Limb deformities have a close pathological link with peripheral nerve injuries; however, there is currently a lack of analysis and summary of research trends in this field aimed at elucidating the close relationship between limb deformities and peripheral nerve repair. Based on the Web of Science Core Collection database, this study retrieved 897 articles published between 2001 and 2025. A bibliometric analysis using CiteSpace and VOSviewer was therefore conducted to comprehensively map the research landscape, hotspots, and evolving trends in this field, revealing a sustained annual upward trend in research output. The University of Washington (UW, Seattle) was the institution with the most publications and the greatest impact. The Journal of Pediatric Orthopaedics was the journal with the most publications, while the Journal of Bone and Joint Surgery-American Volume was the journal with the greatest academic impact. Keyword analysis identified two major clusters of interest: diabetic peripheral neuropathy and foot deformities, involving studies on Charcot neuroarthropathy, diabetic foot ulcers, and amputation prevention; and birth-related brachial plexus palsy and its secondary shoulder and elbow deformities, focusing on functional reconstruction strategies such as tendon transfer and osteotomy. Burst keyword analysis revealed a clear shift in the research focus. From 2003 to 2013 (the early period), studies primarily focused on single-site functional impairments and conservative treatments (such as botulinum toxin). From 2014 to 2025 (the recent period), the focus shifted toward investigating "prevalence" and "risk factors," as well as conducting in-depth studies on "reconstructive" surgery, diabetic foot ulcers, and molecular mutation mechanisms. Current research in this field focuses on the bidirectional relationship between "malformations" and "nerves," exploring how nerve injuries cause malformations and investigating secondary nerve compression and damage following malformations. Peripheral neuropathies, such as diabetic peripheral neuropathy, Charcot-Marie-Tooth disease, and obstetric brachial plexus palsy, are the key direct or indirect causes of specific limb deformities (such as foot deformities, talipes, and forearm supination deformities). Research on the mechanical effects of deformities on nerves focuses on how skeletal deformities (such as elbow valgus/varus or knee valgus) result in or exacerbate nerve entrapment syndromes (such as ulnar nerve or common peroneal nerve injuries) through abnormal biomechanical mechanisms (such as excessive traction or dynamic compression). During surgeries for correcting complex deformities, the use of intraoperative nerve monitoring provides real-time early warning to avoid iatrogenic brachial plexus injuries and ensure patient safety, which has become a prominent technical focus. Previous studies have established the criteria for early monitoring of shoulder deformities and Mallet functional assessment following obstetric paralysis. Research over the past 5 years has focused on the mechanisms by which deformities exert mechanical effects on nerves, as well as the application of precision surgical techniques and intraoperative nerve monitoring. Surgical repair strategies for cubital tunnel syndrome and ulnar nerve palsy-induced claw hand are also among the key clinical areas of interest. Overall, these findings indicate that research on limb deformities associated with peripheral neuropathy and injury repair has evolved into two major research domains, focusing on nerve repair for deformities caused by diabetic peripheral neuropathy and limb deformities resulting from obstetric paralysis. Current research trends are moving toward precision, minimally invasive approaches, and multidimensional efficacy assessments. Future research should deepen the understanding of the "deformity-nerve" interaction mechanisms, focus on early warning systems, intraoperative nerve monitoring, and individualized functional reconstruction, and thereby improve patient outcomes and surgical safety.
