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BackgroundSystematic reviews represent the foundation of evidence-based orthopedic practice, yet their methodological rigor relies heavily on accurate and consistent methodological quality assessment. This step remains time-consuming, labor-intensive, and prone to subjectivity. Recent advances in large language models (LLMs) suggest potential for automating parts of evidence synthesis.PurposeThis study examined whether LLMs can perform AMSTAR-1-based methodological quality assessment evaluations in orthopedic systematic reviews with accuracy comparable to human experts.MethodsTen sports medicine knee reviews were analyzed using three LLMs-GPT-4o, GPT-5, and GPT Consensus-and their binary responses were compared against expert AMSTAR-1 ratings from a published umbrella review (110 decisions). An external validation set of four reviews published between 2022 and 2025 was included to assess generalizability and safeguard against information leakage.ResultsAgreement with human reviewers reached 87% for GPT-4o, 89% for GPT-5, and 90% for GPT Consensus; all models achieved 84% agreement in the validation set. Concordance was strongest for structured, explicitly reported domains such as a priori design, literature search, and study characteristics, and lowest for judgment-based items including grey literature inclusion, publication bias, and conflict of interest.ConclusionsLLMs cannot yet replace human reviewers, they can serve as reliable adjunct tools to enhance efficiency, transparency, and reproducibility in systematic review workflows within orthopedic research.
Despite the significant potential for Clinical Decision Support Systems (CDSSs) to improve care processes and health outcomes, several barriers hinder their widespread implementation in healthcare. While numerous systematic reviews have summarized potential barriers and facilitators for CDSS implementation, a comprehensive framework to guide and evaluate the implementation of CDSSs in healthcare is lacking. This overview of reviews, aims to establish a framework-GUIDE-CDSS-aimed at guiding and evaluating implementation of CDSSs in healthcare. An overview of systematic and scoping reviews was conducted by searching 6 databases. Systematic reviews or scoping reviews that used qualitative research methods to described implementation determinants for CDSSs in the healthcare domain were included. The AMSTAR 2 tool was used to assess the methodological quality. Results were collated into the GUIDE-CDSS framework. This framework describes implementation determinants and elements within those determinants found to impact implementation of CDSSs in healthcare. Twenty-three reviews were included in the analysis. All reviews had at least 2 critical weaknesses, showing a limited methodological quality of included reviews. Eight determinants and 38 elements for implementation of CDSSs in healthcare and were described in the GUIDE-CDSS framework: perceived relevance, perceived effect, trustworthiness, ease of use, workflow, training and skills, resources, and implementation strategy. This overview provides a comprehensive synthesis of the determinants influencing the implementation of CDSSs in healthcare, collated in the GUIDE-CDSS framework. The findings underscore that for successful CDSS development, implementation and evaluation is multifactorial. This study was registered in PROSPERO (No. CRD42024512455).
Systematic reviews and meta-analyses represent the highest level of evidence in clinical research, but the process of article retrieval and screening is labor-intensive. Large language models, such as ChatGPT-5, may offer an efficient alternative, yet their performance in full systematic review workflows remains untested. This study compares ChatGPT-5's Deep Research and Agent Modes with human researchers in replicating gold standard systematic reviews in total joint arthroplasty. Five published systematic reviews were selected as reference articles. Three groups: orthopaedic research fellows, ChatGPT-5 Deep Research Mode, and ChatGPT-5 Agent Mode, independently identified eligible articles using standardized search terms and inclusion/exclusion criteria. Artificial intelligence (AI) searches were repeated 3 times for reproducibility. Extracted articles were evaluated against the gold standard for recall, precision, false positives/negatives, and time efficiency. Newly identified eligible studies were also assessed. The research fellows dedicated 268 hours to screening 9101 articles, achieving 85.2% recall of gold standard articles. Deep Research and Agent Modes averaged 12-14 minutes per search, identifying 47.5% and 40.9% of gold standard articles, respectively. Fellows had fewer false negatives (n = 5) compared with Deep Research (n = 19) and Agent Mode (n = 12). AI models retrieved several additional eligible studies not captured by humans, demonstrating complementary potential. Human reviewers remain superior to current AI models in replicating systematic review article selection, particularly for nuanced inclusion/exclusion criteria. However, ChatGPT-5 significantly reduces search time and can identify additional relevant studies, suggesting its role as a valuable adjunct in systematic review workflows with expert oversight.
