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[This corrects the article DOI: 10.2106/JBJS.OA.25.00278.].
Large Language Models (LLMs) are increasingly used for health information, but concerns exist regarding performance disparities for non-English speakers, potentially exacerbating health inequities. Appropriate information is critical for patients with limited English proficiency undergoing orthopedic procedures such as total hip arthroplasty (THA). This pilot study evaluated differences in the clinical reliability of English and Spanish responses to common THA questions generated by leading LLMs. Three widely accessible LLMs (ChatGPT-4o, Gemini 2.0 Flash, and Microsoft Copilot) were evaluated using 10 standardized frequently asked questions on THA, posed in English and Spanish. Responses were independently graded by language-fluent medical experts using a 4-point rubric (1 = Unsatisfactory to 4 = Excellent) assessing clinical reliability and appropriateness. Nonparametric statistics, including Wilcoxon signed-rank, Kruskal-Wallis, and effect sizes (Cliff's Delta, η2), were used for comparisons. A statistically significant main effect of language was found (p = 0.014, η2 = 0.151), indicating significantly lower clinical reliability scores for Spanish responses in all LLMs. A nonsignificant within-model score decline was observed across all 3 LLMs. Leading LLMs exhibit significant difference in clinical reliability when providing THA information, performing less reliably in Spanish compared with English. This linguistic gap suggests a potential risk for difference in response interpretation and could potentially worsen health inequities for Spanish-speaking populations. Efforts are needed to improve multilingual capabilities and manage biases in medical artificial intelligence (AI). Clinicians and patients should exercise caution when using LLMs for health information in languages other than English until cross-lingual reliability is demonstrably improved. This study highlights a significant linguistic disparity in AI-generated health information for THA. Improving LLMs' multilingual capabilities is essential to promote equitable access to reliable medical education and prevent the exacerbation of health inequities for non-English speaking patients. Level IV. See Instructions for Authors for a complete description of levels of evidence. This study evaluates LLMs in providing THA information in English and Spanish, revealing that Spanish responses are clinically less reliable. The findings highlight linguistic gap in AI healthcare tools, raising potential concerns for patient safety, and widening health inequities for non-English speakers.
[This corrects the article DOI: 10.2106/JBJS.OA.25.00200.].
Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder primarily managed with transphyseal screw fixation. Opioid pain medication is often used postoperatively, but there is little evidence to guide prescribing practices. The purpose of this study was to describe opioid utilization and prescribing practices for patients after screw fixation of SCFE. This was a prospective observational study of patients with SCFE who underwent transphyseal screw fixation. Patients and guardians were contacted on postoperative days 1, 3, and 5 for data collection. Postdischarge analgesic use, pain severity using a parental proxy, and pain control satisfaction were recorded. Patients who underwent surgical osteotomy or open reduction, patients with cognitive disability, or patients who had other injuries impeding accurate pain assessments were excluded. Of the 34 patients recruited for the study, 91.2% (31/34) of patients were prescribed opioid medications. Of these 31 patients, 4 were lost to follow-up (87% follow-up). In total, 266 opioid doses were prescribed and 28 were used (p < 0.0001). On average, patients were prescribed 9.85 ± 3.8 opioid doses but used an average of 0.77 ± 1.27 opioid doses (p < 0.0001). Sixty percent of patients did not use any of their prescribed opioid medication, and 90% were satisfied with their pain postoperatively. In addition, 90% of prescribed opioid doses went unused. There was no significant difference in pain control between patients who took opioids and those who did not for each postoperative day. Analysis of opioid use distribution demonstrated that a prescription of 3 doses postoperatively would be sufficient for greater than 95% of all patients. Overprescription of opioids occurs following screw fixation of SCFE, introducing oversupply into the population. Most patients do excellently with minimal opioid use and have low levels of pain. With adequate nonopioid analgesia counseling and use, outpatient opioid prescriptions following screw fixation of SCFE should be limited. If providers elect to prescribe opioids, we recommend prescribing no more than 3 doses following screw fixation of SCFE. Level II. See Instructions for Authors for a complete description of levels of evidence.