Distal radial fractures (DRFs) and malleolar fractures (MFs) represent almost one-third of Dutch emergency room fractures. The WARRIOR trials showed that routine follow-up radiographs obtained >2 weeks post-injury were unnecessary in most cases and safe to omit. This study evaluated 2 strategies to reduce such imaging: dissemination of WARRIOR evidence and a tailored de-implementation strategy. This multicenter retrospective observational study included adults with a DRF (OTA/AO 23A to 23C) or MF (Lauge-Hansen SA 2, SE 2 to 4, PE 1 to 4, or PA 1 to 3) treated at 5 hospitals in the West Netherlands region. Centers 1 and 2 (Level I) were participants in the WARRIOR trials; Centers 3 to 5 (Level II) were not. Exclusion criteria were open, pathological, high-energy, or SA 1 fractures. Three cohorts were compared: historical controls (n = 846; at Centers 1 and 2), after dissemination (n = 337; at Centers 1 to 5), and after de-implementation (n = 314; at Centers 1 to 5). The mean age was 55 years, and 67% were female. The de-implementation strategy included educational sessions, performance feedback, and updated guidelines. The primary outcome was the number of routine follow-up radiographs per patient; secondary outcomes were the number of treatment-phase radiographs, the total number of radiographs, and the proportion of patients without routine follow-up imaging. Operative and nonoperative fractures were analyzed jointly. In Centers 1 and 2, the mean number of routine radiographs per patient decreased by 1.41 (95% confidence interval, 1.10 to 1.72) after dissemination and by a further 0.26 (0.07 to 0.46) after de-implementation for MFs, and decreased by 0.71 (0.49 to 0.94) after dissemination but by only a nonsignificant further 0.09 (-0.08 to 0.26) after de-implementation for DRFs. The probability of no routine follow-up imaging increased by 44.2% (37.1% to 51.3%) after dissemination and by a further 13.2% (3.6% to 22.8%) after de-implementation for MFs, and increased by 41.9% (36.5% to 47.3%) after dissemination but changed by a nonsignificant -3.0% (-10.2% to 4.2%) after de-implementation for DRFs. In Centers 3 to 5, the mean number of routine radiographs per patient decreased after active de-implementation by 0.38 (0.18 to 0.57) for MFs, and by 0.30 (0.16 to 0.43) for DRFs, compared with the number after dissemination. The probability of no routine follow-up imaging increased after de-implementation by 11.4% (4.8% to 18.0%) for MFs, and by 21.9% (13.8% to 30.1%) for DRFs, compared with the rate after dissemination. Both research dissemination and a tailored de-implementation strategy substantially reduced routine follow-up radiographs for DRFs and MFs, supporting their use to decrease low-value radiographs in trauma care. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
The use of orthobiologics has received increasing interest given the potential positive treatment effects on symptoms and tissue regeneration. However, there remains substantial variability surrounding the uses of orthobiologics in clinical practice. The purpose of this study was to create an international Delphi expert consensus statement on the use of orthobiologics in musculoskeletal medicine. A working group consisting of 6 members developed 77 initial statements for review by a 24-member panel of international experts. Surveys were conducted in 3 rounds and administered electronically to participants. Participants were asked to respond to each statement using a Likert scale of "strongly disagree," "disagree," "neither disagree nor agree," "agree," and "strongly agree." The final consensus statement included those statements that achieved ≥70% agreement and <20% disagreement. Statements that did not initially achieve consensus were iteratively revised between rounds, which included the incorporation of qualifying language to reflect areas of clinical uncertainty. Sixty-two final statements were utilized in round 3. Each round had 100% participation. Consensus increased sequentially from 48.1% (37 of 77 statements) in round 1 to 96.8% (60 of 62 statements) in round 3. Complete consensus (≥70% agreement and <20% disagreement) was achieved in the following categories: general orthobiologics and PRP (platelet-rich plasma) topics; PRP for knee, hip, and glenohumeral osteoarthritis; PRP for Achilles tendinopathy; PRP for lateral epicondylitis and rotator cuff tendinitis; PRP for meniscus repair augmentation; bone marrow aspirate concentrate; autologous conditioned serum; amniotic derivatives; gene therapy; exosomes; and biologic delivery methods. Some of the topics concerning PRP for rotator cuff repair augmentation and autologous cell-based therapies did not achieve consensus. A high degree of consensus was achieved across statements concerning appropriate use cases for various orthobiologic therapies. However, many of the adopted statements retained qualifying language, reflecting persistent areas of uncertainty in orthobiologic preparation, dosing, and indication-specific efficacy. Despite high levels of agreement across most categories, experts contended that dosing, preparation methods, and quality control remain areas of uncertainty and inconsistency that require standardization in order to allow for reproducible and meaningful treatment effects.
