Volume 35-2, Summer 2026

The purpose of this study was to determine the effectiveness of the fascia iliaca block (FIB) in on our geriatric hip fracture population and determine its effect on outcome. The study included hip fracture patients 65 and older in a therapeutic case control in an urban, orthopaedic hospital with attending anesthesiologist choice in administering the FIB in the preoperative holding area. Pain scores, narcotic pain usage, physical therapy parameters and discharge disposition were measured. One hundred and nine patients that did not receive the FIB served as the control group, while 80 patients received the FIB. The average patient age was 79 (62 – 100) for the control group and 82 (62 – 102) for the FIB. Postoperatively, the FIB group reported their highest pain score at an average of 30 hours compared to the non-FIB group at 17 hours after surgery (p < 0.006). In the control group, 49 (45%) were discharged home, and 40 (37%) discharged to a skilled nursing facility (SNF) and 20 discharging to a rehab facility. In comparison, only 19 (24%) FIB patients were discharging home, and 61 (55.6%) went to SNF (p < 0.005). The FIB significantly increased the time until the high pain score without decreasing pain for the expected duration of the block. A concern with the FIB use is possible delays in physical therapy due to the duration of the block. Objective physical therapy parameters were more robust for the control on postoperative day 0 and day 1 in regard to ambulation. Level of Evidence: Level III. (Journal of Surgical Orthopaedic Advances 35(2):059–062, 2026)

Key words: fascia iliaca blocks (FIB), hip fractures, elderly, pain control, narcotic consumption, postoperative day (POD) ambulation

TOver the last two decades, operative management of clavicle fractures has become more commonplace. Although traditionally treated with plating techniques, clavicle fractures have also been treated with intramedullary fixation (IMF). While IMF is less invasive, it is not without complications, including hardware migration, and related symptoms. This study presents a novel method of clavicle IMF using titanium elastic nails inserted through the posterolateral clavicle. The principal investigator’s experience with the novel technique at a singular institution was reviewed to develop a comprehensive guide. A singular surgeon has used a novel posterolateral IMF technique for clavicle fractures over 15+ years at a Level 1 trauma and tertiary care system, reporting a high union rate with minimal complications. This technique is technically easy, decreases risk of implant prominence or hardware failure requiring removal, does not result in central hardware migration or cause considerable supraclavicular nerve numbness, and produces a cosmetically pleasing result. (Journal of Surgical Orthopaedic Advances 35(2):107–110, 2026)

Key words: clavicle fracture, clavicle fixation, intramedullary nail, intramedullary fixation

The authors evaluate the clinical outcomes of patients who underwent a total knee arthroplasty with the Balanced Knee® System (BKS®) with at least 3-year follow-up. A retrospective chart review was performed of 335 patients who had TKR with BKS implants and had a minimum follow-up of 3 years. Radiographic and clinical outcomes were analyzed for preoperative, 6-week, 1-year, 4-year and final follow-up. Reoperation for any reason was recorded, and Kaplan-Meier survivorship was analyzed. Overall outcomes for this system were good. Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System physical and mental scores improved significantly. There were nine (2.6%) revisions for any reason during the study period. Kaplan-Meier survivorship was 96% at 5 years. BKS is a modern total knee implant that offers patients excellent patient reported and radiographic outcomes at short to mid-term follow-up. (Journal of Surgical Orthopaedic Advances 35(2):063–067, 2026)

Key words: BKS knee, knee replacement outcome, total knee arthroplasty

This study aims to evaluate the skin surface temperature following an uncomplicated total knee arthroplasty (TKA) compared to the contralateral native knee to inform both patient and provider of what was identified as a normal postoperative inflammatory response. In a retrospective case-control study, 39 patients who underwent uncomplicated TKA between 2017 and 2021 had knee surface temperatures taken in the clinic at 3 weeks, 2 months, and 1 year. The operated knee was compared to the contralateral knee to determine the difference in knee surface temperature. Knee surface temperatures following TKA increased an average of 3.7°C, 3.4°C, and 1.2°C after 3 weeks, 2 months, and 1 year, respectively. Providers can make patients aware of these changes to decrease patient concerns of possible infection when feeling the normal knee surface temperature change associated with TKA. (Journal of Surgical Orthopaedic Advances 35(2):068–071, 2026)

Key words: total knee arthroplasty, postoperative, skin temperature, infection, septic arthritis, total joint replacement