Orthopaedic Surgery remains one of the most competitive medical specialties to successfully match into. Historically, the United States Medical Licensing Examination Step 1 score was a major determinant of match success. Since its conversion to pass/fail status in January 2022, uncertainty has emerged regarding how programs mentor and advise applicants. The purpose of this study was to examine the changes in Orthopaedic Surgery applicant characteristics before the transition from a scored examination (2017-2022) to a pass/fail examination (2023-2025). The authors accessed the Texas Seeking Transparency in Application to Residency survey database, which contains survey information from graduating medical students nationwide regarding residency application characteristics. Characteristics of matched versus unmatched applicants between 2017 to 2022 and 2023 to 2025 were compared. A total of 1,652 Orthopaedic Surgery applicants responded to the survey from 2017 to 2025 (data collected in May 2025). Since the incorporation of a pass/fail Step 1, Step 2 scores and research productivity has increased, volunteerism has decreased, and other academic metrics have remained unchanged. Applicants demonstrated shifts in characteristics without a corresponding change in match rates. From 2023 to 2025, applicants bolstered Step 2 performance and research output as primary differentiators in the absence of a numerical Step 1 score. Traditional academic markers such as class rank, clerkship performance, and Alpha Omega Alpha membership remained stable, while volunteer and leadership involvement declined moderately over the same period. These findings provide evidence-based guidance for navigating the Orthopaedic Surgery selection process in the postnumerical Step 1 era.
Unicompartmental knee arthroplasty (UKA) is an effective treatment for unicompartmental end-stage knee arthritis. Simultaneous bilateral UKAs for patients with bilateral knee arthritis can reduce costs, number of anesthetics, and overall rehabilitation time. It is unknown how the long-term outcomes of unilateral and simultaneous bilateral UKAs compare. In total, 1,939 unilateral and 1,939 simultaneous bilateral medial mobile-bearing UKAs (n = 3,878) from the National Joint Registry were propensity score matched. Kaplan-Meier and Cox regression were used to compare implant survival, revision indications, and mortality. The 10-year implant survival in the simultaneous bilateral group was 92% (95% confidence interval [CI] 90-94) and in the unilateral group was 90% (95% CI 88-92). The simultaneous bilateral group had a lower revision risk (hazard ratio [HR] 0.73, p = 0.01). Revisions for pain were lower in the bilateral group (0.5% vs. 1.2%, p = 0.01). There were no differences in patient mortality. Subgroup analyses found similar trends in 10-year implant survival and revision risk with both cementless (simultaneous bilateral 98% CI 95-99; unilateral 95% CI 91-98; HR 0.66, p = 0.27) and cemented fixation (simultaneous bilateral 91% CI 89-93; unilateral 90% CI 88%-92%; HR 0.85, p = 0.28). Simultaneous bilateral UKAs had better 10-year implant survival and similar mortality to compared with single-unilateral UKAs. For patients with severe symptomatic bilateral unicompartmental knee osteoarthritis, simultaneous bilateral UKAs could be considered to be a safe and effective procedure, particularly as only one operation and postoperative recovery is required. Level IV. See Instructions for Authors for a complete description of levels of evidence.
