Introduction:Stable 2-part intertrochanteric hip fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthoapedic Trauma Association [AO/OTA] 31A1.2) are commonly treated with dynamic hip screw (DHS) or trochanteric fixation nail advanced (TFNA). Although nails are increasingly favored, superiority in stable patterns remains unproven with DHS remains widely used. This study applied mesh-free simulation to investigate construct mechanics and failure behavior in stable fracture models, with implant migration and construct stability as surrogate measures for cutout risk. Methods:Particle models of AO/OTA 31A1.2 fractures were obtained from cadaveric computed tomography scans with bone mineral density mapping. Using volumetric particle modelling (100-400 μm resolution), either DHS (316L stainless steel lag screw/barrel) or TFNA (Ti6Al4V extra low interstitial nail/blade) was inserted at a tip-apex distance of <25 mm. A standardized axial compression test approximating single-leg stance was simulated at 2 m/s along the Z-axis. Two implant conditions were tested: sliding (allowing screw/blade migration) and non-sliding (rigid). Two fracture reductions were modelled: anatomical (0 mm gap) and proximal gap (5 mm). Outcomes were maximum load, displacement at failure, load-displacement curves, and von Mises stress distribution. Results:With anatomical reduction, DHS and TFNA showed nearly identical curves up to 3-4 mm displacement; DHS resisted higher loads beyond. In non-sliding, DHS reached a maximum load of 4,066 N vs. 3,945 N for TFNA; in sliding, DHS reached 4,156 N vs. 3,790 N for TFNA. With gap, early performance was similar, but DHS reached higher loads (2,161-2,504 N) vs. TFNA (1,643-1,877 N). Displacement at failure was comparable (approximately 5 mm). DHS exhibited a more gradual postpeak decline, whereas TFNA showed a steeper loss of resistance. Conclusion:DHS and TFNA provide comparable initial stability but diverge with increasing displacement and reduction imperfection. Rather than establishing implant superiority, these findings highlight differences in construct mechanics and tolerance to suboptimal reduction. Clinical Relevance:DHS may better tolerate reduction imperfections in stable intertrochanteric fractures, potentially guiding implant selection when anatomical reduction is challenging. Results should be interpreted as mechanistic insights requiring clinical validation. Level of Evidence:No level of evidence. See Instructions for Authors for a complete description of levels of evidence.
Background: Artificial intelligence (AI)-generated text has been detected in nearly 90% of orthopaedic peer-reviewed publications, yet public disclosure of AI use remains extremely low. Whether journal and publisher policies for authors on AI use are present, sufficiently detailed, and internally consistent has not been systematically examined in orthopaedics. We characterized the prevalence, scope, and within-publisher consistency of AI policies across a structured sample of leading orthopaedic and biomedical journals. Methods: We performed a cross-sectional analysis of publicly available author instructions, editorial policies, and publisher guidance for 32 journals (6 core orthopaedic, 19 orthopaedic subspecialty, 7 general biomedical) across 12 biomedical publishers. Forty-one variables were extracted per journal between March and April 2026, including presence of policy for AI use for authors, disclosure requirements, and use of AI for data analysis, generating figures and references, and policies for peer reviewers. A second reviewer independently coded a 12-variable subset for 10 journals (31% calibration) to assess inter-rater reliability (Cohen's kappa = 0.90, 96% agreement). Results: Twenty-nine of 32 journals (91%) had an identifiable AI policy for authors; 3 subspecialty journals had none. All core orthopaedic (6/6) and general biomedical (7/7) journals had policies, versus 16 of 19 subspecialty journals (84%). Among journals with policies, 28 of 29 (97%) required disclosure of AI use by authors and 22 of 29 (76%) prohibited listing AI as an author. Coverage of other domains was less frequent: figures and images (66%), hallucinations or fabrication (62%), AI-generated references (48%), peer review (45%), and data analysis (41%). Conclusions: Domains that can directly impact scientific integrity and clinical practice, such as AI-assisted manipulation of data, statistical outputs, fabricated references, and undisclosed image alterations, are currently not consistently queried in detail at manuscript submission. With advances in software technology, biomedical journals can test and adopt AI-detection tools that are both sensitive and specific to screen all submissions before peer-review to maintain scientific integrity and transparency. Level of Evidence: Level IV , Cross-Sectional Study.