Vascular endothelial growth factor inhibitors (VEGFi) are widely used for metastatic cancer management but are known to impair wound-healing. In spinal metastasis surgery, postoperative wound complications remain a clinical challenge, and the perioperative management of systemic antineoplastic therapies remains poorly defined. Current recommendations regarding postoperative VEGFi reinitiation are largely consensus-based and range from 28 to 40 days. The aims of this study were to evaluate the association between perioperative antineoplastic therapies and wound complications and to define the optimal timing of postoperative VEGFi reinitiation. This retrospective cohort study included 1,164 Taiwanese patients (684 male and 480 female; median age, 60.7 years [interquartile range, 51.5 to 68.8 years]) who underwent spinal metastasis surgery at a single tertiary center between 2010 and 2022. The outcome was postoperative wound complications within 90 days. Multivariable logistic regression was used to identify independent risk factors. The association between the timing of postoperative VEGFi reinitiation and wound complications was assessed using receiver operating characteristic curve analysis and the Fisher exact test. Wound complications occurred in 301 patients (25.9%). Multivariable analysis identified diabetes mellitus (odds ratio [OR] = 4.58; p < 0.001), poor performance status (Eastern Cooperative Oncology Group score ≥2; OR = 3.07; p = 0.002), perioperative use of VEGFi (OR = 4.12; p < 0.001), and perioperative use of antimetabolites (OR = 2.24; p = 0.04) as independent risk factors. Patients reinitiating VEGFi within 40 days had higher complication rates than both nonusers and those reinitiating VEGFi after 40 days, with the former comparison reaching statistical significance. One-quarter of the patients undergoing spinal metastasis surgery experienced postoperative wound complications. Perioperative use of VEGFi was an independent predictor, and our results suggest that there should be a postoperative cessation interval of 40 days to reduce wound-related risk. Clinicians should balance the oncologic benefits of early VEGFi reinitiation against the heightened risk of complications. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Although reverse total shoulder arthroplasty (rTSA) is widely used to treat a variety of complex shoulder pathologies, the management of the subscapularis tendon during rTSA remains controversial. The aim of this study was to prospectively compare outcomes following rTSA with and without lesser tuberosity repair for subscapularis management. This patient-blinded randomized controlled trial, conducted at a single institution, enrolled patients with a sufficiently intact subscapularis suitable for reattachment. Patients were randomized to either repair or no repair of the lesser tuberosity osteotomy (LTO) fragment to which the subscapularis was attached. Pre- and postoperative assessments involved radiographs, clinical examinations, and patient-reported outcomes, including a validated internal rotation functional score. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score. Eighty-five shoulders in 81 patients met the inclusion criteria and had at least 2 years of follow-up. Forty-three of these shoulders had been randomized to LTO repair. At 2 years of follow-up, the repair group demonstrated significantly better ASES scores compared with the no-repair group (90.4 versus 82.3, p = 0.01). Repair provided 7 times better odds of achieving improved internal rotation range of motion. There were no significant differences in other active shoulder motions or outcome scores. In primary rTSA, subscapularis reattachment (by repair of the LTO) yielded better functional outcomes and internal rotation range of motion, as well as a trend toward a better internal rotation functional score. These benefits were seen without sacrificing shoulder motion in other planes. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
➢ Argentine orthopaedics was shaped by the influence of Dr. Vittorio Putti (Rizzoli Institute, Bologna, Italy). Dr. Carlos E. Ottolenghi, one of Dr. Putti's most distinguished disciples, together with Dr. José Valls, founded the Instituto de Ortopedia y Traumatología at Hospital Italiano de Buenos Aires in 1926. Prof. Ottolenghi transformed the Orthopaedic Service into a leading academic center and pioneer of subspecialization, serving as a foundational driver of orthopaedic development in Argentina and Latin America, while establishing strong international academic connections and collaborations.➢ Major milestones include the establishment of one of the earliest institutional bone banks and the performance of one of the world's first reported massive bone allograft reconstructions (1948); the performance of the first Charnley total hip replacement in the Americas (1967) and the first total knee replacement in Argentina (1970); and the early adoption of intramedullary nailing (1972), knee arthroscopy (1976), and femoral bone impaction allografting (1987). These contributions helped to define modern orthopaedic practice across Latin America and influenced global reconstructive strategies.➢ Advances such as surgical navigation (2010) and augmented reality (2025) have strengthened its role as a regional and globally connected center of excellence, particularly in musculoskeletal oncology.➢ Over the past 25 years, 180 residents and 160 fellows have been trained in our institute, and more than 500 indexed publications have been produced in the last 10 years, with alumni holding leadership roles across major orthopaedic centers worldwide, amplifying our institute's global footprint.➢ A merit-based, highly selective system based on excellence determines who becomes a staff surgeon. Currently, 85% of the actual staff surgeons completed residency training in our department, fostering a unique sense of institutional identity and perceived belonging. This experience reinforces the concept that excellence in orthopaedics transcends geographic boundaries and can emerge as a global reference from any setting committed to innovation, mentorship, and academic rigor.
