➢ Fragility fracture care remains suboptimal worldwide despite strong evidence supporting timely surgery, orthogeriatric care, early mobilization, unrestricted weight-bearing, and secondary fracture prevention.➢ International quality standards and registry-based audits have translated this evidence into measurable indicators that improve care in many high-income health-care systems.➢ Implementation in low- and middle-income countries (LMICs) is limited primarily by health-system constraints, including workforce shortages, delayed presentation, limited infrastructure, and fragmented care pathways, rather than by lack of evidence.➢ Emerging initiatives demonstrate that evidence-based quality standards can be successfully adapted to local contexts while preserving their core clinical principles.➢ Orthopaedic surgeons have a central role in leading multidisciplinary care, promoting secondary fracture prevention, and driving quality improvement across the entire fragility fracture pathway.➢ Future progress depends on strengthening health systems, embedding auditing and certification programs, and implementing context-sensitive quality standards that bridge the gap between evidence and routine.
➢ Fragility fracture care remains suboptimal worldwide despite strong evidence supporting timely surgery, orthogeriatric care, early mobilization, unrestricted weight-bearing, and secondary fracture prevention. ➢ International quality standards and registry-based audits have translated this evidence into measurable indicators that improve care in many high-income health-care systems. ➢ Implementation in low- and middle-income countries (LMICs) is limited primarily by health-system constraints, including workforce shortages, delayed presentation, limited infrastructure, and fragmented care pathways, rather than by lack of evidence. ➢ Emerging initiatives demonstrate that evidence-based quality standards can be successfully adapted to local contexts while preserving their core clinical principles. ➢ Orthopaedic surgeons have a central role in leading multidisciplinary care, promoting secondary fracture prevention, and driving quality improvement across the entire fragility fracture pathway. ➢ Future progress depends on strengthening health systems, embedding auditing and certification programs, and implementing context-sensitive quality standards that bridge the gap between evidence and routine.
➢ Periprosthetic joint infection (PJI) remains a major complication of joint arthroplasty, associated with morbidity and health-care burden. Although room for progress remains, the management of PJI has evolved over the past 50 years from empiric, procedure-centered approaches to structured, evidence-based, and biologically informed strategies. ➢ This article summarizes key developments in the prevention, diagnosis, and treatment of PJI, driven by advances across multiple clinical and scientific subspecialties. ➢ Diagnostic approaches have advanced from reliance on clinical findings and culture to a multimodal framework integrating validated criteria, serological and synovial biomarkers, and molecular techniques. Surgical management has similarly evolved toward individualized strategies, including debridement with implant retention, 1-stage or 2-stage revision, and salvage surgery tailored to host, pathogen, and disease characteristics. ➢ Advances in microbiology, particularly the recognition of biofilm and the emerging role of the human microbiome, have further reshaped the understanding of PJI. Overall, this article examines how developments in prevention, diagnosis, surgical treatment, and microbiology have driven a transition toward precision-based, biology-informed, and individualized management of PJI.
➢ Peptides lack a rigid tertiary structure, allowing them to adopt a variety of conformations, and can be engineered for specific targets. This article examines the design principles underlying orthopaedic peptide applications, from preclinical candidates to clinically validated drugs. ➢ The use of peptides in orthopaedics began with naturally occurring agents, such as bone morphogenetic proteins, and has evolved toward rationally engineered synthetics. ➢ Teriparatide, a synthetic parathyroid hormone-derived peptide, is used for bone regeneration; PLG0206, a fully engineered antimicrobial peptide, has demonstrated activity against biofilm-forming and multidrug-resistant organisms that conventional antibiotics cannot eradicate, and is advancing through Phase-II and III clinical evaluations. ➢ Peptide engineering has produced candidates with potential for cartilage-penetrating, sustained local drug delivery, although no peptide-based disease-modifying osteoarthritis drug has yet achieved clinical validation. ➢ Artificial intelligence-driven peptide design is accelerating discovery, but the translation of computationally designed sequences to clinical efficacy remains an active challenge.