Background:There are limited results about total ankle arthroplasty (TAA) in the setting of severe malalignment. The aim of this study was to compare midterm patient-reported and radiographic outcomes in patients with severe varus or valgus tibiotalar deformity treated with primary transfibular TAA at a minimum of 5-year follow-up. Methods:Retrospective review was performed of all primary transfibular TAA by a single surgeon from October 2012 to January 2020 and grouped based on preoperative coronal talar tilt angle. Severe preoperative deformity included cases with ≥10° of varus (n = 36) or valgus (n = 33), while cases within 5° of neutral coronal alignment (n = 140) served as a control group. PROMs included 12-item Short-Form Health Survey physical and mental component scores, Ankle Osteoarthritis Scale, and Visual Analog Scale. Alignment and periprosthetic cysts (>2 mm) were assessed on postoperative radiographs. Adverse events and reoperations were reported using the Canadian Orthopaedic Foot and Ankle Society Reoperation Coding System. Results:Aside from age (Neutral vs. Valgus, 58.1 vs. 64.2 years; p = 0.01), there were no significant differences in demographics, preoperative, or postoperative PROMs among the 3 groups. The median preoperative talar tilt was -15.1° (interquartile range [IQR], -17.8° to -13.1°) in the Varus and 16.0° (IQR, 12.0° to 19.5°) in the Valgus groups; there were no significant differences in median tibiotalar alignment between the 3 groups postoperatively. In the Neutral group, 1 patient had postoperative varus, and 2 patients had postoperative valgus deformity. In the Varus group, 1 patient had recurrent varus, and 1 patient progressed to valgus. Seven ankles had periprosthetic cysts. Overall reoperation rates were similar (Neutral, 34%; Varus, 33%; Valgus, 36%) with no implant revisions. Conclusion:Transfibular TAA is capable of correcting severe coronal tibiotalar malalignment in the primary treatment of end-stage ankle arthritis. Patients with ≥10° varus or valgus deformity demonstrated postoperative patient-reported and radiographic outcomes similar to those with neutral ankle alignment at midterm follow-up, without an increased risk of reoperations. Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.
Background:Knee osteoarthritis (OA) causes significant disability with limited effective treatments. Undenatured collagen type II (UC-II), prescription-grade crystalline glucosamine sulfate (pCGS), and diacerein have been proposed as alternatives to conventional analgesics, but their comparative efficacy remains uncertain. We hypothesized that each supplement would demonstrate superior efficacy over placebo in reducing total Western Ontario and McMaster Universities Arthritis Index (WOMAC) score at Week 24 in patients with mild-to-moderate knee OA. Methods:This 4-arm, randomized, double-blind, placebo-controlled trial enrolled 216 Thai adults with symptomatic knee OA (Kellgren-Lawrence grade 2-3). Participants received UC-II (40 mg once daily), pCGS (500 mg 3 times daily), diacerein (50 mg once to twice daily), or placebo for 24 weeks, with follow-up to 36 weeks. The primary outcome was total WOMAC score (22 items; pain, stiffness, and physical function; scored 0-220, higher = worse) at Week 24. Analyses followed intention-to-treat principles using multiple imputation by chained equations (m = 10) and linear mixed-effects models. Results:Of 216 randomized Thai participants, 208 (96.3%) completed follow-up (mean age 61.7 ± 7.1 years; 90.9% female; 73.6% Kellgren-Lawrence grade 2). At Week 24, no supplement demonstrated superiority over placebo. Between-group differences in total WOMAC score were as follows: UC-II -4.7 (95% CI -18.6 to 9.1), pCGS -8.1 (95% CI -21.8 to 5.7), and diacerein -12.3 (95% CI -25.9 to 1.3). All 95% CIs included zero, and all point estimates were at or below, and none clearly exceeded, the minimum clinically important difference threshold. At 36 weeks, results were consistent: UC-II -1.8 (95% CI -15.5 to 12.0), pCGS -4.8 (95% CI -18.4 to 8.7), and diacerein -1.3 (95% CI -14.9 to 12.3). Secondary outcomes including pain scores, joint space width, and functional performance showed no significant between-group differences. Adverse events were mild and comparable across groups; no serious adverse events occurred. Conclusions:Among Thai patients with mild-to-moderate knee OA, UC-II, pCGS, and diacerein did not demonstrate superiority over placebo in reducing pain or improving function at 24 weeks. These findings do not support their routine use as monotherapy for knee OA. Trial Registration:Thailand Clinical Trial Registry (TCTR20210901003). Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Background:Evidence-based and quality-of-care guidelines for hip fracture have recommended providing timely surgery and postacute rehabilitation. We sought to evaluate the cost-effectiveness of providing early surgery (within 24 hours of emergency department admission) and immediate admission to inpatient rehabilitation postacute discharge, or a combination of both for the management of hip fracture patients in Ontario, Canada. Methods:We used a Markov state transition model to compare early surgery and immediate rehabilitation to surgery beyond 24 hours and no postacute rehabilitation or receiving it beyond 24 hours postacute discharge. Costs and Quality-adjusted life-years (QALYs) were estimated in a 5-year horizon for elderly patients, from the perspective of the (public) insurance payer in Ontario, using linked administrative data sets. Transition probabilities and costs were obtained from regression models fitted using linked administrative data sets. EuroQoL 5-Dimension (EQ-5D) utility values were obtained from an international prospective observational study. We performed base-case and probabilistic sensitivity analysis using 