Total ankle arthroplasty (TAA), traditionally performed through an anterior approach, has generally been reserved for older patients. A lateral transfibular approach requires minimal osseous resection and permits implantation into denser bone, which may make it a durable option for younger candidates. This study compared midterm implant survivorship and clinical and radiographic outcomes following primary transfibular TAA in patients younger and older than 55 years. Patients who underwent primary transfibular TAA and had a minimum follow-up of 5 years were included. Patient-reported outcome measures (PROMs) included the 12-Item Short-Form Health Survey (SF-12), Ankle Osteoarthritis Scale (AOS), and visual analog scale (VAS) for pain. Radiographic alignment, range of motion, and periprosthetic cysts (radiolucency of >2 mm) were assessed. Adverse events and reoperations were reported. Outcomes in younger (<55 years old) and older (≥55 years old) patients were compared using multivariable linear regression and linear mixed models. Two hundred and fifty-one ankles (in 236 patients; 86% White) were included. The younger group included 72 ankles (in 70 patients, mean age of 45.4 years [95% confidence interval (CI), 43.7 to 47.1] years) with a mean of 6.9 (6.2 to 7.5) years of follow-up; the older group included 179 ankles (in 166 patients, mean age of 65.7 years [64.7 to 66.7] years) with a mean of 7.0 (6.7 to 7.3) years of follow-up. The younger group more commonly had a primary diagnosis of posttraumatic arthritis (83% versus 61%) and a history of ankle fracture fixation (84% versus 68%) (both p < 0.05). There were no significant differences between the younger and older groups in the rate of adverse events (40.3% versus 33.0%), time to reoperation (21.7 versus 27.4 months), implant revision (1.4% versus 0%), or periprosthetic cysts (5.6% versus 2.8%). In analyses controlling for confounding variables, age did not demonstrate significant associations with pre- or postoperative PROMs, alignment, or range of motion (all p > 0.05). Although this study was not designed to determine equivalence between the age groups, favorable midterm outcomes were observed in both younger and older patients. These results suggest that transfibular TAA may be a viable treatment option for end-stage ankle arthritis across a wide age range, but longer-term follow-up is needed. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Degenerative osteoarthritis (OA) of the hip often arises from structural abnormalities that alter load distribution, which leads to progressive chondrolabral damage. Although substantial advances have been made, the existing terminology in the field of hip preservation remains heterogeneous and inconsistently applied, limiting scientific communication and treatment standardization. The aim of this article is to link evidence from existing literature to develop a framework in the form of a structured lexicon, one that defines the morphological features and pathomechanical mechanisms that are relevant to the symptomatic, pre-arthritic hip. This descriptive framework was developed through the synthesis of current biomechanical, radiographic, and clinical evidence, combined with expert consensus from an international, multidisciplinary panel. Foundational concepts were derived from basic science research, including tribology, mechanobiology, and contact mechanics, to establish a unified terminology. Three principal wear modes-instability, impingement, and mixed mechanisms-are proposed, corresponding to distinct pathological loading environments. Wear mechanisms include dysplasia with rim overload and stress-related cartilage failure, impingement with cam-induced shear or pincer rim conflict, and secondary inflammatory degeneration. Wear damage is classified by tissue involvement, encompassing labral degeneration, chondrolabral detachment, staged cartilage delamination, and subchondral bone changes (sclerosis, cystic change). By linking lesion topography to underlying mechanics, this framework has diagnostic and therapeutic relevance as well as encompasses radiographic measurements and clinical features of wear that are pertinent to hip instability and femoroacetabular impingement. This lexicon provides a coherent framework for pre-arthritic hip disease, establishing a shared terminology to guide basic-science research integration and the interpretation of current clinical practice in hip preservation.
➢ Periprosthetic joint infection (PJI) remains the most common cause of failure after total joint arthroplasty, with current standard therapies associated with failure rates between 10% and 30%.➢ The 2025 International Consensus Meeting in Istanbul, Türkiye, highlighted the potential benefits of bacteriophage (phage) therapy in managing PJI.➢ One of the barriers to integrating phage therapy into standard clinical PJI care is the knowledge gap between preclinical research and clinical practice.➢ This Expert Review summarizes the key therapeutic advantages of using phages as an adjuvant therapeutic platform for PJI. It also highlights the current challenges that are continuing to limit the integration of phages into standard PJI care.
