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AimsThe purpose of this study was to directly compare the Modular Dual Mobility (MDM) Mobile Bearing Hip System (Stryker, USA) and large femoral heads (LFHs) in revision total hip arthroplasties (THAs) at mid-term follow-up, with specific emphasis on survival free of re-revision for dislocation, any re-revision, dislocation, and the risk of metal-related complications.MethodsWe identified 299 revision THAs performed at a single tertiary care academic institution from March 2011 to July 2014. Aseptic loosening of the acetabular component (n = 65), dislocation (n = 58), and reimplantation as part of a two-stage exchange protocol (n = 57) were the most common reasons for index revision. MDM constructs were used in 123 cases, and LFHs were used in 176 cases. Mean age was 66 years (28 to 93), mean BMI was 31 kg/m2 (18 to 55), and 45% (n = 136) were female. Mean follow-up was seven years (2 to 12).ResultsThe ten-year survival free of re-revision for dislocation was 99% (95% CI 95 to 100) in the MDM cohort and 91% (95% CI 84 to 96) in the LFH cohort, with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 7.1 (95% CI 1.3 to 40.8); p = 0.023). The ten-year survival free of any re-revision was 92% (95% CI 82 to 99%) in the MDM cohort and 84% (95% CI 74 to 90) in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.6 (95% CI 1.1 to 5.9); p = 0.024). The ten-year survival free of any dislocation was 95% (95% CI 85 to 99) in the MDM cohort and 87% (95% CI 78 to 92) in the LFH cohort with a significantly increased risk of any dislocation in the LFH cohort (HR 2.7 (95% CI 1.1 to 6.3); p = 0.028). There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.ConclusionIn this head-to-head comparison, revision THAs with a MDM construct safely and effectively lowered the risk of re-revision for dislocation, any re-revision, and any dislocation compared to LFH at mid-term follow-up. There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.Cite this article: Bone Joint J 2025;107-B(1):58–64.

OBJECTIVE The objective of this study was to compare a multiple pelvic screw fixation strategy (dual bilateral 4 pelvic screw fixation [4PvS]) with the use of single bilateral 2 pelvic screw fixation (2PvS), with the aim of addressing lumbosacral junction stability. METHODS This analysis is a single-center, retrospective review of ASD patients treated between 2015 and 2021. All patients had a minimum 2-year follow-up and spinal fusion to the sacrum without sacroiliac fusion and met at least one radiographic and procedural criterion: pelvic incidence–lumbar lordosis ≥ 20°, T1 pelvic angle ≥ 20°, sagittal vertical axis ≥ 7.5 cm, scoliosis ≥ 50°, three-column osteotomy, or spinal fusion of ≥ 8 levels. Two sacropelvic fixation methods were compared: 4PvS versus 2PvS. Primary outcomes included spinal implant-related reoperation and screw breakage, while secondary outcomes included reoperation for symptomatic pelvic screws, screw loosening or bending, L5–S1 pseudarthrosis, and patient-reported outcomes. Propensity score matching and inverse probability of treatment weighting (IPTW) were used to minimize selection bias and estimate causal treatment effects. Clinical outcomes were assessed using conditional multivariable logistic regression. RESULTS In this study of 406 patients (67.98% female, mean age 64.48 years), 349 patients (85.96%) received 2PvS and 57 (14.04%) received 4PvS. Age (OR 1.081, 95% CI 1.027–1.145) and total number of osteotomies (OR 1.180, 95% CI 1.048–1.355) emerged as independent predictors of receiving the 4PvS technique. In unmatched cohorts (n = 406), 2-year implant-related reoperation rates (p = 0.1896) and pelvic screw breakage rates (p = 0.2498) were not significantly different between groups. However, in the 4:1 propensity score–matched cohort, the 2-year reoperation rate (10.53% for 2PvS vs 3.51% for 4PvS; OR 3.27, 95% CI 1.10–9.74 [p = 0.0312]) and the pelvic screw breakage rate (9.21% for 2PvS vs 3.51% for 4PvS; OR 2.87, 95% CI 1.08–7.63 [p = 0.0349]) were significantly higher among the 2PvS groups. The IPTW analysis confirmed these findings, with reoperation rates of 10.45% for 2PvS and 1.18% for 4PvS (p = 0.0244) and pelvic screw breakage rates of 8.72% and 1.18%, respectively (p = 0.0477). A safety assessment revealed comparable operative times and intra- and perioperative complications between the two techniques. CONCLUSIONS Patients who underwent 4PvS demonstrated significantly lower 2-year implant-related reoperation and pelvic screw breakage rates compared with 2PvS, with no differences in intraoperative or perioperative complications.

