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The Journal of the American Academy of Orthopaedic Surgeons · AAOS
Family planning and maternity leave concerns contribute to reasons why the percentage of women in orthopedic surgery is disproportionally and consistently low. Without institutional policies, these stressors are often placed on the pregnant resident in training. The establishment of formal department policies allows for clear, universal expectations, which helps decrease negative peer perception and overall dissatisfaction. This practice not only supports current trainees but can also help attract more diverse applicants to create a sustainable workforce. This is the first of a two-part paper that outlines key evidence-based considerations for pregnancy during residency. Importantly, we address the balance of early disclosure with confidentiality, call schedules, medical appointments, and return-to-work considerations, including lactation policies. Creation of these formal guidelines will require an investment in the department but can lay the foundation for a new generation of surgeons who thrive both at home and in the operating room.
INTRODUCTION: There are limited opportunities for orthopaedic trainees to practice placing Kirschner wires for fracture fixation outside the operating room. We created an inexpensive, low-fidelity simulator to meet this need.
METHODS: The simulator is composed of a bone model, soft-tissue model, light fixture "radiograph," and an electronic component and costs US$53. Validation evidence relevant to test content was evaluated by five fellowship-trained pediatric orthopaedic surgeons using a Likert scale to assess the physical characteristics of the models and their ability to result in transfer of skills to the operating room.
RESULTS: Model 3 had the highest average score for feel of the near (3.4) and far (3.4) cortex. Model 2 had the highest average score for feel of the medullary canal (3.2) and pin visualization (2.6). The simulator had high scores for ease of use and implementation and was rated highly for its ability to support residents' learning to triangulate to a defined target (4.8) and improve motor skills (4.4).
DISCUSSION: We were able to create an inexpensive, low-fidelity simulator with potential for high transferability, which can be used by orthopaedic surgery residents to improve their motor skills in a low risk, high-reward environment.
INTRODUCTION: Osteogenesis imperfecta (OI) is a type I collagen disorder. Fragile and deformed bones increase fracture risk with noninvasive blood pressure (NIBP) cuff use. Patients with OI require multiple surgeries, with blood loss and pain medications risking hypotension. There is not currently a widely accepted protocol for NIBP measurements in patients with OI. We designed a protocol demonstrating the safe implementation of "busting the myth" that this is not feasible.
METHODS: We prospectively enrolled patients with OI undergoing spine or extremity procedures. Inclusion criteria were approval by an orthopaedic surgeon, age 1 to 35 years, and postoperative admittance to a non-intensive care unit (ICU). To minimize fracture risk and detect hypotension, low maximum inflation pressures were used: 120 mmHg-neonatal/infant/pediatric-sized cuffs; 140 mmHg-adult cuffs. Blood pressure (BP) measurements were taken per standard institutional postoperative care: no more than every 4 hours for 24 hours and every 8 hours or less thereafter. Upper extremity BP was measured manually by registered nurses who inspected the limb and inquired regarding signs of fracture (pain with palpation and bruising) before and after each measurement.
RESULTS: Fifty participants were enrolled (median age 12.5 years; 25 girls). Most had moderate (48%) or severe (42%) disease. Twenty-eight patients underwent extremity surgery, and 22 underwent spine surgery. Thirty-three percent of the humeri used were rodded, with an average of 9.5 BP measurements taken postoperatively. Clinical assessment revealed that no fractures occurred. Two participants (4%) withdrew for reasons unrelated to BP cuff complications.
CONCLUSION: Noninvasive BP measurements may be safely obtained in the postoperative period for patients with OI. This study was conducted in a system with a high volume of OI care, and OI-specialized orthopaedic surgeons screened the patients. Within these limitations, we recommend manual cuff use and careful fracture monitoring. This protocol may help patients with OI across other hospitals avoid postoperative arterial catheters and ICU admission and could facilitate preventive care for cardiovascular disease.
INTRODUCTION: Total ankle arthroplasty (TAA) has become a viable alternative to ankle arthrodesis (AA) in recent years. However, implant longevity is a concern because malalignment of either the tibial or talar implants has been shown to predispose to premature wear and necessary revision surgery. Thus, customized surgical tools such as computer navigation and patient-specific instrumentation have been used to theoretically improve intraoperative alignment of implants. The primary outcome of this study is to compare alignment between a computer-assisted navigation (CAN) system for TAA, a preexisting patient-specific instrumentation (PSI) system, and SRG fluoroscopic techniques.
METHODS: TAA was done on 36 artificial ankle joint specimens by a single surgeon: 12 using CAN, 12 with PSI, and 12 with SRG instrumentation. All specimens were scanned both preoperatively and postoperatively using a high-precision 3D scanning tool. Resections and implant placements were then analyzed in 3D processing software and compared between surgical modalities. Statistical analysis included one-way ANOVA with associated Tukey tests to assess for differences between groups.
RESULTS: We found that tibial resections were overall most accurate using CAN, with tibial slope measurements demonstrating significant improvements over PSI (P < 0.001) and conventional instrumentation (P < 0.001). PSI was more accurate than SRG when considering the axial cut height of the tibial resection (P < 0.001). In the talar resections, CAN was statistically superior to SRG methods in two of three measured categories (slope: P < 0.001, axial cut height: P < 0.001). However, PSI fared better than CAN in those same categories (slope: P = 0.002, axial cut height: P < 0.001). Employment of the CAN system also decreased implant placement variability (CAN: ± 0.47 mm, ± 0.62 deg; PSI: ± 0.63 mm, ± 1.03 deg; SRG: ± 0.73 mm, ± 1.21 deg).
CONCLUSION: In this laboratory-based TAA study, we found that both CAN and PSI demonstrated advantages over SRG instrumentation regarding implant placement accuracy. Tibial resections were found to be overall most accurate under CAN guidance, and talar resections were found to be overall most accurate under PSI guidance. In addition, the observed reduction in implant placement variability has potential positive implications for surgeons. However, as this study was conducted on artificial specimens, effects of soft tissue and preoperative deformities or pathologies were not considered. Future studies should include cadaveric specimens with various pathologies to better simulate conditions encountered in an operating room.
LEVEL OF EVIDENCE: Level II - Lesser Quality RCT or Prospective Comparative Study.
Glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1 RAs) are used in diabetic patients for glycemic control. Yet, there has been a notable rise in their use for weight loss management in obese patients. This review critically appraises current evidence on perioperative implications of GLP-1 receptor agonists in TJA patients. The review discusses GLP-1 RA implications and use (physiology, pharmacology, pharmacodynamics, mechanisms of actions, and commonly used GLP-1 Ras), complications and adverse effects, considerations for the anesthesiologist, considerations for the TJA surgeon, and current clinical practice recommendations in 2025.
BACKGROUND: Accurate Evaluation and Management (E/M) coding depends on the precise documentation of medical decision making. Advances in artificial intelligence have introduced ambient listening technology as a novel documentation tool. Despite its rapid adoption, the effect of ambient listening technology on E/M code selection, coding accuracy, and downstream financial implications remains poorly defined. This study aimed to evaluate the effect of ambient listening technology on E/M code selection, coding concordance, and associated revenue implications within an orthopaedic surgery practice.
METHODS: A comparative cross-sectional analysis was done of all outpatient E/M services at a single academic medical center. Providers were required to have a minimum of 20 encounters documented using ambient listening technology and traditional dictation for the same encounter type. The final analytic cohort included 7,236 encounters. A randomized subset of 200 encounters (100 ambient listening and 100 traditional) underwent blinded, independent audit by an experienced orthopaedic coding auditor. Outcomes included concordance between provider-selected and auditor-determined E/M levels, weighted coding discrepancies, accuracy rates, and modeled revenue effect.
RESULTS: Encounters documented with ambient listening technology were associated with higher E/M levels than those documented with traditional dictation, as assessed by both auditors (3.24 vs 2.96) and providers (3.11 vs 2.82). Overall coding accuracy was 68% for ambient listening and 74% for dictation, while focused review of higher-level ambient listening encounters demonstrated 81.3% accuracy. Revenue modeling projected a potential annual increase of $232,313 if dictation-based encounters achieved E/M distributions observed with ambient listening.
CONCLUSION: Ambient listening-generated documentation meaningfully influences E/M code determination in orthopaedic outpatient practice, supporting higher and more appropriate E/M level selection compared with dictation. Although distinct error patterns persist, ambient listening was associated with reduced undercoding and measurable financial impact. These findings position ambient listening technology as a clinically and financially consequential documentation modality, warranting thoughtful implementation and continued coding oversight.
Primary elbow osteoarthritis is a functionally limiting condition, predominantly affecting middle-aged men engaged in repetitive manual labor, and is characterized by pain, stiffness, and mechanical symptoms. Evaluation involves a detailed history focusing on pain, loss of motion, and mechanical symptoms, followed by clinical examination for range of motion deficits, crepitus, and instability. Radiographic assessment, including standard radiographs and, when indicated, computed tomography imaging, is essential for staging disease severity, identifying osteophytes, capsular contracture, and joint space narrowing. Initial management is nonsurgical, emphasizing activity modification, NSAIDs, physical therapy, and intra-articular corticosteroid injections. When conservative measures fail, surgical options include arthroscopic or open débridement, osteocapsular arthroplasty, and procedures such as the Outerbridge-Kashiwagi technique. Both arthroscopic and open approaches reliably improve pain, range of motion, and functional scores, with low complication rates. However, open procedures may yield greater flexion gains in select cases. Nonarthroplasty options for primary elbow arthritis encompass a spectrum from conservative management to arthroscopic and open surgical débridement, with treatment tailored to disease severity, patient age, and functional demands.
Advances in hip arthroscopy have expanded its use beyond intra-articular pathology to include a range of extra-articular conditions (endoscopy) that affect the active adult population. These minimally invasive procedures now provide practical, evidence-based alternatives to open surgery. Endoscopic techniques allow targeted management of greater trochanteric pain syndrome, iliopsoas tendinopathy, extra-articular hip impingement, and gluteal and hamstring tears with reduced morbidity and faster recovery. The purpose of this review is to summarize the current indications, key surgical principles, and clinical outcomes for extra-articular hip endoscopy, emphasizing pearls and pitfalls relevant to the practicing orthopaedic surgeon.
BACKGROUND: Cervical radiculopathy can be managed surgically with anterior cervical diskectomy and fusion (ACDF) or minimally invasive posterior cervical foraminotomy (MIS-PCF). ACDF is widely used and provides indirect decompression and stabilization, while MIS-PCF preserves motion, avoids fusion-related complications, and may offer advantages in perioperative recovery. The aim of this meta-analysis was to compare surgical, patient-reported, and safety outcomes of MIS-PCF versus ACDF to guide clinical decision making.
METHODS: A systematic literature search of PubMed, Scopus, Cochrane Library, and Google Scholar was conducted through October 2025 to identify comparative studies of MIS-PCF and ACDF for cervical radiculopathy. Data from 12 studies involving 3,185 patients were pooled. Outcomes included surgical time, length of stay, hospital cost, pain scores (VAS arm and neck), functional scores (NDI and EQ-5D), revision surgery rates, and complication rates.
RESULTS: MIS-PCF was associated with significantly shorter surgical time (MD = -14.72 min, P < 0.001), reduced length of stay (MD = -0.99 days, P < 0.001), and lower hospital costs (MD = -$9,131.93, P < 0.001) compared with ACDF. Arm pain outcomes showed no significant differences between groups, either immediately postoperatively (P = 0.35) or at 1 to 2 years (P = 0.71). By contrast, MIS-PCF demonstrated significantly greater neck pain reduction immediately after surgery (MD = 0.42, P < 0.001) and at 1 to 2 years (MD = -0.22, P = 0.001). Functional outcomes (NDI and EQ-5D) were comparable between techniques (P ≥ 0.89). Revision surgery and overall complication rates did not differ significantly (P = 0.39 and P = 0.51, respectively).
CONCLUSION: Both MIS-PCF and ACDF are effective surgical options for cervical radiculopathy, with comparable reported safety and functional outcomes. MIS-PCF may offer perioperative advantages and better neck pain outcomes, supporting its role as a motion-preserving and cost-efficient alternative to ACDF in appropriately selected patients.
The American Academy of Orthopaedic Surgeons (AAOS) has developed an Appropriate Use Criteria (AUC) for the Treatment of Mid-Shaft Clavicle Fractures. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop criteria to determine the appropriateness of surgical and nonsurgical treatment in patients who have suffered a mid-shaft clavicle fracture. The Appropriate Use Criteria for the Treatment of Mid-Shaft Clavicle Fractures were derived by identifying clinical indications typical of patients who have suffered a mid-shaft clavicle fracture. These indications were most often variables observable by the clinician, including symptoms or results of diagnostic tests. In addition, "human factor" (eg, activity level or demographic variables) can be considered. The 96 patient scenarios and two treatments were developed by the writing panel, a group of clinicians who are specialists in this Appropriate Use Criteria topic. Next, a separate, multidisciplinary rating panel (made up of specialists and nonspecialists) rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "Appropriate" (median rating, 7 to 9), "May Be Appropriate" (median rating, 4 to 6), or "Rarely Appropriate" (median rating, 1 to 3).
INTRODUCTION: Proper nutrition is a well-established variable in recovery from orthopaedic surgery. The purpose of this study was to explore patient perception of preoperative nutrition before elective shoulder surgery. We hypothesized that patients have a positive attitude toward preoperative nutrition, with interest in receiving nutritional guidance from their healthcare provider.
METHODS: A prospective survey study of 100 patients scheduled for elective shoulder surgery was conducted. All surveys were completed in the preoperative period, with questions designed to evaluate a patient's knowledge and perceptions regarding nutrition, as it relates to their recovery. Survey questions assessed (1) how patients perceive their personal daily nutrition, (2) the importance of quality nutrition with respect to postoperative recovery, and (3) their ability to self-implement nutrition strategies and/or those provided to them.
RESULTS: The majority of surveyed patients (n = 80; 80%) agreed that nutrition is an important part of recovering from orthopaedic shoulder surgery, with most patients (n = 77; 77%) supporting the idea that a formal preoperative nutrition plan would help contribute to postoperative recovery. However, only 40 patients (40%) believed that they understood which foods to eat, 28 (28%) believed that they knew which supplements to take, and 46 (46%) planned to take supplements without instruction. Family support was found to be associated with patient confidence in (P = 0.003) and adherence to (P = 0.023) a preoperative nutrition plan.
CONCLUSION: This study found that there is a clear disconnect between patient perspectives and practical knowledge when it comes to perioperative nutrition before shoulder surgery. Nevertheless, most patients display a positive attitude toward following a nutrition plan if provided by a healthcare provider, and if family support is present. These data indicate the need for established perioperative nutrition plans to aid in effectively optimizing patient nutrition before elective shoulder surgery.
BACKGROUND: Diabetes mellitus (DM) is a well-established risk factor for complications after surgical fixation of ankle fractures. Elevated hemoglobin A1c (HbA1c) has been associated with worse outcomes; however, it remains unclear whether HbA1c alone predicts perioperative risk independent of a formal DM diagnosis and treatment status. This study evaluated whether elevated preoperative HbA1c (≥8.0%) in patients without a documented diagnosis or pharmacologic treatment of DM is associated with increased early postoperative complications compared with patients with established DM.
METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation of ankle fractures. Patients were stratified into four cohorts based on diabetes diagnosis/treatment status and glycemic control: (1) undiagnosed/untreated, HbA1c < 8.0%; (2) undiagnosed/untreated, HbA1c ≥ 8.0%; (3) diagnosed/treated, HbA1c < 8.0%; and (4) diagnosed/treated, HbA1c ≥ 8.0%. Propensity score matching (1:1) on age and sex yielded 388 matched patients (n = 97 per group). Primary outcomes were 30-day mortality, readmission, and revision surgery. Secondary outcomes included surgical site infection, organ-space infection, and medical complications. Multivariable logistic regression adjusted for residual differences in body mass index and comorbidities.
RESULTS: Thirty-day mortality was rare (0.8%) and did not differ between groups (P = 0.381). Significant differences were observed in revision surgery (P = 0.006), superficial surgical site infection (P = 0.003), and organ space infection (P = 0.019). Patients with diagnosed/treated uncontrolled DM had higher odds of these complications compared with those with elevated HbA1c but no documented DM diagnosis or treatment (undiagnosed/untreated uncontrolled) (all P < 0.05).
CONCLUSION: Patients with poorly controlled established diabetes had higher rates of early postoperative complications after ankle fracture open reduction and internal fixation compared with those with elevated HbA1c but no earlier diabetes diagnosis or treatment. Assessment of the presence and treatment status of diabetes may provide more meaningful perioperative risk stratification than HbA1c level alone.
LEVEL OF EVIDENCE: Level III, retrospective cohort study.
