Wayne Hoskins

Prediction of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) relies almost wholly on host factors, and whether the operation itself carries infection risk independent of the patient is unknown. We analyzed 2920 primary TKAs in 2350 patients from a single institution with national joint registry linkage, using death as a competing risk and coronal alignment as a negative-control exposure. A pre-specified surgical-complexity index counted five construct markers at the index operation: constraint, a tibial stem, a femoral stem, a previous implant and a pre-existing extra-articular deformity or fracture. Septic revision was the primary outcome and aseptic revision the control. Fine–Gray subdistribution hazard models with patient-level clustering estimated complexity and, in the paired-radiograph subset, neutral-alignment effects on both outcomes. There were 51 septic and 104 aseptic revisions and 525 deaths over a median follow-up of 7.4 years. Each additional complexity marker raised the subdistribution hazard of PJI (sHR 1.61, 95% CI 1.27–2.04) but not of aseptic revision (sHR 1.06, 95% CI 0.84–1.33); 5-year PJI incidence rose from 1.5% with zero or one marker to 5.9% with two or more. Neutral coronal alignment was protective against aseptic revision (sHR 0.42, 95% CI 0.26–0.67) but null for PJI (sHR 0.87, 95% CI 0.41–1.87). Adjustment for skin-to-skin operative time, available for 93% of the cohort, moved the complexity estimate in the same knees only from 1.58 to 1.55 and attributed 5 % of the effect to operative time. These are observational associations and not causal effects, but surgical exposure merits consideration alongside host factors in infection-risk assessment.

Purpose: To evaluate whether immediate weight bearing as tolerated (WBAT) following open reduction and internal fixation of clavicle fractures with a dual mini-fragmentation plate construct increases complications, implant failure, or worsens functional and patient-reported outcomes compared to a restricted weight-bearing protocol. Methods: Adult patients (≥ 18 years) who underwent open reduction and internal fixation of a clavicle fracture were retrospectively identified and stratified into restricted weight-bearing or weight bearing as tolerated (WBAT) cohorts. Cohorts were matched for demographic and injury characteristics. All WBAT fractures were treated with dual orthogonal mini-fragmentation plate fixation, whereas restricted weight-bearing fractures were treated with either single- or dual-plate fixation. Outcomes included complications (infection, wound dehiscence, hardware prominence, implant failure, and loss of reduction) and PROMIS Physical Function and Pain Interference scores. Results: Among 378 initial patients, 93 were included after propensity score matching: 62 in the restricted weight-bearing group and 31 in the WBAT group. Complication rates were similarly infrequent between groups (all p ≥ 0.326), with no fixation failures or deep surgical site infections occurring in the WBAT group. Conclusions: Early weight bearing as tolerated may be safe following dual mini-fragmentation plate fixation of clavicle fractures, with comparable complication rates, union rates, and patient-reported outcomes to restricted weight-bearing protocols. These findings support the use of early mobilization in patients with rigid internal fixation constructs and may facilitate improved functional recovery and earlier return to activity.