5,000 simulations for willingness-to-pay thresholds from $0-$300,000 Canadian Dollars (CAD). Results:The incremental cost-effectiveness ratio of timely rehabilitation, for both timely surgery and rehabilitation, compared with neither were $124,162 and $83,714 per QALY, respectively. Timely surgery alone was an absolute advantage strategy (Δ Cost = -$2,387, Δ QALY = 0.06). Five-year base-case costs ranged from $130,747 to $156,848 and QALYs from 2.13 to 2.37. Timely surgery alone had the highest probability of being cost-effective up to a willingness-to-pay threshold of $128,000 per QALY, whereas combined surgery and rehabilitation was favored above $130,000 per QALY. Results were qualitatively similar for common diagnoses and procedure modalities. Conclusion:Our population data and modelling results indicate that timely surgery can improve patients' quality of life while reducing costs. Adding inpatient rehabilitation yields greater QALYs but at higher cost. Level of Evidence:Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:Benign and malignant bone and soft-tissue tumors have a broad range of clinical presentations. Operative management ranges from limited excision to complex resection and reconstruction. The work relative value unit (wRVU) is designed to quantify physician time, technical skill, and effort, but it is unclear whether current assignments adequately reflect the overall procedural demands of musculoskeletal orthopaedic oncology. The aim of this study was to compare wRVU generation between orthopaedic oncology procedures and matched nononcologic orthopaedic procedures after controlling for measures of physician time and intensity. Methods:A retrospective observational study was conducted using the American College of Surgeons' National Surgical Quality Improvement Program. Musculoskeletal orthopaedic oncology cases were stratified by Current Procedural Terminology (CPT) code according to tumor type. Mahalanobis distance matching was used to match orthopaedic oncology cases with nononcology orthopaedic controls. Total case wRVU generation was compared between groups. Results:Among 2,138,294 orthopaedic cases, 6,700 were musculoskeletal orthopaedic oncology cases (mean age 48 years, 45% female, 61% White, 9.6% Black, 5.0% Asian, 1.4% Other, and 23% unknown/not reported). After matching, oncology cases had 19.0% lower average wRVU (16.2 vs. 20.0) than matched controls despite similar operative times and case characteristics. The mean total case wRVUs were lower for benign soft-tissue tumors (9.7 vs. 15.8, -38.6%), benign bone tumors (11.0 vs. 15.8, -30.6%), and malignant soft-tissue tumors (18.1 vs. 26.3, -31.1%) compared with matched orthopaedic controls. By contrast, malignant bone tumors generated higher mean total case wRVUs than matched controls (43.9 vs. 37.0, +18.9%). Using a standardized workload of 675 operative hours per year, orthopaedic oncology procedures were estimated to generate 6,883 annual wRVUs vs. 8,570 for matched controls, corresponding to $56,167 lower annualized Medicare-based procedural value. Conclusions:Musculoskeletal orthopaedic oncology procedures generated fewer wRVUs than matched nononcologic orthopaedic procedures. We advocate for hospital and department leaders to consider this discrepancy within the wRVU model and account for it when designing compensation models for orthopaedic oncologists. Level of Evidence:Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background: Traditional orthopaedic residency educational approaches rely on unstandardized lecture series and self-directed study, which can lead to inconsistencies in knowledge acquisition. The Residency Orthopaedic Core Knowledge (ROCK) curriculum, introduced by the American Academy of Orthopaedic Surgeons in 2022, is a structured, comprehensive framework designed to standardize orthopaedic education. This study evaluates resident satisfaction with implementation of the ROCK curriculum within a single orthopaedic residency program and its association with resident performance on the Orthopaedic In-Training Examination (OITE). Methods: A 2-year residency didactics curriculum was designed to incorporate the ROCK curriculum at a single, urban academic orthopaedic residency program with a wider breadth of topics starting in the 2023 to 2024 academic year. To assess pre-/post-implementation response to this change, a survey assessing resident attitudes toward lectures/study patterns was designed. This was administered at the end of the 2022-23 academic year (pre-ROCK), with responses also collected 1 (2023-24) and 2 (2024-25) years after implementation. The survey captured resident demographics, attendance patterns, content satisfaction, and study habits. Questionnaire answers and OITE scores were compared between the year 2022 to 2023 (pre-ROCK) and the years 2023 to 2025 (post-ROCK). Results: A total of 78 responses were recorded over the 3 years (63% male) out of a potential 135 respondents. The proportion of residents who agreed that conferences were high quality (93% vs. 70%, p = 0.013) and were satisfied with conferences (91% vs. 65%, p = 0.006) was greater with the ROCK curriculum. In addition, residents felt there was a more appropriate balance of case-/didactic-based lectures after implementation (86% vs. 57%, p = 0.006). With the new curriculum, program OITE percentile increased from 68th percentile in 2022 (pre-ROCK) to 79th percentile in both 2023 and 2024 to 83rd percentile in 2025. Conclusions: Integrating the ROCK curriculum into an orthopaedic residency didactics curriculum led to high resident satisfaction and an overall trend toward higher OITE scores. These results support the use of the ROCK curriculum to augment resident education. Orthopaedic program directors and education leaders alike can replicate or adapt our proposed lecture schedule.