BACKGROUND: Unimalleolar, bimalleolar, and trimalleolar ankle fractures and syndesmosis injuries represent a spectrum of increasing instability and surgical complexity. Although the work Relative Value Unit (wRVU) system is designed to account for surgical time and technical complexity, previous studies suggest a mismatch between procedural complexity and proportional reimbursement rate. Our study aims to evaluate whether current wRVU allocation across ankle fracture types adequately reflects procedural complexity and to assess whether more complex cases are relatively undercompensated.
METHODS: The national surgical quality improvement program (NSQIP) database (2021 to 2024) was queried for patients undergoing open reduction and internal fixation for ankle fractures and syndesmosis injuries, using current procedural terminology (CPT) codes. Cases involving tibial shaft or pilon fractures or multiple CPT codes were excluded. Compensation metrics included surgical time, total wRVUs, wRVUs per hour (wRVU/hr), and hourly reimbursement rate ($/hr). 1:1 propensity score matching was done based on age, sex, American Society of Anesthesiologists class, and inpatient versus outpatient status. Analysis of covariance was subsequently used to adjust for preoperative comorbidities and postoperative complications affecting compensation metrics.
RESULTS: Among 17,833 cases, 779 patients per group were identified after propensity score matching. Surgical time (minutes) increased significantly with complexity (unimalleolar: 64.1 ± 35.5; syndesmosis: 64.2 ± 37.9; bimalleolar: 83.5 ± 43.6; trimalleolar: 105.0 ± 53.6; P < 0.001). Although trimalleolar ankle fractures generated the highest total wRVUs (11.7), wRVU/hr decreased as complexity increased (unimalleolar: 10.7 ± 6.3; syndesmosis: 11.3 ± 6.9; bimalleolar: 9.9 ± 5.4; trimalleolar: 8.7 ± 5.5; P = 0.006). Hourly reimbursement rate ($/hr) followed a similar inverse pattern (unimalleolar: 361.9 ± 214.2; syndesmosis: 382.0 ± 234.4; bimalleolar: 335.4 ± 182.6; trimalleolar: 296.1 ± 188.7; P = 0.006).
CONCLUSION: Our study suggests that the current compensation structure for ankle fracture and syndesmosis fixation procedures may not adequately reflect the surgical time and effort required for more complex injuries. Additional evaluation of wRVU allocation for ankle fracture and syndesmosis injury management may be necessary to ensure that compensation more accurately aligns with physician time and effort.
LEVEL OF EVIDENCE: Level III.
BACKGROUND: Unrestricted kinematic alignment (KA) in total knee arthroplasty (TKA) seeks to restore patient-specific limb geometry and ligamentous balance, yet uncertainty persists regarding patellofemoral (PF) complications and postoperative interventions. Comparative evidence centered on objective mechanical outcomes remains limited, and prior meta-analyses have included heterogeneous alignment strategies or mixed implant constructs. The purpose of this study was to compare unrestricted KA with mechanical alignment (MA) in primary TKA with respect to PF safety, postoperative motion, and intraoperative soft-tissue release requirements.
METHODS: A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Randomized and comparative observational studies directly comparing unrestricted KA with MA in primary TKA were eligible without language or date restrictions. Studies were required to report at least 1 predefined objective outcome: postoperative flexion, terminal extension, manipulation under anesthesia (MUA), PF complications, intraoperative soft-tissue releases, or all-cause revision surgery. Data were extracted in duplicate, and random-effects models were used for pooled analyses. Risk of bias was assessed using ROB2 for randomized trials and ROBINS-I for observational studies, and certainty of evidence was graded using GRADE methodology.
RESULTS: Seven studies (five randomized trials and two comparative cohorts) comprising 1,068 primary TKAs met inclusion criteria. Compared with MA, KA resulted in greater postoperative flexion (mean difference [MD], 4.58°; 95% confidence intervals (CI), 1.83° to 7.32°; moderate certainty) and slightly improved terminal extension (MD, -0.99°; 95% CI, -1.86° to -0.12°; moderate certainty). KA required substantially fewer intraoperative soft-tissue releases (risk ratio [RR], 0.34; 95% CI, 0.24 to 0.49; moderate certainty). No significant differences were observed for PF complications (RR, 1.90; 95% CI, 0.63 to 5.74; low certainty), MUA (RR, 0.47; 95% CI, 0.09 to 2.44; low certainty), or all-cause revision surgery (RR, 1.96; 95% CI, 0.75 to 5.14; low certainty). Sensitivity analyses demonstrated stable effect direction across fixed-effects and random-effects models.
DISCUSSION: Unrestricted KA TKA improves postoperative flexion, slightly enhances extension, and markedly reduces soft-tissue releases without increasing early PF complications, MUA, or revision surgery compared with MA TKA. Longer term randomized studies are needed to refine PF-specific risk estimates and assess survivorship.
LEVEL OF EVIDENCE: II.
Knee pain is common, with more than 30% to 45% of middle-aged and older adults having symptomatic osteoarthritis, and 25% to 40% of younger adults having patellofemoral pain syndrome. Components of a detailed history include time of onset; pain duration, quality, and localization; trauma/mechanism of injury; swelling; popping/clicking; aggravating and alleviating factors; sports activities; and limitations to current activity. The physical examination for evaluating knee pain involves five overall components: inspecting the joint for obvious abnormalities, palpating the joint to identify effusion or points of tenderness that may be the source of the pain; testing active and passive range of motion; testing strength; and performing specialized maneuvers that evaluate specific knee joint structures. These maneuvers are most accurate when performed in combination, rather than relying on one specific maneuver to make the diagnosis. In addition to these five examination components, imaging should be obtained if appropriate, with plain radiography typically being the first step. With traumatic injuries, clinical decision rules such as the Ottawa Knee Rule can determine if radiography is needed to detect fractures or other injuries that may require referral. Additional evaluations can include arthrocentesis when joint effusion is present, optimally guided by point-of-care ultrasonography when available, and laboratory testing if infection or inflammatory disorders are suspected.
BACKGROUND: Patients with spinopelvic risk factors such as lumbar fusion or stiff spine exhibit a 5- to 10-fold increased risk of dislocation following total hip arthroplasty (THA), primarily due to altered spinopelvic mechanics that influence cup positioning. The utilization of robotic-assisted THA facilitates personalized planning, enhancing component placement in this high-risk population. This study aims to compare rates of implant-related and medical complications between robotic-assisted and manual THA in these high-risk patients.
METHODS: Data were retrospectively obtained from the TriNetX Research Network. Patients with prior lumbar fusion or spinal conditions associated with stiffness or malalignment, and who subsequently underwent THA, were identified using ICD-10 and CPT codes. Procedure codes defined robotic-assisted and manual THA. After 1:1 propensity score matching for age, sex, body mass index, smoking status, and other comorbidities, outcomes were compared at 3, 6, 12 months and 2 years. A subgroup analysis compared both groups in spinal fusion (SF) and nonfusion (no-SF/stiff spine) patients.
RESULTS: After 1:1 propensity score matching, each cohort included 2,147 patients. At 3 months, robotic THA was associated with lower prosthetic complications (1.4 vs 2.7%; odds ratio [OR]: 1.86, 95%; P = 0.01) and postoperative blood transfusion (0.9 vs. 1.8%; OR: 2.02, P = 0.01). At 1 year, dislocation was reduced (0.9 vs. 1.8%; OR: 2.07; P = 0.01). Revisions were also lower at 1 and 2-year follow-up in the robotic group (1.7 vs. 2.7%, OR: 1.61; 2.0 vs 3.7%, OR: 1.86; all P < 0.05; respectively), and the manual group had 1.9 times the hazard of having revision surgery at 2 years (HR: 1.9, 95%; P = 0.02). In no-SF patients, robotic THA was associated with markedly lower rates of prosthetic complications and revision surgery.
CONCLUSION: Robotic-assisted THA was associated with fewer complications than manual THA in patients with lumbar fusion or clinically relevant spinal stiffness, a population at elevated risk for instability after THA. Precision-based implant positioning may improve outcomes in patients with altered spinopelvic mobility, including those without spinal fusion.
BACKGROUND: As the cost of anatomic total shoulder arthroplasty (aTSA) continues to rise, there is increasing pressure to optimize value through cost-effective care strategies. Patient-level value analysis (PLVA) is an emerging method that quantifies value as the change in patient-reported outcomes (PROs) relative to total cost. Although PLVA has been applied to other orthopaedic procedures, it has not been used to evaluate aTSA. This study aimed to assess 1-year value delivery in aTSA and identify characteristics that influence cost and outcomes.
METHODS: A retrospective cohort study was conducted using prospectively collected patient-reported outcome registries at one healthcare institution. Patients undergoing primary unilateral aTSA for osteoarthritis between 2018 and 2022 were included. Patients were excluded if they lacked preoperative or 1-year American Shoulder and Elbow Surgeons (ASES) scores or experienced complications or revisions. Episode-of-care (EOC) costs were calculated using time-driven activity-based costing (TDABC), including direct and indirect care costs. The value quotient (Vq) was defined as the change in ASES score divided by total EOC cost, multiplied by 100. Multivariate regression was used to assess predictors of cost, outcome, and value.
RESULTS: A total of 139 patients met inclusion criteria. The mean age was 67.8 years, and 54.4% were female. The average 1-year ASES improvement was 32.1 ± 24.9, and the mean EOC cost was $13,301±$3,137. Implants accounted for 49% of the total EOC cost. Surgeries in the ASC setting predicted lower cost (β = -$2,847; P < 0.001), whereas inpatient stay and SNF discharge were associated with higher costs. The average value quotient was 0.23 ± 0.19 for each patient.
CONCLUSION: Cost variability in aTSA is driven by surgical setting, implant selection, and discharge disposition. Higher costs do not correspond to better outcomes, highlighting opportunities to improve value by targeting modifiable cost drivers, particularly implant prices and use of postacute care facilities.
Identifying the correct etiology of total hip arthroplasty (THA) failure is the critical first step in determining the most appropriate course of treatment. In many cases, the cause of failure may not be evident. Thus, a systematic approach to the failed THA is paramount to identifying the correct diagnosis. Many studies provide a detailed understanding of why THAs fail. However, a concomitant methodology to distinguish one failure modality from another is not readily available. In addition, the diagnosis of one mode of failure may lead a surgeon to inadvertently overlook other potential coexisting mode(s) of failure. In this article, we present a systematic approach for determining the cause of THA failure. The essence of this review article lies in the comprehensive worksheet that provides a clear framework to evaluate patients presenting with a failed or painful THA, especially in the absence of obvious causes. A systematic approach minimizes the chances of excluding pertinent information and concomitant modes of failure, which may lead to an inaccurate diagnosis and high likelihood of failure following revision surgery. This simple guide is intended to help residents, fellows, and surgeons in practice to avoid overlooking concomitant etiologies in a failed THA and thereby improve the chances of successful outcomes.
BACKGROUND: Although female representation at national orthopaedic society meetings has increased in recent years, women remain disproportionately more likely to deliver nontechnical presentations. Examining patterns in speaker roles provides a measurable way to assess progress toward equitable representation by sex in academic orthopaedic settings.
QUESTIONS/PURPOSES: This study aimed to (1) evaluate trends in female speaker representation at the Orthopaedic Trauma Association (OTA) Annual Meeting from 2014 to 2024 and (2) assess sex-based differences in speaker roles, including the likelihood of delivering technical versus nontechnical presentations.
PATIENTS AND METHODS: Speaker names, session titles, and roles (speaker, moderator, or committee member) were extracted from OTA Annual Meeting programs spanning 2014 to 2024. Sessions were classified as technical or nontechnical, and speaker sex was determined through publicly available information. A total of 514 sessions were analyzed, including 390 technical and 124 nontechnical sessions. Trends in speaker roles by sex were assessed over time, and odds ratios (ORs) were calculated to evaluate the likelihood of men versus women delivering technical presentations.
RESULTS: Female representation increased across all roles over the study period. The proportion of female speakers rose from 8.85% in 2014 to 22.22% in 2024, and the proportion of female moderators increased from 4.84% to 12.99%. Four women served as committee members since 2021, with one serving as cochair. Men were significantly more likely to give technical talks in 2024 (OR 2.8, 95% CI, 1.47-5.41, P = 0.0018) and 2021 (OR 3.0, 95% CI, 1.59-5.87, P = 0.0009).
CONCLUSION: Female representation at the OTA Annual Meeting has increased substantially over the past decade, mirroring trends observed in other orthopaedic subspecialty societies. However, sex-based differences in the distribution of technical versus nontechnical presentations were observed in multiple years. Continued efforts are needed to promote equitable access to academic and leadership roles for women in orthopaedic trauma.
LEVEL OF EVIDENCE: Level III (retrospective observational study).
INTRODUCTION: Pathology of the long head of the biceps tendon is a frequent source of shoulder pain. Biceps tenodesis is a common surgical intervention, and many patients seek information online. The readability and quality of online resources regarding biceps tenodesis remain unexamined. The purpose of this study was to evaluate the source type, readability, and quality of online patient-facing resources regarding biceps tenodesis.
METHODS: Search Engine Optimization Minion extracted "People Also Ask" (PAA) questions from four terms: "biceps tenodesis," "biceps tenodesis indications," "biceps tenodesis complications," and "biceps tenodesis recovery." Searches were done in an incognito browser with data cleared. Three reviewers categorized sources and assessed credibility using the Journal of the American Medical Association (JAMA) benchmark criteria and readability using the Flesch-Kincaid Grade Level (FKGL), Flesch-Kincaid Reading Ease, and Gunning Fog Index against national patient-education standards.
RESULTS: Four hundred queries and associated sources were analyzed. Journals were the most common (115, 28.8%), followed by academic sources (107, 26.8%) and medical practice websites (73, 18.3%). Most sources (317, 79.3%) exceeded recommended sixth-grade to eighth-grade levels: mean FKGL 9.8 (SD = 2.5), GFI 13.7 (SD = 2.7), and FKRE corresponding to grade level 12.5 (SD = 2.9). The mean JAMA score was 2.2 (SD = 0.9). Government websites were the easiest to read, FKGL M = 4.1 (SD = 0.0); GFI M = 7.8 (SD = 0.0), and moderately credible, JAMA M = 2.0 (SD = 0.0), but represented only 13 (3.3%). Journal sources had the highest credibility, JAMA M = 3.2 (SD = 0.5), yet the lowest readability, FKGL M = 11.5 (SD = 2.1); GFI M = 15.3 (SD = 2.0).
CONCLUSION: The prevalence of difficult-to-read and low-quality information on biceps tenodesis highlights a gap between patient interest and the quality of accessible resources. Future efforts should explore simplifying medical content and improving the readability of online materials related to biceps tenodesis.
INTRODUCTION: The existing literature on anterior cervical diskectomy and fusion (ACDF) predominantly focuses on 1- and 2-level procedures, leaving limited data comparing outcomes of 3- versus 4-level standalone ACDFs. Thus, the aim of this study was to compare surgical outcomes and patient-reported outcome measures (PROMs) of 3- versus 4-level ACDF.
METHODS: Patients who underwent 3- or 4-level ACDF within a single academic health system (2014 to 2020) were retrospectively identified. Surgical outcomes and PROMs were evaluated, including the 0 to 10 numeric rating scale for neck and arm pain, Short Form-12, Modified Japanese Orthopaedic Association (mJOA), and Neck Disability Index (NDI). Patients were excluded if they did not have complete preoperative or 1-year postoperative mJOA scores, underwent ACDF for tumor/trauma/infection, or had concomitant posterior cervical fusion.
RESULTS: A total of 256 patients were included (46 4-level ACDFs). Patients undergoing 4-level ACDF had higher BMI (30.8 vs. 28.9; P = 0.032) and a greater prevalence of myelopathy (45.7% vs. 33.3%; P = 0.018) but were otherwise demographically similar to 3-level ACDF patients. Four-level ACDF patients had a higher dysphagia rate (20% vs. 8.6%; P = 0.033) and a higher 30-day ED visit rate (6.5% vs. 0%; P = 0.005) but similar readmission rates and all other surgical outcomes. Patients with 4-level ACDF had better 6-month NDI scores but worse 1-year mJOA scores. All other PROM comparisons and deltas were similar at all time points.
CONCLUSION: Patients undergoing 4-level ACDF had higher BMI and a greater prevalence of myelopathy than those undergoing 3-level ACDF; 4-level ACDF was associated with a higher rate of dysphagia and early postoperative ED utilization, but not readmissions. The groups otherwise did similarly with respect to surgical outcomes and PROM improvements. These findings suggest that extending fusion from three to four levels was not associated with increased surgical risk or inferior short-term functional or pain outcomes compared with 3-level ACDF.