A common problem in long spinal fusions is caudal end fixation failure. To address sacral screw loosening, fixation may be extended to the pelvis using iliac screws. Iliac screws provide strong anchor strength, but loosening is common due to high strain. A novel ‘Eiffel Tower’ (E-T) construct is introduced to reduce iliac screw strain. A saw-bone spine model was instrumented with pedicle screws and rods from T9 to S1 as native fixation. L5 and S1 screw strain was measured with application of 25Nm loading in flexion, extension, lateral bending and rotation. Strain was measured for L5, S1 and iliac screws after fixation was extended to the pelvis. The conventional model used a bridge connecting a screw in the medial iliac crest to the main rod superior to L5. The E-T fixation used two rods connected to the main rods at L1 and to two screws in the superolateral iliac crest. S1 strain is reduced by 65% by conventional fixation and 77% by E-T fixation. S1 screw strain reduction was greater with E-T fixation compared to conventional fixation in all loading directions. Iliac screw strain was decreased with E-T fixation compared to conventional fixation in all loading directions. Conventional fixation increased L5 screw strain compared to native fixation, but E-T fixation did not. Both conventional and E-T fixation reduce S1 screw strain, but E-T fixation did so to a greater extent. Terminal fixation at the iliac screw suffered a higher load with conventional fixation relative to E-T fixation. (Journal of Surgical Orthopaedic Advances 35(2):072–076, 2026)

Key words: proximal junction failure, dynamic stabilization system, screw pull out

This study compared distance traveled by total joint arthroplasty (TJA) patients to surgeons’ clinics who are language concordant (LC) versus language discordant (LD) with their surgeons. A retrospective review of all non-English speaking patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), stratified according to language concordance, was conducted at a single institution between 2011 and 2021. The distance from home to clinic zip code where patients received TJA care was recorded. Of the 837 patients receiving THA, 401 (47.9%) were in the LD group and 436 (52.1%) were in the LC group. In total, 1,675 patients received TKA, with 874 (52.2%) in the LD group and 801 (47.8%) in the LC group. Both TKA and THA LD patients traveled significantly farther from home to clinic than the LC groups (p < 0.001). Non-English-speaking patients undergoing TJA who are language concordant with their surgeon may live closer to their surgeons’ clinic. Level of Evidence: Level III. (Journal of Surgical Orthopaedic Advances 35(2):077–080, 2026)

Key words: total joint arthroplasty (TJA), language concordance, language discordance, distance

This study examines the impact of social determinants of health (SDoH) on cardiovascular complications after hand surgery, focusing on income, unemployment, insurance, and education. Using PearlDiver data (2011 – 2022), adult patients with Medicare Advantage, Medicaid, or private insurance were analyzed. Cardiovascular complications (e.g., cardiac arrest, deep vein thrombosis, arrhythmia, pulmonary embolism, myocardial infarction) within 90 and 365 days post-surgery were assessed via logistic regression adjusted for demographics and SDoH. Among 1,693,829 patients (mean age 66.3, 64% female), 0.9% had complications at 90 days, 2.3% at 365 days. Higher income and insurance rates reduced risk, while unemployment increased it. Education showed no significant effect. Lower income, higher unemployment, and reduced insurance coverage predict cardiovascular risks after hand surgery, highlighting the need for addressing socioeconomic disparities to improve outcomes. (Journal of Surgical Orthopaedic Advances 35(2):081–085, 2026)

Key words: complications, cardiovascular, hand surgery, socioeconomics, demographics

Limited knowledge exists surrounding the relationship between hand and leg dominance and knee osteoarthritis (OA) laterality. The authors of this study characterized sex differences between hand and leg dominance and knee OA laterality in 100 adults undergoing unilateral primary total knee arthroplasty (TKA). A total of 455 electronic medical records (EMR) with primary unilateral TKA in the past 5 years at Atrium Health Wake Forest Baptist were reviewed. One hundred phone surveys were conducted to characterize self-reported hand and leg dominance preferences. Of 100 patients, there were 40 males and 60 females with a mean age of 73. There was no association between hand (p = 0.573) or leg (p = 0.121) dominance with ipsilateral TKA. Males showed contralateral associations for hand (p = 0.008) and leg (p = 0.004) dominance with TKA laterality. Females showed ipsilateral associations for both hand (p = 0.004) and leg (p < 0.001) dominance with TKA laterality. Understanding this relationship may improve the efficacy of future orthopaedic risk assessments, disease prevention recommendations, and targeted rehabilitation plans. (Journal of Surgical Orthopaedic Advances 35(2):086–090, 2026)