Antidepressants are commonly prescribed in patients undergoing total joint arthroplasty. While depression influences recovery, the association between perioperative antidepressant use and opioid-related outcomes remains unclear. Given the opioid crisis, we examined whether antidepressant exposure around surgery is independently associated with postoperative opioid abuse after total knee (TKA) and hip arthroplasty (THA), along with systemic and prosthetic complications over short-term and long-term follow-up. We conducted a retrospective cohort study using the TriNetX Research Network (2005-2025). Adults undergoing elective primary TKA or THA were identified using International Classification of Diseases-10/current procedural terminology codes. Patients with antidepressant prescriptions within 3 months before or after surgery were compared with nonusers. Propensity score matching (1:1) balanced demographics, comorbidities, and concurrent medications. Outcomes included opioid abuse diagnoses, opioid prescribing, systemic complications, and prosthetic failures at 90 days and 5 years. Odds ratios (ORs) with 95% CIs were calculated. After matching, 90-day cohorts included 106,516 TKA patients and 46,227 THA patients per group; 5-year cohorts included 44,251 TKA and 16,019 THA patients per group. Despite modest prescribing differences, antidepressant use was associated with higher opioid-abuse diagnoses. At 90 days: TKA 0.10% vs. 0.02% (OR 4.3) and THA 0.12% vs. 0.02% (OR 5.7). At 5 years: TKA 0.74% vs. 0.12% (OR 6.0) and THA 0.42% vs. 0.09% (OR 4.5). Antidepressant users also had increased systemic and prosthetic complications, including prosthetic joint infection, periprosthetic fracture, and revision. Perioperative antidepressant use is independently associated with increased postoperative opioid abuse and higher complication rates after TKA and THA. These findings support preoperative psychiatric screening, medication review, multimodal pain strategies, and closer monitoring to mitigate opioid-related harm in vulnerable arthroplasty patients. Level III. See Instructions for Authors for a complete description of levels of evidence.
Optimal postoperative management of unstable ankle fractures after internal fixation remains unclear. Traditional care uses prolonged immobilization and delayed weight-bearing (DWB), but early mobilization may accelerate recovery. This study evaluated whether early weight-bearing (EWB) and mobilization improve functional outcomes, rehabilitation progress, and complication rates after surgical fixation. This randomized controlled trial included 52 adult patients (18-65 years) with acute unilateral unstable ankle fractures treated through open reduction and internal fixation. Participants were randomly allocated into 2 groups: (1) EWB and mobilization (initiated after 2 weeks of non-weight-bearing) and (2) DWB (continuing non-weight-bearing an additional 4 weeks). The primary outcomes were time to return to work, time to full weight-bearing, and functional recovery measured by the Olerud-Molander Ankle Score (OMAS). Secondary outcomes included range of motion (ROM), physiotherapy sessions, and complication rates. Both groups followed a standardized postoperative rehabilitation program; however, the EWB group commenced protected weight-bearing and physiotherapy at 2 weeks postoperatively, whereas the DWB group remained non-weight-bearing until 6 weeks, when physiotherapy began. Patients in the EWB group demonstrated a faster return to work (41.38 ± 10.20 vs. 51.88 ± 6.18 days, p < 0.001) and required fewer physiotherapy sessions (85% needing <8 sessions vs. 11.5% in the control group, p < 0.001). Functional outcomes were superior in the EWB group, with significantly higher OMAS scores from 6 weeks onward (p < 0.001). ROM improved rapidly in the intervention group, showing significant differences at 6 weeks and persisting through 12 months (p < 0.001). Despite early mobilization, complication rates, including wound complications (3.8% vs. 7.7%, p = 0.552) and fixation failure, were comparable between groups. EWB and mobilization after internal fixation of unstable ankle fractures enhance functional recovery, accelerate rehabilitation, and reduce the time to return to daily activities without increasing complications. However, given the modest sample size and single-center design, these findings should be interpreted cautiously, and confirmation in larger studies is needed before routine adoption. This study was retrospectively registered in the Iranian Registry of Clinical Trials (IRCT20201124049484N1). Level 1b (Individual Randomized Controlled Trial) according to OCEBM Levels of Evidence Working Group. "The Oxford 2011 Levels of Evidence." Oxford Centre for Evidence-Based Medicine. See Instructions for Authors for a complete description of levels of evidence.