Trust in physicians remains a cornerstone of effective healthcare delivery; however, the rapid expansion of online and non-physician health information sources has introduced new challenges to patient decision-making. In orthopedic practice, delayed evaluation of musculoskeletal symptoms-particularly those concerning for malignancy-may be influenced by misinformation and alternative care pathways. We conducted a cross-sectional, nationally weighted survey of U.S. adults (n=200) to evaluate care-seeking behavior, trust in information sources, and endorsement of cancer-related misconceptions. The survey assessed willingness to delay care for persistent bone or back pain, reliance on physician versus non-physician information sources, and responses to conflicting health information. Stratified analyses were performed based on chronic pain status and prior cancer-related experience. Although 85% of respondents identified physicians as their most trusted source of health information, 55% reported regular use of online or social media platforms. A substantial proportion of participants reported willingness to delay care for ≥3 weeks or until symptom progression. Individuals with chronic pain demonstrated significantly higher odds of delayed care-seeking (p<0.05) and misinformation endorsement (OR 1.5-2.5, p<0.05). Reliance on online information was independently associated with delayed medical evaluation (OR ~2.0, p<0.01). Notably, a subset of respondents reported prioritizing online information over physician recommendations when conflicts arose, representing the highest-risk group for delayed care. A pronounced trust-behavior paradox exists in orthopedic care, wherein high trust in physicians does not consistently translate into timely care-seeking. Misinformation and reliance on non-physician information sources contribute to diagnostic delay, particularly among individuals with chronic pain or prior cancer-related experience. Targeted patient education and engagement in digital information spaces are critical to mitigating these risks.
Large language models (LLMs) are a form of artificial intelligence (AI) that have emerged as potential tools to augment systematic review workflows. This study aimed to evaluate GPT-5 as a third reviewer for full-text screening across orthopaedic subspecialties. Three review topics were selected. Python scripts were developed to call on the GPT-5 model via the OpenAI application programming interface (API) to perform full-text screening using predefined inclusion and exclusion criteria. Two human reviewers simultaneously performed screening based on the same criteria. Performance metrics such as specificity, sensitivity, accuracy, positive predictive value (PPV), negative predictive values (NPV), and F1 scores for GPT-5 were calculated based on a gold-standard inclusion and exclusion list developed by a third human adjudicator. Efficiency metrics included total cost and completion time. The number of full-texts screened were 35, 70 and 146 amongst the three review topics. For topic one, sensitivity, specificity, PPV, NPV, accuracy and F1 scores were 100% each. For topic two, sensitivity, specificity, PPV, NPV, accuracy and F1 scores were 93.3%, 98.2%, 93.3%, 98.2%, 97.1% and 93.3% respectively. For topic three, sensitivity, specificity, PPV, NPV, accuracy and F1 scores were 93.3%, 100%, 100%, 99.2%, 99.3% and 96.7%, respectively. Time to completion ranged between 18.1 and 58 min. Cost ranged from $0.84 to $3.29 USD. GPT-5 demonstrated high diagnostic accuracy as a third reviewer for full-text screening across three different subspecialties, with high agreement with final consensus adjudication decisions. These findings suggest that modern LLMs can potentially augment dual-review screening workflows by providing efficient decision-support while preserving methodological rigour. However, the small number of included studies within each topic resulted in wide confidence intervals, and additional validation across larger datasets are necessary. Not applicable.
The SICOT-J, an open-access orthopedic journal affiliated with the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), has been a global orthopedic research platform since 2015. This study provides a scientometric analysis of SICOT-J publications from 2015 to 2025 to evaluate research productivity, citation impact, and collaboration patterns. 542 documents published in SICOT-J and indexed in the Scopus database were analyzed using bibliometric indicators. Data on publication types, subject areas, authorship, institutional and geographic affiliations, funding disclosures, collaboration networks, and citation metrics were extracted. Microsoft Excel was used for data processing and analysis. Key indicators included citations per publication (CPP), relative citation index (RCI), and total link strength (TLS) for collaborative connections. From January 1 2015, to June 30 2025, SICOT-J published 542 articles with an overall CPP of 10.29. Research articles comprised 78.6% of publications, while reviews - though fewer in number - had the highest CPP (23.38). The most frequent topics were arthroplasty (25.83%) and trauma/fractures (24.17%), with the hip and knee as the most studied anatomical regions. Only 5.17% of the articles reported external funding. Fifteen highly cited papers (≥50 citations) were mostly reviews and internationally co-authored. SICOT-J has demonstrated consistent publication growth and international participation, though with notable concentration in a few high-income countries. The high citation impact of reviews and collaborative works highlights the importance of strategic content development. Enhancing funding transparency, supporting underrepresented regions, and promoting emerging topics strengthen the journal's global impact.
