Controversies exist regarding the appropriateness of antibiotic prophylaxis in patients undergoing a dental procedure following joint replacement surgery. The American Academy of Orthopaedic Surgeons has developed an Appropriate Use Criteria (AUC) for the Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop criteria to determine the appropriateness of antibiotic prophylaxis to reduce the theoretical risk of post-surgical prosthetic joint infection in patients seeking dental care. The AUC algorithmic decision support tool was derived by identifying clinical indications typical of patients undergoing dental procedures following total knee or hip arthroplasty. Four patient scenarios and two treatment options were developed by the writing panel to cover appropriate scenarios related to this topic. Next, a separate, multidisciplinary voting panel rated the appropriateness of each scenario using a nine-point scale. The purpose of this article is to highlight the findings of this AUC and summarize the usage of the AUC for determining appropriateness of antibiotic prophylaxis for post-surgical joint replacement patients in various scenarios.
The United States is a diverse nation, with over 22% of the population speaking a language other than English at home. Barriers and care disparities persist for orthopaedic patients with a non-English preferred language, particularly for those treated in language-discordant settings. The purpose of this study was to assess the linguistic diversity of orthopaedic surgeons and evaluate this relative to census-level linguistic diversity. This cross-sectional observational study analyzed the American Academy of Orthopaedic Surgeons database to assess surgeon language diversity. Data on state, subspecialty, and language(s) spoken were extracted for all surgeons listed. Descriptive statistics were used to evaluate linguistic diversity among surgeons. Differences between surgeon-level and population-level linguistic diversity were quantified using residuals from an expected 1:1 representation, reflecting ideal language concordance. Among the 19,505 orthopaedic surgeons registered in the database, 1,615 (8.28%) spoke at least one language aside from English, with 172 (0.88%) speaking three or more languages. Spanish (61.55%), French (20.87%), and German (12.07%) were the most common second languages. Pediatrics (7.77%) and spine (5.67%) had the highest percentage of multilingual surgeons, while trauma (3.70%) and musculoskeletal oncology (3.19%) had the lowest. Utah (16.59%), New Mexico (13.91%), Florida (12.46%), and Arizona (12.11%) had the highest proportions of multilingual surgeons. In 39 of 50 states, the proportion of Spanish-speaking surgeons is lower than that of Spanish speakers in the population, with the greatest discrepancies in California, Texas, and New Mexico. This study highlights linguistic disparities between patients and orthopaedic surgeons, indicating gaps that may contribute to language-discordant care and reliance on interpreters. Additional assessment of opportunities to increase multilingual representation and care capabilities across health systems is essential to ensure patient-centered and equitable care.
The rise in popularity of battery-powered 2-wheeled electric scooters (e-scooters) has fostered safety concerns, particularly because of a lack of universally recommended safety precautions. Orthopaedic injuries are common in the pediatric population, yet little is known about the trends of e-scooter-related orthopaedic injuries in this population. The aim of this study was to investigate the national trends in orthopaedic injuries among children operating e-scooters over a twenty-year period. The National Electronic Surveillance System, a publicly available database of 102 emergency departments, was retrospectively queried for patients aged 0 to 21 years with an orthopaedic injury related to e-scooter usage between 2005 and 2024. Each case was assigned a sampling weight to produce nationally representative estimates. Linear regressions were used to calculate trends. An estimated 55,653 pediatric orthopaedic injuries were reported during the study period. The weighted estimates of orthopaedic injuries related to e-scooter use had an upward trend from 2005 to 2024, with notable peaks in 2020 and 2024, which were paralleled by annual incident rates. The estimated average annual incidence rate was 204 injuries per 100,000 children per year. Most (65%) of the injuries occurred in male individuals. Children (aged 0-13) accounted for 63% of injuries, and adolescents (aged 14-21) accounted for 37% of injuries. Fractures were the most common injury (71.7%), followed by strain or sprain (25.2%). Most commonly injured anatomical areas were in the upper extremities, particularly the wrist (21.5%), forearm (15.6%), and shoulder (8.4%). Most (90.2%) of the injuries were treated and discharged on the same day. Pediatric orthopaedic-related e-scooter injuries have increased over the past 20 years, with injuries occurring more commonly in male individuals and children sustaining mostly fractures and upper body injuries. As new technologies facilitating high-speed travel emerge, orthopaedic surgeons should be cognizant of the injuries associated with the new products.