Background: Patients and families of school children with unilateral corrected talipes equinovarus (TEV, idiopathic clubfoot) have anecdotally noted a difference in sporting function from the unaffected side to the clubfoot. The purpose of this study was to assess difference in strength, balance, performance, and patient perception of their sporting ability using contemporary sports research technology. Methods: Following Institutional Review Board approval, 27 unilateral Ponseti-treated patients with clubfoot (ages 8-15) enrolled in a cross-sectional study. Demographics and patient-reported outcomes (Patient Reported Outcomes Measurement Information System [PROMIS] and Oxford Ankle Foot Questionnaire for Children [OxAFQ-C]) were collected. Strength, range of motion, and functional mechanics were measured using dynamometry, markerless motion capture, and forceplates, respectively (VALD ForceFrame, HumanTrak, and ForceDecks). Comparisons between affected and unaffected limbs were conducted using paired Student’s t tests. Results: Mean evaluation age was 11.2 years (30% male); mean initial Dimeglio score was 10.5. Most (78%) participated in >2 sports. PROMIS Physical Activity mean score was 52.3 (SD 6.6), and mean OxAFQ-C Physical score was 81.5 (SD 17.5). Comparing TEV and unaffected limbs in range of motion and strength found differences in ankle dorsiflexion force (mean 58.4N [SD 20.8] vs. 68.6N [28.1]; p = 0.02) and lateral spine tilt during lunge stance (−0.2° [2.6] vs. −1.5° [2.4]); p = 0.04). No significant differences were noted with most performance measures, with small differences noted in single leg stand on the clubfoot limb (1005 mm vs. 781 mm), and mean velocity (67 mm/s vs. 52 mm/s; p < 0.001), jump height (1.6 in vs. 2.2 in; p < 0.001), and peak power (749W vs. 808W; p = 0.02). Conclusions: Children with unilateral TEV report favorably on standardized reports of patient-reported and functional assessments including sports participation. Although differences were noted with decreased balance with flexibility, single leg stance, and jump height on the clubfoot limb, overall, the magnitude of these differences was generally small, and their clinical significance remains uncertain given the lack of established minimal clinically important differences (MCIDs) for this population. Level of Evidence: Prognostic Level IV (cross-sectional, small sample size). See Instructions for Authors for a complete description of levels of evidence.
Background:Intestinal dysbiosis and systemic microbial translocation potentially contribute to chronic joint inflammation. However, the role of the gut-joint axis in the genesis of osteoarthritis still needs to be elucidated. This investigation characterized taxonomic signatures and proinflammatory metabolic pathways within the hip joint to define their contribution to the pathophysiology of osteoarthritis relative to nonarthritic controls. Methods:A prospective cohort of 48 patients undergoing hip arthroplasty was enrolled. Specimens including synovial fluid, articular cartilage, and acetabular fossa tissue were collected from patients with primary hip osteoarthritis (n = 20) and femoral neck fracture (n = 20). Metagenomic profiling was performed using 16S-rRNA gene sequencing (V3-V4 region). Alpha and beta diversity, taxonomic composition, and predicted functional pathways (PICRUSt2) were compared based on diagnosis (arthritis vs. fracture) and sample location. Results:Osteoarthritic samples demonstrated reduced alpha diversity evenness compared with fracture controls (p = 0.031). While beta diversity was primarily driven by specimen type rather than diagnosis, significant taxonomic differences were observed at the genus level. Pseudomonas, Atopostipes, and Staphylococcus showed significant differential abundance between groups, both by specimen location and diagnosis. Functional predictive analysis revealed a marked enrichment of the KDO2-lipid A biosynthesis pathway in osteoarthritic specimens, specifically within the genus Pseudomonas. Key genes involved in lipopolysaccharide biosynthesis and export, including lpxB, lpxL, and lpxM, exhibited significantly higher median abundances in osteoarthritic joints compared with controls (p < 0.00000001). Conclusions:Patients with hip osteoarthritis exhibited specific taxonomic and predicted lipopolysaccharide-related pathways differences compared with nonarthritic controls, consistent with microbial molecular signatures in a noninfectious inflammatory joint environment, despite the absence of major diagnosis-driven community-level differences. Level of Evidence:Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background:Previous biomechanical studies have shown that suture tape augmentation (STA) in anterior cruciate ligament reconstruction (ACLR) can improve the graft which can translate to reduced failure rate in a clinical setting. Previous meta-analysis did not show benefits to STA in patients undergoing ACLR. However, the included studies were retrospective and are subject to heterogeneity which can result in confounding bias. By including only prospective and matched retrospective studies, this meta-analysis will assess the benefits of STA in patients undergoing ACLR. Methods:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, Cochrane, and Google Scholar were accessed and explored until November 2025. The extracted data consisted of the risk arthrofibrosis, graft failure, return to sports (RTS), time to RTS, and postoperative functional outcomes (The Knee Injury and Osteoarthritis Outcome Score [KOOS] subscales and The International Knee Documentation Committee [IKDC] scale). Results:Six studies met the final inclusion criteria including 414 patients in the STA group with age ranging from 19 to 36 years and 450 patients in the control group with age ranging from 20 to 39 years. There was no difference between the 2 groups in arthrofibrosis, graft failure, RTS, and time to RTS. In addition, there were no differences in postoperative KOOS pain, symptoms, activities of daily living, sports, and quality of life subscales as well as IKDC. Conclusion:The results of this meta-analysis revealed that the systematic use of STA did not provide additional clinical benefits in patients older than 18 years undergoing ACLR.