INTRODUCTION: The combination of disproportionate pain intensity and limb disuse is often diagnosed as complex regional pain syndrome (CRPS), a label that may imply a specific measurable pathophysiology. In a review of studies of pathophysiology associated with diagnosis of CRPS, we asked, "How often are studies based on comparisons of diagnosed limbs and either undiagnosed limbs or healthy controls, and how many different research groups have addressed specific measures?"
METHODS: We searched PubMed, Embase, and Cochrane using keyword terms to identify studies of CRPS pathophysiology. Peer-reviewed experiments measuring pathophysiology in ≥10 people diagnosed with CRPS were included. Pilot searches demonstrated sufficient attempts to measure pathophysiology, and a structured review was deemed feasible. A formal search yielded 1,207 studies. Fifty studies from each database (150 in total) were audited revealing no eligible studies, confirming that initial screening captured the relevant evidence.
RESULTS: Thirty-seven studies measured different aspects of pathophysiology: molecular concentrations (serum cytokines, induced blister fluid and CSF cytokines, and serum autoantibodies, protease, and CGRP), neuropathophysiology in skin biopsy (fiber degeneration and nerve fiber density), cell type (mast cells/keratinocytes, monocytes, and T lymphocytes), metabolism (skin lactate, tissue oxygenation, and protein extravasation), and others (serum OPG, amino acids/antioxidants/B-endorphin, alpha-1 adrenoceptors, and MMP) among 1,340 people diagnosed with complex regional pain syndrome and 960 control subjects. Ten studies compared measurements between diagnosed and undiagnosed limbs and eight reported a difference. Thirty-four studies compared measurements between people diagnosed and not diagnosed with CRPS and 30 reported a difference.
CONCLUSION: To date, the measured physiological differences between limbs diagnosed with CRPS and other limbs are compatible with known consequences of limb disuse and are somewhat inconsistent. While experiments continue to search for treatable pathophysiology, CRPS can be accurately and usefully associated with universal and treatable aspects of human illness behavior such as kinesiophobia and worst-case thinking.
BACKGROUND: There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears.
PURPOSE: The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears.
STUDY DESIGN: This was an economic and decision-analysis study; Level II.
METHODS: A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D-based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty.
RESULTS: Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%.
CONCLUSION: Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.
Orthopaedic surgeons frequently treat patients on antirheumatic medications for rheumatoid arthritis, psoriatic arthritis, lupus, and other inflammatory conditions. When these patients require surgery, surgeons face competing therapeutic priorities: continuing medications risks impaired wound healing and infection, whereas discontinuing them may trigger disease flares and functional decline. Management decisions are further complicated by inconsistent guidelines and limited data on newer biological therapies. Antirheumatic medications disrupt wound healing at multiple stages,some affect early inflammatory responses, whereas others interfere with collagen remodeling. These wound healing disruptions are especially concerning in high-risk patients, such as those with cancer, where complications can derail overall treatment plans. Current knowledge is largely limited to joint arthroplasty in rheumatoid arthritis patients, leaving notable gaps for other procedures and newer medications. This review addresses these gaps by providing evidence-based guidance for medication timing, dosing adjustments, and monitoring strategies, emphasizing multidisciplinary approaches to optimize surgical outcomes.
Adductor injuries represent a notable musculoskeletal burden among athletes accounting for half of acute hip injuries in soccer and nearly one quarter in professional basketball. The pyramidalis-anterior pubic ligament-adductor longus complex represents a critical anatomic concept for understanding injury patterns with the adductor longus most injured. Clinical evaluation follows the Doha agreement classification, emphasizing adductor tenderness and pain on resisted adduction testing to differentiate adductor-related groin pain from other etiologies. Magnetic resonance imaging provides comprehensive injury characterization, with validated classification systems predicting return-to-play timelines. Prevention strategies target modifiable risk factors including adductor weakness and reduced hip rotational range of motion, with strengthening programs demonstrating potential to reduce injury incidence. Nonsurgical management remains the cornerstone of treatment for most injuries with return to play averages 2 to 3 weeks for partial tears and 8 to 12 weeks for complete tears managed nonsurgically, although recurrence rates are as high as 19%. Surgical intervention is considered for acute avulsions with greater than 2 cm retraction or chronic injuries refractory to conservative treatment, although comparative evidence versus structured nonsurgical care is limited. Surgical management options include repair, partial tenotomy, or complete tenotomy. All three surgical approaches demonstrate good outcomes in nonrandomized cohort studies with return to play averaging 10 to 14 weeks and repair being favored for traumatic complete avulsion particularly in professional athletes.
Orthopaedic surgeons routinely consult search engines, journals, and curated websites to stay current on orthopaedic knowledge. The emergence of large language models, such as OpenAI ChatGPT and Google MedGemma, is changing the way we search for information and how residents learn. Although many orthopaedic surgeons are users of artificial intelligence (AI), most are uncertain about how these tools actually work and why they sometimes give impressively accurate explanations alongside glaring factual errors and fabricated citations. This review provides an overview of the underlying preclinical studies behind large language models at the level of detail needed to empower orthopaedic surgeons with the knowledge needed to critically evaluate AI outputs, design future research projects, and effectively incorporate AI tools into clinical practice and resident education. Through clinical examples including a Schatzker VI tibial plateau fracture and an L4 pedicle screw sizing question, we illustrate two distinct classes of AI failure-retrieval failures and reasoning failures-and demonstrate how understanding the preclinical studies behind these errors equips surgeons to evaluate any AI tool regardless of where or how it runs.
OBJECTIVE: To gain insight into higher fracture risk in individuals with type 2 diabetes, we determined the association of type 2 diabetes glycemic status and severity with longitudinal changes in peripheral bone density and microarchitecture.
RESEARCH DESIGN AND METHODS: We conducted a longitudinal study of 769 participants from the Framingham Study who underwent high-resolution, peripheral, quantitative computed tomography (HR-pQCT) at the tibia and radius, in 2012-2016 and 2021-2023 (mean 8-year follow-up). Linear regression models estimated mean 8-year percent changes in bone measures, across indicators of diabetes severity, adjusting for age, sex, weight, and height.
RESULTS: The mean age was 67 ± 7 years, and 59% of participants were women. More than half (57%) were normoglycemic (fasting plasma glucose [FPG] <100 mg/dL, not on any treatment), 31% had prediabetes (100 ≤ FPG ≤125 mg/dL), and 12% had type 2 diabetes (FPG >125 mg/dL or on treatment). Adjusted mean percent changes in HR-pQCT bone measures were similar across diabetes severity, including glycemic status, use of diabetes medications, duration of diabetes, and HbA1c. For example, cortical volumetric bone mineral density at the radius changed by -1.50% (95% CI -2.43, -0.56) in type 2 diabetes and -1.96% (-2.53, -1.39), in prediabetes, compared with -2.42% (-2.86, -1.97) in normoglycemia (reference group; all P > 0.05).
CONCLUSIONS: The magnitude of peripheral bone loss over 8 years did not differ between individuals with type 2 diabetes and those with normoglycemia, suggesting that bone deterioration alone does not explain the higher fracture risk in older adults with type 2 diabetes. Future studies should address other contributors to skeletal fragility.
BACKGROUND: Patellar maltracking remains a notable cause of postoperative pain and dissatisfaction after total knee arthroplasty (TKA), often from femoral component internal rotation and trochlear groove (TG) malpositioning. Although the Coronal Plane Alignment of the Knee (CPAK) classification evaluates coronal alignment, it does not account for three-dimensional anatomy. As newer alignment philosophies like kinematic alignment (KA) gain traction, risk of patellar maltracking may increase, especially when using implants designed for mechanical alignment. This study evaluates TG orientation in axial and coronal planes after virtual KA-based placement of a standard femoral component in 85,604 patients undergoing primary TKA.
METHODS: We analyzed 85,604 CT scans of patients with arthritis. For each, we calculated CPAK classification, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), hip-knee-ankle (HKA) angle, and posterior condylar to transepicondylar axis (PCA to TEA). Using kinematic alignment principles, we virtually implanted a femoral component with a 6° lateral trochlear groove. The average quadriceps line of force (QLF), defined as 3.2° lateral to the femoral mechanical axis (FMA), was considered ideal for tracking. TG orientation was then measured relative to the QLF and the standard 6° reference point.
RESULTS: Mean values were as follows: LDFA 87.1°, MPTA 85.7°, HKA 176.7°, and PCA to TEA 3.2°. In the coronal plane, 41% had a TG medial to the QLF, and 9% of cases had a TG medial to the native MA. CPAK types 2 (74%), 3 (100%), and 6 (58%) showed the highest internal rotation and medial TG orientation. To achieve KA, approximately 30% of patients required >3° of internal rotation and valgus tilt and approximately 2% required >5°.
CONCLUSION: A large proportion of patients demonstrated TG malpositioning and excessive internal rotation when placing MA-designed implants in KA. This highlights the need for three-dimensional classification systems and alignment-specific designs or alignment guardrails to prevent implant malpositioning.
INTRODUCTION: Pregnancy during orthopedic surgery practice presents unique challenges related to family planning, workplace accommodations, occupational exposures, board certification requirements, and postpartum return to work. Despite increasing numbers of women entering orthopedic surgery, there remains a lack of centralized guidance addressing pregnancy-related considerations. The purpose of this review is to summarize current evidence, to provide practical recommendations for orthopedic surgeons navigating pregnancy during their career, and to guide practice partners and organizations on how to create a culture of support and belonging during this time frame.
METHODS: Available literature, professional society guidance, federal workplace regulations, and occupational safety data were reviewed. Key topics included advanced maternal age and fertility considerations, American Board of Orthopaedic Surgery (ABOS) certification accommodations, workplace disclosure and legal protections, occupational exposure to methyl methacrylate (MMA) and ionizing radiation, physical demands of orthopedic practice, postpartum support, parental leave, and breastfeeding accommodations.
RESULTS: Delayed childbearing associated with orthopedic training and career progression may contribute to increased rates of infertility and obstetric complications among female orthopedic surgeons. Federal protections, including the Pregnant Workers Fairness Act, Family and Medical Leave Act, and Equal Employment Opportunity Commission regulations, provide important frameworks for workplace accommodations. Contemporary evidence demonstrates that occupational exposure to MMA and radiation during orthopedic procedures remains below established safety thresholds when appropriate precautions are employed. Physical demands such as prolonged standing, heavy lifting, and extended work hours may warrant workplace modifications during pregnancy. Postpartum support, equitable parental leave policies, and access to lactation accommodations may improve surgeon well-being and facilitate successful return to clinical practice.
CONCLUSION: Pregnancy should be recognized as a normal life event rather than a barrier to success in orthopedic surgery. Evidence-based accommodations, occupational safety measures, supportive workplace policies, and equitable parental leave practices can promote maternal and infant health while supporting professional development. Normalizing pregnancy and postpartum support within orthopedic surgery is essential to fostering a more inclusive and sustainable workforce.
IMPORTANCE: The Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018 greatly expanded Veterans Affairs (VA) enrollees' access to non-VA (community care) services. Since then, community-based utilization has increased substantially, but the quality of noncardiac surgical procedures has not been compared in VA and community care facilities.
OBJECTIVE: To compare surgical outcomes among veterans at VA vs community care facilities.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used adjusted restricted mean survival time (RMST) to compare survival at 30, 90, and 365 days after carotid endarterectomy (CEA), cholecystectomy (CCY), primary total hip arthroplasty (THA), and primary total knee arthroplasty (TKA) among VA enrollees at VA and community care facilities between October 1, 2019, and July 31, 2024. Follow-up was completed July 31, 2025.
EXPOSURE: CEA, CCY, THA, and TKA performed at VA vs community care settings.
MAIN OUTCOMES AND MEASURES: Adjusted RMST at 30, 90, and 365 days.
RESULTS: A total of 215 542 unique surgical procedures-87 653 in VA-based and 127 889 in community-based facilities-were observed. The mean (SD) age of patients was 65.6 (11.7) years; 191 958 procedures (89.1%) were performed in male patients, and 94 105 (43.7%) were performed in patients who lived in rural or highly rural areas. Actuarial mortality rates were meaningfully higher for community-based CEA (30 days, 1.6% vs 0.9%; 90 days, 3.0% vs 2.0%; and 365 days, 8.5% vs 6.3%) and CCY (30 days, 1.4% vs 0.5%; 90 days, 2.6% vs 1.0%; and 365 days, 5.7% vs 2.8%) but similar for TKA (30 days, 0.1% vs 0.2%; 90 days, 0.4% vs 0.3%; and 365 days, 1.3% vs 1.2%) and THA (30 days, 0.3% vs 0.2%; 90 days, 0.7% vs 0.5%; and 365 days, 2.0% vs 1.7%). After CEA in a VA setting, adjusted survival times at 30 days increased by 0.12 (95% CI, 0.04-0.21) days; at 90 days, by 0.82 (95% CI, 0.45-1.19) days; and at 365 days, by 7.11 (95% CI, 4.71-9.51) days. After CCY in a VA setting, adjusted survival times at 30 days increased by 0.14 (95% CI, 0.11-0.18) days; at 90 days, by 0.82 (95% CI, 0.67-0.96) days; and at 365 days, by 6.20 (95% CI, 5.33-7.06) days. After THA in a VA setting, adjusted survival at 30 days increased by 0.002 (95% CI, -0.02 to 0.02) days; at 90 days, by 0.07 (95% CI, -0.02 to 0.16) days; and at 365 days, by 0.44 (95% CI, -0.17 to 1.05) days. After TKA in a VA setting, adjusted survival at 30 days increased by 0.004 (95% CI, -0.01 to 0.01) days; at 90 days, by 0.01 (95% CI, -0.04 to 0.04) days; and at 365 days, by 0.31 (95% CI, -0.03 to 0.65) days.
CONCLUSIONS AND RELEVANCE: In this cohort study, veterans who underwent surgery at community care vs VA facilities had significantly decreased survival times at 30, 90, and 365 days after CEA and CCY and similar survival times after THA and TKA. The reasons for these survival differences deserve further study.
IMPORTANCE: The VACTERL (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal defects, and limb defects) pattern of birth defects is a complex congenital condition with largely unknown causes. Studies suggest a link between in vitro fertilization (IVF) and birth defects, including VACTERL, but it remains unknown whether IVF has a unique association with VACTERL.
OBJECTIVE: To characterize the association between IVF and VACTERL.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 1 555 936 live births in 4 US States (Massachusetts, New York, North Carolina, and Texas) between January 1, 2004, and December 31, 2018. A total of 175 161 births were IVF conceived, and 1 380 775 naturally conceived children were selected as a 10:1 comparison group. Births were linked to IVF cycle data from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System. Data were analyzed from August 2 to October 30, 2025.
EXPOSURES: Method of conception (IVF vs natural) and IVF treatment parameter information.
MAIN OUTCOMES AND MEASURES: VACTERL, defined as 3 or more of the defects included in the pattern. Multivariable logistic regression models were used to estimate adjusted odds ratios and 95% CIs.
RESULTS: A total of 1 555 936 live births were included in the analysis (796 892 males [51.2%]). The naturally conceived group included 1 380 775 children; the IVF-conceived group, 175 161. Approximately half of children were male in both groups, while IVF-conceived children were more often born to older mothers and those with a higher educational level and were from multiple-gestation pregnancies. Two hundred children with VACTERL (41 IVF and 159 non-IVF) were identified. The prevalence of VACTERL among IVF-conceived births was 2.3 (95% CI, 1.7-3.2) per 10 000 live births. After adjusting for demographic, socioeconomic, and pregnancy-related factors, IVF conception was associated with increased odds of VACTERL (adjusted odds ratio, 1.86; 95% CI, 1.16-2.98).
CONCLUSIONS AND RELEVANCE: This population-based prospective cohort study identified an association of IVF with the multiple congenital anomaly pattern VACTERL. Although the absolute risk among live births remains low, these findings highlight the need for further investigations of child health outcomes by method of conception.
BACKGROUND: As the use of artificial intelligence (AI) and large language models (LLMs) is increasingly adopted into scientific writing, it is important to understand AI's ability to produce clear and accurate content that is on par with human-authored content in the field of orthopaedics, including orthopaedic oncology. The aim of this study was to compare a series of editorials written by orthopaedic oncologists with those written by a single LLM (ChatGPT 4.0) using a variety of quality metrics.
METHODS: Volunteer orthopaedic oncologists submitted a 3- to 4-paragraph persuasive editorial on a topic of their choice in the field of musculoskeletal oncology. ChatGPT 4.0 was then prompted to write a corresponding editorial for each topic. Each editorial was evaluated by two blinded peer reviewers and graded using a 25-point scale on the following quality metrics: content, clarity, grammar, persuasiveness, and creativity. The evaluators were also asked to indicate whether they believed the editorials were written by humans or by AI.