Surgical therapy plays a crucial role in the management of osteochondral lesions of the talus to restore joint function and prevent additional deterioration. This study aims to conduct a bibliometric analysis to investigate the research trends and patterns in surgical therapy for osteochondral lesions of the talus. A thorough literature search was conducted on the Web of Science Core Collection (WoSCC) database. Bibliometric and visualized analysis was done using VOSviewers (V 1.6.20), CiteSpace (V 6.3.R1), and the R package "bibliometrix" (V 4.3.3). A total of 413 articles were analyzed. These articles were authored by 2,053 individuals from 1,107 institutions across 180 countries or regions, published in 115 journals, and cited 6,581 references. The annual publication volume showed a fluctuating upward trend with an annual growth rate of 8.12%, peaking in 2021. The United States was the most productive country (n = 127). Among institutions, the University of Amsterdam contributed the most articles. Foot & Ankle International had the highest H-index, total publications, and citations. The top high impact authors included Kennedy JG and Giannini S. The keyword analysis revealed four distinct research clusters spanning from early surgical techniques (2010 to 2014) to advanced regenerative medicine (2018 to 2024), with current emphasis on "bone marrow stimulation," "cartilage repair," and "platelet rich plasma." The citation burst analysis identified "platelet rich plasma" and "arthroscopic findings" as latest emerging topics. This bibliometric analysis demonstrates the evolution from foundational surgical techniques to sophisticated regenerative medicine approaches in OLT treatment. Research frontiers emphasize biological augmentation strategies and precision medicine for personalized therapeutic interventions.
Early, controlled weight-bearing using an antigravity treadmill may improve outcomes following definitive fixation of lower extremity periarticular fractures. We hypothesized that patients randomized to 10 weeks of antigravity treadmill therapy would report better 6-month joint-specific patient-reported function compared with standard of care. This prospective, multicenter, randomized trial included patients 18 to 55 years of age with fractures of the knee and distal tibia randomly assigned to either 10 weeks of antigravity treadmill therapy (intervention) or standard of care (control). The primary outcome was 6-month patient-reported function (Knee injury Osteoarthritis Outcome Score) for patients with knee fractures and Ankle Osteoarthritis Scale for patients with distal tibia fractures. Secondary outcomes included 6-month Patient-Reported Outcomes Measurement Information Systems Physical Function scores, 12-month fracture healing and complications, and 6-week, 3- and 6-month satisfaction with therapy. Of 80 randomized patients, 78 were included in the final analysis (intervention n = 38; control n = 40). Their mean age was 37 years; 55 (71%) had knee fracture and 23 (29%) had distal tibia fracture. The average Knee injury Osteoarthritis Outcome Score were 54 and 61 in the intervention and control groups, respectively (adjusted difference: -6.1; 95% confidence interval, -18.4, 6.2; P = 0.32). The average Ankle Osteoarthritis Scale scores were 28 and 50 for the intervention and control groups, respectively (adjusted difference: -19.5; 95% confidence interval, -39.3, 0.30; P = 0.05). No difference was found between treatment groups in Patient-Reported Outcomes Measurement Information Systems Physical Function, fracture healing, or complications. Patients in the intervention group reported higher satisfaction with their therapy at 6 weeks (9.5 vs. 8.5; P = 0.01) and 3 months (9.5 vs. 8.6; P = 0.04). This study suggests that antigravity treadmill therapy may be beneficial for patients with distal tibia fractures. Moreover, the study demonstrates that a 10-week antigravity treadmill therapy program is safe and feasible with high patient satisfaction, providing foundation for future effectiveness trials for patients with periarticular injuries.