The purpose of this clinical practice guideline is to provide evidence-based recommendations for the treatment of pediatric flexible flatfoot, developed in accordance with the Appraisal of Guidelines for Research and Evaluation II framework and with evidence certainty assessed using the GRADE framework and the Oxford Centre for Evidence-Based Medicine levels of evidence system. A multidisciplinary guideline development group under the Limb Reconstruction Committee of the Orthopedics Branch of China International Exchange and Promotion Association for Medical and Health Care systematically searched and reviewed evidence from primary studies including randomized controlled trials, cohort studies, and comparative studies, supplemented by existing systematic reviews and expert society surveys, to evaluate the effectiveness of conservative and surgical interventions and to guide clinicians and families on the content of an optimal treatment pathway. The guideline targets children and teenagers with flexible flatfoot and addresses interventions available to orthopedic surgeons, podiatrists, rehabilitation physicians, and orthotists, including observation, rehabilitative exercises, foot orthoses, subtalar arthroereisis, calcaneal osteotomy, and criterion-based progression to surgery. Structured conservative management should be considered the mainstay of care for all symptomatic children, with a minimum 6-month trial before surgical referral. However, there is limited evidence on the optimal type, dose, and duration of conservative treatment, and what constitutes an adequate trial of nonoperative care remains undefined. Foot orthoses can be helpful for symptomatic relief when pain or functional limitation is present, and rehabilitative exercise programs may allow superior normalization rates compared to orthoses alone. Pain-free ambulation and return to unrestricted sport are key milestones for both conservative and surgical pathways. However, no validated progression or discharge criteria exist to guide the transition from one treatment phase to the next. While the certainty of evidence was low to very low for most components of the treatment pathway, all 15 recommendation statements were formulated through two rounds of Delphi consensus polling, with 13 achieving the predefined ≥75% agreement threshold. This guideline also highlights the need for standardized diagnostic definitions, multicenter registry data, and age-stratified surgical indications not systematically addressed in previously published literature.
Inflammatory bowel disease (IBD) is associated with a range of extraintestinal manifestations, including renal complications. While chronic kidney disease in IBD is well described, the risk of acute kidney injury (AKI) remains less well quantified. We aimed to evaluate the risk of AKI among hospitalized patients with IBD compared to non-IBD populations, and to assess this risk across clinical subgroups. We conducted a systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and registered the protocol with PROSPERO. A comprehensive search of PubMed, MEDLINE, Embase, Scopus, and Cochrane CENTRAL was conducted from inception to June 2025. Eligible studies included cohort, case-control, and randomized control trials reporting on AKI outcomes in IBD versus non-IBD comparators. Meta-analyses were performed using random-effects models. Subgroup analyses were conducted by surgical status, infection, acute coronary syndrome, and general hospitalization. Seventeen retrospective cohort studies involving 20 127 976 patients (140 482 with IBD) were included. IBD was associated with significantly increased odds of AKI (pooled odds ratio [OR]: 1.87; 95% confidence interval [CI], 1.53-2.29). The association was especially prominent in surgical patients (OR: 2.17; 95% CI, 1.73-2.73), including orthopedic (OR: 2.22; 95% CI, 1.50-3.30) and spinal (OR: 2.15; 95% CI, 1.66-2.78) subgroups. Associations in acute coronary syndrome and infection subgroups were less consistent. ROBINS-E (Risk Of Bias In Non-randomized Studies-of Exposures) assessments revealed a moderate risk of bias. A diagnosis of IBD is potentially associated with the development of AKI, particularly in surgical settings. Routine renal monitoring could be considered, especially during hospitalizations and perioperative care.