➢ This review commemorates the centennial of orthopaedic practice at Severance Hospital and Yonsei University College of Medicine by tracing its historical evolution and milestones in modern orthopaedic surgery in South Korea.➢ Chejungwon, the predecessor of Severance Hospital and Yonsei University College of Medicine, was founded in 1885 as Korea's first Western-style hospital and played a pivotal role in the introduction and institutionalization of modern medicine in Korea. This development was made possible through the efforts of American missionaries, who contributed to the early establishment of Western medical education and clinical practice.➢ Modern orthopaedic practice at Severance began in 1926 with the return of Yong-Seol Lee, the first Korean physician to receive structured orthopaedic training in the United States, marking the emergence of orthopaedics as a distinct specialty in Korea.➢ The establishment of an independent Department of Orthopaedic Surgery at Severance Hospital in 1953 further strengthened its academic and clinical foundations during a period characterized by war-related trauma, infectious diseases, and national reconstruction.➢ Over subsequent decades, the department has contributed to the development of orthopaedic subspecialties, clinical excellence, and academic research, while playing a central role in founding and leading the Korean Orthopaedic Association.
Stacked metaphyseal cone constructs can be used to address extensive metaphyseal and metadiaphyseal bone loss encountered during complex primary or revision total knee arthroplasty (TKA). Our study reports the 5-year outcomes of a multicenter cohort of stacked-cone constructs used to manage extensive bone loss encountered during primary or revision TKA. A retrospective review was conducted to identify patients who underwent primary or revision TKA with tibial and/or femoral stacked-cone constructs between July 2016 and September 2025 at 4 tertiary academic institutions. Demographic, operative, clinical, and radiographic data were obtained and analyzed. Five-year implant survivorship free from all-cause reoperation, all-cause revision, and stacked-cone construct revision for aseptic loosening was analyzed using Kaplan-Meier estimation. Eighty-four cases with a mean patient age of 67.3 years and a mean follow-up of 20.85 months were identified. Five-year survivorship was 56.5% (95% confidence interval [CI], 22.7% to 78.3%) free from all-cause reoperation, 65.2% (95% CI, 25.8% to 87.1%) free from all-cause revision, and 91.7% (95% CI, 52.5% to 99.8%) free from stacked-cone construct revision for aseptic loosening. Stacked-cone revision due to aseptic loosening was performed on the tibial side in 1 case (1.2%) at 3.6 years following the index surgery. Five other stacked cones were revised for periprosthetic joint infection (4 all femoral stacked-cone cases) and tibial implant fracture (1 tibial stacked-cone case). Stacked-cone constructs demonstrated excellent 5-year survivorship free from aseptic loosening. However, all-cause reoperations and revisions were common in this cohort, reflecting the complex nature of this patient population. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
The purpose of this study was to determine whether placement of triangular titanium implants (TTI) suprajacent to S2-alar-iliac (S2AI) pelvic fixation screws during multilevel spinal fusion surgery for adult spine deformity reduces pelvic fixation failures. This prospective, multicenter, international, partially blinded randomized clinical trial included 222 patients scheduled for multilevel spinal fusion surgery with S2AI-based pelvic fixation. In the S2AI+TTI group, the mean age was 64.9 years, 54.1% were female, 3.7% were Hispanic, 5.5% were African American, and 1.8% were Asian. In the S2AI-alone group, the mean age was 64.8 years, 58.4% were female, 3.5% were Hispanic, 7.1% were African American, and 0.9% were Asian. Subjects were randomized to pelvic fixation using S2AI screws alone versus S2AI+TTI. Scheduled follow-up included a 24-month full-spine radiograph and a high-resolution computed tomography (CT) scan, which was independently interpreted. The primary composite radiographic end point (S2AI screw breakage, lucency, or pullout, or posterior spinal rod breakage distal to S1) occurred less frequently in the S2AI+TTI group than in the S2AI-alone group (11.0% versus 20.4%, p = 0.0415). Except for rod-screw dissociation and rod fracture distal to S1, all components of the primary composite end point occurred less frequently in the S2AI+TTI group. TTI placement did not affect sagittal or coronal spinal alignment parameters. The rate of rod fracture throughout the spinal construct was slightly higher in the S2AI+TTI group (9.2% versus 5.3%) but the difference was not significant (p = 0.197). Placement of TTI suprajacent to S2AI screws reduced the rate of pelvic fixation failure in patients undergoing multilevel spinal fusion with pelvic fixation. Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