Background:Avascular necrosis (AVN) is a devastating complication of pediatric septic arthritis (SA). While traditionally attributed to increased intra-articular pressure, emerging evidence suggests that the host's systemic response to infection may contribute to ischemic injury. We hypothesized that an immunocoagulopathic phenotype characterized by extreme inflammation and platelet consumption would identify children at the highest risk of developing AVN. Methods:Following institutional review board approval, children aged younger than 18 years diagnosed with SA between 2010 and 2016 were retrospectively identified from a multicenter database. The primary outcome was the development of AVN. Demographic, clinical, microbiologic, and early laboratory variables were collected. Multivariable logistic regression using Firth's penalized likelihood method was used to account for rare events. Subgroup-level predicted risks of AVN were calculated based on combinations of dichotomized laboratory markers. Results:Among 616 children with SA, 23 developed AVN (incidence, 3.7%). Patients with AVN demonstrated greater early inflammatory burden, including higher C-reactive protein (CRP) levels, lower platelet counts, and more frequent positive blood and tissue cultures. In multivariable analysis, extreme CRP elevation (>160 mg/L) and relative thrombocytopenia (<245 × 103/µL) were each associated with nearly 7-fold increased odds of AVN, while elevated admission white blood cell count (>9.3×103/µL) and erythrocyte sedimentation rate (>60 mm/h) were associated with approximately threefold increased odds. A prediction model using these markers demonstrated excellent discrimination (area under the curve, 0.85), with an estimated AVN risk of 43% in the highest-risk group. Conclusions:In this multicenter cohort, AVN occurred in 3.7% of children with SA. The development of AVN was strongly associated with an immunocoagulopathic phenotype, defined by extreme inflammation (CRP >160 mg/L) and coagulopathy (relative thrombocytopenia <245 × 103/µL). These findings support the hypothesis that pathological immunothrombosis, rather than mechanical pressure alone, drives ischemic injury in SA. Early recognition of this profile identifies patients who may benefit from heightened surveillance and aggressive perfusion-sparing management. Level of Evidence:Level IV, prognostic. See Instructions for Authors for a complete description of levels of evidence.
Introduction:In 2021, the US Hispanic and Latino (H&L) population made up 19% of the national population, an increase from 14% in 2006. There is limited literature assessing the trends of H&L representation among residents, fellows, and attending physicians in orthopaedic surgery. We sought to analyze their current representation in light of recent changes in national demographics. Methods:Demographic data for the US population was obtained from the decennial Censuses. Race and ethnicity data for in-training residents from 2006 to 2021 were extracted from the Graduate Medical Education Census from the American Medical Association. Similar data were obtained from the 2008 and 2018 AAOS (American Academy of Orthopedic Surgeons) Censuses of fully trained orthopaedic surgeons. Representation was analyzed for the following groups: H&L, Black, Asian, Native American, Multiracial, and White. H&L fellows representation per subspecialty (adult reconstruction, foot and ankle, hand, oncology, sports medicine, spine, trauma, and pediatrics) was also analyzed. Results:A total of 57,187 orthopaedic surgery residents were in training over the 15-year study period (2006-2021), 2,812 (4.9%) identified as H&L. Total number of orthopaedic residents in-training grew by 36% from 2006 to 2021 (3,305 to 4,616). H&L residents doubled from 118 to 281 to comprise 6.1% of trainees. Representation for H&L trained orthopaedic surgeons grew from 484 (1.9%) in 2008 to 663 (2.2%) in 2018, a 37% increase in absolute number and 16% as percentage of the orthopaedic workforce. Conclusion:Across the 15-year study period, H&L representation in orthopaedic surgery moderately increased at all levels but remained low relative to the H&L population. H&L resident representation relative to H&L national demographic weight is significantly low (p < 0.001) compared with other ethnic/racial groups. H&L residents were represented at a rate 3 times lower than White residents and almost 7 times lower than Asian residents when compared with the H&L national population.