The optimal management of acute, minimally displaced, or undisplaced scaphoid waist fractures is a clinical equipoise. Although cast immobilization is effective, it requires prolonged wrist restriction. Early surgical fixation aims to expedite recovery but introduces operative risks and incurs higher costs. This systematic review and meta-analysis synthesizes contemporary, high-quality evidence comparing the effectiveness of these two management strategies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search of PubMed, MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) was conducted for randomized controlled trials (RCTs) and prospective comparative cohorts published since January 2013. We included studies comparing early surgical fixation versus cast immobilization in adults with acute, minimally displaced (≤ 2 mm) scaphoid waist fractures. The primary outcomes were radiological non-union incidence and time to union. Secondary outcomes included functional scores, complication rates, and return to work. A random-effects meta-analysis was performed using a restricted maximum likelihood (REML) estimator with Hartung-Knapp-Sidik-Jonkman (HKSJ) adjustments. The risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) and Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tools. The certainty of the evidence was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420261324973). Four RCT cohorts comprising 559 patients met the inclusion criteria. Surgical fixation was associated with a significantly lower risk of non-union than cast immobilization (risk ratio (RR) 0.35; 95% confidence interval (CI), 0.15 to 0.82; I² = 0%). The pooled non-union rate in the cast immobilization arm was 6% (95% CI, 0.00-0.45). The mean difference in the time to radiographic union favored surgery by -3.85 weeks, but this finding was imprecise and not statistically significant (95% CI, -21.60 to 13.90). High-certainty evidence from the largest included trial demonstrated no significant difference in long-term patient-reported functional outcomes (Patient-Rated Wrist Evaluation (PRWE)) at one or five years. The certainty of evidence for non-union and time to union was graded as moderate and downgraded for imprecision. Early surgical fixation reduces the relative risk of non-union in minimally displaced scaphoid waist fractures. However, given the high absolute union rate achievable with conservative management (94%) and the absence of demonstrable long-term functional benefit, the evidence supports initial cast immobilization as a highly effective and appropriate first-line management strategy for these patients. This approach maximizes fracture union while minimizing patient exposure to unnecessary surgical risks and healthcare expenses. Operative intervention should be reserved for cases of confirmed non-union or specific patient-related circumstances.
Frozen shoulder (FS) is a common condition characterized by pain and restricted range of motion; however, its definition varies widely across randomized controlled trials (RCTs). This variability in eligibility criteria may compromise comparability across studies and hinder evidence synthesis. In this scoping review, we aimed to systematically map how FS has been defined in RCTs and identify key elements requiring standardization. We searched the CENTRAL, MEDLINE, and EMBASE databases from their inception to December 2024. RCTs involving adults with frozen shoulder or adhesive capsulitis were included. Two independent reviewer pairs screened the studies based on eligibility criteria. We extracted data from the included studies and categorized them into five domains based on definitional components, including age-related criteria, pain characteristics, range of motion (ROM) limitations, symptom duration, and imaging requirements. Reporting patterns were summarized descriptively and visualized using frequency plots and heat maps. This scoping review was performed in accordance with the Extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews. Of 4,426 records identified, 310 RCTs were included. Use of terminology was inconsistent across studies, with 57.7% employing the term "adhesive capsulitis" and 42.3% using "frozen shoulder." Across domains, age-related criteria showed the greatest convergence; most trials targeted middle-aged adults, typically setting a lower age limit of approximately 40 years and an upper limit between 60 and 70 years. Conversely, the pain criterion was poorly aligned; nearly half of the studies omitted pain thresholds, and those that used diverse Visual Analogue Scale/Numerical Rating Scale cutoffs infrequently specified night pain and functional disturbances. For ROM, most studies required loss in at least two or three planes (commonly flexion, abduction, and external rotation); however, quantitative cutoffs and movement combinations varied, and many trials provided ambiguous thresholds. Symptom duration was unreported in approximately 40% of RCTs; among those that reported it, a minimum duration of ≥3 months was the most common, but it was not universal. Similarly, imaging requirements were inconsistent; plain radiographs were the most frequently used modality, with magnetic resonance imaging and ultrasound utilized in a minority of trials, and >60% of the studies did not cite reference literature to justify their diagnostic criteria. The definition of FS in RCTs differs substantially across diagnostic domains, which may affect the comparability of study populations and the interpretation of treatment outcomes. The development of standardized, clearly described eligibility criteria, particularly regarding terminology, disease stage, pain and ROM criteria, symptom duration, and exclusion of other shoulder pathologies, will help strengthen methodological rigor and improve the interpretability of future clinical trials. Scoping Review; Research Methodology.