Medicare reimbursements for orthopaedic surgeries have consistently declined over past decades, raising concerns about surgeons opting out of Medicare and reducing coverage for older adults. However, little is known about this phenomenon. We conducted a retrospective evaluation of orthopaedic surgeon Medicare opt-outs as of January 2025. We analyzed charge-payment ratios of orthopaedic surgeries performed in areas with versus without opt-outs and examined the 3-year moving averages and population demographics for areas with opt-outs. As of January 2025, 341 orthopaedic surgeons have opted out of Medicare, representing 0.7% of all opted-out practitioners and 1.7% of 2022 Medicare-enrolled orthopaedic surgeons. The median charge-payment ratio for all orthopaedic surgeries is 18.3% higher in areas with these opt-outs compared with those without (95% confidence interval [CI], 11.7% to 30.1%; P < 0.0001) and 34.5% higher for joint arthroplasty and reconstruction surgeries (95% CI, 9.2% to 51.9%; P = 0.0003). These opt-outs primarily occurred in high-cost regions, with approximately 70% of surgeons practicing in areas with regional price parities greater than 110% of the national average. Consequently, Medicare opt-outs by orthopaedic surgeons have risen from 0.3 to 32.0 annually from 2002-2004 to 2022-2024. In 2022, there were 958 reported Medicare beneficiaries of orthopaedic surgeries per zip code in areas with opt-outs, 612 higher than in areas without opt-outs (95% CI, 277 to 629; P < 0.0001). The median proportion of Medicare-eligible individuals by age in areas with opt-outs is 35.8%, 18.1% higher than the national rate (95% CI, 16.3% to 19.3%; P < 0.0001). Orthopaedic surgeons practicing in high-cost and relatively lower reimbursed areas are increasingly opting out of Medicare, disproportionately affecting older adults and higher need areas. These results suggest that correcting declining Medicare surgery reimbursements is critical to minimize coverage lapses for a growing older adult population, which is an important issue in orthopaedic surgery.
The prevalence of degenerative knee and lumbar spine pathologies has been rising given the aging population. It is increasingly common for patients to undergo both total knee arthroplasty (TKA) and lumbar fusion (LF). The purpose of this study is to determine whether there is a disparate risk of and time to revision lumbar fusion (rLF) in patients with a history of TKA. We retrospectively queried the national Premier Healthcare Database ® for individuals who received a LF from 2016 to 2022. Patients with a history of TKA prior to their lumbar fusion were noted (TKA + LF). Patient characteristics were compared using chi-squared for categorical variables and t-tests for continuous variables. Multivariate logistic regression was used to determine odds of rLF using these covariates: age, gender, race, inpatient/outpatient status, primary lumbar fusion diagnosis, obesity status, osteoporosis status, and Elixhauser comorbidity count. 1:1 propensity-score-matched Cox Proportional Hazards models and Kaplan-Meier curves were created to assess time-based risk for rLF. The TKA + LF cohort was composed of 11,696 patients (mean age = 69.2 years, male = 40.6%, white = 85.5%). The LF cohort was composed of 117,688 patients (mean age = 60.9 years, male = 46.6%, white = 83.1%). The TKA + LF cohort had a higher proportion of patients with obesity (34.7% vs. 23.0%, p < 0.001) and osteoporosis (8.1% vs. 4.4%, p < 0.001). The TKA + LF cohort had a higher rate of rLF (10.8% vs. 6.5%, p < 0.001). There was no difference in time to revision between cohorts (512.18 ± 455.86 vs. 499.05 ± 470.45 days, p = 0.356). Multivariate logistic regression found increased odds of rLF in the TKA + LF cohort (OR = 1.695, 95% CI = 1.588-1.809, p < 0.001), and propensity-matched Cox models (n = 11,696 patients) found a higher time-based risk for rLF in the TKA + LF cohort (HR = 1.685, 95% CI = 1.541-1.844, p < 0.001). This study demonstrates increased odds and time-based risk for rLF in the TKA + LF cohort. Future research is needed to clarify the mechanisms driving this association between TKA history and rLF. These results highlight a need for comprehensive treatment of knee and spine pathology to achieve maximal outcomes.