Introduction:Flipped classroom models, which use active, case-based discussion, have shown promise across graduate medical education. Previous literature demonstrates that transitioning to a flipped classroom model resulted in significant increases in overall Orthopaedic In-Training Examination (OITE) scores. This observational study retrospectively compares foot and ankle OITE scores for orthopaedic surgery residents before and after implementation of a flipped classroom curriculum. Methods:This retrospective study reviewed OITE scores for orthopaedic residents, comparing a lecture-based curriculum (n = 49) to a flipped classroom curriculum (n = 61). Residents who started their second year in July 2020 or later were defined as treated. The curriculum is given to the postgraduate year-2 (PGY2) residents only. Percentage of correct foot and ankle questions (F&A) were analyzed via mixed-effects models using random-subject intercepts. Fixed effects included PGY, overall performance on other sections, and flipped classroom status. All statistical analyses were performed in R version 4.4.1. Results:Residents in the flipped classroom cohort demonstrated a statistically significant increase in F&A questions answered correctly. The average increase was 7% (95% confidence interval: 4%, 10%; p < 0.001). This improvement trend became clearly visible in PGY3 and grew stronger in senior residents. Specifically, PGY3 residents improved their mean percentage correct from 62.26% to 66.07% (p = 0.16). PGY4 residents improved from 69.16% to 74.83% (p = 0.013), and PGY5 residents improved from 69.03% to 75.53% (p = 0.006). Historically, approximately 75% of traditional PGY5 residents scored lower on the F&A section than on the rest of the examination. Conversely, in the flipped classroom group, approximately 75% of PGY4 and PGY5 residents scored higher on the F&A section compared with other sections. Discussion:The implementation of a flipped classroom model was associated with a statistically significant improvement in resident performance on the F&A section of the OITE. The educational benefits of this curriculum appear cumulative over the course of residency, with the most substantial performance gains realized by senior residents in their fourth and fifth years of training. Level of Evidence:Level III, Observational Study. See Instructions for Authors for a complete description of levels of evidence.
Background:Vertebral body tethering (VBT) offers fusionless correction for idiopathic scoliosis, yet midterm growth modulation remains poorly characterized. This study established a clinically relevant success criterion and characterized growth modulation kinetics with associated predictors. Methods:This multicenter prospective study enrolled patients with idiopathic scoliosis with Sanders stage ≤7A, preoperative fulcrum-bending flexibility rate ≥50%, and ≥2-year follow-up after VBT. Parameters were collected before surgery and at 7 postoperative time points. Two-year success was defined as Cobb angle <35° (group 1) and correction rate (CR) ≥50% without overcorrection (Group 2). Group 3 included cases with an instrumented Cobb angle <35° but CR <50%. Curves were further classified as undercorrection (CR <50%), overcorrection (negative curve), and short-term clinical success (same as group 2) at 2 years postoperatively. Results:Thirty-eight patients (50 curves, mean age 11.9 ± 1.17 years; 89.5% female) were analyzed. Coronal CR was 63.2% at 24 months. T2-12 kyphosis (p = 0.637), thoracolumbar kyphosis (p = 0.104), lumbar lordosis (p = 0.869), and sacral slope (p = 0.091) remained unchanged. While pelvic obliquity improved at 12 months (2.1° vs. 1.6°, p = 0.001) and trended toward recurrence at 24 months (2.1° vs. 1.8°, p = 0.142), the difference was below the minimally clinically important difference. Apical (11.3° vs. 6.8°) and upper end vertebral (8.5° vs. 2.8°) rotation improved significantly, while lower end vertebral rotation remained unchanged. Although no significant differences were found between group 1 (n = 39) and group 2 (n = 25) in CR and postoperative revisions, among curves under group 1 but not group 2 (group 3, n = 14), a significantly higher revision rate was observed compared with group 2 (28.6% vs. 4.0%, p = 0.047). Eighty-four percent of successful operations under the new criterion remained successful at the 3.4-year follow-up. The change in correction (Δcorrection) diverged at 3 to 6 months postoperatively. Overcorrection was associated with greater flexibility, a younger Risser sign, lower body mass index (14.5 ± 0.86 kg/m2), and higher immediate CR (84.9%). Conclusion:VBT effectively corrects coronal and axial deformity. A short-term success criterion based on a Cobb angle CR ≥ 50% without overcorrection better reflects a favorable biological response than the <35° benchmark at 2 years. Skeletally immature, lean patients with high flexibility and continued correction beyond 6 months may signal overcorrection risk. Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Systematic reviews and meta-analyses remain time-consuming and labor-intensive. We developed and validated a locally executed agentic artificial intelligence (AI) framework for deduplication, screening, and structured data extraction in systematic reviews, reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Transparent Reporting of AI in Comprehensive Evidence Synthesis (trAIce) guidelines. A multiagent pipeline of specialized agents for deduplication, title/abstract screening, structured data extraction, and verification was executed entirely locally to ensure data governance and reproducibility. Human-in-the-loop validation compared outputs against dual independent reviewers across 3 spine surgery systematic reviews, assessing accuracy, inter-rater agreement (Cohen's κ), time savings, and clinically critical error rates. Across 6,214 records, deduplication achieved near-perfect agreement with human reviewers (κ = 0.98), title and abstract screening yielded higher concordance than human screening (κ = 0.91) while reducing full-text review volume by 83%, and structured data extraction reached substantial agreement (κ = 0.87). The framework reduced reviewer time by 91.1% (90.8%-91.4%), a mean saving of 19.5 hours per review (p < 0.001). Clinically critical discrepancies were rare (<1%) and traceable, with no fabricated or hallucinated data introduced. A locally executed agentic AI framework has the potential to deliver accurate, efficient, and secure automation of systematic review tasks with human oversight, offering a reproducible pathway for trustworthy evidence synthesis under PRISMA-trAIce standards.