Key words: hand dominance, leg dominance, osteoarthritis, total knee arthroplasty, sex differences

This study reviews literature on corrective osteotomies without bone grafting for malunion of distal radius fractures (MDRF). A systematic review was performed on the treatment of MDRF without bone graft. The primary functional outcome measures were time to radiological union, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Visual Analogue Scale (VAS) scores, Mayo Wrist scores, grip strength, and range of motion (ROM) at final follow-up. A total of 285 patients across 11 studies met search criteria. Radiological union occurred in 98.9% of cases with a mean time of 3.9 months. Postoperatively, DASH improved an average of 25.9 points, VAS improved an average of 2.1 points, and Mayo Wrist improved an average of 34.3 points. A total of 133 complications (46.7%) were reported. Correction of MDRF without graft can produce excellent clinical outcomes, short time to union, and comparable complication rates to the bone grafting. (Journal of Surgical Orthopaedic Advances 35(2):091–094, 2026)

Key words: distal radius fracture, malunion, bone graft, corrective osteotomy, nonunion

The purpose of this cross-sectional study is to analyze how orthopaedic program directors (PDs) use their public social media accounts to connect with followers. Orthopaedic residency PDs’ (n = 202) Instagram accounts were evaluated for type of account (public versus private), followers/following, and posts. The most common forms used were Doximity (98%) and LinkedIn (52.5%), followed by Instagram (33%), Facebook (14%), and Twi!er (12.8%). Of the 67 (33%) PDs with personal Instagram accounts, there was a higher proportion of personal content posts 525 (55%) (p < 0.01). Educational content was identified in 19% of posts. There was a larger number of followers for PDs with public Instagram accounts (324 +/- 400) compared to those with private accounts (145 +/- 183) (p = 0.016). Social media is a way for PDs to display their program and reach a broader audience. There is significant room for growth by PDs to increase the volume of educational and academic content. Further research is needed to determine optimal social media educational and academic impact for PDs. (Journal of Surgical Orthopaedic Advances 35(2):095–097, 2026)

Key words: social media, orthopaedic residency, program director, Instagram, Doximity

Despite studies highlighting magnetic resonance imaging (MRI)/magnetic resonance angiogram (MRA) accuracy in diagnosing shoulder pathologies, there remains a paucity of data regarding false negative results of these tests. The authors retrospectively characterized demographic and intraoperative data of 34 patients (19 male, 15 female; average age 23 years), the majority with atraumatic dominant shoulder pain, who underwent diagnostic shoulder arthroscopy after normal preoperative MRI/MRA as read by a board-certified musculoskeletal radiologist. Patients averaged 426 days from first clinic visit and 266 days from MRI until surgical intervention. Modern imaging does not accurately diagnose shoulder injuries in a small subset of patients who tend to be younger and have a clinical history of atraumatic pain in their dominant shoulder. Posterior labral tears and capsular laxity were the most encountered intraoperative pathologies. Careful and thorough clinical history and physical examination are necessary, as are the use of imaging technologies as adjuvant rather than conclusive diagnostic tools for shoulder injuries. (Journal of Surgical Orthopaedic Advances 35(2):098–102, 2026)

Key words: shoulder pain, shoulder, MRI, arthroscopy

Ankle stress view (ASV) radiographs and medial clear space (MCS) are important components for determining operative fixation of ankle fractures but variability in the appropriate use of indications and radiograph quality has yet to be thoroughly investigated. This is a case series of 130 patients who sustained an ankle fracture between 2012 and 2019. ASV radiographs were indicated for isolated Weber B fracture types with MCS < 4 mm on mortise views. Patient demographics, appropriate indications, adequacy of radiographs, and operative management were recorded. A MCS value of 4.9 mm served as our institution’s operative threshold (area under the curve: 0.60, 95% confidence interval: 0.95 – 0.79). It was found that 36 of 130 (27%) patients had an ASV that was not indicated, and 40 of 130 (30%) had an ASV that was of inadequate quality. Notably, of the 40 patients with inadequately performed stress views, 24 (60%) underwent surgical intervention. Only 51% of ASV radiographs were appropriately indicated and adequately performed. (Journal of Surgical Orthopaedic Advances 35(2):103–106, 2026)

Key words: ankle stress view, medial clear space (MCS), Danis-Weber, Medial malleolus