OBJECTIVE While the relationship between smoking and subarachnoid hemorrhage is well established, data regarding the probability of detecting unruptured intracranial aneurysms (UIAs) in smokers remain sparse. The aim of this systematic review and meta-analysis is to provide a comprehensive understanding of the relationship between smoking and the likelihood of identifying UIAs in healthy asymptomatic patients who underwent brain imaging for indications unrelated to UIAs. METHODS A systematic review was conducted following the PRISMA guidelines. The PubMed and Scopus databases were searched for studies published before March 2024 that reported on the presence of UIAs in healthy asymptomatic patients who had undergone brain imaging for indications unrelated to UIAs. Three independent reviewers assessed the eligibility of all retrieved studies. Risk of bias for the included observational studies was assessed using the methodological index for non-randomized studies. Data on UIA prevalence, smoking status, and patient and aneurysm characteristics were extracted. The association between smoking and the presence of UIA was studied. A prevalence proportional meta-analysis was conducted across the included studies. A meta-analysis was performed with a random-effects model by using summary statistics from the included studies. RESULTS Six studies involving 47,788 patients who had undergone brain imaging were identified for quantitative analysis. The pooled UIA prevalence in the sample was 3.07% (95% CI 2.27%–4.16%). Patients who smoked had higher rates of aneurysm detection than the patients who did not smoke (pooled prevalence of 2.96%, 95% CI 2.68%–3.27% vs 2.23%, 95% CI 2.08%–2.39%). Although the relation between the two was not statistically significant (p = 0.06), smoking was associated with higher odds for UIA detection, yielding an OR of 1.34 (95% CI 1.07–1.67) with an I 2 value of 53%. CONCLUSIONS This study suggests a potentially higher risk of UIAs in patients who smoked than in those who never smoked. However, the results of this meta-analysis revealed that smoking was not statistically associated with higher UIA detection. This result could be explained by the limited number of studies published on this topic. If these findings reach statistical significance in future larger studies, it could justify revising guidelines to include cigarette smokers in intracranial aneurysm screening.

Abstract Objective To assess the association of systolic and diastolic blood pressure (SBP and DBP) in recently menopausal women with white matter hyperintensity (WMH) volume later in life and determine whether short-term menopausal hormone therapy (mHT) modifies these associations. Methods Kronos Early Estrogen Prevention Study (KEEPS) was a multicenter, randomized, double-blinded, placebo-controlled 4-year mHT trial (oral conjugated equine estrogens or transdermal 17β-estradiol). KEEPS continuation was an observational follow-up of the participants 10 years after the end of mHT. The associations between KEEPS baseline blood pressure (BP) with KEEPS continuation WMH volume were examined adjusting for covariates in model 1 (age, total intracranial volume, study site, mHT type) and model 2 (additionally conventional CVD risk factors). Interaction terms (BP × mHT type) were added into the linear regression models. Results The mean ± SD ages of participants were 53 (±2) years at KEEPS baseline and 67 (±2) years at KEEPS continuation. Elevated BP at KEEPS baseline was associated with greater WMH volume measured 14 years later (model 1: SBP: β = 0.01 [95% CI, 0.001‐0.01] and DBP: β = 0.01 [95% CI, 0.003‐0.03]) and after additionally adjusting for CVD risk factors (model 2). We did not find any evidence that mHT versus placebo modified these associations. Topographically, higher BP was associated with greater periventricular WMH in the frontal and parietal lobes. Conclusion Our findings suggest the importance of maintaining normal BP in recently postmenopausal women with low CVD risk, irrespective of short-term mHT usage, to potentially reduce the risk of WMH later in life.