Plate fixation in skeletally immature children can cause angular deformity with longitudinal growth even when the plate does not overlie the adjacent physis. While this phenomenon has been described for the distal femur, angular deformity has not been reported following plating in other long bones. The aim of the study was to characterize whether sagittal-plane deformity occurs following volar plating of radius fractures in skeletally immature children and to determine associated risk factors. A retrospective review of volar plating of acute radius fractures in children with an open distal radius physis at a single institution was completed. In patients with at least 4 months of follow-up, the first radiograph and the last follow-up radiograph were evaluated for any change in sagittal angulation distal to the plate. Demographic information was obtained from the electronic medical record. Linear regression analysis was used to determine if distance from the plate to the physis, follow-up time, age, or coexisting ulnar fracture was predictive of any observed changes in angulation. Sixty-one acute radius fractures treated with volar plating at a mean age of 12.1 years (67% male, 70.5% White, 90.2% non-Hispanic) were included. When analyzing by fracture location, 78% (21/27) of the distal-third radius fractures with appropriate follow-up developed at least 10° of apex volar angular deformity, with 44% (12/27) exhibiting greater than 20°. Middle-third and proximal-third fractures did not exhibit similar degrees of angulation (only 13% [4/30] and 0% [0/4] of included patients developed more than 10° of deformity, respectively). Linear regression analysis revealed distance of the plate to the physis and follow-up time to be strong predictors of angulation (both p < 0.0001). Children with radius fractures, particularly those in the distal-third, treated with a volar plate may develop apex volar angular deformity. While the exact rate of this phenomenon is unclear, these findings underscore the importance of strict surgical indications and vigilant postoperative monitoring beyond fracture healing, and represent a paradigm shift in understanding growth modulation following plating. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Conversion total hip arthroplasty (THA) is performed as a salvage operation for patients who develop symptomatic posttraumatic arthritis following open reduction internal fixation (ORIF) of displaced acetabular fractures. Historically, high failure rates in this patient population were related to acetabular loosening. Recent studies, however, have demonstrated improved outcomes with modern techniques. This study aims to evaluate the outcomes and survivorship of early conversion THA after high-energy acetabular fractures at our institution. A retrospective review was performed of all patients who underwent acetabular ORIF and subsequent conversion THA at a Level I trauma center between 2002 and 2022. Patients with less than 1 year follow-up after conversion THA without complication were excluded. Patient demographics, injury characteristics, perioperative details of ORIF and THA, complications, and subsequent reoperations and revisions were recorded. A total of 144 cases were included. The average age was 51.3 years at the time of ORIF with transverse posterior wall (46.5%) and posterior wall (30.6%) fracture patterns predominating. The median time from ORIF to conversion THA was 1.1 years (interquartile range [IQR], 0.7-1.8). Complications occurred in 47 THAs (32.6%), with dislocation (n = 19, 13.2%) and periprosthetic joint infection (n = 17, 11.8%) being the most common. The reoperation and revision rate following conversion THA was 21.5% and 18.1%, respectively. The median time from conversion THA to revision THA was 0.5 years (IQR, 0.1-1.3), with 69.2% of revisions occurring within the first year. Early conversion THA following acetabular ORIF in our cohort was associated with a marked rate of complication and revision surgery. Although aseptic loosening was less prevalent, instability and infection rates were significant concerns. These findings underscore the need for continued improvements in managing this challenging patient population. Level III. See Instructions for Authors for a complete description of levels of evidence.
The literature comparing patient-reported outcomes of the same patient's primary and revision total knee arthroplasty (TKA) is nonexistent, and comparisons between revision and primary TKA are sparse. We aimed to fill this gap by comparing the Oxford Knee Score (OKS) and satisfaction for the same patient between their primary and revision TKA and assess these by different reasons for revision. We identified an 11,584-patient single-center TKA cohort of whom 382 patients went on to revision during 2005 to 2024. Patients answered OKS and satisfaction questionnaires as part of routine clinic visits, which we assessed preoperatively and postoperatively at years 1, 5, and 10 for both primary and revision TKA. We performed descriptive analyses and used logistic regression to estimate the association between patient characteristics and dichotomous outcomes. Infection was the most common reason for first revision (N = 127) followed by instability, loosening, and stiffness. Patients revised for aseptic loosening/osteolysis reported the highest rates of satisfaction. OKS is lowest for patients revised for stiffness both before and after their revision (mean OKS 18.5 preop, 21.6 at 1 year). Furthermore, most of the patients who were not satisfied after their primary were not satisfied after their revision. Despite the low postrevision OKS, exactly half (50%) of patients revised for stiffness who were not satisfied after their primary TKA, reported being satisfied with their revision. Patients revised after 10 years were more likely to be satisfied a year after their revision than those revised in the first 2 years, odds ratio 9.7 (95% confidence interval 1.2-80.2). Patients who initially had good results and had a late failure of their primary TKA generally fared well after revision, especially when revised for mechanical issues such as aseptic loosening. Patients revised earlier, especially those with stiff knees or who had worse early satisfaction scores, were less likely to see benefits from revision. Level III retrospective cohort study. See Instructions for Authors for a complete description of levels of evidence.