Complex regional pain syndrome (CRPS) and chronic postsurgical pain (CPSP) are postoperative outcomes that present with debilitating symptoms for patients. The recovery of patients with these conditions is complicated by the lack of standardized prevention and treatment strategies. Current literature suggests that vitamin C may prevent the development of CRPS. Due to the overlapping proposed mechanisms of CRPS and CPSP, the aim of this review is to summarize the available data on the benefits of vitamin supplementation on CRPS and CPSP. A search of the literature for articles published in the last 10 years was conducted. Systematic reviews, meta-analyses, case reports, and articles that were not published in English were excluded. Ultimately, 10 articles met inclusion criteria. The data suggests that systemic vitamin C plays a significant role in preventing CRPS following various orthopedic surgeries and may possess therapeutic benefit as well. Vitamin B12 improved short-term functional and mental health outcomes as well as decreased neuropathic analgesic consumption. While no clinical studies have been performed on alpha-lipoic acid (ALA), preclinical studies suggest that administration decreases cold allodynia and pain in mice models. Moreover, while no studies have evaluated the effects of vitamin D on CRPS and CPSP, retrospective analysis reveals that CRPS incidence is increased in patients with low vitamin D levels. The literature reviewed reveals that there may be value in considering nutritional supplementation through vitamins in CRPS and CPSP, however, large-scale, randomized controlled clinical trials are warranted to evaluate the potential beneficial effects of these supplements in patients.
Fracture nonunion develops in 5-10% of all fractures and the industry offers biological grafting solutions to address this. Autologous bone marrow aspirate (BMA) may represent an inexpensive alternative, minimally invasive, biologically active adjunct to surgery. This scoping review aimed to analyze the current evidence on the effectiveness and safety of autologous bone marrow aspirate as a standalone treatment in patients with impaired fracture healing (minimum 3 months post-fracture). The data was extracted from Embase, Medline, Cochrane Library, Web of Science, and ClinicalTrials.gov, up to October 30, 2024, and conducted according to the Joanna Briggs Institute Scoping Review Manual and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Randomized controlled trials, non-randomized trials, prospective or retrospective cohort studies, and case series with a minimum of five participants were included. Studies had to report on BMA as a standalone treatment for nonunion and assess at least one outcome related to effectiveness (ex: time to union, radiographic healing, etc.). Two members of the research team independently carried out the screening, selection, and data extraction processes, with a third member resolving any discrepancies. Descriptive data were presented in tabular form, while other findings were synthesized descriptively. Four hundred and sixty-nine articles were found, 55 met the inclusion criteria and 14 were included after full-text review (311 patients) Union rates ranged from 50% (3/6 patients) to 100%, with most studies reporting rates above 80%, within 1.5-10 months. Reported volume and density of injected BMA varied. There were no serious complications or donor-site morbidity. While union rates are encouraging, the absence of control groups across all included studies means that the contribution of BMA to these outcomes cannot be determined. Functional outcomes were not often assessed, and study heterogeneity limits a broader generalization. Defining the concentration and BMA volume needed appears as a next step to validate its effectiveness and guide clinical use, along with adequate control groups. V.