Ethnic, racial, and socioeconomic disparities are well-documented in orthopaedics, including pediatric scoliosis. Spanish-speaking patients face compounding disparities in accessing linguistically and culturally concordant physician-patient interactions and patient resources. This study contributes to existing literature by providing an updated and extended analysis of the quality, credibility, and readability of online Spanish-language patient educational materials on pediatric scoliosis. A search for the top 50 results of "escoliosis en los niños" (scoliosis in children) was conducted across search engines. Spanish-speaking patients are likely to interact with Google, Yahoo, and Bing. Duplicates were removed, primary review assessed inclusion and exclusion criteria, and secondary review evaluated relevance. Each source was assessed independently by two reviewers for the following: categorization, Journal of American Medical Association Benchmark Criteria, Brief DISCERN questionnaire, and the Fernández-Huerta Index for credibility, quality, and readability, respectively. Scores were compared using Wilcoxon rank-sum tests. Of the 61 sources, most were categorized as Physician/Community Hospital, Industry, and News. The median readability score aligned with an eighth-grade to ninth-grade reading level. No websites achieved the recommended reading level (<6th grade) for patient educational materials. The median Journal of American Medical Association Benchmark score was 2 (interquartile range, 1 to 3), with only four websites meeting all criteria. The median Brief DISCERN score was 14 (interquartile range, 11 to 18), with only 36% meeting the >16 threshold for adequate quality. No statistical differences were observed in quality, credibility, or readability between the two most common categories: Physician/Community Hospital and Industry. These findings revealed an insufficient standard of resources on pediatric scoliosis that Spanish-speaking patients are likely to access through online search engines. Given disparities in orthopaedic care for Spanish-speaking patients, this highlights a need for increased awareness among healthcare professionals and institutions to create accessible, credible, transparent, and readable resources on pediatric scoliosis in Spanish.
Degenerative lumbar spine disease represents a leading global source of disability, with spondylolisthesis contributing substantially to the burden of low back pain and impaired function. Lumbar fusion remains a commonly performed surgical strategy for degenerative spondylolisthesis, although decompression alone versus decompression with fusion continues to be an area of active debate, particularly in select low-grade cases. This study aimed to compare inpatient complications, discharge disposition, mortality, and costs between anterior lumbar interbody fusion (ALIF) and posterolateral fusion (PLF) for degenerative lumbar spondylolisthesis. The National Inpatient Sample was queried from 2016 to 2022 for elective admissions of adults with a primary diagnosis of lumbar spondylolisthesis undergoing ALIF or PLF. Encounters with both approaches or additional interbody techniques were excluded. Outcomes included perioperative complications, in-hospital mortality, discharge disposition, length of stay, and inflation-adjusted costs. Survey-weighted logistic regression and generalized linear models adjusted for demographics, comorbidities, and hospital factors. Significance was set at the P < 0.05 level. We identified 57,475 weighted admissions: 12,410 ALIF and 45,065 PLF. In adjusted models, PLF was associated with higher odds of transfusion (OR, 2.60; P < 0.001), acute posthemorrhagic anemia (OR, 1.47; P < 0.001), cerebrospinal fluid leak/dural tear (OR, 3.57; P < 0.001), and the adverse-events composite (OR, 1.68; P < 0.001). PLF also demonstrated greater odds of nonroutine discharge (OR, 1.19; P = 0.002). In-hospital mortality was exceedingly rare and not meaningfully different. ALIF was associated with higher mean costs ($43,000 vs. $31,500; P < 0.001) despite shorter length of stay (2.81 vs. 3.31 days; P < 0.001). ALIF for degenerative spondylolisthesis was associated with fewer perioperative complications and lower odds of nonroutine discharge than PLF, though at substantially higher inpatient costs. These findings highlight a clinical-economic tradeoff between anterior and PLF strategies at the national level. III.
Innovations in reverse total shoulder arthroplasty (rTSA) have improved outcomes and mitigated complications through improvements in implant design, surgical techniques, and enabling technologies. The purpose of this study was to evaluate the association between technologic evolutions in rTSA and the incidence of acromion and scapular spine fracture (ASF). The authors hypothesize that ASF incidence has decreased over time and that this decrease is temporally associated with successive changes in implant design, surgical technique, and enabling technology within a single-design platform. A retrospective case series from January 2007 to December 2024 was conducted. All patients undergoing rTSA by a single-implant manufacturer with a constant implant design philosophy (Enovis) were included. Patient-specific and surgical variables were collected. Five cohorts were formed based on major technologic advances focused on implant design, surgical technique, and virtual planning. Descriptive statistics were used to compare cohorts, while regression and moving average statistics assessed longitudinal trends. In total, 2,380 patients met inclusion criteria, including 2,068 primary rTSA and 312 revision rTSA cases. The overall incidence of ASF was 5.4% with no notable difference between primary and revision procedures. A higher incidence of ASF was observed for patients with rotator cuff deficiency when compared with rotator cuff-intact patients (7.39% vs. 2.8%; P < 0.001). A significant decrease in ASF incidence was observed across the study period (P < 0.001), with reductions between successive technologic cohorts. Regression analysis of the data revealed a logarithmic best-fit with r2 = 0.765. Year-to-year variability in ASF incidence was significantly lower during periods of routine preoperative planning compared with earlier periods (0.45% vs. 5.33%; P = 0.008). In 2014, the difference between the rates of cuff-intact and cuff-deficient cases disappeared (P = 0.025). Advancements in implant design and surgical technique within a single rTSA implant design philosophy were temporally associated with lower observed ASF incidence. Routine use of preoperative virtual planning coincided with the lowest ASF rates and reduced year-to-year variability. These findings should be interpreted in the context of time-related confounding, including surgeon experience and practice evolution. III.
