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Aims Periacetabular osteotomy (PAO) is performed in young, opioid-naive patients and is associated with postoperative pain. Optimizing perioperative analgesia while limiting opioid exposure remains a priority. This study evaluated postoperative pain trajectories, hospital length of stay (LOS), and opioid-prescribing patterns associated with an institutional transition from epidural-based to periarticular injection (PAI)-based analgesia after PAO. Secondary aims were to assess the influence of preoperative opioid exposure and compare outcomes between ropivacaine-based and bupivacaine PAI formulations. Methods The study included 724 patients who underwent PAO between January 2010 and December 2022 at a single academic institution, with epidural use replaced by PAI in 2016. Patients were stratified by postoperative analgesia strategy: epidural catheter (n = 333) or PAI (n = 391). Outcomes included daily postoperative pain scores, LOS, discharge opioid prescriptions (morphine milligram equivalents (MMEs)), total opioid exposure, and 30-day refill rates. Statistical comparisons were performed using chi-squared, Fisher’s exact, and Kruskal–Wallis tests. Results Baseline characteristics were similar between groups. Epidural analgesia was associated with lower pain scores during the first 48 hours (last pain postoperative day 0 to 1: mean 2.9 (SD 2.0) vs 4.7 (SD 2.1); p < 0.001), whereas the PAI group had a shorter LOS (mean 2.2 days (SD 1.0) vs 3.4 days (SD 0.9); p < 0.001) and higher pain scores at discharge (mean 4.8 (SD 1.9) vs 4.0 (SD 1.9); p < 0.001). Median discharge opioid prescriptions (313 (IQR 225 to 388) vs 825 (IQR 600 to 1,000) MMEs) and total 30-day opioid exposure (360 (IQR 275 to 575) vs 900 (IQR 638 to 1,100) MMEs) were lower in the PAI group (both p < 0.001), while refill rates were higher (34.0% vs 19.2%; p < 0.001). Within the PAI cohort, ropivacaine-based and bupivacaine injections showed similar pain trajectories and refill rates. Conclusion Epidural analgesia provided superior early postoperative pain control, whereas PAI-based pathways enabled earlier discharge and lower overall opioid prescribing but with higher refill rates. These findings highlight trade-offs in contemporary perioperative pathways and support individualized analgesic strategies after PAO. Cite this article: Bone Jt Open 2026;7(11):1410–1418.

Introduction: Scuba diving is a popular sport that carries risks unique to the underwater environment. Paediatric emergency department presentations for scuba diving injuries are incompletely characterised, particularly in comparison with adults. Methods: We retrospectively analysed scuba-related injuries recorded in the National Electronic Injury Surveillance System (NEISS) from 2005–2024. We estimated national paediatric emergency department presentations using NEISS weights and compared injury categories and hospitalisation rates between paediatric and adult patients. Results: We identified 68 paediatric cases, corresponding to an estimated 122 paediatric scuba-related emergency department presentations annually. Trauma was the most common injury category (41.2%), followed by otitis (17.6%) and ear, sinus, ocular, or dental barotrauma (16.2%). Hospitalisation was most common among patients with possible decompression sickness or arterial gas embolism (DCS/AGE) (42.9%) and drowning/aspiration (25.0%). Compared with adults, paediatric patients were less often hospitalised (10.3% vs 21.4%, P = 0.038), more likely to present with traumatic injuries (41.2% vs 26.1%, P = 0.010), and less likely to present with possible DCS/AGE (10.3% vs 25.0%, P = 0.006). Conclusions: Among patients presenting to United States emergency departments with scuba-related injuries, paediatric patients most commonly had trauma, otitis, or ear, sinus, ocular, or dental barotrauma. Paediatric divers were also less likely than adults to experience DCS/AGE injuries and were less likely than adults to require hospitalisation. Our data describes emergency department presentation patterns rather than overall injury risk among paediatric scuba divers.

