the consequences of total joint arthroplasty. Although there is unsatisfactory evidence supporting pain reduction in extroverted individuals, extroversion has been associated with improved quality of life and postoperative functional outcomes. Additionally, neuroticism has a negative correlation with quality of life and is linked to increased pain levels. Pessimism is associated with greater pain, reduced knee function improvement, and increased activity limitations. Based on quality-of-life questionnaires, extroversion and melancholic traits were associated with higher scores. However, neuroticism showed a negative correlation with Short Form (SF)-36 scores. Conclusions: Pain was the most significant assessed outcome. A positive association was observed between pain and traits such as extroversion, neuroticism, pessimism, anxiety, depression, and persistence. Concerning quality of life, features like extroversion and melancholic temperament were associated with higher quality of life, whereas neuroticism had a negative correlation with SF-36. Based on these findings, considering personality and psychological factors can contribute to improving surgical outcomes, and preoperative counseling is recommended.

Image-based navigation-assisted total hip arthroplasty (THA) has been increasingly adopted to improve component positioning and reduce complications; however, its clinical benefit in patients who have morbid obesity remains unclear. The purpose of this study was to compare (1) surgical complications, (2) thromboembolic events, and (3) reoperation and revision rates between image-based navigation-assisted and manual THA in a matched cohort of patients who have morbid obesity. Using an administrative claims database, we conducted a retrospective matched cohort study of patients who had morbid obesity (BMI ≥ 40) and underwent elective primary THA between 2010 and 2023. Image-based navigation-assisted cases were matched 1:3 to manual THA controls by age, sex, year of surgery, diabetes, hypertension, tobacco use, and alcohol use. After matching, 5,835 patients who had morbid obesity undergoing THA were analyzed (1,473 navigation-assisted; 4,362 manual) with comparable baseline demographics and comorbidities. Outcomes included surgical complications (prosthetic joint infection [PJI], surgical site infection, dislocation, periprosthetic fracture, mechanical loosening, limb length discrepancy [LLD]), thromboembolic events (pulmonary embolism, deep vein thrombosis [DVT]), same-day blood transfusions, and revision surgeries (septic and aseptic) assessed at multiple postoperative timepoints including 30-days, 90-days, one-year, and two-year timepoints. Across all timepoints, image-based navigation-assisted THA was not associated with reduced rates of surgical complications, thromboembolic events, or revisions compared with manual THA (P > 0.05), with the exception of same-day blood transfusions (0.8% versus 1.9%, P = 0.005). PJI, dislocation, mechanical complications, DVT, pulmonary embolism, and septic or aseptic revision rates were statistically similar between cohorts at all time points analyzed (P > 0.05). In a large national cohort of patients who had morbid obesity and underwent primary THA, image-based navigation-assistance did not generally confer measurable clinical advantages over manual techniques outside of same-day blood transfusions. Despite increasing utilization, these findings suggest that routine use of image-based navigation in this high-risk population may not provide added clinical value within two years postoperatively, raising important considerations regarding its cost-effectiveness and role in value-based care.

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Necrotizing fasciitis (NF) is a severe orthopaedic emergency. While surgical management and critical care have improved survival, long-term quality of life (QoL) for survivors remains poorly understood. This study evaluates patient-reported QoL post-surgery using the EuroQol-5 Dimensions-5 Levels (EQ-5D-5L) and 26-Item Short Form Survey (SF-36), examining their relationship with initial disease severity as measured by the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score. This cross-sectional study included 21 patients treated surgically for NF between 2015-2025, each with ≥ one year of follow-up. LRINEC scores were calculated from preoperative labs, EQ-5D-5L responses converted to U.S. utility indices, and SF-36 scored on a 0-100 scale. Associations between LRINEC and QoL domains were assessed with Spearman correlations. Mean follow-up was 5.4 years (SD 3.7). The mean EQ-5D-5L utility index was 0.6 (SD 0.4). Pain/discomfort was the most reported problem overall (76.2%), with moderate-severe symptoms most common in pain/discomfort (57.1%) and mobility (47.6%), and least common in anxiety/depression (28.6%). SF-36 median domain scores were worst in Role-Physical (25.0/100) and best in Role-Emotional (100/100). The mean LRINEC score was 4.6 (SD 3.0), with no statistically significant correlation to any QoL measure in this cohort (P > 0.05). Among responding NF survivors, the observed long-term health status was characterized by frequent pain, mobility problems, and physical role limitations, while emotional domains had comparatively better scores across both instruments. No statistically significant association between LRINEC score at presentation and QoL was detected in this cohort. These findings highlight the potential for meaningful mental health recovery and underscore the importance of physical rehabilitation as part of comprehensive long-term care.