Orthopaedic surgery still has one of the lowest representations of female physicians of all specialties. This investigation evaluated the association of female non-orthopaedic surgeon faculty (NOSF) and female orthopaedic surgeon faculty (OSF) with female resident composition in orthopaedic surgery residency programs. A secondary objective was to evaluate the association between female leadership and female residents. It was hypothesized female NOSF, OSF, residency program leadership, and departmental leadership are positively correlated with female resident composition. Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs for the 2024 to 2025 academic year were included. Military residencies and residency programs that did not report residents and faculty were excluded. The total number of OSF and female OSF was recorded from both program websites (W-OSF) and programs' self-reported data (SR-OSF) in 2 publicly available databases. The number of female residents, NOSF, and leadership was extracted from program websites. Gender identity was confirmed using the National Provider Identifier database. Univariate, multivariate, and correlation statistics between female residents, OSF, NOSF, total faculty, and other program characteristics were examined. In all, 198 programs reported residents and faculty and were included. The percentage of female residents was significantly correlated with the number of female W-OSF (rs = 0.495, p < 0.001), female NOSF (rs = 0.489, p < 0.001), and female SR-OSF (rs = 0.401, p < 0.001), and the percentages of female W-OSF (rs = 0.402, p < 0.001) and female SR-OSF (rs = 0.339, p < 0.001). Programs with female faculty had significantly larger resident cohorts (23.4 vs. 14.1, p < 0.001) and percentages of female residents (22 vs. 12.7, p < 0.001). Programs with female residents had more total residents (23.1 vs. 12.8, p = 0.002), OSF (32.6 vs. 17.4, p = 0.014), and percentage of female OSF (12.2 vs. 4.9, p = 0.011). Programs with female program directors had significantly more female residents (6.9 vs. 5, p = 0.021) and higher percentages of female W-OSF (17.9 vs. 11.1, p = 0.003) and female residents (25.1 vs. 20.6, p = 0.048). Female non-orthopaedic surgeon faculty were associated with female resident diversity. Female orthopaedic surgeon faculty and program directors were also associated with more female residents. Efforts to increase female faculty and leadership may be associated with increased female trainees. Level III. See Instructions for Authors for a complete description of levels of evidence.
