Ronny Lopes,1 Pieter D’Hooghe,2 Giovany Padiolleau,3 Alessandro Carrozzo4 1Foot and Ankle Department, Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, Lyon, France; 2Foot and Ankle Department, Fortius Clinic, London, UK; 3Foot and Ankle Department, Santé Atlantique, Saint-Herblain, France; 4Orthopedic Surgery Department, Link Campus University, Rome, ItalyCorrespondence: Ronny Lopes, Foot and Ankle Department, Centre Orthopedique Santy, FIFA Medical Center of Excellence, Hôpital Privé Jean Mermoz, Groupe GDS-Ramsay, 24 Avenue Paul Santy, Lyon, 69008, France, Email docteurronnylopes@gmail.comAbstract: Chronic ankle instability is a common condition with a substantial public health burden. When non-operative treatment fails, surgery should address both the ligament injury and associated lesions. Their identification relies on a comprehensive physical examination, which remains challenging and has limited reproducibility. This narrative Current Concepts review summarizes the mechanical and structural physical examination findings, the clinical tests used to assess the lateral ligament complex, medial ligamentous structures, the distal tibiofibular syndesmosis, the subtalar joint, associated impingement lesions, and generalized joint hypermobility, that inform surgical planning. For the lateral ligament complex, the anterior drawer and talar tilt tests demonstrate high specificity but limited sensitivity. Modified maneuvers, including the anterolateral and reverse anterolateral drawer tests, may improve diagnostic accuracy. However, reported reliability and accuracy remain inconsistent, and no single test is both highly sensitive and specific, supporting a bilateral, comparative, multi-test examination. A secondary aim of this review is to evaluate how patient positioning influences examination feasibility. No single position enables complete assessment, and comparative reliability studies are lacking. Based on biomechanical rationale and clinical experience rather than comparative evidence, the prone position may offer practical advantages, allowing a lateral ankle view and isolated subtalar assessment, but these potential advantages have not been confirmed by comparative studies. Current best practice remains a systematic, bilateral examination using complementary tests while recognizing the limitations of each maneuver.Keywords: ankle joint, joint instability, physical examination, lateral ligament, ankle, patient positioning, reproducibility of results
Dustin J Kress,1 Ayush Ippalapelli,2 Moaid Shaik,3 Natalie Dunn,3 Jenna R Skiff,3 Lucy Nordberg,1 Toufic R Jildeh11Department of Orthopedics, Michigan State University, East Lansing, MI, USA; 2College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA; 3College of Human Medicine, Michigan State University, East Lansing, MI, USACorrespondence: Toufic R Jildeh, Department of Orthopedics, Michigan State University, 4660 S Hagadorn Road, Suite 420, East Lansing, MI, 48823, USA, Tel +1 517 884 6100, Email touficjildeh@gmail.comPurpose: Antipsychotic prescribing continues to rise among older adults, the group most likely to present for orthopedic surgery, and orthopedic surgeons now operate regularly on patients taking these agents. Guidance for managing them around an operation sits largely in the psychiatric, anesthesiology and pharmacologic literature rather than the surgical one. This narrative review gathers the orthopedic-specific evidence and organizes it by whether a finding reflects the medication or the psychiatric illness for which it was prescribed.Findings: Antipsychotic exposure is associated with higher all-cause revision and periprosthetic fracture after total knee arthroplasty, and second-generation exposure raises all-cause and aseptic revision after shoulder arthroplasty independent of psychiatric diagnosis. Venous thromboembolism roughly doubles after primary total knee arthroplasty. Among geriatric hip fracture patients antipsychotics are the only medication class independently linked to in-hospital falls, and preoperative use independently predicts postoperative delirium that prophylaxis does not prevent. Spine, sports medicine and trauma surgery all show worse outcomes in patients carrying a psychiatric diagnosis, yet none of those literatures disentangles the drug from the disorder. Thromboembolism and the shoulder revision signal are the clearest drug-attributable exceptions. Hyperprolactinemia-mediated hypogonadism, metabolic derangement and impaired fracture healing remain plausible but unproven. Nearly all available evidence is retrospective.Conclusion: Antipsychotic therapy should continue through the perioperative period unless a specific reason exists to stop it. Abrupt discontinuation risks psychiatric relapse, which is harder to manage than the perioperative risks the drugs themselves carry. Low bone mineral density, poor glycemic control and thromboembolic risk are all worth addressing before surgery, drawing on psychiatry and internal medicine. Antipsychotics are not recommended for delirium prophylaxis. Whether altering therapy improves orthopedic outcomes has not been studied prospectively.Keywords: antipsychotic medications, orthopedic surgery, perioperative management, periprosthetic fracture, venous thromboembolism, postoperative delirium
