Citations

Purpose To evaluate the clinical outcomes of patients with increased posterior tibial slope (PTS ≥12°) undergoing primary anterior cruciate ligament reconstruction (ACLR) with concomitant lateral extra‐articular tenodesis (LET) and to determine whether the addition of LET mitigates the elevated risk of graft failure associated with increased tibial slope. Methods This single‐center retrospective cohort study included patients ≥16 years who underwent primary ACLR with LET between 2013 and 2022 with a minimum 2‐year follow‐up. Patients were stratified by PTS ≥12° versus <12° and required preoperative lateral radiographs for slope measurement and high‐risk features (pivot shift ≥2, Beighton ≥4, or return to pivoting sports). Outcomes included graft failure, residual pivot shift, complications, and patient‐reported outcomes (International Knee Documentation Committee and Lysholm). Achievement of minimal clinically important difference was assessed. Multivariable logistic regression and Cox proportional hazards analysis were performed to identify independent predictors of graft failure. Results A total of 289 patients (mean follow‐up, 38 months) were included: 45 with PTS ≥12° (13.0° ± 1.2°) and 244 with PTS <12° (8.1° ± 1.5°). Graft failure occurred in 24% versus 18%, respectively ( P = .411). On multivariable Cox proportional hazards analysis, no independent predictor of graft failure was identified, including PTS (hazard ratio, 1.07 per degree; 95% confidence interval, 0.95‐1.19; P = .260). Complications and contralateral anterior cruciate ligament injury rates were similar between groups. On sex‐disaggregated analysis, similar patterns were observed in both male and female cohorts, with no significant between‐group differences in graft failure, retear, or complication rates by tibial slope. Patient‐reported outcomes were comparable at all time points. At final follow‐up, minimal clinically important difference achievement for International Knee Documentation Committee and Lysholm was 98% and 100%, respectively, with no between‐group differences. Conclusions In high‐risk patients with a PTS of ≥12°, primary ACLR with LET led to similar clinical results as patients with a PTS of 12 or less. A PTS of ≥12° may be considered an indication for the addition of an LET during primary ACLR. Level of Evidence Level III, retrospective comparative case series.

Abstract Distal radius fracture (DRF) open reduction and internal fixation (ORIF) is a common procedure performed across inpatient and outpatient settings. This study compared postoperative complications and healthcare utilization between these settings using a large national claims database. Patients aged 18 years and older who underwent DRF ORIF were identified in the PearlDiver Mariner database using International Classification of Diseases and Current Procedural Terminology codes. Service location determined surgical setting. Patients with pathological fractures, malignancy, or polytrauma were excluded. Cohorts were propensity matched 1:1 based on age, sex, Charlson and Elixhauser comorbidity indices, and relevant comorbidities. The matched cohort included 9,697 inpatient and 9,697 outpatient DRF ORIF cases. Serious postoperative complications occurred in 16.8% of inpatient procedures versus 5.0% of outpatient procedures. Inpatient surgery was associated with higher odds of surgical site infection (OR 2.23, 95% CI: 1.78–2.79), wound dehiscence (OR 2.57, 95% CI: 1.07–6.17), and deep vein thrombosis (OR 7.75, 95% CI: 3.53–17.04). Inpatients also had greater odds of emergency department visits (OR 1.17, 95% CI: 1.05–1.31), readmissions (OR 3.64, 95% CI: 2.91–4.54), reoperations (OR 2.15, 95% CI: 1.70–2.73), and higher 90-day reimbursements. Inpatient DRF ORIF was associated with significantly higher complication rates and increased postoperative healthcare utilization compared with outpatient procedures, with the largest absolute differences seen in readmissions, reoperations, and 90-day reimbursements. These associations are unlikely to be causal, as inpatient admission typically reflects greater medical necessity and clinical complexity not fully captured by administrative data. Nonetheless, because admission status is readily available at the point of care, it may serve as a practical flag to identify patients who warrant closer post-discharge surveillance and individualized follow-up planning. III.