Venous thromboembolism (VTE) poses significant risk of morbidity and mortality in orthopaedic trauma patients. Thromboelastography (TEG) analysis has been demonstrated to provide value in demonstrating hypercoagulability and predicting the risk of post-injury VTE. The primary aim was to investigate if TEG analysis at the time of admission following severe extremity trauma predicts thromboembolic events. We hypothesized that previously described elevations in maximal amplitude (MA) on initial TEG would correlate with an increased risk of VTE. This was a secondary study of PREVENT CLOT, a multicenter, randomized trial that enrolled adult patients with an extremity fracture (from hip to midfoot or shoulder to wrist) treated operatively or any pelvic or acetabular fracture. TEG at admission was performed according to local protocols. The primary outcome of this analysis was postoperative VTE. We assessed the association between admission TEG values and VTE using bivariate and multivariable regression analyses. Statistical significance was set at p < 0.05. Thousand one hundred eighty-three patients enrolled participants in the PREVENTion of CLots in Orthopedic Trauma (PREVENT CLOT) trial had TEG analysis performed on initial presentation. Of these patients, 47 (3.97%) had a symptomatic postoperative VTE at a median of 9 days (interquartile range, 4-18 days). There were no differences in VTE rates when examining MA of ≥65, ≥69, or ≥72 (p = 0.12, 0.21, and 0.19, respectively). However, on admission TEG, reaction time (R-time) was significantly higher among those who experienced a postoperative deep venous thrombosis (2.45 vs. 1.79, p < 0.01). After controlling for confounders, R-time of ≥2.0 was associated with a 2.1-fold increased odds of VTE (OR 2.13, 95% confidence interval 1.06-4.28, p < 0.001). In contrast to previous smaller retrospective studies, elevated admission-TEG MA values were not predictive of VTE following operative orthopaedic extremity trauma in this secondary analysis of a large multicenter prospective study. Our findings suggest that an increased R-time on the admission TEG, which is thought to be indicative of a longer time to form a clot, may be paradoxically associated with an increased VTE risk in orthopedic trauma patients. Level II. See Instructions for Authors for a complete description of levels of evidence.
Revision total hip arthroplasty (R-THA) often requires removal of well-fixed acetabular components, where minimizing bone loss and operative time are critical. While manual extraction tools have been the traditional approach, powered systems device may improve efficiency, yet comparative clinical data remain limited. We performed a retrospective review of 98 R-THAs (32 powered, 66 manual) from an institutional database (2021-2024). Patient demographics, operative characteristics, extraction times, and healthcare utilization outcomes (length of stay [LOS], discharge disposition, 90-day readmission, 90-day complications, and 1-year reoperations) were analyzed using nonparametric and categorical statistical tests. Baseline characteristics were similar across groups. Cup sizes removed and reimplanted were largely comparable between groups, indicating minimal differences in bone preservation. Time to cup removal was significantly shorter with the powered device, with 82% completed in ≤10 minutes and none exceeding 20 minutes, compared with the manual group where 58% required 5 to 10 minutes, 33% required 10 to 20 minutes, and 8% exceeded 20 minutes (p < 0.001). Healthcare utilization metrics, including LOS ≥3 days (50.0% vs. 56.4%, p = 1.000), nonhome discharge (25.0% vs. 18.2%, p = 0.572), 90-day readmission (21.9% vs. 7.6%, p = 0.054), 1-year reoperation (6.3% vs. 7.6%, p = 1.000), and 90-day complications (21.9% vs. 13.6%, p = 0.457), did not differ significantly. The use of the powered acetabular extraction system was associated with significantly reduced extraction times compared with a manual extraction device in R-THA. One-year reoperation rates were comparable, as were complication/readmission rates and replacement cup sizes. These findings highlight the efficiency benefits of powered explantation as well as its safety. Level III (Retrospective comparative cohort study). See Instructions for Authors for a complete description of levels of evidence.
Total knee arthroplasty (TKA) clinical trials inform surgical decisions by reporting adverse events (AEs), including serious adverse events (SAEs), other adverse events (OAEs), and deaths. However, concerns persist regarding discrepancies in AE reporting between trial registries, such as ClinicalTrials.gov, and peer-reviewed publications, even after the implementation of Food and Drug Administration Amendments Act Section 801 and the Final Rule of 2017, laws introduced to mitigate selective reporting and enhance public transparency. We conducted a systematic registry-to-publication comparison of 92 TKA-focused clinical trials with posted results on ClinicalTrials.gov between 2009 and 2024. Data on SAEs, OAEs, and deaths were extracted from registries and matched peer-reviewed publications using a pre-registered protocol. Descriptive statistics were used to evaluate discrepancies and trends over time. Regression analysis was used to assess the impact of the Final Rule and variables associated with changes in reporting score. AE reporting was consistently more complete in ClinicalTrials.gov entries than in publications. SAE count mismatches were present in 95% of trials, and mortality data were omitted from 87% of pre-Final Rule Applicable Clinical Trial (ACT) publications. Post-Final Rule trials continued to underreport SAEs and deaths in publications, with no significant improvement in reporting completeness. Only 15% of trials listed AEs as formal outcomes in registries, and 66% of post-Final Rule ACTs omitted SAE reporting in the publication. Despite regulatory mandates, AE reporting in TKA trials remains inconsistent and incomplete across publications. These discrepancies risk undermining surgical decision-making and evidence-based guidelines. Enhanced enforcement, editorial accountability, and stricter adherence to reporting standards such as Consolidated Standards of Reporting Trials Harms are necessary to improve transparency and patient safety in orthopaedic research. Level II. See Instructions for Authors for a complete description of levels of evidence.