➢ Argentine orthopaedics was shaped by the influence of Dr. Vittorio Putti (Rizzoli Institute, Bologna, Italy). Dr. Carlos E. Ottolenghi, one of Dr. Putti’s most distinguished disciples, together with Dr. José Valls, founded the Instituto de Ortopedia y Traumatología at Hospital Italiano de Buenos Aires in 1926. Prof. Ottolenghi transformed the Orthopaedic Service into a leading academic center and pioneer of subspecialization, serving as a foundational driver of orthopaedic development in Argentina and Latin America, while establishing strong international academic connections and collaborations. ➢ Major milestones include the establishment of one of the earliest institutional bone banks and the performance of one of the world’s first reported massive bone allograft reconstructions (1948); the performance of the first Charnley total hip replacement in the Americas (1967) and the first total knee replacement in Argentina (1970); and the early adoption of intramedullary nailing (1972), knee arthroscopy (1976), and femoral bone impaction allografting (1987). These contributions helped to define modern orthopaedic practice across Latin America and influenced global reconstructive strategies. ➢ Advances such as surgical navigation (2010) and augmented reality (2025) have strengthened its role as a regional and globally connected center of excellence, particularly in musculoskeletal oncology. ➢ Over the past 25 years, 180 residents and 160 fellows have been trained in our institute, and more than 500 indexed publications have been produced in the last 10 years, with alumni holding leadership roles across major orthopaedic centers worldwide, amplifying our institute’s global footprint. ➢ A merit-based, highly selective system based on excellence determines who becomes a staff surgeon. Currently, 85% of the actual staff surgeons completed residency training in our department, fostering a unique sense of institutional identity and perceived belonging. This experience reinforces the concept that excellence in orthopaedics transcends geographic boundaries and can emerge as a global reference from any setting committed to innovation, mentorship, and academic rigor.
➢ Osteochondral autograft transfer (OAT) restores hyaline cartilage and subchondral bone in a single stage, offering a durable joint-preserving option for focal full-thickness articular cartilage defects in young, active patients. ➢ Optimal candidates have unipolar femoral condyle, patellofemoral, or tibial plateau lesions measuring 1 to 4 cm 2 ; outcomes become less predictable once the defect size exceeds 3 cm 2 . Outcomes are further influenced by age, activity level, sex, alignment, instability, and meniscal deficiency, with older, lower-demand patients and those with larger lesions demonstrating comparatively inferior results. ➢ Technical success requires meticulous recipient-site preparation, perpendicular graft harvest, and flush implantation; both arthroscopic and open approaches achieve reliable results. ➢ OAT demonstrates high return-to-sport rates (often >85% within 6 months), significant functional improvements, and superiority over microfracture. Outcomes may be comparable or superior to cellular resurfacing or allograft techniques in appropriately selected patients. ➢ Emerging biologic adjuncts, recess-filling strategies, and donor-site substitutes may enhance graft integration and reduce morbidity, although long-term clinical benefits remain unproven.