In asymptomatic adults, a harmonious T4-L1-hip axis requires a T4-pelvic angle (T4PA) within 4° of the L1-pelvic angle (L1PA). We evaluated whether T4PA-L1PA mismatch is associated with mechanical complications (MCs) and patient-reported outcomes (PROs) after long-segment surgery for adult spinal deformity (ASD). This single-center retrospective study involved a cohort of patients with ASD undergoing >6-level posterior spinal fusion (PSF) for spinal deformity. T4PA - L1PA was assessed at 6 weeks and followed for ≥2 years. The primary outcome was MCs (implant-related reoperations, with a particular focus on proximal junctional failure [PJF]) events. Multivariable logistic regression included linear and quadratic terms for T4PA - L1PA, adjusted for the Charlson Comorbidity Index (CCI), preoperative alignment, upper instrumented vertebra (UIV), pelvic fixation, and correction magnitude. Predicted probability curves depicted MC risk across the T4PA - L1PA spectrum. Secondary outcomes were attainment of the minimal clinically important difference (MCID) for the Scoliosis Research Society (SRS)-22r and Oswestry Disability Index (ODI). The study included 427 patients (mean age, 61.16 ± 14.82 years; 285 [66.7%] female; mean of 12.50 ± 4.16 instrumented levels), with 78.7% undergoing pelvic fixation; 66 (15.5%) underwent MC-related reoperations. In multivariable analysis (area under the curve [AUC] = 0.72, p < 0.001), higher CCI (OR = 1.21, p = 0.029), pelvic fixation (OR = 2.78, p = 0.022), and greater (T4PA - L1PA)2 (OR = 1.01, p < 0.001) independently predicted MCs; the modeled risk suggested that both under- and overcorrection increased the risk of MCs. (T4PA - L1PA)2 was not associated with MCID attainment for the PROs. Construct- and patient-related factors-particularly pelvic fixation-were associated with MCs. T4PA-L1PA deviation conferred additional nonlinear (U-shaped) risk: normalization was associated with fewer MCs, undercorrection was associated with implant-related failure, and overcorrection was associated with proximal junctional complications. Normalization was not associated with PRO improvement or attainment of the MCIDs for the SRS-22r and ODI. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
The purposes of this study were to determine whether frailty and surgical invasiveness are independently associated with perioperative outcomes and to describe the outcome rates when these 2 risk domains are considered together in pediatric patients undergoing spinal fusion for deformity. This was a retrospective cohort study. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric database (2016 to 2023) was queried for patients who underwent spinal fusion for any spinal deformity. Frailty was classified using the Pediatric Spine Frailty Index (non-frail = 0; mildly frail = 1; frail = 2, 3, or 4, severely frail = 5 or 6). Surgical invasiveness was defined using the Pediatric Spine Surgical Invasiveness Index (low, <5; moderate, 5 to 15; high, >15). The outcomes were any adverse event, severe adverse event, unplanned reoperation, and unplanned readmission within 30 days after surgery. Multivariable logistic regression analyses were performed. A total of 46,399 patients were included (mean age, 13.8 ± 2.6 years; 67.7% female). Increasing surgical invasiveness was associated with increasingly higher rates of adverse events, severe adverse events, unplanned reoperation, and unplanned readmission across almost all frailty categories. Compared with patients who were non-frail, those who were severely frail had markedly higher odds of any adverse event (OR, 6.71; p < 0.001), severe adverse event (OR, 23.17; p < 0.001), unplanned reoperation (OR, 2.81; p < 0.001), and unplanned readmission (OR, 4.13; p < 0.001). Increasing surgical invasiveness was also independently associated with progressively higher odds of adverse outcomes. Compared with low invasiveness, high invasiveness was associated with increased odds of any adverse event (OR, 1.61; p < 0.001), severe adverse event (OR, 2.10; p < 0.001), unplanned reoperation (OR, 1.62; p < 0.001), and unplanned readmission (OR, 1.40; p < 0.001). Both frailty and surgical invasiveness were independently associated with increased perioperative risk in pediatric spinal fusion. Patients with greater frailty who were undergoing more invasive procedures had the highest observed rates of adverse outcomes. Incorporating both patient vulnerability and anticipated operative magnitude into preoperative assessment may support more individualized counseling, shared decision-making, and perioperative planning. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Surgical smoke is a gaseous intraoperative byproduct that contains numerous toxic compounds, including fine particles with a diameter of ≤2.5 µm (PM2.5). However, intraoperative exposure during joint arthroplasty has not been well characterized. In this study, we aimed to quantify PM2.5 exposure during arthroplasty and to determine, by procedure and approach, how often it reached potentially harmful levels. We conducted a single-center prospective study of 83 primary arthroplasties (20 bipolar hemiarthroplasties [BHAs] via a direct lateral approach, 35 total hip arthroplasties [THAs] via a direct anterior approach, and 28 total knee arthroplasties [TKAs]). Intraoperative PM2.5 concentrations were measured using a portable monitor and were mapped to Air Quality Index (AQI) categories. Summary metrics, including maximum and cumulative PM2.5 exposure, were calculated by procedure. Logistic regression was used to estimate odds ratios (ORs) for exceeding AQI thresholds. In BHA and TKA, PM2.5 concentrations increased sharply during field development, whereas they remained low throughout THA. The median maximum PM2.5 concentrations were 129.50 µg/m3 (interquartile range [IQR], 85.44 to 275.28 µg/m3) for BHA, 6.14 µg/m3 (IQR, 2.54 to 23.94 µg/m3) for THA, and 118.80 µg/m3 (IQR, 56.23 to 208.04 µg/m3) for TKA. The concentrations were significantly higher in BHA and TKA (both adjusted p < 0.001) than in THA. At 25% of the normalized surgical time, 80% of BHA cases and 71% of TKA cases reached an AQI of Unhealthy or worse, whereas most THA cases remained within the Good or Moderate categories. The adjusted ORs for reaching an AQI of Unhealthy or worse were 34.280 (95% confidence interval [CI], 7.479 to 215.044; p < 0.001) for BHA and 21.971 (95% CI, 6.011 to 101.814; p < 0.001) for TKA compared with THA. BHA via a direct lateral approach and TKA generated substantially higher intraoperative PM2.5 concentrations than THA via a direct anterior approach, and many cases reached an AQI of Unhealthy or worse. Procedure and approach are not readily modifiable determinants of surgical smoke exposure, underscoring the need for comprehensive control strategies, including smoke evacuation and high-efficiency masks, in arthroplasty practice. Operating room teams may be exposed to potentially harmful levels of surgical smoke during arthroplasty. Understanding the characteristics of this exposure may help to guide strategies to optimize the operating room environment.
Efficient allocation of operating room (OR) time is critical in trauma centers, where unpredictable volumes lead to wasted resources. Forecasting trauma volume is challenging, but integrating exogenous factors with historical patterns may enable proactive scheduling tailored to daily operative demand. This study develops time-series and machine learning models to predict daily orthopaedic trauma operative caseloads. Data for patients undergoing operative management for orthopaedic trauma from January 2012 to December 2023 were aggregated. Models predicted daily caseload in hours using features from hospital records plus regional population and environmental data. Data were split in chronological order into the training set (70%), the validation set (15%), and the test set (15%). Time-series and machine learning models were trained to minimize the mean absolute error (MAE). We evaluated the model's accuracy in predicting 7-hour and 8-hour clinical volume thresholds, using 95% predictive intervals (PIs), and compared its performance with rolling averages and an intuitive model. A total of 9,637 procedures were included. The mean daily caseload was 8.17 ± 5.38 hours. Pattern mining and discovery seasonal autoregressive integrated moving average (PMD-SARIMA) with manually selected features achieved the lowest test MAE of 1.80 hours, outperforming rolling averages over 7 days (MAE, 4.37 hours), 14 days (MAE, 4.23 hours), and 30 days (MAE, 4.15 hours) and intuitive modeling (MAE, 4.73 hours). Most machine learning and time-series models correctly predicted whether daily caseload would exceed an 8-hour OR block ≥85% (95% PI, 77% to 96%) of the time, substantially outperforming rolling average baselines (49% to 57%). Integrating exogenous environmental, temporal, and system-level factors with historical trauma patterns enabled accurate forecasting of daily orthopaedic trauma caseload, substantially outperforming current models. This framework serves as a template that trauma centers can calibrate to their local context to support OR scheduling, staffing, and resource allocation. This predictive framework enables trauma centers to proactively allocate OR time and surgical staff in response to anticipated daily demand. By optimizing these operational resources, hospitals can minimize surgical delays and ensure timely, efficient care delivery for patients with orthopaedic trauma.