» Conventional treatment of shoulder periprosthetic joint infection (PJI) consists of prolonged intravenous (IV) antibiotics injected into a PICC line. This method can be associated with adverse events such as catheter-related infections, extended hospitalizations, and higher medical costs. » The OVIVA trial demonstrated that oral antibiotics are no less effective than IV antibiotics as previously thought for complex orthopedic infections. These findings have sparked interest in the use of oral antibiotics for shoulder PJI. » Current data on the use of oral antibiotics in shoulder PJI is limited but growing. A number of studies assess the effects of oral antibiotic therapy on the shoulder, with most being small and retrospective. » Early evidence in shoulder PJI suggests that oral antibiotic therapy may provide satisfactory outcomes in select cases, though confirmation in high-quality, multicenter trials is essential.
Hip arthroplasty implants are classified as Class III medical devices by the US Food and Drug Administration (FDA), requiring rigorous evaluation to ensure safety and efficacy. While these standards aim to ensure safety, device recalls remain an essential component of postmarket surveillance to address unforeseen performance issues. The objective of this study was to characterize the frequency, causes, and regulatory origins of FDA-recalled hip arthroplasty implants, identifying trends in device failure and implications for patient safety. A retrospective review of the FDA's medical device recall database was conducted, focusing on implantable hip arthroplasty devices and assistive technology from 2002 to 2024. Data were categorized by device type, recall class, reason for recall, and regulatory approval pathway. Trends over time were analyzed using negative binomial regression. Of 1,863 hip-related recall records screened, 771 implantable devices met inclusion criteria. Design flaws accounted for the most recalls (35.8%), followed by packaging (24.9%) and labelling errors (11.7%). Most recalls were Class II (94.3%) and approved through the 510(k) pathway (94.7%). The number of recalls peaked in 2014 and has declined in recent years (p < 0.001). Robotic-assisted and navigation-related systems accounted for 1.8% of recalls and were frequently associated with software-related design problems (57.1%). Most recalled hip implants were approved through the 510(k) pathway. However, this likely reflects the high volume of devices approved through this mechanism rather than inherent pathway risk. Design-related failures were most prevalent, often involving modular junctions or material degradation. Although robotic and navigation systems currently account for a small minority of recalls, they introduce novel, distinct software-related failure modes that warrant continued postmarket surveillance as these technologies evolve. Level III. See Instructions for Authors for a complete description of levels of evidence.