BACKGROUND:Timely surgery is emphasized in hip fracture care. Prior studies examining this have failed to distinguish adequately between delays for medical optimization and those due to limited operative capacity, introducing important confounders. This study aimed to determine the impact of capacity-related delays on mortality after a hip fracture in older individuals, as well as the factors moderating these effects. METHODS:This retrospective cohort study involved patients treated in a U.K. teaching hospital from January 2020 to June 2024. Primary outcomes were mortality at 30 and 365 days. The exposure of interest was capacity-delayed hip fracture surgery, defined as operative anesthesia for hip fracture surgery occurring >36 hours after emergency department presentation. Patients aged ≥65 years with an operatively managed fracture of the native proximal femur were included. Patients were excluded if surgery was delayed for medical reasons. Multivariable logistic regression was used to examine mortality risk factors, and propensity-score matching was performed on the basis of covariates affecting mortality and survival analysis. RESULTS:Of 3,094 screened patients, 2,358 were eligible. Mortality status was available for 96.9% of patients at 365 days. One thousand and eighty-seven (46%) received timely surgery while 1,271 (54%) experienced capacity-related delay. After propensity-score matching, the median age was 85 years (interquartile range, 78 to 90 years), 73% were female, and 98% were White. Capacity delay was associated with a greater hazard of 365-day mortality (hazard ratio [HR] = 1.37, 95% confidence interval [CI]: 1.15 to 1.63), and the hazard was most pronounced in the first 30 days (HR = 1.71, 95% CI: 1.11 to 2.65). Shorter-term (30-day) mortality in patients with a higher Clinical Frailty Scale score (>4) was most affected by delay (odds ratio [OR] = 1.76, 95% CI: 1.06 to 3.02), while effects on less frail patients were not significant. CONCLUSIONS:Capacity-related delays in hip fracture surgery were associated with greater mortality after accounting for patient-related risk factors. This study overcomes a key confounder by isolating capacity-related delay. The results may support prioritizing timely hip fracture surgery for more vulnerable patients. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
BACKGROUND:Patients with a bone-anchored prosthesis (BAP) previously expressed preferences regarding (i.e., indicated the importance of) 5 treatment attributes: change in quality of life (QoL), short- and long-term complications, implant survival, and out-of-pocket contributions (costs). However, preference heterogeneity is unclear. We aimed to identify latent preference subgroups, quantify attribute importance per subgroup, and describe background characteristics associated with each subgroup. METHODS:A discrete choice experiment to reveal preferences for BAP characteristics among 247 patients from The Netherlands was analyzed using a latent class logit model. Subgroups (classes) were interpreted using relative attribute weights and patient characteristics. RESULTS:A model with 3 classes (with 49% [n = 121], 27% [n = 67], and 24% [n = 59] of the patients in Classes 1, 2, and 3, respectively) fit best. Across classes, short-term complications were least important, and patients considered opting out of BAP treatment when outcomes were unfavorable. Within the classes, when BAP was selected, QoL remained a key driver (31% of decision weight in Class 1, 53% in Class 2, and 26% in Class 3). Class 1 weighted QoL and out-of-pocket contributions most; Class 2 prioritized QoL and disregarded short-term complications; Class 3 placed the most weight on long-term complications and was sensitive to out-of-pocket contributions mainly at high cost levels (€20,000 to €25,000) and to osseointegrated implant survival only when survival dropped from 20 to 5 years. Background profiles differed: compared with the other classes, Class 1 (66% male) had a greater proportion of patients with transtibial amputations and longer BAP experience; Class 2 (48% male) included a greater proportion with higher education and income levels and worse pre-treatment mobility, pain, and anxiety; and Class 3 (80% male) had a greater proportion with lower education and income levels, and the highest proportion awaiting surgery. CONCLUSIONS:Patient preferences for key aspects of BAP treatment are heterogeneous. We identified 3 distinct subgroups, and a patient's background characteristics can help estimate membership in a particular subgroup. Patient-reported outcomes should be interpreted in light of these preference differences. Future work should integrate preference assessment into pre-treatment triage to better align counseling and selection with what patients value, ideally using a brief choice-task screening tool; the optimal screening tasks remain to be established. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
➢ Peptides lack a rigid tertiary structure, allowing them to adopt a variety of conformations, and can be engineered for specific targets. This article examines the design principles underlying orthopaedic peptide applications, from preclinical candidates to clinically validated drugs. ➢ The use of peptides in orthopaedics began with naturally occurring agents, such as bone morphogenetic proteins, and has evolved toward rationally engineered synthetics. ➢ Teriparatide, a synthetic parathyroid hormone-derived peptide, is used for bone regeneration; PLG0206, a fully engineered antimicrobial peptide, has demonstrated activity against biofilm-forming and multidrug-resistant organisms that conventional antibiotics cannot eradicate, and is advancing through Phase-II and III clinical evaluations. ➢ Peptide engineering has produced candidates with potential for cartilage-penetrating, sustained local drug delivery, although no peptide-based disease-modifying osteoarthritis drug has yet achieved clinical validation. ➢ Artificial intelligence-driven peptide design is accelerating discovery, but the translation of computationally designed sequences to clinical efficacy remains an active challenge.