Background:Opioid stewardship is a priority after total knee arthroplasty (TKA). Although scheduled, outpatient oxycodone adds clinically meaningful benefit to contemporary multimodal, nonopioid analgesia remains uncertain. Methods:We conducted a phase-II, single-center, triple-blind, randomized, placebo-controlled trial. Adults undergoing primary TKA received immediate-release oral oxycodone (5 mg twice daily) or matching placebo for 1 month in addition to a standardized multimodal regimen (acetaminophen, celecoxib, pregabalin). The primary outcome was knee pain on the Visual Analog Scale (VAS) on postoperative days 1, 7, and 30. Secondary outcomes were hospital length of stay, Knee Injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), Pittsburgh Sleep Quality Index (PSQI), patient satisfaction, and adverse events through 6 months. Analyses followed the intention-to-treat principle. Results:Between July 2023 and July 2024, 190 patients were randomized (95 per group); 2 placebo recipients died of myocardial infarction before the 6-month visit. Baseline characteristics were balanced. On postoperative day 1, the mean VAS pain was 6.7 ± 1.5 (mean ± SD) with oxycodone and 7.2 ± 1.5 with placebo (mean difference, 0.48 cm; 95% confidence intervals, 0.06-0.92; P = 0.015); the difference did not reach the minimal clinically important difference (MCID) (1.0 cm). No between-group differences were observed on day 7 or day 30. Length of stay was reduced by 0.2 days (1.7 vs. 1.9 days, P = 0.047), a statistically significant but clinically modest difference. KOOS, OKS, PSQI, and patient satisfaction were comparable at 1 or 6 months. Minor adverse events were similar between groups; no serious events were attributed to the study drug. Conclusions:In patients undergoing primary TKA with optimized multimodal, nonopioid analgesia, a fixed 1-month course of oral oxycodone produced small improvements in day 1 pain and length of hospital stay that were statistically significant but below established MCID thresholds. These findings support individualized prescribing through shared decision making rather than routine scheduled oxycodone use after TKA. Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Background:. Physical therapy (PT) is essential to recovery after orthopaedic surgery, yet predictors of postoperative PT utilization across procedure types remain poorly understood. This study aimed to identify demographic and clinical predictors of PT utilization after 8 common orthopaedic procedures using a diverse national cohort. Methods:. Patients undergoing 8 orthopaedic procedures were identified from the National Institutes of Health All of Us Research Program. The primary outcome was PT utilization within 180 days of surgery. Sequential multivariable logistic regression evaluated predictors of PT utilization, adjusting for demographics, comorbidities, insurance, employment, preoperative PT, 0- to 14-day postoperative opioid prescriptions, and procedure type. Procedure-stratified analyses were performed. Statistical significance was set as p < 0.050. Results:. Among 12,666 patients (59% female; mean age, 58 ± 13 years), including 1,531 (12%) Hispanic/Latino and 1,445 (11%) Black patients, overall postoperative PT utilization was 44%. Female sex was associated with lower odds of PT utilization compared with male sex (adjusted odds ratio [aOR], 0.85; 95% confidence interval [CI], 0.78 to 0.92; p < 0.001), an effect that persisted after full adjustment. Preoperative PT (aOR, 8.91; 95% CI, 7.75-10.23; p < 0.001) and 0- to 14-day postoperative opioid prescriptions (aOR, 1.66; 95% CI, 1.50-1.83; p < 0.001) were independently associated with higher PT utilization. The association between female sex and lower PT utilization reached statistical significance in the total knee arthroplasty subgroup only in procedure-stratified analyses (aOR, 0.78; 95% CI, 0.67-0.91; p = 0.001). PT utilization was associated with lower 90-day emergency department visits (aOR, 0.67; 95% CI, 0.59-0.76; p < 0.001). Conclusions:. Preoperative PT and early postoperative opioid prescriptions were the strongest predictors of postoperative PT utilization. Female sex was associated with lower PT utilization after comprehensive adjustment, although structural and unmeasured factors may partially account for this finding. These findings identify factors associated with rehabilitation access after orthopaedic surgery. Preoperative PT engagement, equitable opioid-prescribing practices, and strategies to address insurance-related barriers warrant further investigation as potential approaches to improve postoperative rehabilitation access. Level of Evidence:. Level III, Prognostic. See Instructions for Authors for a complete description of levels of evidence.