RESULTS: A total of 20 editorials were submitted by human authors and matched with 20 prompted AI editorials. No notable difference in average total quality score for human versus AI submissions was observed. AI-generated articles scored markedly higher in grammar, but there were no notable differences in any other quality metric. Reviewers correctly identified author type 59% of the time.
DISCUSSION: LLMs such as ChatGPT can generate editorial content in orthopaedic oncology that matches human-written quality, suggesting a potential supportive role for AI in scientific communication, with implications for authorship standards, editorial practices, and peer review.
INTRODUCTION: As robotic-assisted total knee arthroplasty (TKA) gains traction in revision procedures, the urgent need to investigate its effectiveness compared with manual methods becomes apparent.
METHODS: Data were retrospectively obtained from the TriNetX Collaborative Network. Revision TKA (rKA) cases were identified using CPT codes and categorized as manual or robotic assisted using ICD-10 procedure codes. Cohorts were balanced with 1:1 propensity score matching for demographics, comorbidities, and revision history. Complication rates were compared across follow-up using chi-square analysis.
RESULTS: An initial query identified 19,088 manual and 2,709 robotic-assisted rKA cases. After 1:1 propensity matching, 2,010 patients remained in each group. Robotic rKA had significantly lower mechanical implant‑related complications at 3 and 6 months (OR 1.67 and 1.66; P < 0.001) and lower early VTE, while PJI, readmission, and revision rates were not significantly different. Manual rKA showed higher opioid use at 0 to 3 months (OR 1.40, 95% CI, 1.14 to 1.71, P < 0.001) and 3 to 6 months (OR 1.28, 95% CI, 1.12 to 1.47, P < 0.001) and throughout the 3 years of follow-up.Throughout the follow-up period, patellar dislocation, wound infection, non‑implant-related complications, and transfusion did not differ. At 1 year, manual rKA had higher instability (OR 1.59; P = 0.001) and higher hazard of mechanical implant‑related complications (HR 1.52, 95% CI, 1.32 to 1.75; P = 0.049). Instability, loosening, and periprosthetic fracture remained higher at 2 to 3 years, and revision was significantly more frequent at 3 years (13.5% vs. 11.4%; OR 1.22, 95% CI, 1.02 to 1.46; P = 0.03).
DISCUSSION: Robotic-assisted rKA was associated with markedly lower mechanical implant‑related complications across early and midterm follow-up, including reduced rates of instability, aseptic loosening, periprosthetic fracture, VTE, and lower opioid requirements. Rates of PJI, readmission, and revision were largely comparable, although manual rKA demonstrated a markedly higher revision rate by 3 years. These findings suggest that robotic assistance may improve implant reliability and postoperative recovery, but prospective studies and cost-effectiveness analyses remain necessary.
IMPORTANCE: Antiretroviral therapy (ART), particularly regimens containing tenofovir alafenamide with dolutegravir or bictegravir, is associated with substantial weight gain, potentially exacerbating cardiometabolic risk in people with HIV.
OBJECTIVE: To determine whether a regimen with doravirine, lamivudine, and tenofovir disoproxil fumarate results in less weight gain than a regimen with dolutegravir, emtricitabine, and tenofovir alafenamide while maintaining noninferior viral suppression.
DESIGN, SETTING, AND PARTICIPANTS: Open-label, noninferiority randomized clinical trial including ART-naive adults (≥18 years of age) with an HIV RNA level greater than 500 copies/mL and no detectable baseline, high-level doravirine resistance. The study was conducted at 2 South African sites and individuals were recruited between October 2023 and March 2025. The final participant visit occurred in February 2026.
INTERVENTIONS: A once-daily regimen with 100 mg of doravirine, 300 mg of lamivudine, and 300 mg of tenofovir disoproxil fumarate (n = 299) or 50 mg of dolutegravir, 200 mg of emtricitabine, and 25 mg of tenofovir alafenamide (n = 301).
MAIN OUTCOMES AND MEASURES: The primary outcome was viral suppression (HIV RNA level <50 copies/mL) at week 48 (prespecified noninferiority margin of -10 percentage points). The key secondary outcomes included changes in body weight, treatment-associated effects on body composition, and safety and adverse events.
RESULTS: Among 600 participants, 597 (99.5%) were Black African, 413 (68.8%) were assigned female at birth, and the median age was 34 years (IQR, 28-41). At week 48, 266 participants (89.0%) in the doravirine, lamivudine, and tenofovir disoproxil fumarate group achieved viral suppression (HIV RNA level <50 copies/mL) vs 273 participants (90.7%) in the dolutegravir, emtricitabine, and tenofovir alafenamide group (between-group difference, -1.7 percentage points [95% CI, -6.6 to 3.1], meeting the prespecified noninferiority margin of -10 percentage points). The median weight gain was 3.0 kg in the doravirine, lamivudine, and tenofovir disoproxil fumarate group vs 5.0 kg in the dolutegravir, emtricitabine, and tenofovir alafenamide group (between-group difference, -2.0 kg [95% CI, -3.0 to -1.0 kg]; P < .001). Among participants in the doravirine, lamivudine, and tenofovir disoproxil fumarate group, the median change in hip bone mineral density (BMD) was -2.1% (IQR, -4.1% to -0.5%) and was -3.2% (IQR, -5.4% to -0.8%) for spine BMD vs -0.5% (IQR, -1.9% to 1.2%) for hip BMD and -1.3% (IQR, -3.2% to 0.8%) for spine BMD with dolutegravir, emtricitabine, and tenofovir alafenamide (P < .001 for each between-group comparison). Resistance to doravirine emerged among 7 of 9 participants experiencing virologic failure in the doravirine, lamivudine, and tenofovir disoproxil fumarate group. Of these 7 participants, 5 of 6 achieved viral suppression after switching to dolutegravir-based therapy and 1 was lost to follow-up. Serious adverse events and deaths (n = 2) were infrequent and not considered treatment-related.
CONCLUSIONS AND RELEVANCE: Among predominantly Black African adults initiating ART, a regimen with doravirine, lamivudine, and tenofovir disoproxil fumarate was noninferior to a regimen with dolutegravir, emtricitabine, and tenofovir alafenamide for 48-week viral suppression and was associated with less weight gain.
TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05924438.
BACKGROUND: High tibial osteotomy (HTO) is a joint-preserving procedure used to relieve pain and delay, or even eliminate, the need for total knee arthroplasty (TKA). The aim of this study was to quantify the incidence of TKA after HTO and identify risk factors associated with conversion.
METHODS: Patients undergoing HTO at a single academic center from 1996 to 2015 were identified using a validated deidentified synthetic data platform from real patient data, ensuring a minimum of 10 years of follow-up. Patients aged 18 years with procedural codes for HTO were included. The primary outcome was TKA incidence; the secondary outcome was time to TKA. A modified Poisson regression evaluated associations between TKA, age, and BMI among individuals with complete BMI data.
RESULTS: A total of 207 patients (mean age, 41.3 ± 11.2 years; 62.8% male) were identified. Mean follow-up was 17.8 ± 4.8 years. Overall, 20 patients (9.9%) underwent TKA. Those converting to TKA were significantly older at HTO (45.3 ± 6.1 vs. 40.9 ± 11.6 years; P = 0.009) and had higher BMI (35.7 ± 6.4 vs. 29.4 ± 5.2; P = 0.01). TKA incidence increased over time: 5.9% at 10 years, 10.8% at 15 years, and 22.0% at 20 years. Higher BMI was independently associated with increased TKA risk (RR = 1.13; 95% CI, 1.04 to 1.23; P = 0.004).
CONCLUSION: In this cohort with minimum 10-year follow-up, HTO demonstrated approximately a 90% knee survivorship at a mean of 17.8 years. Age and BMI at the time of HTO were associated with increased risk of TKA conversion and should be considered during patient counseling and selection.
Clinic days can be laborious and frustrating. Success starts with identifying the goals of clinic, developing a strategy for scheduling patients, preparing required items for each visit, and training all team members. The check-in experience sets the stage for the patient visit and can increase patient flow efficiency. Surgeons can influence patient perceptions by considering their attire, use of computers, and level of patient education. Preoperative and procedure visits require special planning and organization by the clinic team. Medical documentation can be onerous, but tools such as patient-completed history questionnaires and scribes can ease that burden. Closing out the visit thoughtfully can improve patient adherence to treatment plans and postvisit satisfaction. Preemptively preparing the team for common clinic obstacles such as late or disruptive patients and physician delays can minimize frustration. Physicians should take the lead in organizing the mechanics of clinic and training the entire clinic team. Doing so can create an enjoyable working environment for their staff and can transform clinic into an enjoyable and rewarding part of a surgeon's practice. The purpose of this article is to provide surgeons with guidance on the basics of clinic management to improve both clinic efficiency and enjoyment.
Our collective understanding of the pathogenesis, risk factors, and management of adjacent segment disease (ASD) following lumbar fusion has expanded markedly in recent years, necessitating an updated and comprehensive review. ASD is now recognized as a multifactorial process in which postoperative biomechanical changes accelerate degeneration, further amplified by predisposing genetic factors. Key risk factors have been identified and linked to increased rates of ASD, including elevated body mass index, preexisting degeneration at adjacent levels, and inadequate restoration of sagittal alignment, particularly pelvic incidence-lumbar lordosis mismatch. Innovative surgical techniques, including minimally invasive approaches and robotic-assisted instrumentation, have been increasingly used and researched over the past decade with the goal of reducing the incidence and progression of ASD, although long-term evidence remains mixed. Although these advancements are promising, it is important to evaluate their efficacy, limitations, indications, and contraindications using the most current available evidence. Finally, advances in diagnostic imaging and emerging biologic therapies represent a potential paradigm shift in our understanding of the pathogenesis and preventability of ASD.
OBJECTIVE: To quantify the excess risk of any fractures, major osteoporotic fractures (MOF), and hip fractures in type 1 diabetes (T1D) by age, stages of diabetic kidney disease (DKD), and sex, and to evaluate risk factors for fractures.
RESEARCH DESIGN AND METHODS: The study included 5,035 individuals from the Finnish Diabetic Nephropathy Study (FinnDiane) and 12,286 control individuals without diabetes. We assessed the standardized incidence ratios (SIRs) for fractures in individuals with T1D compared with control individuals. Cox regression analyses were conducted in individuals with T1D to identify potential factors associated with fractures.
RESULTS: SIR for any fracture was 2.15 (95% CI 2.06-2.25), 2.60 (2.41-2.79) for MOF, and 5.24 (4.55-6.02) for hip fracture. SIR of hip fracture was the highest in those aged 40-49 years, 8.13 (5.75-11.2). All age-groups after 10-19 years had excess fracture risk. The SIR of any fracture increased with the DKD stages; 2.54 (2.36-2.72) in individuals without albuminuria, 3.47 (3.02-3.98), in those with moderate albuminuria, 3.73 (3.27-4.25) in those with severe albuminuria, and 5.08 (4.16-6.16) in those with kidney failure. SIRs for MOF were 2.62 (2.34-2.93) in those without albuminuria, 3.84 (3.10-4.71) in those with moderate albuminuria, 4.53 (3.72-5.48) in those with severe albuminuria, and 5.85 (4.38-7.68) in those with kidney failure. Hypoglycemic coma episodes (hazard ratio 1.04 [1.01-1.07]) and HbA1c (1.11 [1.06-1.15]) were associated with risk of any fracture, and episodes of diabetic ketoacidosis were associated with risk of MOF (1.18 [1.11-1.25]) in T1D.
CONCLUSIONS: Findings suggest that fracture risk assessment may need to be considered earlier than currently recommended, especially among individuals with DKD.
BACKGROUND: Cup protrusion has been recognized as the most sensitive and specific radiological parameter to predict iliopsoas (IP) impingement after total hip arthroplasty (THA): it is a necessary but not sufficient factor. We aimed to investigate the following: (1) whether radiological differences exist between protruding cups associated with symptomatic IP impingement and asymptomatic ones; (2) which positional parameters correlate with symptomatic IP impingement in THA with cup protrusion.
METHODS: This retrospective case-control study included 35 noncemented THAs with CT-confirmed IP impingement (clinical, radiographic, and arthroscopic diagnosis) and 17 asymptomatic noncemented THAs with comparable protrusion and ≥5 years of follow-up. Postoperative CT scans were evaluated for cup protrusion in all planes, inclination, anteversion, cup tilt, femoral and acetabular offsets, eccentric reaming, leg length discrepancy (LLD), and stem antetorsion. Groups were comparable for age, sex, side, diagnosis, and protrusion magnitude.
RESULTS: Symptomatic hips showed markedly greater acetabular diameter mismatch (1.7 mm vs-1.8 mm; Cohen's d = 1.16), higher cup anteversion (19.8° vs 11.5°; d = 0.88), greater sagittal tilt (19.9° vs 11.2°; d = 0.81), and smaller LLD (1.4 vs 6.8 mm; d = 0.73). In the exploratory Firth penalized logistic regression model, acetabular diameter mismatch was the only variable associated with symptomatic IP impingement (OR 1.33, 95% CI, 1.09 to 2.26), whereas anteversion, tilt, and LLD did not retain independent associations.
CONCLUSION: Among THAs with comparable cup protrusion, cup oversizing showed the strongest and most consistent association with symptomatic IP impingement, whereas increased anteversion and sagittal tilt appeared to modulate the mechanical consequences of protrusion.
LEVEL OF EVIDENCE: Level of Evidence: III.
Mid-shaft clavicle fractures in the adult and postpubescent adolescent population are a common injury treated by orthopaedic surgeons. This injury has a notable burden of disease due to its prevalence, effect on the patient, and effect on the society through cost of treatment and time lost from social activity. Determining surgical and nonsurgical care for a clavicle fracture can represent a clinical challenge. To assist clinicians with this treatment decision, the American Academy of Orthopaedic Surgeons has developed and adopted an appropriate use criteria to recommend nonsurgical and surgical treatment based on a variety of patient and injury characteristics. These criteria are available online and through phone-based applications. This article aims to illustrate how the criteria may be applied in clinical practice.
RATIONALE: Hip osteoarthritis is a major public health issue. International treatment guidelines recommend exercise to manage symptoms. This is an update of a review first published in 2009 and last updated in 2014.
OBJECTIVES: To determine the effects of land-based exercise on pain, physical function, quality of life, participant-reported treatment success, study withdrawals, and adverse events in people with hip osteoarthritis.
SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and two trial registries from February 2013 (search date for last update) to 5 February 2025. We also checked reference lists for additional studies.
ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) of adults with hip osteoarthritis. Eligible comparisons were as follows. • Exercise versus attention control/placebo. • Exercise versus no treatment/usual care/limited education. • Exercise plus a co-intervention (A) versus the co-intervention (A) alone. We excluded perioperative exercise programmes; interventions involving vibration therapy, gait aids, or retraining; and studies that added unequal co-interventions in both groups or that compared only one form of exercise to another.
OUTCOMES: Our critical outcomes were pain, physical function, and quality of life. Our important outcomes were participant-reported treatment success, study withdrawals, and adverse events.
RISK OF BIAS: As this was a review update, we used the original Cochrane risk of bias tool (RoB 1).
SYNTHESIS METHODS: We used standard methodological procedures expected by Cochrane. We synthesised results for each outcome using random-effects meta-analysis where appropriate. We used the GRADE approach to assess certainty of evidence.
INCLUDED STUDIES: Eighteen studies (1368 participants) met our inclusion criteria. Two studies (123 participants) evaluated exercise versus attention control or placebo, 10 studies (494 participants) evaluated exercise versus no treatment/usual care/limited education, and seven studies (751 participants) evaluated exercise plus a co-intervention (A) versus the co-intervention (A) alone. One trial (210 participants) included two comparator categories. Most studies were small and unblinded.