Implicit gender biases in letters of recommendation (LoRs) may differentially influence the success of applicants to residency positions. With the inevitable use of large language models (LLMs) such as ChatGPT to draft LoRs, concerns have emerged regarding whether these models reproduce human biases in their writing. The purpose of this study was to examine whether ChatGPT exhibits gender bias when drafting LoRs for hypothetical orthopaedic surgery residency applicants. Thirty paired prompts were created describing a variety of mentor-mentee relationships, manipulating only the applicant's gendered name and pronouns while holding all other factors constant. Prompts were sequentially input into ChatGPT-5.0, and output LoRs were saved. Linguistic Inquiry and Word Count (LIWC) software was used to characterize LoRs across 4 summary measures and 28 word categories. Paired t tests were used to compare the composition of male and female letters across these dimensions. Word counts were compared similarly. The mean length of recommendations for men was 304 ± 53 words. For women, the mean length was 310 ± 47 words. There was no significant difference in word count between groups (p = 0.364). However, recommendations for women were composed of more auxiliary verbs (4.67% ± 1.10% vs. 4.17% ± 1.02%; p = 0.045), communication-related words (0.80% ± 0.51% vs. 0.59% ± 0.46%; p = 0.047), and personal pronouns (10.48% ± 1.18% vs. 9.82% ± 0.87%; p = 0.005) than recommendations for men. A follow-up analysis using a gender-neutral name, while only varying pronouns between prompts demonstrated that recommendations for women were composed of more "prosocial" words than recommendations for men (3.27% ± 1.16% vs. 2.79% ± 1.00%; p = 0.003). ChatGPT-assisted drafting of LoRs includes nuanced and systematic gender-based linguistic differences. For orthopaedic letter writers, the use of LLMs must be accompanied by structured review, bias-aware training, and standardized templates to avoid inadvertently perpetuating inequities.
This 5-year longitudinal study evaluated changes in occupational radiation exposure and radiation-induced skin injury among orthopaedic surgeons, focusing on the effects of educational campaigns. Orthopaedic surgeons at Hirosaki University were surveyed in 2019 and 2024. Self-reported weekly fluoroscopy ("beam-on") time and dermatologist-graded hand skin findings were compared. Educational campaigns (2020-2023) emphasized As Low As Reasonably Achievable principles and personal protective equipment. We hypothesized that repeated education would improve radiation-safety attitude, reduce self-reported fluoroscopy time, and mitigate dermatologic injury. The proportion of surgeons cautious about radiation increased from 5.8% to 70.9%. The median weekly self-reported fluoroscopy time decreased from 9.5 to 8.0 minutes (p = 0.045). The prevalence of radiation-induced skin injury declined from 34.9% to 25.6%. Inter-rater reliability was excellent (weighted κ = 0.910). Nonspine surgeon status predicted improvement in skin condition. During the 5-year period in which repeated radiation-safety education was conducted, surgeons demonstrated improved safety attitudes, decreased self-reported fluoroscopy time, and improved dermatologist-graded skin findings. These observations indicate an association between educational activities, self-reported exposure, and skin findings, but do not establish causality because exposure was self-reported and the study lacked a control group. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The growth of value-based purchasing programs has increased interest in understanding risk factors for readmission and preventing unplanned readmissions. The aim of this study was to estimate rates and risk factors for 30-day readmission following inpatient total shoulder arthroplasty (TSA) in Pennsylvania between 2010 and 2018. We examined inpatient TSA between 2010 and 2018 in Pennsylvania using a statewide administrative discharge data set. Readmissions were for any cause and to any hospital in the state, and not only to the operating hospital. Potential risk factors included patient demographics, comorbidities, and discharge destination. Logistic regression was used to identify significant risk factors. Among 14,333 patients receiving TSA, 469 (3.27%) were readmitted within 30 days. Patients admitted on an urgent or emergent basis had 65% greater odds (odds ratio [OR] = 1.65, p = 0.009) than patients treated on an elective basis. While patients covered by commercial insurance had 24% lower odds of readmission (OR = 0.76, p = 0.04), patients covered by Medicaid had twice (OR = 1.95, p = 0.002) the odds of readmission. Relative to patients with no comorbidities, patients with 1 to 2 comorbidities had 54% greater odds (OR = 1.54, p < 0.0001), and patients with 3+ comorbidities had triple the odds (OR = 3.14, p < 0.0001) of readmission within 30 days. Discharge destination was a significant predictor of readmission, with patients discharged with home health having 50% greater odds (OR = 1.49, p < 0.0001) and patients discharged to a skilled nursing facility having more than twice the odds (OR = 2.19, p < 0.0001) of readmission within 30 days. In this statewide analysis, there were several significant risk factors for 30-day readmission following inpatient admission for TSA, many of which may be useful targets for hospitals to prevent costly orthopaedic surgery readmissions. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.