ABSTRACT Background Olfactory neuroblastoma (ONB) exhibits variable recurrence patterns, with significant late recurrences occurring years after treatment. We investigated cutoff periods to define late recurrence and identified predictors that distinguish patients at risk of late recurrence from those considered cured. Methods From a multi‐institutional cohort of 219 ONB patients treated at nine centers, we analyzed 77 patients with documented recurrence. Using a 48‐month cutoff to define early (< 48 months) versus late (≥ 48 months) recurrence, we evaluated 35 clinical, anatomic, and treatment variables using Firth penalized logistic regression across three comparisons: (1) late versus early recurrence timing, (2) late recurrence versus no recurrence, and (3) early recurrence versus no recurrence. Results Thirty‐four of the 77 (44.2%) recurrences were classified as late. Among the 77 patients who recurred, smaller tumor volume (OR 0.243, p = 0.035) and lower novel Dulguerov staging (OR 0.802, p = 0.038) were associated with late, rather than early recurrence. When patients with late recurrence were compared to those who remained disease‐free, radiographic skull base bone involvement was the strongest independent predictor (OR 2.90, 95% CI 1.14–8.64, p = 0.025), and this effect strengthened after adjusting for tumor volume (OR 3.80, p = 0.029). Pathologic dural invasion (OR 3.29, p = 0.013), Kadish stage (OR 2.02, p = 0.026), and T‐stage (OR 1.32, p = 0.040) were also significant. Conclusions A 48‐month cutoff effectively stratifies ONB recurrence risk. Skull base bone involvement independently predicts recurrence when compared to nonrecurrent cases and uniquely persists as a risk factor for late recurrence. These findings establish skull base bone involvement as a novel biomarker for risk‐stratified surveillance protocols.

Abstract Osteochondral lesions of the knee, particularly in patients with early osteoarthritic changes, remain a clinical challenge. The Agili‐C implant (CartiHeal, Smith & Nephew), an aragonite‐based osteochondral scaffold, offers a single‐stage, off‐the‐shelf solution designed to regenerate both cartilage and subchondral bone. Unlike cell‐based therapies, Agili‐C eliminates the need for cell harvesting, culturing, or bioreactors, and avoids the morbidity associated with autografts and allografts. Recent multicenter randomized controlled trials have showed superior functional outcomes and pain reduction with Agili‐C compared to microfracture and debridement, even in patients with early osteoarthritis (Kellgren‐Lawrence grades 0‐3). This Technical Note describes the surgical technique for Agili‐C implantation and highlights key technical pearls to optimize outcomes.

Purpose To project the future utilization of open and arthroscopic rotator cuff repair (RCR) in the Medicare population through 2050, incorporating post‐COVID recovery data to provide insight into evolving surgical preferences, economic pressures, and implications for health care delivery. Methods We analyzed 2003‐2024 data from the Centers for Medicare and Medicaid Services Medicare Part‐B National Summary, which captures all Medicare beneficiaries undergoing open or arthroscopic RCR as identified by Current Procedural Terminology codes. Projections were based on 2003‐2019 and 2023‐2024 data, reflecting post‐COVID‐19 recovery and avoiding distortions from 2020 to 2022 pandemic‐related disruptions. Statistical models evaluated included log‐linear, Poisson, negative binomial, and autoregressive integrated moving average. Autoregressive integrated moving average was selected based on the lowest normalized root mean square error, reflecting superior predictive accuracy and its ability to capture time‐dependent trends, and was used to forecast RCR volumes through 2050. Results In 2024, there were 23,154 open and 188,700 arthroscopic RCR procedures, which served as the baseline for modeling. Open RCR is projected to decline on average by 5.91% annually, while arthroscopic RCR is projected to grow by 2.88% annually. By 2050, arthroscopic RCR volume is expected to reach 394,434 procedures (95% forecast interval: 363,424‐425,321), whereas open RCR is expected to decline to 4748 procedures (95% forecast interval: 1243‐43,747). Conclusions Autoregressive integrated moving average modeling projects that by 2050 arthroscopic RCR utilization will increase by 2‐fold and open RCR will decline to one‐fifth compared with 2024 baseline volumes. Level of Evidence Level III, retrospective cohort study.