Background: Anterior cruciate ligament (ACL) injuries are increasing in young athletes and many are related to non-contact, spontaneous mechanical fatigue-related ruptures. The objective of this narrative review is to identify and synthesize the anatomical, histological, physiological, and biomechanical basis of extracellular matrix (ECM) factors that contribute to ACL injuries and suggest ways to decrease their occurrence. Methods: The primary investigator searched PubMed, Web of Science, and Google Scholar database titles and abstracts using search phrases with Boolean operators: "anterior cruciate ligament" OR "ACL", OR "cranial cruciate ligament" AND "disease"; "anterior cruciate ligament" OR "ACL", OR "cranial cruciate ligament" AND "spontaneous rupture" OR "non-contact injury"; and "anterior cruciate ligament" OR ACL, OR cranial cruciate ligament" AND "crosslink", "collagen" OR "extracellular matrix"; and "anterior cruciate ligament" OR "ACL", OR "cranial cruciate ligament" AND "microtrauma", OR "sudden" OR "fatigue failure". The primary investigator and a sports orthopedic surgeon reviewed titles and abstracts of diverse evidence sources. From these identified sources, the study team performed full text reviews, selected contributing articles, performed Strength of Recommendation Taxonomy (SORT) grading, and synthesized the following themes: A Hostile Environment, ACL Strain, and Poor Nutrient Delivery; Accumulative ACL Microtrauma and Mechanical Failure; The ACL Differs From Other Ligaments; Collagen, the ECM, and ACL Mechanobiology; Crimps and ACL ECM Stretch; Crosslinks Improve ECM Mechanical Properties; The Delicate Collagen Synthesis and Degradation Balance; Exercise Training and the ACL; Can Nutraceuticals Help Restore the Balance?; Training Induced ACL Hypoxia; Estrogen and the Female Athlete; Counting Pitches or Counting Collagen Fiber Ruptures; and Restoring A Positive Anabolic-Catabolic Collagen Balance. Results: Regular exercise training within a physiologically safe loading range is vital to ACL ECM health. However, low or moderate evidence suggested that poor blood supply, slow metabolism, and a hypoxic environment may unbalance anabolic and catabolic homeostasis. Active rest and recovery concepts that prevent youth baseball shoulder and elbow injuries may help prevent non-contact ACL injuries. Conclusions: More prescriptive active rest and recovery intervals and neuromuscular control training may restore the anabolic-catabolic balance that increases mature crosslink density and improves ACL ECM strength. Confirmatory studies are needed to better establish therapeutic intervention mode(s), timing, dosage, and frequency optimization.
Medial meniscus posterior root tears (MMPRTs) reproduce the biomechanics of subtotal meniscectomy. Repair is favored, but the role of all-inside repair (AR) remains unclear relative to transtibial pull-out (TP). This study aimed to review the biomechanical and clinical evidence on AR for MMPRTs. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO). MEDLINE, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Outcomes included patient-reported outcome measures (PROMs), magnetic resonance imaging (MRI), and biomechanical performance. When available, random-effects meta-analysis was performed. Thirteen studies were included. AR restored contact mechanics and showed load to failure comparable to TP, with lower stiffness. Meta-analysis showed lower conversion to total knee arthroplasty with AR versus non-repair (RR 0.18, 95% CI 0.05-0.58), and no significant PROM differences between AR and TP. AR showed favorable biomechanical properties and improved outcomes versus non-repair. Compared with TP, no significant clinical differences were observed. AR may represent a reasonable option in selected scenarios.
Primary bone tumors are rare yet present a significant burden to patients, with surgery being the mainstay of treatment. We reviewed outcomes of limb salvage (LS) and amputation for management of upper extremity tumors. We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews. A total of 2,886 studies were screened, and 5 studies were included (n = 187 patients; LS = 101, Amputation = 86). Commonly reported outcomes included local recurrence, metastasis at follow-up, and survival. Metastasis and local recurrence rates were in favor of LS surgery, with some studies reporting no differences. Survival was consistently reported to be statistically significantly in favor of LS.