Online patient educational materials (PEMs) have poor readability, limiting their intended purposes in improving patient comprehension of health topics. Orthopaedic oncology PEMs are particularly complex. Although ChatGPT has demonstrated limited success in simplifying PEMs to the recommended sixth-grade reading level, other large language models (LLMs) have not been thoroughly evaluated. The goals of this study were to (1) assess baseline readability of online orthopaedic oncology PEMs, (2) evaluate five LLMs (ChatGPT-4o, Google Gemini, DeepSeek AI, Microsoft Copilot, and Meta AI) for improving readability while preserving accuracy and comprehension, and (3) to examine tradeoffs when PEMs were simplified below the sixth-grade level. Seventy-two PEMs were collected from academic and professional sources. Readability metrics included the Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), and Flesch Reading Ease (FRE). Each PEM was rewritten by the five LLMs using the prompt: "rewrite this document to a sixth-grade reading level." Two independent graders then evaluated outputs for comprehension and accuracy (F1 score). ANOVA with pairwise comparisons assessed differences among LLMs and versus baseline (PEMs as written). A secondary analysis evaluated the effect on readability, accuracy, and comprehension of prompts to the fifth-grade, fourth-grade, and third-grade reading level. Baseline FKGL (8.7 ± 1.5) was between the eighth-grade and ninth-grade reading level, and GFI (10.5 ± 1.9) was slightly higher. Baseline FRE was 53.9 ± 8.2. All LLMs significantly improved readability (P < 0.001), and ChatGPT-4o, DeepSeek AI, and Google Gemini conversion produced the most readable outputs. Google Gemini achieved the highest F1 score of 0.986 (range: 0.765-0.986) and 100% comprehension. Accuracy and comprehension were compromised for MetaAI when prompted below sixth grade. ChatGPT-4o, Google Gemini, and DeepSeekAI effectively improved readability while preserving comprehension and accuracy. These findings may guide patient use of LLMs and inform healthcare-AI partnerships.
Forefoot fractures are among some of the most common orthopaedic injuries. Treatment of zone 2 fifth metatarsal or Jones fractures is controversial and many times dependent on surgeon preference. Management of these injuries remains without clear guidelines. Accordingly, the goal of the current systematic review is to compare the clinical outcomes and complications for both surgical fixation and conservative treatment. Two independent authors completed a systematic review using the PubMed, EMBASE, and Cochrane Library databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol and Cochrane Handbook guidelines were followed. In addition, the Methodological Index for Non-Randomized Studies score was used to evaluate the quality and bias of the nonrandomized controlled trials. Our criteria included only studies that reported on both conservative and surgical treatment of Jones fractures. Ten studies including 998 patients met our criteria for inclusion. A total of 787 patients underwent conservative management while 211 patients underwent surgical fixation. The surgical cohort had a significantly lower rate of total complications (18/211 (8.5%)) in comparison with the conservative cohort (123/787 (15.6%; P = 0.02). Similarly, those who underwent surgery had a lower rate of nonunion (7/211 (3.3%) versus 91/787 (11.6%; P = 0.04)). Patient-reported outcome scores, including American Orthopaedic Foot and Ankle Society scores were significantly better at final follow-up in the surgical group (96.5) in comparison with the conservative group (84.1; P = 0.005). This systematic review found markedly fewer total complications, a lower nonunion rate, and higher mean American Orthopaedic Foot and Ankle Society scores in patients who underwent surgical management for Jones fractures in comparison with those who were treated nonoperatively. Although, conservative treatment is also a successful method of treatment, our findings support surgical treatment of Jones fractures.