Chimeric antigen receptor (CAR) T-cell therapy is a transformative modality for refractory hematologic malignancies; however, its adoption in Latin America and the Caribbean (LAC) is severely constrained by prohibitive manufacturing costs, limited specialized infrastructure, and fragmented regulatory frameworks. To address this translational gap, we propose a pragmatic, cost-adapted model for establishing Good Manufacturing Practice (GMP) laboratories tailored to the socioeconomic realities of LAC. This model advocates for decentralized, modular cleanroom facilities that integrate fully closed automated manufacturing platforms with risk-based quality management systems. Furthermore, we emphasize the strategic implementation of artificial intelligence (AI) and digital health tools—such as electronic batch records and predictive analytics—to optimize resource utilization and ensure stringent regulatory compliance. Essential to this framework is the cultivation of a specialized local workforce and the promotion of regional regulatory harmonization through initiatives like PAHO’s Red PARF. Ultimately, this scalable approach provides a realistic roadmap to democratize CAR T-cell therapy in LAC, fostering regional biomanufacturing autonomy and promoting equitable patient access.

Aims Extensor mechanism disruption is a major complication following total knee arthroplasty, with treatment often consisting of extensor mechanism reconstruction utilizing monofilament polypropylene mesh (Marlex mesh, C. R. Bard, Inc). Infection following this procedure is devastating, often resulting in revision surgery and mesh removal, with permanent limb dysfunction. This study evaluated the in vitro ability of vancomycin-loaded polypropylene mesh to inhibit growth of isolates of three Staphylococcus species from patients with periprosthetic joint infection. Methods The mesh was prepared in two configurations – single-layer and eight-layer – and soaked for ten minutes in either sterile water (control) or vancomycin solution (50 mg/ml), after which the mesh was placed on tryptic soy agar plates inoculated with staphylococci and incubated at 37°C for 18 to 24 hours. Zones of inhibition were measured daily over seven days, with mesh transferred to freshly inoculated plates daily. Testing was performed in triplicate, with experiments repeated three times for each bacterial isolate. A total of 30 clinical isolates were tested (five methicillin-susceptible Staphylococcus epidermidis , five methicillin-resistant S. epidermidis , ten methicillin-resistant Staphylococcus aureus , and ten Staphylococcus lugdunensis ). Results Across all species, the eight-layer vancomycin-loaded mesh produced statistically significantly larger median zones of inhibition than the single-layer mesh. The antibacterial activity of the eight-layer mesh persisted through to day 7, while the single-layer mesh showed reduced activity by days 4 to 5. Conclusion Compared with single-layer vancomycin-loaded mesh, multilayer vancomycin-loaded mesh, which mimics clinical application, provides enhanced and sustained antibacterial activity in vitro. Cite this article: Bone Joint Res 2026;15(8):998–1004.

Objective: To determine whether sleep apnea–specific hypoxic burden (SASHB) is associated with self-reported hypertension beyond conventional obstructive sleep apnea metrics in rail workers. Methods: Cross-sectional study of 84 Argentine rail workers undergoing home sleep apnea testing. Associations between SASHB and hypertension were evaluated using adjusted logistic regression. Drowsy driving was examined as an unadjusted exploratory secondary outcome. Results: Higher SASHB was independently associated with hypertension in the fully adjusted model (OR per SD 2.42; 95% CI 1.24–5.29; p=0.015). Higher SASHB was also associated with more severe self-reported drowsy driving in unadjusted exploratory ordinal analyses (OR per SD 1.78; 95% CI 1.09–3.28; p=0.035). Conclusions: SASHB may provide complementary information beyond conventional OSA metrics for cardiovascular risk assessment in occupational populations.