Despite growing evidence supporting lateral extra-articular procedures (LEAP) in anterior cruciate ligament reconstruction (ACLR), clear guidelines on their indication in patients younger than 21 years are lacking, complicating clinical decision-making in this high-risk population. To evaluate whether concomitant LEAP provides clinical benefits compared with isolated ACLR in patients aged ≤ 21 years, while also exploring potential differences between LEAP techniques. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was preregistered on the International Prospective Register of Systematic Reviews (PROSPERO) (<<blinded for review>>). Studies which investigated patients younger than 21 years undergoing primary ACLR combined with a LEAP were included. The primary outcome measure was anterior cruciate ligament (ACL) graft failure. Secondary outcomes comprised patient-reported outcome measures (PROMs), clinical findings, return-to-sport parameters, postoperative complications, reoperation rates, and time to ACL graft failure. A comprehensive literature search was performed in Embase, MEDLINE, PubMed, and Scopus without date restrictions and limited to studies published in English or German. Level I-IV clinical studies with a minimum follow-up of 12 months were included. Study selection and data extraction were conducted independently by two reviewers, and methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Due to anticipated heterogeneity, narrative synthesis without meta-analysis was performed. Overall, the evidence was derived from nine studies including a total of 598 patients with a mean age across studies ranged from 13.0 to 17.0 years. Included studies had a mean follow-up period ranging from 2.0 to 4.3 years. Primary outcomes showed ACL graft failure ranging from 0 to 5.3% following ACLR with LEAP. In comparative studies, graft failure occurred less frequently in ACLR with LEAP (0-6%) than in isolated ACLR (5-12%). Secondary outcomes demonstrated high postoperative functional scores, with Lysholm scores ranging from 92 to 95 and International Knee Documentation Committee (IKDC) scores from 82 to 93, and Tegner activity scores indicating return to moderate-to-high activity levels (7-9). Objective knee stability outcomes showed low rates of grade III pivot shift and limited anterior-posterior laxity. Return-to-sport rates ranged from 88% to 100%, with 61-76% of patients returning to their pre-injury level and mean time to return to sport of approximately 9-11 months. The included studies demonstrated considerable heterogeneity in study design, patient characteristics, and reported outcomes, limiting comparability of the results. In individuals ≤21 years, the addition of a LEAP to primary ACLR may be associated with lower ACL graft failure, improved functional outcomes and rotatory knee stability in comparison to isolated ACLR. However, these findings should be interpreted with caution given the limited and heterogeneous evidence. Level IV. CRD420251083532.
Early mobilization and mobility are essential components of the recovery process following surgery and trauma-related hospitalization. In addition to personalized support from physiotherapists and health care professionals, assistive devices such as walkers play a crucial role in facilitating safe and effective mobility. This scoping review aims to provide a comprehensive overview of the current state of the literature on the design, sensor technologies, and functional applications of smart walkers and to assess the extent to which existing studies reflect clinical use cases. Peer-reviewed English articles published between 2015 and 2024 were identified by searching PubMed, CINAHL, SSCI, and IEEE, focusing on the topic of smart walkers. Secondary analyses and walkers with 2 wheels or fewer were excluded in abstract screening. Study screening and selection were performed according to the Joanna Briggs Institute guidelines for scoping research and reported following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The Rayyan systematic review management software was used for study selection. The articles included were analyzed with respect to the sensor technologies used, their functional capabilities, and their application scenarios. Of the 800 articles screened, 44 (5.5%) met the inclusion criteria. Most of these articles were research reports (n=36, 81.8%) and were conducted in laboratory-based environments (n=30, 68.2%). Most studies evaluated smart walkers in asymptomatic populations (n=29, 65.9%), with half (n=22, 50%) involving younger adults. Among the sensor modalities reported, camera-based and light detection and ranging-based sensors were most prevalent for half of the implementations. Light detection and ranging-based sensors can be categorized according to their primary functions: gait analysis (n=11, 25%), collision detection (n=9, 36%), and navigation (n=5, 11.4%). Load sensors (n=10, 22.7%) and ultrasonic sensors (n=11, 25%) were among the most frequently cited sensor modalities in the literature. Load sensors, also known as force sensors, are integrated into the handlebars, frame, forearm supports, or chest pads of smart walkers. These sensors measure the user's load, providing essential data for calculating body weight support or inferring the user's intention to move. The smart walkers described in the literature were predominantly tested in asymptomatic and younger populations. Bridging the gap between current laboratory-based research and real-world clinical environments, as well as the daily lives of end users, remains a critical objective. Addressing the specific needs of older adults through comprehensive requirements analyses and iterative testing continues to be an ongoing challenge, yet these processes can serve as integral components of research and development projects.