Musculoskeletal conditions, particularly osteoarthritis, account for >40 million disability-adjusted life years worldwide among persons aged 60 years and above. Research has also demonstrated that up to half of older adults have multimorbidity, which requires optimization for positive surgical outcomes. The World Health Organization introduced the concept of intrinsic capacity, which refers to the physical, mental, and psychosocial capacities that a person can draw upon to maintain their health and that are foundational components of healthy aging. Intrinsic capacity includes 5 domains: locomotion, vitality, cognition, sensory function, and psychological well-being. Two of these domains, locomotion and vitality, are directly relevant to orthopaedic surgery, as they focus on neuromuscular function, skeletal muscle mass, bone health, and related metabolic and nutritional factors. Substantial increases in the rates of primary arthroplasty worldwide create an important opportunity to incorporate interventions into existing orthopaedic surgical care processes in order to optimize locomotion and vitality and keep older adults healthy and out of the hospital. Orthopaedic surgeons are uniquely positioned to influence healthy aging well beyond the operating room. Three simple and effective interventions that can be championed by orthopaedic surgeons are (1) encouraging locomotion by giving patients a written prescription for muscle strengthening and balance training, (2) supporting vitality through malnutrition screening and reinforcing optimal nutrient intake, and (3) being a leader in bone health optimization. Addressing these factors can optimize intrinsic capacity, reduce falls and fragility fractures, improve surgical outcomes, and keep older adults out of the hospital long after the surgical episode has ended.
BACKGROUND:First metatarsophalangeal joint (MTPJ) subluxation or dislocation represents a common yet unquantified pathological feature in hallux valgus (HV). In this study, we introduce the concept of the articular dislocation angle (ADA), defined as the angle between a line perpendicular to the proximal articular surface of the proximal phalanx and a line perpendicular to the distal articular surface of the first metatarsal, to quantitatively evaluate the degree of joint subluxation or dislocation. Using the ADA concept, this study quantitatively investigated the relationships between HV-related angular parameters (hallux valgus angle [HVA], distal metatarsal articular angle [DMAA], distal articular set angle [DASA], and ADA), thereby precisely delineating the pathological deformity components contributing to HV. METHODS:We measured HVA, DMAA, DASA, and ADA on weight-bearing radiographs of 70 feet (52 patients) with HV to investigate their interrelationships and quantify their respective contributions to HV. The mean patient age was 58 years, 63 feet were in female patients, and all patients were Asian. Additionally, by comparing DMAA and DASA measurements obtained from weight-bearing radiographs versus computed tomography (CT) scans, we systematically evaluated the accuracy of measurements on weight-bearing radiographs. RESULTS:Radiographic data demonstrated that the relationship HVA = DMAA + DASA + ADA held true across all HV severity grades. Quantitative analysis revealed a progressive increase in the ADA contribution with increasing disease severity (mild: 43.3%; moderate: 52.6%; severe: 69.3%), while DMAA and DASA contributions