Background: Prior studies have reported higher rates of periprosthetic fracture, superficial infection, and neurologic deficit with the direct anterior approach (DAA), and higher rates of dislocation with the posterior approach (PA) for total hip arthroplasty (THA). Despite these differences, the overall clinical burden of complications between approaches remains unclear. The purpose of this study was to compare the profiles, severity, impact, and resolution of 5 clinically important complications between DAA and PA THA. Methods: A retrospective review was conducted of 11,783 consecutive primary THAs performed between 2010 and 2021 across 3 centers within a single healthcare system, using either the DAA (n = 4,451) or the PA (n = 7,332). Complications assessed included dislocation, infection, periprosthetic fracture (PPFx), aseptic loosening, and neurologic deficit. Severity was graded using the Clavien-Dindo classification (I = minor, V = death). Impact was defined by reoperation burden, and outcomes were categorized as resolved or persistent. Kaplan-Meier survivorship and propensity-weighted Cox proportional hazards models were used to compare complication risk. Results: The overall 1-year risk of surgical complications did not differ between DAA and PA (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.75-1.06; p = 0.208). Dislocation occurred more frequently with PA THA than DAA THA (1.9% vs. 0.4%; HR, 5.20; 95% CI, 3.04-8.90; p < 0.001). Superficial infections were more frequent with the DAA (1.6% vs. 0.8%; HR, 2.43; 95% CI, 1.68-3.53; p < 0.001). The risk of deep infection, PPFx, aseptic loosening, and neurologic deficit did not differ significantly between approaches. Among patients with complications, the proportion classified as severe (Clavien-Dindo III–V) was similar, and adjusted analyses showed no difference in the odds of severe complications (adjusted odds ratio 1.34 for PA vs DAA; 95% CI, 0.95-1.91; p = 0.099). Complication impact and resolution were likewise comparable. Conclusion: Although the profile of complications differed between DAA and PA THA, the severity, early clinical impact, and resolution of complications appeared similar. Notably, DAA was associated with a lower risk of dislocation and a higher risk of superficial infection compared with PA THA. Level of Evidence: Level III , Retrospective Comparative Study. See Instructions for Authors for a complete description of levels of evidence.

Interleukin 33 (IL-33) is a cytokine of the IL-1 family that acts as an alarmin in both innate and adaptive immunity. IL-33 is constitutively nuclear in epithelial and endothelial cells, where its activity is limited by nuclear retention. Release of IL-33 in response to cellular stress or injury can mediate type 2 immune responses or tissue repair, depending on the local tissue environment. IL-33 activity is regulated at multiple levels, including nuclear retention, oxidation, proteolytic processing, and metabolic regulation. Following its release, oxidation rapidly suppresses IL-33 activity, while mast cell and neutrophil proteases can generate smaller active fragments that target cells expressing the IL-33 ST2 receptor. Simultaneously, tissue metabolic status influences cellular responsiveness through the mTORC1 and AMPK pathways, which link metabolic capacity to effector function. These conditions may explain why IL-33 can mediate an inflammatory response, but in other circumstances, it contributes to tissue repair. Such pleiotropic properties may also underline the variability in clinical responses to IL-33/ST2-targeted therapies across various diseases. The appreciation of IL-33 as a cytokine whose activity is conditioned by its structural, redox, and metabolic environment is critical to optimizing its therapeutic potential as a target.

Background: Greater trochanteric (GT) fractures after total hip arthroplasty (THA) are typically managed nonoperatively. However, outcome data for patient counseling remain limited. We evaluated the nonoperative results, focusing on fracture union rates and the presence of persistent limp in relation with fracture location, displacement magnitude, and direction. Methods: We retrospectively reviewed 82 postoperative GT fractures not associated with trochanteric osteolysis following primary THA performed between 1984 and 2020. The mean follow-up was 9 years. Fracture location was classified relative to the contralateral lesser trochanter as tip, waist, or base. Initial displacement, migration, final displacement, and bony union were assessed radiographically. Clinical outcomes included the presence of a persistent limp and Harris Hip Score. Multivariable analyses were performed to identify factors associated with nonunion and limp. Results: Fractures were classified as tip (n = 32), waist (n = 29), or base (n = 21). The mean initial displacement was 8.9 mm, with 43% displaced >10 mm. Initial displacement was significantly lower in base fractures (4.8 mm) compared with tip (10.1 mm) or waist (10.8 mm) fractures (p < 0.05). The mean final displacement was 14.6 mm. 45% of fractures achieved complete bony union, and 38% of patients demonstrated a persistent limp. In multivariable analysis, greater final displacement (>12 mm), and tip and waist fractures were independently associated with nonunion. Posterior fracture displacement was significantly associated with persistent limp. Conclusions: Outcomes following nonoperative management of GT fractures after THA depend on fracture morphology and displacement characteristics. Tip and waist fractures and fractures with final displacement >12 mm have a higher risk of nonunion, whereas posterior and superior displacement is associated with persistent limp. Greater than 20 mm of displacement is associated with both limp and nonunion. These findings may assist surgeons in counseling patients and in identifying fracture patterns at higher risk for adverse outcomes of nonoperative management. Level of Evidence: Level III (Prognostic Study). See Instructions for Authors for a complete description of levels of evidence.