Introduction: To analyze the association of patient characteristics on operating room (OR) times for robotic-assisted partial nephrectomies (RAPNs). Methods: In total, 248 consecutive RAPNs were performed by a single surgeon from October 2018 to August 2022. Data were collected on the following patient factors: sex, age, race, weight, body mass index (BMI), diabetes, hypertension (HTN), tumor side, tumor mass, and American Society of Anesthesiologists (ASA) score. Total fixed OR times were evaluated as the sum of in-room time to anesthesia-release time (IRAT), anesthesia-release time to cut time (ARCT), close time to wheels out time (CTWO), and in-room time to cut time (IRAT + ARCT). Total variable OR times were defined as cut time to close time (CTCT). Total operative time was defined as wheels into wheel out (WIWO). Results: Median OR time was 265 minutes (interquartile range [IQR]: 247–298 minutes) for WIWO, 191 minutes (IQR: 170–225 minutes) for CTCT, and 75 minutes (IQR: 68–83 minutes) for total fixed time. There was a significant increase in WIWO with the following patient variables: male sex (18.0 minutes, 95% confidence interval [CI]: 6.3–29.7 minutes), weight (5.6 minutes, 95% CI: 2.8–8.4 minutes), BMI (14.3 minutes, 95% CI: 4.2–24.4 minutes), HTN (15.1 minutes, 95% CI: 3.7–26.5 minutes), pathology tumor size (cm) (6.4 minutes, 95% CI: 2.2–10.6 minutes), and ASA score (13.8 minutes, 95% CI: 3.1–24.4 minutes). Sex, age, BMI, weight, HTN, and pathology tumor size significantly impacted CTCT ( P < 0.05). Total fixed OR time was only affected by ASA score ( P = 0.02). Conclusions: Patient variables significantly affect total OR time and variable OR time. These variables do not impact total fixed OR times, confirming fixed OR time as a viable OR efficiency point.

Background: Effective pain management is crucial for both comfort and outcomes, yet predicting and managing this pain is difficult. This study aimed to analyze postoperative pain in patients undergoing hand surgery at the Mayo Clinic Florida, examining how patient characteristics and anxiety affect pain outcomes. Methods: We conducted a single-arm clinical trial at Mayo Clinic Florida, recruiting patients undergoing hand surgery. Preoperative pain and anxiety were assessed using the Pain Catastrophizing Scale (PCS) and State-Trait Anxiety Inventory (STAI). Postoperatively, patients used an iPhone app to record pain levels and medication use every four hours. Devices were collected three days after surgery. We analyzed the relationship between demographics, PCS, STAI scores, and pain levels using linear and logistic regression models. All statistical tests were two-sided with significance set at p < 0.05, analyzed with R4.2.2. Results: Data were collected from 62 patients (62.9% women, 37.1% men) undergoing hand surgery. Participants were mainly White (90.3%), with 50% being in the middle-aged adult group. Most had low anxiety levels (80.6% STAI-S, 82.3% STAI-T) and low catastrophizing (61.3% PCS). Postoperative pain was low, with median scores between 1.0 and 2.0 over three days. Demographics, anxiety, and catastrophizing were not significant predictors of pain levels. Logistic regression showed time as a significant factor, with pain levels peaking on Day 3. Conclusions: Postoperative pain after hand surgery was generally low, with time being a significant predictor of increased pain. Demographic factors, anxiety, and catastrophizing did not significantly affect pain levels. Pain management should emphasize time-sensitive interventions and ongoing monitoring.

AbstractBackgroundThe clinical significance of natural and treatment‐emergent antibodies specific for amustaline/glutathione pathogen‐reduced red blood cells (PRRBCs) is not known.Study Design and MethodsA Phase 3, randomized clinical trial of PRRBCs (ReCePI) compared PRRBCs with conventional RBCs in cardiac or thoracic‐aorta surgery. Subjects transfused during and for 7 days after surgery were screened for PRRBC‐specific antibodies at baseline, 28 and 75 days post‐surgery. Subjects with treatment‐emergent antibodies were assessed for evidence of hemolysis. Cryopreserved subject RBC samples were assayed by flow cytometry for circulating PRRBCs using an acridine‐specific (2S197‐2M1) monoclonal antibody, and for human IgG‐coated RBCs. RBC‐surface acridine density was quantitated using a commercial calibrated phycoerythrin (PE)‐bead panel.ResultsFive of 159 (3.1%) PRRBC and zero of 162 conventional RBC recipients developed treatment‐emergent PRRBC‐specific IgG, low titer antibodies detected 26–80 days post‐surgery after exposure to 1–3 PRRBC units, without clinical evidence of hemolysis. DAT and eluate were weak (w+) positive and PRRBC‐specific in one subject. A monocyte monolayer assay (MMA) was non‐reactive in the three subjects with an interpretable result. Flow cytometry demonstrated circulating PRRBCs in all five subjects expressing surface acridine concentrations at the limit of detection (approximately 150–301 PE molecules/RBC) compared with freshly transfused PRRBCs (approximately 7500 PE molecules/RBC). In some samples, loss of surface acridine expression could not be distinguished from clearance of the PRRBCs.DiscussionTreatment‐emergent PRRBC‐specific antibodies with the characteristics of nonclinically significant antibodies were detected in five subjects transfused with PRRBCs. Flow cytometry demonstrated persistent circulating PRRBCs with minimal surface acridine expression. (www.ClinicalTrials.gov Identifier NCT03459287).