Background: National joint replacement registries inform prosthesis selection and health policy using a consistently recorded set of patient, implant, and surgical variables. However, preoperative radiographic alignment and detailed diagnostic complexity are rarely, if ever, captured. Surgeons pay close attention to limb alignment and deformity because both reflect the complexity of the knee being replaced and are associated with the risk of failure. However, the incremental value of recording these measurements, beyond the variables that registries already collect, has not been quantified. As preoperative alignment can be read from the same long-leg radiographs that many surgeons already obtain, even a small improvement in identifying which knees will be revised could justify the modest cost of recording it. Questions/purposes: In a 15-year, single-center, TKA group with comprehensive preoperative alignment assessments and national joint replacement registry linkage, we asked: (1) How well do the variables that a national joint replacement registry routinely records identify which knees will later be revised (as quantified by a metric called discrimination, where 0.50 is no better than chance and 1.00 is perfect prediction)? (2) Does adding diagnostic-complexity variables improve that discrimination? (3) Does adding preoperative alignment variables improve it further? (4) When alignment is left out, by how much do the risk estimates that registries report for common surgical decisions (their HRs) change? Methods: A retrospective analysis of 2341 primary TKAs in 1917 patients performed between January 2010 and May 2024 at a single tertiary center was conducted, all with national-registry linkage and a documented preoperative long-leg standing radiograph. The primary outcome was aseptic revision, modeled with nested Fine-Gray regression and death treated as a competing risk, meaning that a patient who dies can no longer be revised and is not simply removed from the denominator. To check that the findings were not an artifact of incomplete imaging, we repeated the entire analysis in a more completely imaged group (a prespecified sensitivity analysis), which was a subset of 1567 procedures with both preoperative and postoperative long-leg radiographs (the paired-imaging subset). We built the models (M) stepwise to determine how much each kind of information added. The M1 used the variables that a registry routinely records, M2 added three diagnostic-complexity variables, and M3 added three preoperative alignment variables. To measure how much each group of variables contributed, we compared neighboring models statistically, using an intermediate model (M2.5) to isolate the share attributable to limb alignment. We measured how well each model separated the knees that were later revised from those that were not using a score called the concordance index (C-index): 0.50 means that the model is no better than a coin toss, 1.00 means it is always right, and 0.66 means it ranks a revised knee above a nonrevised one about two-thirds of the time. Because any model flatters itself on the same knees that were used to build it, we also tested each model on knees it had not seen by rebuilding it on part of the data and checking it on the rest, repeatedly, keeping both knees of a patient together. That cross-validated C-index is the honest figure and the one we rely on. The in-sample figure is reported alongside it because earlier studies report it, and the gap between the two shows how much of the apparent gain is optimism rather than real predictive information. Results: The registry-only variable set (M1) identified the risk of aseptic revision only modestly (apparent C-index 0.66 in the primary group and 0.67 in the sensitivity group; cross-validated 0.59 and 0.61). Adding diagnostic-complexity variables (M2) did not improve this. Adding preoperative alignment (M3) raised apparent discrimination to 0.68 in the primary group and 0.69 in the sensitivity group, but it did not improve cross-validated discrimination in either. Taking everything the models added from M1 to M3, that addition was detectable as a whole only in the sensitivity group, not in the primary group. Within it, limb alignment carried most of the information in the sensitivity group (68%; p < 0.001) and about half of it in the primary group (47%; p = 0.02); diagnostic complexity accounted for the remainder (31% and 52%) but could not be distinguished from the effects of chance, and the knee-specific angles added nothing detectable in either (1%). In the full model, the preoperative mechanical hip-knee-ankle angle was associated with aseptic revision in the sensitivity group (subdistribution HR 1.06 for each degree, the angle entered as its signed difference from 180°, where 180° is a straight limb, < 180° is varus, and > 180° is valgus [95% confidence interval (CI) 1.00 to 1.12]; p = 0.03); the same association was present but not statistically distinguishable from the effects of chance in the primary group (subdistribution HR 1.04 [95% CI 0.99 to 1.09]; p = 0.11). Leaving alignment out changed some registry-style HRs. For example, the HR for tibial stem use shifted by 17% in the primary group. The findings were consistent, and stronger, in the more completely imaged subset (n = 1567; 68 revisions). When alignment was added, about 30% of knees in the primary group and 34% in the subset moved into a different third of predicted risk. Conclusion: The variables that registries routinely record identify the risk of aseptic TKA revision only modestly. Preoperative limb alignment adds a small but consistent and clinically interpretable amount of predictive information, and it is stronger in the subset of knees for which both preoperative and postoperative imaging existed, although we did not test postoperative alignment as a predictor in its own right. Leaving alignment out also shifts the registry-style...

Background: No consensus exists on the optimal syndesmotic fixation for unstable ankle fractures. We compared strategies using a network meta-analysis (NMA) of randomized controlled trials (RCTs). Methods: Seven databases and trial registers were searched through November 1, 2025 for RCTs of adults undergoing fixation of an ankle fracture with syndesmotic injury; quasirandomized and duplicate/follow-up reports were excluded. Interventions were grouped a priori as suture-button/dynamic fixation, metallic 3-cortex screw (reference), metallic 4-cortex screw, bioabsorbable screw, and no fixation. A frequentist random-effects NMA estimated mean differences (MD) for function (Olerud-Molander Ankle Score [OMAS] at 1 year, the outcome reported by the most trials; AOFAS) and odds ratios (OR) for malreduction and reoperation (primary definition excluding planned implant removal), with treatments ranked by P-score and effects interpreted against the minimal clinically important difference (MCID). Certainty was rated with a CINeMA-equivalent assessment. Results: Twelve RCTs (883 patients) formed a connected network. For 1-year OMAS, suture-button fixation ranked highest (P-score 0.86; MD +5.2 points versus the 3-cortex screw; 95% CI, +1.1 to +9.2)—statistically significant but below the 10-point MCID—while the 4-cortex screw ranked lowest; heterogeneity was low (I ² = 10%) without inconsistency. The AOFAS did not differ between suture-button and the 3-cortex screw (MD 0.0; 95% CI, −4.5 to +4.5). Malreduction was lower with suture-button fixation (OR 0.26; 95% CI, 0.06-1.11; 0.27 [0.11-0.64] fixed-effect). Unplanned reoperation was numerically lowest with suture-button fixation (OR 0.34; 95% CI, 0.11-1.05 versus the 3-cortex screw), though no between-construct difference reached significance; all-cause reoperation favored the suture-button and bioabsorbable constructs. Certainty of evidence was low to very low. Conclusions: Suture-button/dynamic fixation provides 1-year function at least equivalent to screws, with lower malreduction and fewer all-cause reoperations from avoiding routine implant removal. Functional differences are small and below the MCID, and certainty is low. Level of Evidence: Therapeutic, Level I . See Instructions for Authors for a complete description of levels of evidence. Registration: PROSPERO CRD420251166994.