SYNTHESIS OF RESULTS: We converted all continuous effect estimates from standardised mean differences to mean differences (MDs) on a scale of 0 to 100. For pain and physical function, a negative MD indicates an improvement, while for quality of life, a positive MD indicates an improvement. Pain, physical function, quality of life, and participant-reported treatment success were measured immediately after treatment, while study withdrawals and adverse events were recorded at the end of follow-up. Exercise versus attention control/placebo Exercise, compared to attention control/placebo, may have little to no effect on pain (MD -6.31 points, 95% confidence interval (CI) -12.98 to 0.35; 2 studies, 123 participants; low certainty). Exercise may improve physical function slightly (MD -7.44 points, 95% CI -13.86 to -1.01; 2 studies, 123 participants; low certainty). No studies reported quality of life or participant-reported treatment success. Exercise may have little to no effect on study withdrawals (relative risk (RR) 0.83, 95% CI 0.23 to 3.03; 1 study, 106 participants; low certainty). Exercise may increase the risk of adverse events, but the evidence is very uncertain (RR 8.00, 95% CI 1.13 to 56.79; 1 study, 18 participants; very low certainty). Exercise versus no treatment/usual care/limited education Exercise, compared to no treatment/usual care/limited education, probably reduces pain slightly (MD -7.19 points, 95% CI -10.70 to -3.68; 9 studies, 449 participants; moderate certainty) and probably improves physical function slightly (MD -8.79 points, 95% CI -12.00 to -5.41; 9 studies, 447 participants; moderate certainty); however, these improvements are unlikely to be clinically meaningful. Exercise probably has little to no effect on quality of life (MD 2.31 points, 95% CI -1.15 to 5.91; 6 studies, 279 participants; moderate certainty). Exercise may have little to no effect on participant-reported treatment success (RR 1.57, 95% CI 0.62 to 3.99; 2 studies, 69 participants; low certainty) or study withdrawals (RR 1.51, 95% CI 0.80 to 2.86; 7 studies, 404 participants; low certainty). Exercise may have little to no effect on adverse events, but the evidence is very uncertain (RR 2.95, 95% CI 0.62 to 13.96; 6 studies, 257 participants; very low certainty). Exercise plus a co-intervention (A) versus the co-intervention (A) alone Exercise plus a co-intervention (A), compared to the co-intervention (A) alone, probably has little to no effect on pain (MD -3.86 points, 95% CI -8.07 to 0.35; 7 studies, 751 participants; moderate certainty), physical function (MD -2.37 points, 95% CI -6.59 to 1.86; 7 studies, 751 participants; moderate certainty), or quality of life (MD 3.60 points, 95% CI -1.30 to 8.36; 4 studies, 456 participants; moderate certainty). Exercise may have little to no effect on participant-reported treatment success (RR 1.25, 95% CI 0.62 to 2.54; 2 studies, 399 participants; low certainty), and probably has little to no effect on study withdrawals (RR 0.85, 95% CI 0.55 to 1.32; 6 studies, 683 participants; moderate certainty). Exercise probably reduces the risk of adverse events slightly (RR 0.75, 95% CI 0.58 to 0.97; 6 studies, 731 participants; moderate certainty).
AUTHORS' CONCLUSIONS: Compared with attention control or placebo, exercise may have little to no effect on pain and may improve physical function slightly. There was no evidence for quality of life or participant-reported treatment success. Exercise may have little to no effect on withdrawals. Evidence regarding adverse events is very uncertain. Compared with no treatment, usual care or limited education, exercise probably improves pain and physical function slightly, although these effects are unlikely to be clinically meaningful. Exercise probably has little to no effect on quality of life and may have little to no effect on participant-reported treatment success or withdrawals. Evidence regarding adverse events is very uncertain. Exercise plus a co-intervention (A), compared to the co-intervention (A) alone, probably has little to no effect on pain, physical function, quality of life, and study withdrawals, and may have little to no effect on participant-reported treatment success. Exercise probably reduces the risk of adverse events slightly.
FUNDING: No funding.
REGISTRATION: The original protocol was for a review on exercise for osteoarthritis of the hip or knee (https://doi.org/10.1002/14651858.CD004376). The review on hip osteoarthritis alone was first published in 2009 (https://doi.org/10.1002/14651858.CD007912), and last updated in 2014 (https://doi.org/10.1002/14651858.CD007912.pub2).
INTRODUCTION: Limited range of motion (ROM) and arthrofibrosis are complications that affect approximately 1 to 13% of patients after primary total knee arthroplasty (TKA). Manipulation under anesthesia (MUA) is the preferred treatment when failure to achieve adequate ROM in the early postoperative period occurs. This study aims to identify predictors for MUA that may guide surgeons in preoperative risk stratification.
METHODS: The Premier Healthcare Database was queried to identify patients aged 18 years or older who underwent elective total knee arthroplasty. Patients who underwent manipulation under anesthesia within 90 days of index surgery were compared with patients who did not. Demographics, comorbidities, and medication usage were compared between cohorts using chi-squared and t-tests. Akaike information criterion and Bayesian information criterion minimization was done to create an optimal mixed-effects model to identify risk factors.
RESULTS: In total, 975,235 TKAs performed between 2015 and 2021 were identified. Of these, 1.55% (15,139) of patients required MUA. Patients in the MUA group were younger (62.47 ± 9.19 vs. 67.03 ± 9.24, P < 0.001) and more likely to be Black (15.91% vs. 8.29%, P < 0.001). Mixed-effects analysis revealed a decreased risk of MUA associated with perioperative dexamethasone (adjusted odds ratio [aOR] 0.925, 95% CI, 0.889-0.962, P < 0.001), daily prednisone usage (aOR 0.433, 95% CI, 0.347-0.542, P < 0.001), and angiotensin II receptor blockers (ARBs) (aOR 0.882, 95% CI, 0.840-0.927, P < 0.001).
DISCUSSION: Younger age, female sex, and Black race were associated with an increased risk of MUA after TKA, while perioperative dexamethasone, daily steroids, and ARB use were protective. These findings may serve to aid surgeons in preoperative risk stratification.
BACKGROUND: Both 2-octyl cyanoacrylate mesh dressings and chlorhexidine gluconate are independently associated with hypersensitivity. Residual chlorhexidine antiseptic trapped under an impermeable mesh dressing may synergistically contribute to skin reactions. We hypothesized that an enhanced washing protocol before dressing application would reduce the incidence of hypersensitivity. We secondarily compared delayed wound healing, infection, and sensitization from prior exposure with mesh dressings.
METHODS: This retrospective study reviewed 214 hip and knee arthroplasty patients receiving 2% chlorhexidine gluconate/70% isopropyl alcohol skin paint and a 2-octyl cyanoacrylate mesh dressing. The standard wash protocol (n = 138) informally wiped the skin prep with saline. The enhanced wash protocol (n = 76) thoroughly removed the skin prep with an isopropyl alcohol-soaked sponge followed by a saline soaked sponge. The chart was reviewed for hypersensitivity, wound healing, infection, and prior exposure.
RESULTS: The enhanced wash protocol was associated with a notable decrease in the rate of hypersensitivity from 14.5 to 2.6% (OR 0.16, 95% CI, [0.04-0.70]). The two reactions in the enhanced protocol occurred immediately and both subsequently revealed a history of adhesive allergy. More folliculitis was observed in the enhanced group (3.9 vs. 0%, P = 0.04). No differences were observed in delayed wound healing, superficial infection, or deep infection (P = 0.75, 0.53, and 1, respectively). Prior mesh exposure had no effect on hypersensitivity.
CONCLUSION: We observed that thorough removal of durable chlorhexidine paint was associated with a lower incidence of hypersensitivity after application of impermeable mesh dressings. The study findings support efforts to reduce chlorhexidine concentration on the skin before the application of dressings. In the absence of a prospective study, we recommend making this inexpensive and simple protocol change before application of a 2-octyl cyanoacrylate mesh dressing to surgical wounds.
BACKGROUND: Percutaneous kyphoplasty is routinely indicated in elderly patients with osteoporotic vertebral compression fractures (VCFs) who have failed conservative management. Although it can effectively stabilize the vertebra and alleviate pain, kyphoplasty has been associated with various complications, including pulmonary embolism and adjacent level fractures. However, there is a lack of consensus on whether office-based kyphoplasty is safer than inpatient or outpatient ambulatory surgery center (outpatient-ASC)-based kyphoplasty.
METHODS: PearlDiver was queried to identify adults undergoing percutaneous kyphoplasty for new age-related osteoporotic VCF between 2016 to 2022. Patients were stratified by service location (ie, inpatient, outpatient-ASC, outpatient office) and matched 1:1 by age, sex, and Charlson Comorbidity Index. Medical complications 90 days after the procedure were compared.
RESULTS: In total, 71,084 patients underwent kyphoplasty for osteoporotic VCFs between 2016 to 2022. The mean age was 74.3 years, 76.2% were female, and mean Charlson Comorbidity Index was 3.5. The proportion of annual kyphoplasty cases performed in the outpatient-office setting increased markedly from 21.7% in 2016 to 29.6% in 2022 ( P = 0.002). After matching, 11,340 patients remained in each cohort. Multivariate logistic regression analyses revealed that the inpatient cohort had the highest odds of acute kidney injury, cardiac arrest, deep vein thrombosis, pneumonia, transfusion, urinary tract infection, site complications, wound complications, and readmissions (all P < 0.004). Both the inpatient and the outpatient-ASC cohorts had higher odds of infection than the outpatient-office cohort ( P < 0.001). Finally, the outpatient-office cohort had the highest odds of nerve injury and secondary fractures ( P < 0.004).
DISCUSSION: In this retrospective cohort study of kyphoplasty performed for osteoporotic VCFs, office-based kyphoplasty procedures were observed to have a lower rate of medical complications compared with inpatient or outpatient-ASC-based kyphoplasty procedures. These findings suggest that office-based kyphoplasty may represent an appropriate treatment setting for carefully selected patients with osteoporotic VCFs.
AIMS: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for perioperative analgesia, but effect on bone healing remains controversial. This umbrella review and reconstructed meta-analysis assessed whether NSAIDs impair bone healing and how risk varies by population, fracture type, dose, and duration.
METHODS: We conducted an umbrella review of systematic reviews/meta-analyses and a reconstructed meta-analysis of primary studies (PRIOR/PRISMA-compliant; PubMed, EMBASE, Web of Science, and Scopus to 9 November 2025). Two reviewers independently screened, extracted, and assessed quality (AMSTAR-2) and risk of bias. Overlapping cohorts were removed, and random-effects models were applied. Prespecified subgroups included age, clinical context (traumatic vs elective procedures), bone type (long bones vs spine), dose, and exposure duration (≤14 days).
RESULTS: Sixteen reviews (10 meta-analyses, six systematic reviews) were included; most suggested that NSAIDs increase impaired bone healing risk, particularly with higher doses or prolonged use, with minimal signal for short, low-dose perioperative regimens, especially in spinal fusion. Quality was low/critically low. The meta-analysis pooled 38 primary studies. NSAID exposure was associated with higher nonunion risk (OR, 1.56, 95% CI, 1.18 to 2.11), but not clearly with delayed union (OR, 1.58, 95% CI, 0.65 to 3.67). Risk increased in adults (OR, 1.67, 95% CI, 1.25 to 2.47) but not in pediatric patients (OR 0.77, 95% CI 0.58 to 1.02), was higher in long-bone fractures than in spinal fusion, trended upward with higher doses, and was not elevated with short-term (≤14 days) use. Risk also differed by clinical context, higher in traumatic versus elective procedures.
CONCLUSIONS: NSAID-related impairment of bone healing seems dose and context-dependent, with clinically important risk particularly in adults, long-bone fractures, and higher dose regimens. Short-term use (≤14 days) was not associated with increased nonunion risk. Risk seemed higher in traumatic fractures than in elective procedures. These findings support caution in higher risk scenarios, suggesting that short-duration NSAID use may be safe when avoiding higher dose exposure.
Subchondral bone impaction at the level of the radial neck, usually present at the anterior or lateral quadrant, can be an associated feature in radial head fractures. Buttress plating principles suggest that subchondral zones of impaction are best supported by an implant positioned directly on the site of impaction to resist secondary collapse. The anatomical considerations limit the standard radial head plating technique to a narrow safe zone. Therefore, irrespective of the zone of impaction, the standard plating zone remains the same, which may not provide the best possible mechanical construct for radial head fractures where the zone of impaction lies outside the safe zone for plating. In this study, the authors present an alternate subchondral shelf plating technique performed through the zone of impaction. The technique involves supporting the disimpacted radial head using a bent mini-fragment plate that acts as a shelf along with supplemental fixation. The shelf plate remains extra-articular, recessed below the radial head and the proximal radioulnar joint, with scope for impingement-free fixation along the entire circumference of the radial head. The technique was used in 13 adult patients and yielded excellent outcomes. Radiological healing was achieved in all patients with maintenance of reduction. The mean Mayo Elbow Performance Score and the quick DASH score were 96.5 ± 6.5 and 4.9 ± 3.3, respectively, at a mean follow-up of 20 ± 8 months.
IMPORTANCE: More than 14.2 million people worldwide and 280 000 in the US experience a hip fracture each year. The median 1-year mortality rate after a hip fracture is 22% and approximately 42% to 71% of patients regain their prefracture level of basic activities of daily living within 6 months.
OBSERVATIONS: Hip fractures are classified as intracapsular or extracapsular and most commonly occur after a fall. Intracapsular hip fractures include femoral neck (34%) and femoral head (rare). Extracapsular fractures consist of intertrochanteric (48%) and subtrochanteric fractures (5.8%). In the US, between 2008 and 2017, hip fractures were associated with 1-year mortality rates of 26.9% among men and 18.5% among women. Older age is a major risk factor for hip fracture, with a hazard ratio of 1.35 (95% CI, 1.25-1.47) per 5-year increase in age. Women have higher incidence of hip fractures than men due to accelerated bone loss after menopause and higher incidence of falls. Other risk factors for hip fractures include low bone mineral density (bone density of 1 SD or below that of healthy young adults measured by dual-energy x-ray absorptiometry), prior fracture, and factors contributing to falls, such as weak muscles, poor visual acuity, and smoking. Surgery for hip fracture typically consists of hip joint replacement or hip joint stabilization, using embedded hardware (open reduction and internal fixation). Patients with hip fracture benefit from physical therapy and fall reduction strategies, such as muscle-strengthening exercises and modifying medications associated with increased fall risk, such as antidepressants, and should be treated with antiresorptive medications, such as bisphosphonates (alendronate, zoledronic acid) or denosumab to prevent subsequent fracture. To prevent a hip fracture, patients with vertebral osteoporosis at the spine may require anabolic therapy, such as teriparatide, abaloparatide, or romosozumab, before starting an antiresorptive. Hip fractures may lead to mobility limitations; declines in physical, emotional, and social functioning; and reduced health-related quality of life.
CONCLUSIONS AND RELEVANCE: Hip fractures are common among older people and are associated with a 1-year mortality rate of 22% and with reduced mobility and quality of life. Surgical repair for hip fracture typically consists of joint replacement or open reduction and internal fixation. Hip fracture treatment also includes physical therapy, fall reduction strategies, and medications to protect against fracture, such as bisphosphonates; denosumab; or anabolic drugs, such as parathyroid hormone analogues or romosozumab.
Severe acetabular bone loss and pelvic discontinuity in revision total hip arthroplasty present substantial reconstructive challenges, particularly when standard hemispherical cups, augments, or cages cannot achieve durable fixation or restore appropriate hip biomechanics. Custom pelvic implants (CPIs) are designed from patient-specific CT data and produced using additive manufacturing to create monoblock constructs that conform to bony defects and maximize fixation to remaining viable bone. This review summarizes the evolution of CPIs from early "triflange" devices to contemporary porous-coated, biomechanically optimized designs and outlines current nomenclature and indications. Key elements of preoperative evaluation, imaging protocols, and CT-based modeling are reviewed, along with implant design considerations including flange geometry, ischial fixation strategies, and screw trajectory planning. Surgical techniques for managing pelvic discontinuity are discussed with emphasis on achieving construct stability and promoting osseointegration. Published midterm to long-term outcomes demonstrate high implant survivorship, improved function, and low mechanical failure rates, with most revisions attributable to infection or instability. Economic analyses suggest CPIs are cost-comparable with other advanced reconstructive options while offering reliable fixation in complex cases. When applied with appropriate patient selection, careful design collaboration, and meticulous surgical execution, CPIs provide an effective and reproducible strategy for challenging acetabular reconstruction.
The design of fracture-resistant materials has long been hindered by the complexity of toughening mechanisms across multiple length scales. Mechanical metamaterials offer a promising platform to address this challenge, yet existing research has largely focused on passively characterizing fracture in conventional lattice architectures. Recent studies have demonstrated the potential of elastic instabilities to enhance functionalities in architected materials; however, their connection to fracture resistance remains unexplored. Here we demonstrate that fracture behaviours in mechanical metamaterials can be actively programmed by exploiting elastic instabilities, thereby bridging the two traditionally disconnected failure modes. Through a combination of experiments and simulations, we show that controlled manipulation of the inelastic zone size in pseudoplastic metamaterials enables a transition from intrinsic to extrinsic fracture behaviour, accompanied by up to a one-order-of-magnitude increase in fracture energy. This work represents a shift from passive observation to active control of fracture mechanics, establishing a new framework for designing metamaterials with tailored fracture resistance. Our findings not only advance the fundamental understanding of instability-fracture interactions in metamaterials but also suggest a broadly applicable route for programming fracture behaviours through instability design.