ABSTRACTBackgroundAnemia is frequently observed as a comorbidity in atrial fibrillation (AF), especially in elderly patients and in those on anticoagulation. This has been associated with poor clinical outcomes. We aim to investigate the impact of anemia on clinical outcomes in patients with AF on oral anticoagulation.MethodsWe comprehensively searched PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through March 2024 and conducted a prognostic systematic review and meta‐analysis. All analyses were performed using R V. 4.3.1. This meta‐analysis was registered at PROSPERO (CRD42024556023).ResultsWe included 23 studies comprising 286,781 patients for analysis. Anemia had a significant association with an 84% increase in risk of major bleeding (HR: 1.84 with 95% CI [1.59, 2.13], p < 0.01), a 32% increase in the risk of intracranial hemorrhage (HR: 1.32 with 95% CI [1.10, 1.58], p < 0.01), a 98% increase in the risk of gastrointestinal bleeding (HR: 1.98 with 95% CI [1.67, 2.35], p < 0.01), and a 91% increase in the risk of all‐cause mortality (HR: 1.91 with 95% CI [1.46, 2.51], p < 0.01). However, the impact of anemia did not significantly affect the risk of stroke, transient ischemic stroke (TIA), or systemic embolism (HR: 1.07 with 95% CI [0.93, 1.22], p = 0.36).ConclusionAnemia was significantly associated with an increased risk of major bleeding, intracranial hemorrhage, gastrointestinal bleeding, and all‐cause mortality. However, anemia did not significantly impact stroke, TIA, or systemic embolism.

AbstractBackgroundConventional approaches for emergent or expedited palliative radiotherapy (RT) involve the application of cumbersome vendor‐provided solutions and/or multiple patient appointments to complete the RT workflow within a compressed timeframe.PurposeThis report delineates the clinical development of an in‐house, semi‐automated Cone‐beam computed tomography (CBCT)‐based simulation‐free platform for expedited palliative RT on conventional linacs, intended to supplant existing techniques employed at this institution.MethodsThe internal software, termed SimFree Wizard (SFW), was engineered utilizing a C#‐based application programming interface integrated within the treatment planning system (TPS). Generated scripts were compiled as stand‐alone executables, with a graphical user interface (GUI) customized via an integrated development environment. The platform was conceived as a framework for accelerated CBCT‐based RT, bypassing the requirement for standard simulation imaging. SFW employs full automation where feasible to minimize user intervention, supplemented by graphical instructions for tasks requiring manual execution. During development, relevant temporal metrics from 10 end‐to‐end tests for palliative spine RT were quantified. User feedback was solicited via a simple questionnaire assessing the overall platform usability. Automated in‐house secondary verification software was developed for validation of the TPS‐calculated monitor units (MUs).ResultsThe mean duration for workflow execution was 41:42 ± 3:18 [mm:ss] (range ∼37–46 min). SFW satisfactorily generated simple, multi‐field CBCT‐based 3D treatment plans within seconds following delineation of the desired treatment area. User feedback indicated enhanced usability compared to previously employed solutions. Validation of the secondary verification software demonstrated accurate results for palliative spine RT and other simple cases wherein the dose calculation point resides in a predominantly homogenous medium.ConclusionA novel in‐house solution for expedited CBCT‐based RT was successfully developed, facilitating completion of the entire workflow within approximately 1‐hour or less for simple palliative/emergent scenarios. Overall, this application is expected to improve the quality and safety of palliative RT while greatly reducing workflow duration, thereby improving access to palliative care.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, impacting approximately 6.1 million adults in the United States, with projections to increase two-fold by 2030. AF significantly increases the risk of stroke and other adverse cardiovascular events, leading to increased morbidity and mortality. The 2023 ACC/AHA/ACCP/HRS guidelines present a paradigm shift in AF management, moving from a duration-based classification to a more comprehensive, patient-centered approach. This includes a novel AF classification system that emphasizes early detection and intervention, including risk factors and lifestyle modification tailored to each patient’s risk profile. Moreover, the recommendations advocate for a multidisciplinary care model, ensuring coordinated management involving primary care providers and specialists. Primary care providers play a crucial role in initiating risk factor management and lifestyle interventions, even before the development of AF. This review aims to thoroughly examine the guidelines for the diagnosis and management of AF and equip general internists with the necessary insights to navigate the evolving landscape of AF care effectively.