Rita Saad,1 Johnny Saadeh,1 Fouad Assaf,1 Emanuel Youssef Dib,1 Ali Khalouf,1 Elyssa Kiwan,1 Ramzi Moucharafieh1– 31Department of Orthopaedics and Traumatology, Faculty of Medicine, University of Balamand, Balamand, Lebanon; 2Department of Orthopaedic Surgery, Clemenceau Medical Center, Beirut, Lebanon; 3Department of Medicine, European University Cyprus, Nicosia, CyprusCorrespondence: Rita Saad, Department of Orthopaedics and Traumatology, Faculty of Medicine, University of Balamand, Koura, Balamand, Lebanon, Tel +96171362406, Email ritahsaad@hotmail.comAbstract: Exosome-based orthobiologics have emerged as a potential cell-free regenerative strategy in sports medicine and orthopaedics through extracellular vesicle (EV)-mediated modulation of inflammation and tissue repair. However, translation into clinical practice remains limited by heterogeneous product definitions and manufacturing methods, inconsistent characterization, uncertain potency, and limited high-level clinical evidence. This narrative review examines EV biology, musculoskeletal applications, consensus standards, and regulatory considerations relevant to clinical translation. PubMed and Google Scholar were searched from December 2025 through April 2026 for scientific literature addressing EV biology, musculoskeletal applications, product characterization, clinical evidence, safety, and regulation, supplemented by relevant regulatory and consensus sources. Recurring scientific, regulatory, patient-safety, and governance considerations identified during the review informed development of the EOAF domains. Because the term "exosome” is frequently applied to heterogeneous EV preparations without confirmation of exosomal biogenesis, EV is used as the preferred terminology where appropriate, while "exosome” is retained when referring to vesicles of established exosomal origin or products marketed as "exosomes”. Based on the considerations identified in the reviewed literature, we propose the Exosome Orthobiologic Accountability Framework (EOAF), an unvalidated due-diligence model comprising five domains: Regulatory Accountability, Product Accountability, Evidence Accountability, Patient Accountability, and Governance Accountability. These domains organize the evaluation of regulatory status, product identity and manufacturing transparency, evidence quality, patient protection, and institutional oversight. The EOAF is intended as a conceptual framework rather than a validated clinical decision tool and requires stakeholder evaluation and prospective validation before its clinical utility can be established. Current evidence supports the biological potential of EV-based therapies, but routine musculoskeletal use remains constrained by limited clinical evidence and insufficient product standardization. Future translation will require reproducible manufacturing, rigorous EV characterization, validated potency assays, long-term safety assessment, and well-designed clinical trials.Keywords: exosomes, orthobiologics, extracellular vesicles, accountability framework, regenerative medicine
Youssef Jamaleddine,1,2 Emanuel Youssef Dib,3 Majed Ali,3 Ihab Nahle,1,2 Joseph Mouawad,1,2 Chahine Assi,1,2 Nizar Natout,4 Ramzi Moucharafieh,3,4 Mohammad Badra3,41Department of Orthopedic Surgery, Lebanese American University Medical Center–Rizk Hospital, Beirut, Lebanon; 2Department of Orthopedic Surgery, Lebanese American University School of Medicine, Beirut, Lebanon; 3Department of Orthopedic Surgery, Faculty of Medicine, Balamand University, Beirut, Lebanon; 4Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center, Johns Hopkins International, Beirut, LebanonCorrespondence: Joseph Mouawad, Department of Orthopedic Surgery, Lebanese American University Medical Center–Rizk Hospital, Beirut, Lebanon, Email joeamouawad@gmail.comAbstract: Spinal fusion alters segmental biomechanics and redistributes mechanical load to the levels above and below the arthrodesis, which may accelerate degeneration at those levels. When such degeneration becomes symptomatic, producing new-onset back pain, radiculopathy, or neurological deficit, the