showed corresponding decreases (DMAA: 40.7%, 38.1%, 28.1%, respectively; DASA: 16.0%, 9.3%, 2.5%). Comparative analysis indicated excellent agreement between CT and weight-bearing radiographs for DMAA measurements, whereas radiographs systematically underestimated DASA values versus CT (mean differences: mild, -5.1°; moderate, -5.4°; severe, -7.8°), with the discrepancy magnitude increasing with disease severity. CONCLUSIONS:ADA provides an accurate quantitative assessment of first MTPJ subluxation or dislocation severity. The introduction of the ADA establishes a clear geometric relationship among HVA, DMAA, and DASA, formulated as: HVA = DMAA + DASA + ADA. Preoperative application of this formula allows effective assessment of the pathological components contributing to HV, thereby assisting surgeons in developing appropriate surgical strategies. LEVEL OF EVIDENCE:Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background: Surgical smoke is a gaseous intraoperative byproduct that contains numerous toxic compounds, including fine particles with a diameter of ≤2.5 µm (PM2.5). However, intraoperative exposure during joint arthroplasty has not been well characterized. In this study, we aimed to quantify PM2.5 exposure during arthroplasty and to determine, by procedure and approach, how often it reached potentially harmful levels. Methods: We conducted a single-center prospective study of 83 primary arthroplasties (20 bipolar hemiarthroplasties [BHAs] via a direct lateral approach, 35 total hip arthroplasties [THAs] via a direct anterior approach, and 28 total knee arthroplasties [TKAs]). Intraoperative PM2.5 concentrations were measured using a portable monitor and were mapped to Air Quality Index (AQI) categories. Summary metrics, including maximum and cumulative PM2.5 exposure, were calculated by procedure. Logistic regression was used to estimate odds ratios (ORs) for exceeding AQI thresholds. Results: In BHA and TKA, PM2.5 concentrations increased sharply during field development, whereas they remained low throughout THA. The median maximum PM2.5 concentrations were 129.50 µg/m 3 (interquartile range [IQR], 85.44 to 275.28 µg/m 3 ) for BHA, 6.14 µg/m 3 (IQR, 2.54 to 23.94 µg/m 3 ) for THA, and 118.80 µg/m 3 (IQR, 56.23 to 208.04 µg/m 3 ) for TKA. The concentrations were significantly higher in BHA and TKA (both adjusted p < 0.001) than in THA. At 25% of the normalized surgical time, 80% of BHA cases and 71% of TKA cases reached an AQI of Unhealthy or worse, whereas most THA cases remained within the Good or Moderate categories. The adjusted ORs for reaching an AQI of Unhealthy or worse were 34.280 (95% confidence interval [CI], 7.479 to 215.044; p < 0.001) for BHA and 21.971 (95% CI, 6.011 to 101.814; p < 0.001) for TKA compared with THA. Conclusions: BHA via a direct lateral approach and TKA generated substantially higher intraoperative PM2.5 concentrations than THA via a direct anterior approach, and many cases reached an AQI of Unhealthy or worse. Procedure and approach are not readily modifiable determinants of surgical smoke exposure, underscoring the need for comprehensive control strategies, including smoke evacuation and high-efficiency masks, in arthroplasty practice. Clinical Relevance: Operating room teams may be exposed to potentially harmful levels of surgical smoke during arthroplasty. Understanding the characteristics of this exposure may help to guide strategies to optimize the operating room environment.