Background:. Industry funding may support surgical training but also raises conflict-of-interest concerns, particularly among financially vulnerable residents. This study examined whether the prevalence and magnitude of Centers for Medicare & Medicaid Services (CMS) Open Payments general payments differed between postgraduate year 5 (PGY-5) orthopaedic surgery (OS) and general surgery (GS) residents graduating in 2025, and whether these payments varied by institution type and geographic region. Methods:. We performed a cross-sectional analysis of CMS Open Payments (2018-2024) for PGY-5 residents in OS and GS graduating in 2025. Residency programs were identified, and PGY-5 rosters were compiled from program websites. Residents were linked to Open Payments records. Payments were categorized as Consulting Fees/Grants/Charity, Travel/Education Support, and Hospitality. Payment prevalence and payment amounts were compared between specialties, with adjustment for institution type and geographic region. Results:. Across 150 institutions (120 GS programs, 117 OS programs), 1,591 residents were analyzed. Overall, 861 of 1,591 residents (54%) had ≥1 payment; OS residents had higher prevalence than GS (57% vs. 52%; OR 1.25, 95% confidence interval [CI]: 1.03-1.53; p = 0.03). Unadjusted mean payments were $3,176 (OS) versus $798 (GS) (p < 0.0001). Adjusted mean payments remained higher for OS ($3,202) than GS ($653), a 4.90-fold difference (p < 0.0001), with significant interactions by institution type and region. Conclusions:. Over half of PGY-5 GS and OS residents receive industry payments, although OS receive substantially more overall. These payments are highly concentrated at the top tier of recipients. Training programs, governing bodies, and other key stakeholders should consider developing a structured approach that capitalizes on the industry financial support while minimizing bias in resident education and delivering a more equitable distribution to all residents. Level of Evidence or Clinical Relevance:. Level III (cross-sectional observational study); clinically relevant to graduate medical education policy and conflict-of-interest oversight. See Instructions for Authors for a complete description of levels of evidence.
» Native femoral version (NFV) demonstrates inconsistent correlation with prosthetic femoral version (PFV) and should not be relied upon in isolation for femoral version planning in cementless total hip arthroplasty (THA). » Final stem version is strongly influenced by intramedullary canal morphology, fixation mechanics, and stem design philosophy. Straight, tapered wedge, and diaphyseal-engaging stems demonstrate greater variability in PFV, whereas anatomic and calcar-guided short stems may better preserve NFV. » Current planning methods inadequately characterise three-dimensional canal anatomy and fail to simulate canal-stem interaction, limiting accurate prediction of PFV. » Intraoperative estimation methods remain inconsistent and highly dependent on surgeon experience. Robotic-assisted THA enables real-time PFV measurements and supports femur-first strategies to optimise combined anteversion, although current systems still rely on computed tomography templating without true canal-stem interaction modelling. » Reliable PFV prediction will likely require next-generation planning platforms integrating internal canal anatomy, statistical shape modelling and artificial intelligence-driven modelling into planning workflows.
Background: Gender-based reimbursement disparities in orthopedic surgery remain poorly understood, particularly when accounting for practice composition and setting. The purpose of this study was to compare and evaluate gender-based differences in Medicare reimbursement and practice patterns among female and male orthopedic surgeons. Methods: A cross sectional analysis of public Medicare data from 2013 to 2021 was performed. Outcomes included annual Medicare payments, submitted charges, total services, service categories, and beneficiaries treated by orthopedic surgeons who bill Medicare. Univariate and multivariable analyses quantified differences in payment, practice volume and composition, geographic adjustment, and Current Procedural Terminology (CPT)-matched reimbursements. Results: A total of 29,357 orthopedic surgeons (27,442 men and 1,919 women) billed Medicare fee-for-service during the study period. Female surgeons, on average, submitted 48.3% fewer total charges and received 44.1% lower annual Medicare payments per surgeon compared with male surgeons. These differences persisted after multivariable regression adjusted for practice metrics and excluded top and bottom earners. Female surgeons also billed fewer services, treated fewer beneficiaries, and submitted fewer unique CPT codes. However, payment disparities persisted even after matching surgeons by volume of services, beneficiaries, and years in practice. Male surgeons performed higher volumes of all 10 highest-paying orthopedic CPT codes. In CPT matched analyses, female surgeons received lower reimbursement per service than male surgeons performing identical procedures. Conclusion: These findings suggest that the observed gender-based disparities in orthopedic surgery Medicare reimbursement cannot be explained by differences in volume, procedural mix, or geographic practice cost. Instead, they likely reflect a combination of structural and behavioral mechanisms described in prior literature that may influence how access to clinical opportunities, referrals, and reimbursement practices unfold in surgical practices. Variations in coding practices may represent an important focus for future investigation and targeted educational initiatives. Level of Evidence: Level III , Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence.