Management of unstable upper lumbar fractures with corpectomy and posterior fixation is technically demanding, and conventional workflows may require intraoperative repositioning, increasing operative complexity. Lateral mini-open upper lumbar corpectomy (LMULC) paired with robotic-assisted (RA) posterior percutaneous pedicle screw fixation (PPPSF) can be performed in a single position to facilitate ventral spinal decompression and stabilization in the anatomically constrained upper lumbar spine. In this study, we describe the operative technique and report four illustrative cases of unstable L1 or L2 fractures treated with single-position LMULC, RA-PPPSF, and short-segment fusion. Clinical, radiological, intraoperative variables and postoperative outcomes were evaluated. The mean age was 52.3 ± 17.7 years. The median operation time was 314 min (range 268–361 min); the median estimated blood loss (EBL) was 225 mL (range 100–400 mL). The median preoperative kyphosis was 10.15° (range 8.4–14.6°), the median postoperative kyphosis measured 6.65° (range 1.7–10.8°) and the median correction achieved was 3.5° (range −2.4–12.9°). The median visual analog scale (VAS) pain score reduced from 7 (range 7–9) preoperatively to 4.5 (range 2–6) postoperatively at discharge. At a median follow-up of 12 months (range 6–15 months), all patients had uncomplicated recoveries, demonstrated solid fusion on imaging, and reported favorable MacNab outcomes. Single-position LMULC with RA-PPPSF was technically feasible in this preliminary illustrative series and resulted in favorable clinical and radiographic outcomes. However, further studies in larger cohorts are warranted to help confirm these findings and better define the potential advantages and limitations of this technique.

Importance Adjuvant radiotherapy can improve locoregional control and survival in patients with olfactory neuroblastoma (ONB), particularly with advanced-stage and histologic-grade disease. Standard radiotherapy treatment is with intensity-modulated radiotherapy (IMRT). Proton beam radiotherapy (PBRT) provides theoretical advantages in greater sparing of dose to uninvolved organs at risk. Objective To investigate if there are differences in the effectiveness and radiation treatment–related adverse events (RTAEs) between adjuvant IMRT and PBRT for patients with ONB. Design, Setting, and Participants This propensity score–matched cohort study included patients with ONB treated between February 2005 and April 2021 with either IMRT or PBRT at 9 academic tertiary care centers in North America. Patients were matched 1:2 based on age, modified Kadish stage, and Hyams grade. Data were analyzed from July 2024 to January 2025. Exposure Adjuvant IMRT or adjuvant PBRT. Main Outcomes and Measures Local recurrence-free survival (RFS), any RFS, and overall survival (OS). RTAEs, ie, grade 2 events or higher based on Common Terminology Criteria for Adverse Events, were recorded for both modalities. Results Of 54 included patients, 27 (50%) were female, and the mean (SD) age was 46.2 (15.4) years. A total of 18 were treated with PBRT and 36 were treated with IMRT. Most patients had modified Kadish stage C disease (33 of 54 [61%]), and 24 patients (44%) had Hyams grade III or IV disease. The RTAE rate was 20% (8 of 40); IMRT had a rate of 21% (6 of 29), and PBRT had a rate of 18% (2 of 11). The difference in the point estimates for 10-year RFS showed a potential clinical benefit favoring IMRT, although the wide confidence interval indicates uncertainty (10-year RFS: IMRT, 63.3%; 95% CI, 44.6-89.8; PBRT, 37.8%; 95% CI, 14.2-100; difference, 25.5 percentage points; 95% CI, −17.6 to 68.6). There were no clinically meaningful differences in 10-year local RFS (IMRT, 75.6%; 95% CI, 59.8-95.4; PBRT, 72.7%; 95% CI, 45.2-100; difference, 2.9 percentage points; 95% CI, −35.9 to 41.7) or 10-year OS (IMRT, 61.8%; 95% CI, 42.8-89.1; PBRT, 57.1%; 95% CI, 24.3-100; difference, 4.7 percentage points; 95% CI, −49.2 to 58.6), although wide confidence intervals indicate considerable uncertainty. Conclusions and Relevance Due to the imprecision of estimates, no definitive conclusions can be made regarding the comparative effectiveness of IMRT vs PBRT for patients with ONB. These preliminary data may inform the design of appropriately powered prospective studies evaluating the efficacy of PBRT vs IMRT in this population.