Training programs to prepare novice advanced practice providers (APPs) to reduce fractures have not been described or evaluated. The current study evaluated the effectiveness of a structured training program for APPs to deliver effective fracture care independently in emergency department settings. We performed a retrospective review of the first 5 independent distal radial fracture reductions performed by each participant. Radiographic measurements and information regarding patient injury, loss of reduction, and the need for surgery due to failure of closed management were collected. Patients were treated by (1) APPs with structured training (APP group), (2) traditionally trained postgraduate year (PGY)-2 residents (TR2), (3) PGY-2 residents with additional simulation training (SR2), and (4) experienced PGY-4 residents (TR4). We identified 136 patients: 28 treated by the APP group; 24, by TR2s; 52, by SR2s; and 32, by TR4s. Significant differences were seen in post-reduction angulation and percent contact, with the APPs and TR4s achieving better initial reductions as indicated by the least residual angulation and greatest percent contact (all p < 0.05). At the time of follow-up, reductions by the APP group had more favorable outcomes, compared with those performed by residents, with respect to angulation on lateral radiographs (p = 0.047) and percent contact on anteroposterior (p = 0.036) and lateral (p = 0.004) radiographs. Reductions performed by the APP group also showed lower rates of loss of reduction (p < 0.001) and subsequent surgery (p = 0.005). APPs receiving structured training prior to independent care delivery achieved better reductions overall, placed better casts, and had lower rates of loss of reduction and subsequent surgery compared with junior orthopaedic residents. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Sacral fractures are difficult to diagnose. In dual-energy computed tomography (DECT) water/Ca images, edema at fracture sites appears as locally increased water-equivalent density. This study developed an edema-enhanced CT (EECT) technique based on DECT and evaluated its diagnostic performance for sacral fractures. Fifty Japanese patients with suspected sacral fractures (mean age, 82.4 years; 41 women) underwent single-energy CT (SECT), DECT, and magnetic resonance imaging (MRI). On sagittal DECT, the water-equivalent density at the S1 vertebral midline was defined as the standard value (SV); in 16 regions of interest per patient, the relative standard value (RSV) was calculated as the ratio relative to the SV and classified according to MRI findings. Receiver operating characteristic curve analysis determined the optimal RSV cutoff for fracture detection, and EECT images highlighted regions exceeding this threshold. Thirty patients were then independently assessed twice (>3-month interval) by orthopaedic surgeons with <3 years (group A) or >10 years (group B) of experience using SECT (S group), DECT (D group), and EECT (E group) to evaluate fracture presence and localization. Sensitivity, specificity, inter- and intraobserver reliability, and diagnostic accuracy were compared among groups using Cochran Q, McNemar, and Fisher exact tests. The optimal RSV cutoff was 1.000. For both fracture detection and localization, EECT showed the highest sensitivity, specificity, and diagnostic accuracy, particularly for fracture site identification. Inter- and intraobserver reliability were also the highest with EECT, and the performance gap between less experienced and experienced observers seen with SECT was not observed when using EECT. EECT showed better performance than DECT and SECT in sacral fracture detection and localization, providing high accuracy and reliability regardless of observer experience, and it may be useful for sacral fractures. Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Robotic platforms, proprietary registries, and advanced analytics have transformed total joint arthroplasty into a data-intensive subspecialty. Contemporary procedures generate granular operative metrics that are increasingly linked to longitudinal outcomes, benchmarking systems, predictive analytics, and artificial intelligence algorithm development. Yet governance structures defining analytic access, publication rights, secondary data use, and transparency to patients remain incompletely articulated. Surgeons generate operative data, but vendors frequently warehouse and structure these data sets within proprietary ecosystems, while registry governance and contractual agreements may influence analytic access and dissemination. These challenges extend beyond privacy concerns. Arthroplasty data sets increasingly inform quality measurement, reimbursement models, public reporting, and future algorithm development. Without clear governance standards, control over data stewardship, analytic framing, and scientific dissemination may progressively shift away from practicing surgeons and patients. This Viewpoint article examines emerging governance-related challenges within arthroplasty data ecosystems and proposes a framework centered on transparency to patients, data portability, publication protections, and independent oversight. The goal is not to impede innovation, but to ensure that the expanding digital architecture of arthroplasty evolves within transparent, ethically grounded, and academically independent governance structures.
➢ Osteochondral autograft transfer (OAT) restores hyaline cartilage and subchondral bone in a single stage, offering a durable joint-preserving option for focal full-thickness articular cartilage defects in young, active patients.➢ Optimal candidates have unipolar femoral condyle, patellofemoral, or tibial plateau lesions measuring 1 to 4 cm2; outcomes become less predictable once the defect size exceeds 3 cm2. Outcomes are further influenced by age, activity level, sex, alignment, instability, and meniscal deficiency, with older, lower-demand patients and those with larger lesions demonstrating comparatively inferior results.➢ Technical success requires meticulous recipient-site preparation, perpendicular graft harvest, and flush implantation; both arthroscopic and open approaches achieve reliable results.➢ OAT demonstrates high return-to-sport rates (often >85% within 6 months), significant functional improvements, and superiority over microfracture. Outcomes may be comparable or superior to cellular resurfacing or allograft techniques in appropriately selected patients.➢ Emerging biologic adjuncts, recess-filling strategies, and donor-site substitutes may enhance graft integration and reduce morbidity, although long-term clinical benefits remain unproven.