Open tibial fractures remain the most prevalent open fracture, necessitating orthoplastic management with flap reconstruction. Early soft tissue coverage, ideally within 72 hours, is widely regarded as the gold standard for reducing infection, promoting bone healing, and improving limb salvage. However, injury severity, patient comorbidities, and pre-theater coordination pose challenges to the recommended management window, thereby increasing the number of patient-reported complications. A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and were prospectively registered with PROSPERO (CRD420251033412). A comprehensive search of six databases identified comparative studies evaluating flap reconstruction performed within 72 hours versus beyond 72 hours following injury. The primary outcome addressed operative complications. Risk of bias was assessed using ROBINS-I (Cochrane Collaboration, London, UK) and RoB2 (Cochrane Collaboration, London, UK), while evidence quality and methodology review were evaluated using GRADE and AMSTAR-2. From 2010 to 2025, 14 articles met the inclusion criteria among 21 potentially eligible studies, comprising 2652 patients (1859 males and 793 females). Early reconstruction within 72 hours was associated with fewer complications compared with delayed reconstruction. Meta-analysis demonstrated lower risks of infection, osteomyelitis, and amputation (risk ratios of 0.69, 0.28, and 0.55; confidence intervals of 0.47-1.02, 0.16-0.49, and 0.27-1.12, respectively), with a statistically significant reduction in osteomyelitis. Prior reviews had critical methodological flaws, whereas this study achieved a high confidence rating. Flap coverage within 72 hours is associated with improved clinical outcomes and should be prioritized whenever feasible for patients with open fractures of their lower limbs. Despite guideline recommendations, the majority of flap reconstructions are still performed more than 72 hours after injury. This highlights the need for improved multidisciplinary coordination and timely access to specialist orthoplastic care.
Wound complications after direct anterior approach (DAA) total hip arthroplasty (THA) are an important source of postoperative morbidity. Although several risk factors and management strategies have been proposed, data remain heterogeneous. This systematic review aims to characterize the incidence, risk factors, and management of wound complications after DAA THA. A systematic review was done across eight databases (PubMed, Embase, Scopus, Cochrane Library, CINAHL, Web of Science, Ovid MEDLINE, and ClinicalKey) according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies were included if they reported wound complications after primary DAA THA. Data were extracted on complication incidence, risk factors, closure and dressing techniques, and management strategies. A meta-analysis comparing wound complication rates between transverse (bikini) and longitudinal incisions was done using a common-effects model. Thirty-six studies encompassing 35,300 DAA THA were included. The most common wound complications were superficial dehiscence/drainage (1.41%), superficial surgical site infection (1.34%), delayed wound healing (1.15%), and hematoma/seroma (0.80%). Obesity and female sex were the most frequently identified risk factors. Pooled analysis demonstrated that transverse (bikini) incisions were associated with a significantly lower risk of wound complications compared with longitudinal incisions (relative risk 0.45, 95% confidence interval, 0.23 to 0.89; P = 0.0219). Closure technique and dressing choice showed variable influence on complication rates. Most wound complications were successfully managed with local wound care, avoiding the need for revision surgery. Wound complications after DAA THA are relatively uncommon and often manageable with conservative measures. Obesity, female sex, and longitudinal incisions are associated with higher complication risk. Surgical technique, including consideration of incision type and appropriate postoperative wound management, may help minimize complications.
The calcaneo-stop procedure is a minimally invasive surgical technique widely used to treat symptomatic flexible flatfoot (FFF) in pediatric patients. Although generally considered safe, complication rates vary across studies, and no quantitative synthesis has specifically evaluated its adverse event profile. A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Five databases were searched up to May 2025. Studies reporting postoperative complications after calcaneo-stop in patients younger than 18 years were included. Pooled complication rates were calculated using random-effects models, with subgroup analyses based on age, sex, screw type, and diameter. Twenty-two studies involving 1777 patients and 3082 operated feet were included. The overall pooled complication rate was 7.97% (95% confidence interval: 5.96-9.97%). The most frequent complications were postoperative pain (2.79%), reintervention (2.27%), incision-site symptoms (2.23%), peroneal spasm (1.72%), screw breakage (1.42%), superficial infection (1.37%), and screw loosening (0.72%). Higher complication rates were observed in patients older than 13 years (15.84%; P < 0.001), in cortical screws (13.2%), and in screws greater than or equal to 4.5 mm in diameter (13.9%; P = 0.0019). Bioabsorbable screws and 6.5 mm implants showed the lowest complication rates. The calcaneo-stop procedure appears to be a safe and effective treatment for symptomatic pediatric FFF, with complication risk influenced by patient age and implant characteristics.