condition is termed adjacent segment disease (ASD). ASD is a recognized cause of late postoperative morbidity and revision surgery after lumbar fusion, with cumulative estimates of approximately 16.5% at 5 years and 22– 36% at 10 years. Conventional management has centered on neural decompression combined with extension of the existing fusion construct. Although effective, revision fusion carries greater operative complexity, increased blood loss, prolonged recovery, and higher complication rates than the index procedure, and lengthening the construct transfers stress to newly adjacent levels. Endoscopic spine surgery has emerged as a less invasive alternative that permits targeted neural decompression through small working corridors while preserving the paraspinal musculature and posterior stabilizing structures. This narrative review examines the evolving role of endoscopic techniques in ASD after lumbar fusion and compares them with conventional revision fusion in terms of indications, outcomes, and limitations. The transforaminal, interlaminar, and unilateral biportal endoscopic approaches are described, together with the technical challenges imposed by reduced disc height, epidural scarring, and distorted anatomy in previously operated segments. Reported series demonstrate significant improvements in pain and function, favorable perioperative profiles, and low complication rates, with clinical efficacy comparable to open revision surgery in controlled comparisons. A pragmatic treatment algorithm is proposed that stratifies patients by symptom pattern, imaging-defined pathology, and segmental stability. Endoscopic decompression appears most appropriate for stable segments with focal neural compression, after assessing segmental translation and angulation on flexion-extension radiographs; significant instability or deformity remains an indication for fusion-based revision. The available evidence is dominated by retrospective series, and randomized comparative trials are lacking.Keywords: adjacent segment disease, spinal fusion, surgical decompression, lumbar vertebrae, endoscopy, reoperation
Fouad Assaf,1 Rita Saad,1 Johnny Saadeh,1 Georges Sakhat,1 Hussein Akil,1 Hady Ezzeddine,1 Mohammad Badra,1,2 Ramzi Moucharafieh1,21Department of Orthopedics and Traumatology, Faculty of Medicine, University of Balamand, Tripoli, North Governorate, Lebanon; 2Department of Orthopaedic Surgery, Clemenceau Medical Center, Beirut, Beirut, Governorate, LebanonCorrespondence: Fouad Assaf, Department of Orthopedics and Traumatology Faculty of Medicine, University of Balamand, Kalhat, Al-Kurah, P.O. Box 100, Tripoli, North Governorate, Lebanon, Tel +961 71 313 044, Email fouadassaff@gmail.comAbstract: Disorders of the long head of the biceps tendon (LHBT) are a common source of anterior shoulder pain and are frequently encountered in patients undergoing shoulder surgery. Biceps tenodesis has gained popularity because it addresses biceps-related symptoms while preserving muscle contour and function. This narrative review summarizes contemporary evidence on LHBT tenodesis, with particular emphasis on fixation constructs and tenodesis level, and integrates current evidence into a practical framework for surgical decision-making. A literature review was performed using PubMed/MEDLINE, Scopus, and Google Scholar, incorporating clinical studies, biomechanical investigations, systematic reviews, and meta-analyses evaluating tenodesis techniques, fixation methods, outcomes, and complications. Current evidence indicates that top-of-groove, suprapectoral, and subpectoral tenodesis can provide favorable pain and functional outcomes, with comparative clinical studies generally demonstrating limited clinically meaningful differences between levels. Subpectoral tenodesis may more completely address groove-related pathology but is associated with approach-specific risks, whereas biomechanical differences among interference screws, suture anchors, cortical buttons, and onlay constructs have not consistently translated into differences in clinical outcomes. Rehabilitation protocols vary considerably and are commonly influenced by concomitant procedures. The available evidence is limited by heterogeneous techniques and patient populations, relatively few randomized comparisons, and limited long-term follow-up. Accordingly, no single tenodesis level or fixation construct can currently be considered universally superior. Patient-specific factors, groove pathology, surgical context, and the strength and applicability of the available evidence should inform individualized surgical decision-making.Keywords: biceps tenodesis, long head of biceps tendon, suprapectoral, subpectoral, fixation