Ambulatory surgery centers (ASCs) have become a dominant site of orthopaedic procedural growth in the United States, with expanding indications that now include select total joint arthroplasty. Although clinical protocols have enabled safe outpatient care, ASC performance is frequently determined by nonclinical infrastructure. Surgeon-owned ASCs function as regulated financial entities governed by operating agreements and a layered contract architecture that directly influences reimbursement integrity, fixed overhead exposure, throughput reliability, compliance risk, and long-term equity value. Operating agreements define governance authority, ownership rights, capital obligations, profit distribution, dispute resolution, and buy-sell valuation methodology. Managed care contracts establish procedure-level revenue feasibility, including implant reimbursement structure, denial and recoupment risk, audit exposure, and escalation provisions. Lease agreements represent the largest fixed liability and may determine survivability during reimbursement contraction. Equipment, purchasing, anesthesia, and staffing agreements further shape operational capacity and cost control, while revenue cycle and information technology contracts influence collections performance and cybersecurity vulnerability. This review provides a structured, surgeon-focused framework for evaluating ASC contract domains, emphasizing negotiation priorities, implementation strategy, and regulatory safeguards. A disciplined approach to ASC contracting is essential to preserve autonomy, protect margins, and sustain long-term enterprise value in an increasingly outpatient-driven orthopaedic economy.
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of methotrexate for people with osteoarthritis of the hand.
OBJECTIVE: The study aims to determine the outcome of the new technique in terms of the correction rates in comparison to results reported in the literature for the standard procedure.
METHODS: A prospective study was conducted between September 2017 to August 2025 on 53 feet in 41 children who developed dynamic supination after a complete initial correction with the Ponseti technique. Preoperative and postoperative functional assessments were done independently by two senior orthopaedic consultants using standardized gait evaluation and the Laaveg-Ponseti functional score. Follow-up ranged from 20 to 61 months.
RESULTS: Initial correction was achieved in 49 feet, whereas four feet demonstrated postoperative residual dynamic supination; out of these, three resolved with physiotherapy, whereas one foot required surgical intervention. Another four feet (7.5%) developed deformity recurrence later in follow-up; one corrected with physiotherapy, whereas three required surgical management. The final overall success rate of the procedure was 88.7% after excluding the resistant, recurrent, and overcorrected cases that needed surgical correction. Preoperative Laaveg-Ponseti scores improved markedly to exclusively good or excellent at the final follow-up (P < 0.001).
CONCLUSION: Tibialis anterior transfer to the peroneus brevis can be performed in children, as it does not require lateral cuneiform ossification. This modification is a practical and effective alternative to the standard technique.
BACKGROUND: Aspirin after an initial short course of rivaroxaban has been shown to be safe and effective for the prevention of venous thromboembolism after total hip or total knee arthroplasty, but uncertainty remains about the use of aspirin alone.
METHODS: In this multicenter, double-blind, randomized, controlled trial, we assigned patients to receive once-daily thromboprophylaxis with either 81 mg of aspirin or 10 mg of oral rivaroxaban for the first 5 days after total hip or total knee arthroplasty. All the patients then received further thromboprophylaxis with 81 mg of aspirin daily for 9 additional days after knee arthroplasty and for 30 additional days after hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism, which consisted of either proximal deep-vein thrombosis or pulmonary embolism (primary effectiveness outcome), and for bleeding complications (primary safety outcome). The noninferiority margin for aspirin alone as compared with rivaroxaban-aspirin was 0.7 percentage points.
RESULTS: A total of 5429 patients underwent randomization. Venous thromboembolism developed in 13 of 2718 patients (0.48%) in the aspirin-alone group and in 12 of 2647 patients (0.45%) in the rivaroxaban-aspirin group (risk difference, 0.02 percentage points; 95% confidence interval [CI], -0.34 to 0.39; P<0.001 for noninferiority). Major bleeding or clinically relevant nonmajor bleeding events occurred in 45 of 2718 patients (1.66%) in the aspirin-alone group and in 54 of 2647 patients (2.04%) in the rivaroxaban-aspirin group (risk difference, -0.38%; 95% CI, -1.11 to 0.34).
CONCLUSIONS: After total hip and total knee arthroplasty, the use of aspirin alone was not inferior to a strategy of using rivaroxaban followed by aspirin for the prevention of symptomatic venous thromboembolism, with no clinically relevant difference in bleeding events. (Funded by the Canadian Institutes of Health Research; EPCAT III ClinicalTrials.gov number, NCT04075240.).
INTRODUCTION: Pilon fractures are high-energy injuries with substantial soft-tissue compromise and risk of impaired healing, sometimes necessitating revision surgery to promote bone healing (RPBH). The aim of this study was to identify factors associated with RPBH after surgical fixation of pilon fractures.
METHODS: A retrospective cohort study was conducted at a single Level I trauma center (2014 to 2019). Adult patients who underwent surgical fixation of pilon fractures (AO/OTA 43) were included; those with less than 6 months of follow-up or amputation before definitive fixation were excluded. Demographic, injury, surgical, and postoperative characteristics were compared between patients with and without RPBH. Statistical significance was defined as P < 0.05.
RESULTS: Of 349 patients included, 48 (13.8%) required RPBH. The mean age was 46.0 years, and 54.4% were male. Patients requiring RPBH more frequently sustained open fractures (50.0% vs. 24.6%, P = 0.001) and had higher BMI (32.2 vs. 28.5 kg/m 2 , P = 0.005). Bone grafting (25.0% vs. 4.7%), skin grafting (14.6% vs. 4.7%), and flap coverage (12.5% vs. 2.3%) were more common among patients with RPBH (all P < 0.001). Plate fixation overlapping external fixator pin sites occurred more frequently in the RPBH group (35.4% vs. 18.3%, P < 0.001), whereas medial column fixation was less common (43.8% vs. 69.1%, P < 0.001). Fracture-related infection (FRI) was the strongest independent predictor of RPBH (OR = 11.17, 95% CI 4.33 to 28.81, P < 0.001), while medial column fixation was associated with reduced odds (OR = 0.41, 95% CI 0.19 to 0.89, P = 0.024).
CONCLUSION: One in seven patients required revision surgery to promote bone healing after pilon fracture fixation. FRI emerged as the strongest independent predictor of RPBH, while medial column fixation as part of the overall fixation construct was associated with reduced odds of RPBH. Although plate-pin site overlap was more common among patients with RPBH, it was not independently associated after controlling for FRI. Strategies to optimize medial stability and minimize infection risk may improve healing outcomes.
Orthopaedic surgeons are in a unique position to recognize and solve unmet needs in musculoskeletal health. However, the process of innovation in the marketplace is typically taught in business schools rather than in medical schools and residency/fellowship training programs. There is a required base of knowledge, and there are numerous challenges to overcome. Up to 90% of MedTech startup companies fail for a host of reasons. Our study builds on a related 2019 publication in the Journal of the American Academy of Orthopaedic Surgeons and provides a roadmap for innovators in medical devices and related software (a.k.a. MedTech) who want to pursue and market a solution to an unmet need. For all orthopaedic surgeons, an understanding of the MedTech startup process can be useful in gauging the value of newly marketed musculoskeletal devices.
Mentorship and faculty advocacy have long been recognized as key drivers of succeeding in the orthopaedic surgery residency match. However, some attendings, particularly those who may be unfamiliar with current trends, often lack clear guidance on how to advocate effectively for students during the orthopaedic surgery residency application process. Orthopaedics is unique in that it is highly competitive, with increasingly limited positions, a strong emphasis on away rotations, and recent implementation of preference signaling. The purpose of this review article was to (1) examine the evolution of advocacy in orthopaedic surgery during the residency application process and (2) discuss safe, effective, and ethical strategies that attendings can use to advocate for medical students applying into orthopaedic surgery.
INTRODUCTION: Social media has become an important tool for medical education and residency recruitment; however, its utilization among orthopaedic trauma fellowship programs remains unclear. The objective of this study was to evaluate the prevalence, activity, and characteristics of social media utilization among orthopaedic trauma fellowship programs.
METHODS: A list of accredited orthopaedic trauma fellowship programs were obtained from the Orthopaedic Trauma Association website. Fellowship-specific social media on Facebook, Twitter (X), Instagram, and LinkedIn were identified using systematic Google and platform-specific searches conducted between August and September 2025. Identified accounts were evaluated for platform type, activity status, content characteristics, and engagement metrics.
RESULTS: Of 68 orthopaedic trauma fellowship programs identified, 6 (9%) maintained a fellowship-specific social media account. Five programs (7%) had Instagram accounts, and one program (1%) had a Twitter/X account; no accounts were identified on Facebook or LinkedIn. Three (60%) of the Instagram accounts identified were active within the past month, representing 4% of all accredited orthopaedic trauma fellowship programs. Engagement among active Instagram accounts was substantial, with total likes exceeding 4,000 for regularly posting programs, average likes per post ranging from approximately 380 to 442, and consistent comment activity. All Instagram accounts shared deidentified case-based content, whereas none provided fellowship recruitment or application-specific information.
CONCLUSION: Fellowship-specific social media use among orthopaedic trauma fellowship programs is uncommon and inconsistently maintained. Leveraging this untapped resource could expand program visibility, offer applicants meaningful insight into case complexity, training experiences, and strengthen recruitment in an increasingly competitive subspecialty.
BACKGROUND: Socioeconomic disparities are a critical risk factor for poor health outcomes yet remain under investigated in the context of developmental dysplasia of the hip (DDH). Childhood Opportunity Index (COI) 3.0 is a composite index of socioeconomic resources available to a child. Few studies have leveraged COI to investigate social determinants of health and outcomes of DDH.
METHODS: A retrospective review of patients younger than 9 months who presented with ultrasonographic evidence of DDH and treated with a Pavlik harness from January 1, 2016, to July 1, 2023, at a single tertiary care orthopaedic hospital was conducted. Participants were stratified by high and low opportunity using nationally normed COI 3.0 quintiles. Demographic data, clinical presentation, and treatment outcomes were compared.
RESULTS: Two hundred eighty-seven patients with DDH treated with Pavlik harness were included; 194 and 93 patients were included in the high-COI and low-COI groups, respectively. Age at Pavlik harness initiation was not different between the low-COI (29.2 days ± 35.0) and high-COI groups (31.2 days ± 36.0, P = 0.66), nor was the proportion of patients presenting with bilateral DDH (63% versus 57%, respectively, P = 0.37). Per hip analysis demonstrated no difference in alpha angle at presentation between the low-COI (54.1° ± 6.7) and high-COI groups (53.6° ± 8.2, P = 0.54) or the percentage of dislocated hips (8% per group, P = > 0.99). The proportion of patients requiring rigid abduction orthosis after harness treatment was not different between the low-COI (18%) and high-COI groups (21%, P = 0.64) nor was the proportion of patients requiring surgical intervention (10% and 9%, respectively).
CONCLUSION: At a tertiary care, urban orthopaedic hospital, lower childhood opportunity index (COI) was not associated with age or severity of DDH at presentation, nor success in Pavlik harness treatment, aligning with our current understanding of DDH and COI. Despite racial and ethnic differences between high-COI and low-COI groups, individual patient outcomes remained similar.
Direct anterior approach (DAA) total hip arthroplasty has seen increased adoption in the United States, although utilization varies globally with posterior approaches remaining prevalent in many regions. The muscle-sparing interval and potential for early functional recovery have contributed to its use; however, DAA introduces distinct technical challenges, particularly with femoral exposure and implant positioning. Intraoperative fractures, although relatively uncommon, represent a clinically important complication affecting both the acetabulum and the femur. Effective management requires early recognition, careful assessment of implant stability, and a structured, approach-specific decision-making strategy. Stable constructs may be managed with observation or supplemental fixation, whereas unstable implants often require revision techniques, extensile exposure, or alternative surgical approaches. This review outlines DAA-specific risk factors, mechanisms of injury, and evidence-based management strategies for intraoperative acetabular and femoral fractures, with emphasis on practical intraoperative decision making to restore stability and optimize outcomes.
INTRODUCTION: The purpose of this study was to assess whether patients can accurately predict and perceive their pain using an objective test. The authors hypothesized that sports medicine patients would demonstrate the ability to predict their pain tolerance.
METHODS: Two hundred two patients receiving care from a single surgeon at an academic medical center consented to participate in this study. Exclusion criteria included non-English speaking subjects and those younger than 18 years. Subjects were administered a survey and a pain tolerance threshold test using the "OUCH Test" by a research assistant in an examination room during their clinical encounter. The "OUCH Test" is an instrument for predictive pain tolerance, with higher levels indicating higher pain tolerance.
RESULTS: One hundred ninety patients (94%) reached the highest level of the "OUCH Test." One hundred sixteen patients (57%) reported that they had reached a higher level on the device than they initially predicted. The correlation between actual and predicted level reached on the "OUCH Test" device was significant (r = 0.344 confidence interval, 0.217-0.461; P < 0.001). No notable differences were observed in "OUCH Test" results when comparing male and female patients, smokers and nonsmokers, Worker's Compensation patients, or patients who used pain medication in the 24 hours before their clinic visit.
DISCUSSION: This study demonstrates that sports medicine patients can predict and perceive their pain tolerance with relative accuracy, offering a valuable tool for optimizing clinical decision making.
LEVEL OF EVIDENCE: II-Prospective Cohort Study.
AIMS: The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) reported no notable difference in functional outcomes between surgical fixation and cast immobilization for minimally displaced scaphoid waist fractures in UK settings. We aimed to emulate SWIFFT using Chinese hospital electronic health record (EHR) data to evaluate whether similar treatment effects are observed in a population with different risk profiles and to identify subgroups that may benefit differentially from surgery.
METHODS: This target trial emulation used a clone-censor-weight design with inverse probability of treatment and censoring weighting. Deidentified EHR data were extracted from three Tertiary A teaching hospitals in China (July 2018 to August 2024). Adults aged 16 years or older with a bicortical scaphoid waist fracture (displacement ≤2 mm) presenting within 14 days of injury were eligible. Patients received either headless compression screw fixation (n = 2,544) or below-elbow cast immobilization (n = 4,225). The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 52 weeks.
RESULTS: Among 6,769 patients (mean age 32.1 years; 81.6% male; 42.4% current smokers), surgery produced statistically significant DASH improvements at all time points. At 52 weeks, the adjusted mean difference was -4.2 (95% CI, -4.9 to -3.5; P < 0.001), below commonly cited MCID estimates (10 to 15 points) but approaching lower proposed thresholds (7 to 10 points). Surgery halved nonunion risk (8.4% vs 17.5%; RR 0.48, 95% CI, 0.41 to 0.55) but increased complications sevenfold (14.1% vs 2.0%), predominantly screw-related. Subgroup analyses showed larger surgical benefits among patients with displaced fractures (-8.5) and current smokers (-6.7). Nearly one in five cast-treated patients (18.1%) ultimately required surgery for nonunion.
CONCLUSION: Surgery was associated with statistically significant but modest DASH improvements, halved nonunion risk, and a sevenfold increase in complications. Cast immobilization remains a reasonable initial strategy for undisplaced fractures, while surgery offers measurable advantages for displaced fractures or smokers.
IMPORTANCE: Aromatase inhibitors (AIs) profoundly suppress estrogen synthesis and accelerate bone loss in postmenopausal women with early breast cancer (EBC). Although body mass index (BMI)-defined obesity has been considered protective for skeletal health, emerging evidence suggests a paradoxical association with fracture risk.
OBJECTIVE: To evaluate whether fat mass percentage (FM%) greater than 40.8%, measured by dual-energy x-ray absorptiometry (DXA), is associated with vertebral fracture (VF) progression in patients with EBC receiving AIs.
DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective cohort study included consecutive postmenopausal women with EBC (stages I-III) recruited in a single referral center between September 2014 and June 2024. All patients received adjuvant endocrine therapy and underwent serial DXA assessments. Patients treated with tamoxifen or with major comorbidities affecting skeletal fragility were excluded.
EXPOSURES: Body composition and bone fragility parameters evaluated by DXA at baseline and at 18, 24, and 30 months.
MAIN OUTCOMES AND MEASURES: Adiposity excess was defined as FM% greater than 40.8%, and VF progression was defined as new incident fractures and/or worsening by at least 1 Genant grade at a previously fractured vertebral level. Their association was evaluated using a joint model; time-dependent associations were evaluated using extended Cox regression. Secondary analyses explored associations with bone mineral density, trabecular bone score (TBS), appendicular lean mass index (ALMI), and traditional fracture risk factors.