BACKGROUND:Unplanned excisions (UEs) of soft-tissue sarcoma are resections performed without appropriate preoperative imaging or biopsy confirmation. These procedures represent a large proportion of referrals to sarcoma centers and can negatively influence oncologic outcomes. Limited evidence exists regarding the impact of consultation timing after UE. This study aimed to compare oncologic outcomes of patients evaluated early versus late at a sarcoma center following UE. METHODS:Of 397 patients treated for soft-tissue sarcoma from 2012 to 2020 at 2 tertiary centers, 117 underwent UE followed by later tumor bed excision and were analyzed. Consultation with a sarcoma specialist was defined as the patient's first visit with a multidisciplinary sarcoma team member, marking entry into the coordinated cancer center. Patients were stratified into early (≤2 months) and late (>2 months) consultation groups. Demographic, clinical, and tumor characteristics were collected. Primary outcomes included local recurrence-free survival (LRFS), metastasis-free survival (MFS), and overall survival (OS). Chi-square and t tests were used for univariate comparisons, and Kaplan-Meier analyses were performed. Multivariable Cox regression and logistic regression analyses were performed, adjusting for patient age, sex, and comorbidities; tumor size, depth, grade, stage, and margin status; and/or follow-up duration. RESULTS:Among the 117 patients (mean age, 56 years; 55% female; 84% White; 65% non-Hispanic), 26 were seen early and 91 late. The rate of metastasis was significantly higher in the late cohort (48.4% versus 11.5%, p = 0.0016), as was mortality (30.8% versus 3.8%, p = 0.0109). Five-year Kaplan-Meier survival outcomes favored early consultation, including LRFS (84.6% versus 63.7%, p = 0.041), MFS (88.5% versus 50.5%, p = 0.003), and OS (96.2% versus 64.8%, p = 0.005). On multivariable analysis, late consultation was independently associated with inferior LRFS (hazard ratio [HR] = 1.95, p = 0.046), MFS (HR = 2.76, p = 0.004), and OS (HR = 2.53, p = 0.022). Logistic regression showed increased odds of metastasis (odds ratio [OR] = 7.11, p = 0.0027) and mortality (OR = 11.29, p = 0.021) at 5 years in the late group. CONCLUSIONS:Delayed consultation after UE was associated with significantly worse outcomes, including higher rates of metastasis and mortality and lower LRFS, MFS, and OS. These results emphasize the importance of timely referral to sarcoma centers for early multidisciplinary management. LEVEL OF EVIDENCE:Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Orthopaedic practice is increasingly shaped by evidence-based guidelines, quality metrics, documentation requirements, insurer authorization pathways, and medicolegal scrutiny. These developments have improved care in important ways, but they may also narrow the space for individualized clinical reasoning when protocols are applied too rigidly. This Viewpoint argues that orthopaedic judgment should be understood not as a license to depart casually from evidence-based care, nor as a defense of paternalism, but as the professional capacity to integrate evidence, clinical context, and patient preferences through shared decision-making. I suggest that the standard of care is best conceptualized as transparent, well-documented, context-sensitive reasoning. When several reasonable options exist, the task of the surgeon is to help patients navigate uncertainty, tradeoffs, and real-world constraints rather than to simply default to the most defensible-looking protocol. Examples from osteoarthritis, distal radial fracture care, and complex trauma illustrate how judgment remains necessary even in an era of guidelines and metrics. The surgeon-jurist, as a conceptual figure, reminds us that responsible care depends not only on evidence and accountability but also on deliberation, communication, and discretion.
Background: Antibiotic-loaded ceramic bone grafts (ACBGs) are widely assumed to provide extended local antimicrobial protection, maintaining concentrations above the minimum inhibitory concentration (MIC) for 28 to 42 days. However, this time frame is mainly based on in vitro elution assays with simplified washout models, and its relevance to in vivo performance is uncertain. This study compared the in vivo and in vitro release and behavior of gentamicin from 2 commercial ACBGs. Methods: Gentamicin-loaded hydroxyapatite/calcium sulfate (HA-CS) and calcium sulfate (CS) composites were investigated using a murine implantation model and in vitro elution assays. Gentamicin content in recovered depot material and elution media was quantified by liquid chromatography with tandem mass spectrometry. Model calculations evaluated how the assay design affects the estimated time above the MIC. Results: Both ACBGs released >98% of gentamicin within 6 hours and >99% within 24 hours in vivo. In vitro assays likewise indicated early depot depletion, with concentration-time profiles beyond 48 hours driven by serial dilution rather than release. Model calculations suggested that the apparent prolonged antibiotic activity in previous in vitro assays was largely due to the assay design, not to sustained release, implying that freely administered antibiotics could produce similar profiles. Conclusions: Neither ACBG demonstrated measurable sustained release beyond an initial 24-hour burst phase. This may have important clinical implications, as expectations of prolonged local antimicrobial protection are not supported by the cumulative-release data showing rapid antibiotic depot depletion.