RESULTS: A total of 769 White women (median [range] age, 63 [30-87] years; median [range] BMI, 24.6 [15.6-46.1]) entered the study. During follow-up, 69 patients (9.0%) experienced VF progression. FM% greater than 40.8% was independently associated with increased VF progression (adjusted hazard ratio [HR], 2.00; 95% CI, 1.44-2.82; P < .001). Higher ALMI (HR, 0.38; 95% CI, 0.22-0.65; P < .001) and BMD (HR, 0.79; 95% CI, 0.66-0.94; P = .01) were associated with lower risk of VF progression.
CONCLUSIONS AND RELEVANCE: In this retrospective cohort study of patients with EBC receiving AIs, adiposity excess was identified as a novel fracture risk factor, whereas higher muscle mass was protective. These findings support incorporating body-composition assessment into fracture-risk evaluation and preventive strategies for patients undergoing AI therapy.
IMPORTANCE: Obesity, type 2 diabetes (T2D), and weight loss are associated with increased fragility fracture risk. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are widely prescribed, yet their effects on skeletal outcomes remain uncertain.
OBJECTIVE: To evaluate the association between GLP-1 RA initiation and 3-year fragility fracture risk compared with dipeptidyl peptidase-4 inhibitor (DPP-4i) initiation among adults with T2D.
DESIGN, SETTING, AND PARTICIPANTS: This comparative effectiveness study using retrospective target trial emulation examined data from the TriNetX Research Network (January 1, 2015, to December 31, 2022), a multicenter US electronic health record database. Adults aged 50 to 90 years with T2D who newly initiated a GLP-1 RA or DPP-4i were followed up for up to 3 years. A separate cohort stratified by T2D status was also analyzed. The database was queried on January 26, 2026, to generate a line-level analytic dataset.
EXPOSURES: Initiation of GLP-1 RAs vs DPP-4is.
MAIN OUTCOMES AND MEASURES: The primary outcome was incident fragility fracture, defined as fractures after low-energy trauma (eg, fall from standing height). Cohorts were propensity score matched. Time-varying mediation analyses were used to evaluate the contribution of changes in body mass index and hemoglobin A1c.
RESULTS: After matching, 133 606 patients (66 803 per group; GLP-1 RA vs DPP-4i: mean [SD] age 63.2 [8.1] vs 63.8 [8.5] years; 35 195 [52.7%] vs 36 098 [54.0%] male) were included. Initiation of GLP-1 RA was associated with lower fragility fracture risk compared with DPP-4i initiation (hazard ratio [HR], 0.79 [95% CI, 0.76-0.83]; absolute risk reduction, 0.79% [95% CI, 0.60%-0.99%]; number needed to treat, 126 [95% CI, 101-168]). The largest risk reductions were observed with vertebral (HR, 0.68 [95% CI, 0.63-0.73]) and hip or femur (HR, 0.70 [95% CI, 0.63-0.79]) fractures. In a sensitivity analysis stratified by diabetes status, fracture risk reduction was observed among patients with T2D (HR, 0.91 [95% CI, 0.88-0.95]) but not among those without T2D (HR, 1.13 [95% CI, 1.04-1.23]; interaction P < .001). Mediation analyses showed that the direct association between GLP-1 RA use and lower fracture risk persisted (HR, 0.81 [95% CI, 0.76-0.86]).
CONCLUSIONS AND RELEVANCE: This target trial emulation study of adults with T2D found that initiation of a GLP-1 RA was associated with lower 3-year fragility fracture risk compared with initiation of a DPP-4i, independent of changes in body mass index and hemoglobin A1c. Prospective studies are needed to establish causality and define long-term skeletal effects.
IMPORTANCE: Oxycodone and hydrocodone are the most frequently prescribed opioids for postoperative joint arthroplasty pain, yet comparative effectiveness data remain limited.
OBJECTIVE: To compare postoperative pain outcomes and opioid consumption for hydrocodone vs oxycodone among patients undergoing elective joint arthroplasty.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a preplanned secondary analysis of a randomized clinical trial conducted among cytochrome P450 2D6 (CYP2D6) normal metabolizers (NMs) who underwent elective joint arthroplasty in 5 US surgery clinical sites from March 2021 to September 2023 and received hydrocodone or oxycodone postoperatively. Follow-up concluded in March 2024. Data analysis was conducted from October 2024 to December 2025.
EXPOSURE: Postoperative analgesia with hydrocodone or oxycodone within a multimodal pain management approach (opioids and nonopioids).
MAIN OUTCOMES AND MEASURES: Coprimary outcomes were composite pain score at postoperative day 10 (sum of current, worst, and mean pain over 7 days; range 3-15) and cumulative morphine milligram equivalents (MMEs) over 10 days. Secondary outcomes included mobility scores at day 10 and Patient-Reported Outcomes Measurement Information System anxiety and depression scores at day 30. Multivariable regressions were adjusted for demographic and clinical covariates.
RESULTS: Among 663 participants (mean [SD] age, 66 [10.6] years; 384 [57.9%] female), 217 received oxycodone and 446 received hydrocodone. Hydrocodone was associated with significantly lower composite pain scores compared with oxycodone (mean [SD], 9.0 [2.0] vs 9.3 [2.2]; adjusted P = .001) and significantly lower cumulative MME (mean [SD], 93.5 [159.3] vs 154.5 [121.6]; adjusted P < .001). Secondary outcomes did not differ between groups (mobility score: mean [SD], 26.3 [10.4] vs 30.9 [14.7]; P = .29; anxiety score: mean [SD], 45.4 [8.3] vs 45.5 [8.7]; P = .31; depression score: mean [SD], 43.8 [7.8] vs 44.0 [7.9]; P = .97). Findings were consistent in sensitivity analyses, restricting to opioid and acetaminophen combinations, restricting to sites prescribing both opioids, and in subgroups of knee arthroplasty, but not consistent in hip arthroplasty.
CONCLUSIONS AND RELEVANCE: In this cohort study of CYP2D6 NMs undergoing joint arthroplasty, within multimodal analgesia, hydrocodone provided comparable pain control to oxycodone with significantly lower opioid exposure, supporting its use as a viable and possibly preferable analgesic option.
IMPORTANCE: High-quality evidence guiding opioid prescribing decisions for acute pain across common diagnoses is lacking.
OBJECTIVE: To describe pain trajectories and patterns of opioid and nonopioid treatment use among individuals who were offered opioids for the treatment of acute pain.
DESIGN, SETTING, AND PARTICIPANTS: This was a prospective cohort study of patients recruited from 5 US health systems between September 2020 and March 2023 in emergency departments (EDs), primary care clinics, dental practices, or after cesarean delivery or knee replacement. Eligible patients were opioid-naive adults aged 18 years or older at all study sites, as well as adolescents aged 15 to17 years undergoing impacted molar extraction at 1 site, who were offered an opioid prescription for acute pain. Analysis was conducted April 2023 through February 2026.
EXPOSURE: Offer of a prescription for an opioid analgesic.
MAIN OUTCOMES AND MEASURES: Time to pain resolution (3 consecutive reports of no pain), patterns of opioid and nonopioid treatment use, and opioid-related adverse effects, ascertained from digital questionnaires.
RESULTS: Among 1708 enrolled patients (median age, 38 years [IQR, 28-52 years]; 615 [36.0%] reporting race or ethnicity underrepresented in studies of acute pain management) followed up for 180 days, 915 (53.6%) were recruited in EDs, 307 (18.0%) in primary or urgent care, 263 (15.4%) in dental settings, and 223 (13.1%) in inpatient settings. Pain sources included dental (302 patients [17.7%]), trauma or injury (302 [17.7%]), obstetric (176 [10.3%]), musculoskeletal (131 [7.7%]), and low back (100 [5.9%]). Among 1502 patients reporting pain level at least once, median time to pain resolution irrespective of the treatment approach was 20 days (IQR, 8-88 days), with longer durations for surgical pain (74 days [IQR, 30 days to not reached]) and low back pain (69 days [IQR, 18 days to not reached]). The median time to opioid discontinuation among 1189 patients (69.6%) who reported any opioid use was 7 days (IQR, 2-31 days); an estimated 10.0% (95% CI, 7.7%-12.7%) of patients used opioids for at least 90 days, with higher rates in people reporting frequent pain before enrollment. Of 1482 patients (86.8%) completing at least 1 survey during the first 2 weeks of follow-up, 1153 (77.8%) reported using any opioids and 1287 (86.8%) reported using acetaminophen or ibuprofen. Among 619 (52.1%) patients with any opioid use who reported the dose of opioids taken in the first 15 days, daily doses were low (median, 10 [IQR, 5-15] morphine milligram equivalents). Most respondents reported leftover opioids (657 of 982 responding [66.9%]).
CONCLUSIONS AND RELEVANCE: In this cohort study of opioid-naive patients with acute pain, opioid use was generally low dose and of short duration, although some patients reported prolonged opioid use; most reported achieving pain resolution within 3 weeks, with longer times for surgical and low back pain. The findings suggest current guidelines for multimodal treatment and for short-duration opioid prescriptions if needed will serve many but not all patients, and treatment should be tailored to address individual patients' needs.
PURPOSE: To evaluate the effect of baseline dementia on postoperative outcomes in hip fracture patients undergoing hemiarthroplasty.
METHODS: A retrospective review was conducted of patients aged 55 years or older who underwent hemiarthroplasty for displaced femoral neck fracture (AO/OTA 31B) between 2012 and 2024 at a large urban academic institution. Dementia was identified by ICD-10 codes and confirmed by chart review. A 3:1 propensity score matched cohort was created using the Score for Trauma Triage in Geriatric and Middle-aged (STTGMA). Demographics and baseline characteristics were compared to ensure similarity. Outcomes included total complications, major and minor complications, periprosthetic dislocation, length of stay, ICU admission, discharge location, 30- and 90-day readmission, revision surgery, inpatient, and 30-day and 1-year mortality.
RESULTS: A total of 1,030 patients were included, with 241 patients with dementia and 839 controls. After 3:1 STTGMA propensity matching, baseline characteristics were comparable (mean age 82.75 vs. 83.0 years, P = 0.065; Charlson Comorbidity Index 1.96 vs. 1.92, P = 0.42; STTGMA 0.022 vs. 0.020, P = 0.50). Patients with dementia had increased major complications (17.92% vs. 10.93%, P = 0.013), including sepsis (5.00% vs. 2.21%, P = 0.027), urinary tract infections (13.33% vs. 6.78%, P = 0.002), and hip hemiarthroplasty dislocations (6.25% vs. 2.21%, P = 0.002). Patients with dementia also had longer length of stay (7.84 ± 5.83 vs. 6.80 ± 2.24 days, P = 0.030), increased 30-day readmissions (15.83% vs. 8.85%, P < 0.001), increased 90-day readmission (20.00% vs. 11.76%, P < 0.001), and higher 1-year mortality (16.25% vs. 8.02%, P < 0.001). No differences were observed in pneumonia, stroke, myocardial infarction, cardiac arrest, venothromboembolism, acute kidney injury, anemia, and revision surgery.
CONCLUSION: Dementia was associated with increased major complications, hip hemiarthroplasty dislocations, higher readmission, and mortality after hemiarthroplasty. These findings highlight the need for targeted perioperative planning and multidisciplinary care pathways in cognitively impaired patients.
Complex extremity wounds, if not addressed properly, are a leading cause of major limb amputation. Chronic wounds in salvaged extremities contribute to long-term morbidity in the extremity. Orthoplastic surgery treats limb-threatening conditions through the combined application of orthopaedic and plastic surgical principles, applied to clinical problems simultaneously. Key components include early stakeholder evaluation of the limb and patient and open collaborative communication between orthopaedic and plastic surgeons. Meticulous débridement at the time of presentation and careful selection of fixation informed by the overall reconstructive plan should be executed when the patient presents to the emergency department. Implementation of Orthoplastic protocols results in quicker time to skeletal stabilization and soft tissue coverage, reduced risk of infection, improved functional outcomes, and less cost for care. This review presents a protocol-driven guide for establishing an Orthoplastic program and optimizing limb salvage outcomes across diverse practice settings.
BACKGROUND: Frailty measures have become increasingly common in the literature as proposed mechanisms for identifying patients at risk of adverse postoperative outcomes. Prophylactic femur fixation in patients with metastatic disease can prevent future fracture and improve quality of life; however, these patients are inherently high-risk surgical candidates. The role of this study is to characterize the relationship between frailty and postoperative outcomes in patients undergoing prophylactic femoral fixation (ProphFF) and compare the predictive ability of different frailty measures for adverse outcomes in this population.
METHODS: Data from the 2015 to 2020 American College of Surgeons National Surgical Quality Improvement Program database was used. The study focused on patients aged ≥18 years undergoing ProphFF and those undergoing PathFF. Frailty was measured using both the revised Risk Analysis Index (RAI-rev) and the five-factor modified Frailty Index (mFI-5). Primary outcomes included 30-day mortality, major complications, unplanned readmission, and unplanned revision surgery, nonhome discharge, and extended length of stay. Propensity score matching was employed to adjust for baseline differences of age, body mass index, sex, functional status, and ASA between ProphFF and PathFF groups. Statistical methods included multivariable logistic regression and receiver operating characteristic curve analysis to evaluate the relationships between frailty measures and postoperative outcomes.
RESULTS: A total of 921 patients (57.7% female, median age 65 years [IQR, 56 to 72 years]) undergoing ProphFF or PathFF were included. Multivariable analysis demonstrated that increasing frailty increased odds of 30-day mortality, with each 1-point increase in RAI-rev and mFI-5 associated with a 5% (OR: 1.05, 95% CI, 1.01 to 1.08; P < 0.01) and 31% (OR: 1.31, 95% CI, 1.01 to 1.71; P < 0.05) higher mortality risk, respectively. Propensity score matching resulted in 842 patients (421 prophylactic and 421 pathologic). Patients undergoing PathFF had higher likelihood of mortality compared with patients undergoing ProphFF (OR: 2.79, 95% CI, 1.61 to 4.82; P < 0.01). RAI-rev (C-statistic 0.73 [95% CI, 0.71 to 0.75]) had superior discrimination for mortality compared with mFI-5 (C-statistic 0.57 [95% CI, 0.54 to 0.59], P < 0.001).
DISCUSSION: Increasing preoperative frailty scores, particularly as measured by the revised Risk Analysis Index, were independent predictors of mortality and morbidity in patients undergoing prophylactic femur fixation. Pathologic fracture fixation demonstrated higher risk of revision surgery and mortality compared with prophylactic fixation. These findings suggest that the RAI-rev may be a valuable tool for identifying high-risk patients and optimizing surgical candidate selection before prophylactic femur fixation, potentially improving outcomes in this complex patient population.
BACKGROUND: Although os acromiale is often noted on preoperative imaging in patients undergoing reverse total shoulder arthroplasty (rTSA), its clinical significance is ill-defined. The purpose of this study was to compare the clinical outcomes in shoulders with an os acromiale undergoing rTSA with a matched control group.
METHODS: We conducted a retrospective review of a prospectively collected shoulder arthroplasty database for patients who underwent primary rTSA with a minimum 2-year clinical follow-up. Preoperative imaging studies taken within 6 months of surgery were assessed for an os acromiale. Sixty-four shoulders with os acromiale were identified and were matched in a ratio of 1:5 to a control group (n = 320) based on age (within 3 years), sex (exact), preoperative diagnosis, preoperative forward elevation (within 5°) and American Shoulder and Elbow Surgeons score (within five points). Clinical outcome scores, shoulder strength, and active range of motion assessed preoperatively and at latest follow-up as well as the incidence of complications were compared between cohorts. Outcomes of meso- and meta-acromion were grouped and compared with preacromion shoulders.
RESULTS: The incidence of os acromiale was 9.7% (64/663) in our institution. Of these, 55% (n = 34) were preacromion, 38% (n = 24) were mesoacromion, and 8% (n = 5) were meta-acromion. No statistically significant differences were found in any outcome score, shoulder strength, or range of motion measures between shoulders with os acromiale and matched controls. Similar proportions of each cohort achieved a clinically significant benefit (minimal clinically important difference/substantial clinical benefit) for the Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, constant score, abduction, forward flexion, external rotation, and internal rotation. Shoulders with os acromiale had a similar overall complication rate compared with matched controls (14% vs. 12%; P = 0.658). No statistical difference in outcomes were observed between the pre- and meso-/meta-acromion shoulders.
CONCLUSIONS: Patients with os acromiale undergoing rTSA have similar postoperative functional outcomes and pain relief compared with matched controls.
LEVEL OF EVIDENCE: Ⅲ, Retrospective Matched Cohort Study.
BACKGROUND: Forefoot fractures are among some of the most common orthopaedic injuries. Treatment of zone 2 fifth metatarsal or Jones fractures is controversial and many times dependent on surgeon preference. Management of these injuries remains without clear guidelines. Accordingly, the goal of the current systematic review is to compare the clinical outcomes and complications for both surgical fixation and conservative treatment.
METHODS: Two independent authors completed a systematic review using the PubMed, EMBASE, and Cochrane Library databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol and Cochrane Handbook guidelines were followed. In addition, the Methodological Index for Non-Randomized Studies score was used to evaluate the quality and bias of the nonrandomized controlled trials. Our criteria included only studies that reported on both conservative and surgical treatment of Jones fractures.
RESULTS: Ten studies including 998 patients met our criteria for inclusion. A total of 787 patients underwent conservative management while 211 patients underwent surgical fixation. The surgical cohort had a significantly lower rate of total complications (18/211 (8.5%)) in comparison with the conservative cohort (123/787 (15.6%; P = 0.02). Similarly, those who underwent surgery had a lower rate of nonunion (7/211 (3.3%) versus 91/787 (11.6%; P = 0.04)). Patient-reported outcome scores, including American Orthopaedic Foot and Ankle Society scores were significantly better at final follow-up in the surgical group (96.5) in comparison with the conservative group (84.1; P = 0.005).
CONCLUSION: This systematic review found markedly fewer total complications, a lower nonunion rate, and higher mean American Orthopaedic Foot and Ankle Society scores in patients who underwent surgical management for Jones fractures in comparison with those who were treated nonoperatively. Although, conservative treatment is also a successful method of treatment, our findings support surgical treatment of Jones fractures.
INTRODUCTION: Hip arthroscopy has increased in utilization with the improvement of surgical technique and technology. Although the rate of complications has historically been low, patient-specific factors may increase complication risk. The effects of preoperative corticosteroid use and resultant immunosuppression on outcomes following hip arthroscopy are not well understood. This study aimed to compare the rates and odds of 90-day medical complications, emergency department (ED) utilizations, and readmissions between corticosteroid users and nonusers undergoing hip arthroscopy.
METHODS: Using the PearlDiver nationwide claims database (2010 to 2021), corticosteroid users (N = 1,735) were propensity score matched in a 1:5 ratio to controls (N = 8,643) based on age, sex, and comorbidities, and Elixhauser comorbidity index. Ninety-day medical complications, ED utilization, and readmissions were compared. Logistic regression models were used to compute odds ratios (ORs) of medical complications, and 90-day ED visits and readmissions in corticosteroid users. Following Bonferroni correction, statistical significance was set at P < 0.01.
RESULTS: Corticosteroid users demonstrated markedly higher odds of medical complications (OR, 4.75; P < 0.0001) compared with controls. Corticosteroid users had elevated rates and odds of deep vein thrombosis (1.27% vs. 0.25%; OR, 5.04; P < 0.0001), pneumonia (5.01% vs. 0.69%; OR, 7.81; P < 0.0001), blood transfusion (0.98% vs. 0.20%; OR, 5.06; P < 0.0001), surgical site infections (0.81% vs. 0.23%; OR, 3.51; P = 0.0003), and deep wound infections (0.69% vs. 0.22%; OR, 3.17; P = 0.001). Corticosteroid users had higher incidence and odds of ED visits (4.27% vs. 2.04%; OR, 2.15; P < 0.0001) and readmissions (4.84% vs. 2.07%; OR, 2.43; P < 0.0001) within 90 days.
CONCLUSION: Corticosteroid users undergoing hip arthroscopy are at higher risk of 90-day medical complications, ED visits, and readmissions compared with noncorticosteroid users. These findings emphasize the need for careful perioperative planning and risk mitigation strategies for this high-risk group.
Exposure to ionizing radiation is a common occupational hazard for the orthopaedic surgeon, ubiquitous among subspecialities. There are known detrimental effects of radiation exposure including cataracts and increased cancer risk. It is imperative for both practicing orthopaedic surgeons and trainees to recognize that these risks exist and to understand what effect our occupational exposure can have over the length of a career. The purpose of this review is to highlight current recommendations and guidelines regarding ionizing radiation dose exposure, summarize the available literature specifically evaluating the effect of radiation exposure among orthopaedic surgeons, and to provide readers with strategies to mitigate radiation exposure and subsequent harmful sequelae.
INTRODUCTION: Racial disparities in total joint arthroplasty (TJA) utilization are persistent and well-characterized. Improving surgeon workforce diversity may attract patients from diverse backgrounds. We sought to determine whether the recent hiring of an arthroplasty surgeon of underrepresented minority (URM) background in a predominantly non-URM arthroplasty practice was associated with increased patient diversity.
METHODS: We retrospectively reviewed all primary and revision elective TJAs by six arthroplasty surgeons at our institution from September 2022 to September 2023. Primary outcomes included patient age, sex, and race/ethnicity. Secondary outcomes included patient-reported outcome measures (PROMs) at preoperative and 3-month postoperative follow-up. Comparison cohorts included the following: (1) a recently hired URM attending surgeon; (2) a recently hired non-URM attending surgeon; and (3) four senior non-URM attending surgeons. Unpaired t-tests were used to compare means for continuous variables and chi-squared tests for qualitative variables.
RESULTS: Overall, 2,101 patients were included, and 168 patients were included in group 1 (URM surgeon), 75 in group 2 (non-URM surgeon); and 1,858 in group 3 (non-URM senior surgeons). Compared with groups 2 and 3, patients within group 1 comprised a markedly greater proportion of female, Black, and Hispanic/Latino patients (64.8%, 33.3% and 59.7%, respectively, P < 0.01). Racial and ethnic demographic differences persisted when examining patients treated by the non-URM division in the year before the hiring of the URM surgeon. Subgroup analysis of URM patients showed markedly improved SF-12 mental scores for URM patients treated by the URM surgeon compared with those treated by senior surgeons (P < 0.05).
CONCLUSION: Compared with an experience-matched non-URM surgeon and non-URM senior surgeons in the same division, the URM surgeon saw a markedly greater proportion of minority patients in their first year of practice. Hiring diverse orthopaedic faculty may represent a viable strategy for improving health care utilization for minority patients in arthroplasty practices.
INTRODUCTION: Midshaft clavicle fractures with a "Z" deformity have historically been considered a surgical indication, although evidence is limited. This study compared rates of surgery to promote fracture healing between Z-type and non-Z-type clavicle fractures managed nonoperatively (nonsurgical cohort) and all-cause unplanned (re)operation rates among operatively and nonoperatively managed Z-type fractures (Z-type cohort).
METHODS: This retrospective cohort study included adult patients with midshaft clavicle fractures treated at two level 1 trauma centers between 2010 and 2023. Z-type fractures were defined as comminuted fractures with complete displacement and a vertically oriented butterfly fragment of ≥1 cm. The primary outcome was the rate of surgery to promote fracture healing in the nonsurgical cohort and the all-cause unplanned surgery rate in the Z-type cohort.
RESULTS: In total, 35 nonsurgical Z-type fractures, 157 nonsurgical non-Z-type fractures, and 95 surgical Z-type fractures were included. Rates of surgery to promote healing were similar between nonoperatively managed Z-type and non-Z-type fractures (17% vs. 22%, P = 0.552). Multivariable analysis showed no association between Z-type fractures and surgery to promote fracture healing (odds ratio, 0.84; 95% confidence interval, 0.29 to 2.17; P = 0.737). Among Z-type fractures, all-cause unplanned surgery rates were comparable between nonsurgical and surgical management (20% vs. 28%, P = 0.333). However, when excluding implant removal, nonoperatively managed Z-type fractures had a significantly higher all-cause unplanned surgery rate (20% vs. 4.2%, P = 0.009). Surgical management of Z-type fractures had a lower rate of surgery to promote fracture healing compared with nonsurgical management (1.1% vs. 17%, P = 0.002).
CONCLUSIONS: Among fractures initially treated nonoperatively, Z-type and non-Z-type midshaft clavicle fractures had similar rates of surgery to promote fracture healing. Surgical management of Z-type fractures demonstrated a lower rate of surgery to promote fracture healing compared with nonsurgical management. Regardless of initial treatment, all-cause unplanned surgery rates were comparable for Z-type fractures.
LEVEL OF EVIDENCE: Therapeutic Level III.
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: The primary objective is to assess the benefits and harms of partial wrist fusion compared with placebo or sham surgery in adults with non-inflammatory osteoarthritis of the wrist. Secondary objectives are to assess the benefits and harms of surgery, including but not limited to, proximal row carpectomy, total wrist arthroplasty, and wrist denervation, compared with placebo or sham surgery, any non-surgical intervention, or other type of surgery.
The main purpose of this study is to test the safety and efficacy of study drug for the treatment of knee pain due to osteoarthritis (OA). This trial is part of the chronic pain master protocol H0P-MC-CPMP (NCT05986292), which is a protocol to accelerate the development of new treatments for chronic pain.
This clinical trial is being done to better understand how daily treatment with Tetrahydrocannabinol (THC), Cannabidiol (CBD), or the combination of CBD plus THC affects knee osteoarthritis pain and other related symptoms.
Consented participants will have a screening period and visit (up to 30 days to treatment start). If participants pass the screening phase, they will be randomly assigned to take one of the investigational study drugs. For this study, participants will not know when or if they are taking CBD, THC, THC plus CBD, and when or if taking placebo.
Clinical pain will be assessed at multiple times throughout the study, and eligibility will be re-assessed at two weeks into the treatment period. It is possible that subjects will not be able to participate in the study after 14 days of of treatment. The treatment period will take approximately 16 weeks and then a follow-up period for approximately 2 weeks. In addition to treatment, participants will have clinical assessments, blood draws, questionnaires, daily pain diaries, sensory testing, as well as have functional connectivity magnetic resonance imaging (fcMRI).
The aim of this study is to assess whether citicoline (TRAUSAN), a neuroprotective agent involved in membrane phospholipid synthesis and neurotransmission, can prevent or attenuate cognitive decline in older adults who develop perioperative delirium during hospitalization for proximal hip fracture. Delirium is a frequent and severe complication in this population and is associated with cognitive and functional deterioration, institutionalization, and mortality.
Participants will be randomly assigned (1:1) to receive citicoline 1000 mg/day for 6 months after discharge, or usual care. Cognitive and functional status will be evaluated at discharge and subsequently at 3 and 6 months follow-up visits.
Perioperative Delirium · Hip Fracture · Post-Operative Cognitive Decline in Older Adults
The primary purpose of this study is to find out if there is a difference in pain experienced in patients with knee arthritis of the inside of their knee if they get a steroid injection on the inside or outside of their knee. Participants will:
1. Be randomly divided into getting their steroid injection on the inside or outside of their knee.
2. Answer a pain survey before their injection as well as over the phone 2 weeks, 6 weeks, and 12 weeks after their injection.
Osteoarthitis · Osteoarthritic Knee Pain · Osteoarthritis (OA) · Osteoarthritis (OA) of the Knee
The goal of this pragmatic randomized trial is to evaluate the effectiveness of remote Tai Chi to treat knee pain in adults with knee osteoarthritis. The main questions the trial aims to answer are:
* Compared to routine care, will patients with Knee OA receiving remote Tai Chi exhibit greater improvement in knee-related pain (WOMAC pain score, primary outcome), pain interference (PROMIS-Pain Interference, secondary outcome), and health-related quality of life at 3 months?
* Does remote tai chi decreases healthcare utilization and analgesic use over the one-year study period?
Researchers will compare remote Tai Chi added to routine care to routine care alone to see if remote tai chi works to treat knee osteoarthritis pain. Participants will participate in remotely delivered web-based tai chi sessions, twice a week for 12 weeks, or will continue to receive routine care. Participants will be followed for 12 months after randomization.
The goal of this randomized controlled trial (RCT) is to test the feasibility of an 10-week telehealth mindful exercise intervention compared to a telehealth exercise only intervention for people with knee osteoarthritis (OA). This RCT will be fully digital with all recruitment, assessments, and intervention being conducted remotely.
Ankle fractures are common injuries that can affect a patient's mobility, mood, sleep, and everyday life for months. The Ankle Fracture Outcome of Rehabilitation Measure (A-FORM) is an English-language patient-reported outcome measure developed in Australia to capture this broader rehabilitation experience. No validated Turkish version of A-FORM currently exists. This prospective multi-centre observational study aims to translate the A-FORM into Turkish (A-FORM-TR), culturally adapt it for use in Turkish-speaking patients, and evaluate its psychometric properties. The investigators will recruit 150 adults with a unilateral ankle fracture, treated either surgically or conservatively, from three orthopedic centres in Turkiye and the Turkish Republic of Northern Cyprus. Participants complete the A-FORM-TR together with two established comparator questionnaires (AOFAS Ankle-Hindfoot Score and the Turkish Olerud-Molander Ankle Score). A subset of approximately 50 participants is re-administered the A-FORM-TR after 7 to 14 days to assess test-retest reliability, with a Global Rating of Change item identifying clinically stable patients. Analyses include classical test theory, confirmatory factor analysis, and Rasch measurement analysis.
The Beads vs Vac trial is a multi-centre randomized controlled trial of 312 participants with a severe open tibia fracture requiring multiple irrigation and debridement surgeries. Eligible participants will be randomized to receive either an antibiotic bead pouch or negative pressure wound therapy (NPWT) for their temporary open fracture wound management. Outcomes will be assessed at 6 weeks, 3 months, and 6 months post-surgery. The primary outcome will be a composite outcome to evaluate clinical status six months after randomization. Components of the composite outcome will be hierarchically assessed in the following order: 1) all-cause mortality, 2) injury-related amputation of the lower extremity, 3) unplanned reoperation to manage wound complications, infection, or delayed fracture healing, and 4) clinical fracture healing as assessed using the Functional IndeX for Trauma (FIX-IT) instrument. The secondary outcomes will independently assess the four components of the primary outcome. This is a Phase III trial.
Data involving orthopaedic conditions and rehabilitation aspects of musculoskeletal and neuromuscular disorders will be collected and stored as part of the normal clinical care of patients seen in the University of Florida (UF) and Shands Orthopaedics and Sports Medicine Institute.
This study aims to evaluate the effectiveness and safety of intra-articular injections of hyaluronic acid conjugated with fibrinogen in patients with knee osteoarthritis.
Knee osteoarthritis is a common degenerative joint disease that causes pain, stiffness, and reduced mobility, significantly affecting quality of life. Hyaluronic acid injections are widely used to relieve symptoms, but their effectiveness may be limited in some patients. Fibrinogen has potential biological effects that may enhance tissue repair and anti-inflammatory responses.
In this single-arm clinical study, patients with knee osteoarthritis will receive intra-articular injections of hyaluronic acid conjugated with fibrinogen. Clinical outcomes, including pain relief, functional improvement, and adverse events, will be assessed during follow-up visits.
The results of this study may provide additional evidence regarding the potential benefits and safety of conjugating hyaluronic acid with fibrinogen for the treatment of knee osteoarthritis.
Osteoarthritis (OA) and inflammatory conditions of the tendons and joints of the shoulder, elbow, hand, and wrist are common yet disabling diseases. Standard management utilizes conservative measures to minimize pain and improve function. Conservative pharmacological management commonly includes corticosteroid and ketorolac injections which have been well investigated as a modality of pain control and improved function in large joint OA. However, fewer studies yielding mixed results on the duration of symptomatic relief exist for arthropathy and tendinopathy of these joints.
The goal of this study is to evaluate the efficacy of ketorolac and triamcinolone injections for common shoulder, elbow, wrist, and hand tendinopathy or arthropathy.
Participants will be blinded to the treatment received. The duration of an individual participant's participation in this study is 24 weeks. During this time period, patients will be asked to return to the clinic for an in-person follow-up 6 weeks after the injection with either ketorolac or triamcinolone) in order to assess participants' outcomes. All work related to this project will take place at the Emory Sports Medicine Complex, Emory Executive Park, Emory Musculoskeletal Institute, the Emory University Orthopaedic and Spine Hospital, and the Emory Saint Joseph's Hospital. This study will add to existing knowledge by providing further insight into how wrist arthropathy should be most optimally and conservatively managed.
Pain control of rib fractures is essential for not only primary pain relief but also preventing secondary complications such as atelectasis or pneumonia which increase the hospital stay, as well as the transition to chronic pain.
The cornerstones of analgesic management are oral and intravenous medications such as paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids as well as regional block techniques as paravertebral block and thoracic epidural.
To avoid opioid as well as regional block related side effects such as pneumothorax and hemodynamic instability, previous studies showed that superficial chest wall block such as thoracic erector spinae plane block and serratus anterior plane block had shown a promising success in management of such pain with few side effects.
In an effort to reduce the pain score, hospital stay and improve the patient's capability of physiotherapy this study compares continuous block of parascapular sub-iliocostalis plane block versus continuous thoracic paravertebral block for analgesia in patients with traumatic multiple rib fractures.