Chemotherapy regimens in high-grade osteosarcoma have markedly improved survival rates, currently reaching approximately 70%. Concerns persist regarding a long-term effect on fertility. Despite the systematic application of many fertility preservation techniques, few studies specifically address fertility in survivors. Our goal was to assess fertility in patients treated for pediatric and young adult osteosarcoma in a long-term follow-up period. This study was retrospective analysis of osteosarcoma survivors treated at our center from 1980 to 2005. All followed a standardized chemotherapy protocol. In cases where contact could not be established at the time of the follow-up for their osteosarcoma, telephone interviews were conducted, querying about pregnancy desires and difficulties. In case of difficulties, we further investigated about the possible reasons behind them. Of 116 consecutive patients initially enrolled, 104 were contacted; 67 (36 women, 31 men) desired pregnancy. Mean age at the beginning of treatment was 16.9 (4 to 33) years. The mean age at the end of follow-up was 46.8 (31 to 64) years, with an average follow-up period of 359 (156 to 480) months. Among the 36 women desiring pregnancy, only 1 (2.7%) faced fertility challenges due to chemotherapy. Of the 31 men desiring pregnancy, 4 (12.9%) experienced difficulties due to azoospermia secondary to chemotherapy and in two cases, the cause is unknown because no fertility studies were conducted for the couple. No discernible chemotherapy dosage differences were found between patients with fertility issues and those without. Survivors of pediatric and young adult osteosarcoma exhibit a high success rate in achieving normal conception and childbirth, aligning with the general population. To inform pediatric and adolescent patients with osteosarcoma, as well as their parents, about the high success rate associated with achieving a normal conception and childbirth should be the standard.
Racial disparities in total joint arthroplasty (TJA) utilization are persistent and well-characterized. Improving surgeon workforce diversity may attract patients from diverse backgrounds. We sought to determine whether the recent hiring of an arthroplasty surgeon of underrepresented minority (URM) background in a predominantly non-URM arthroplasty practice was associated with increased patient diversity. We retrospectively reviewed all primary and revision elective TJAs by six arthroplasty surgeons at our institution from September 2022 to September 2023. Primary outcomes included patient age, sex, and race/ethnicity. Secondary outcomes included patient-reported outcome measures (PROMs) at preoperative and 3-month postoperative follow-up. Comparison cohorts included the following: (1) a recently hired URM attending surgeon; (2) a recently hired non-URM attending surgeon; and (3) four senior non-URM attending surgeons. Unpaired t-tests were used to compare means for continuous variables and chi-squared tests for qualitative variables. Overall, 2,101 patients were included, and 168 patients were included in group 1 (URM surgeon), 75 in group 2 (non-URM surgeon); and 1,858 in group 3 (non-URM senior surgeons). Compared with groups 2 and 3, patients within group 1 comprised a markedly greater proportion of female, Black, and Hispanic/Latino patients (64.8%, 33.3% and 59.7%, respectively, P < 0.01). Racial and ethnic demographic differences persisted when examining patients treated by the non-URM division in the year before the hiring of the URM surgeon. Subgroup analysis of URM patients showed markedly improved SF-12 mental scores for URM patients treated by the URM surgeon compared with those treated by senior surgeons (P < 0.05). Compared with an experience-matched non-URM surgeon and non-URM senior surgeons in the same division, the URM surgeon saw a markedly greater proportion of minority patients in their first year of practice. Hiring diverse orthopaedic faculty may represent a viable strategy for improving health care utilization for minority patients in arthroplasty practices.
Large language models (LLMs) can generate plausible diagnoses from patient symptom descriptions and convey complex medical information in conversational, empathetic language. Given that LLMs may struggle with the vague symptom descriptions characteristic of less healthy mindsets, discordance between LLM and clinician diagnoses might signal misinterpretation of sensations. Among new musculoskeletal outpatients, we studied factors associated with (1) diagnostic discordance between an LLM and a clinician and (2) patient rating of experience interacting with the LLM. One hundred forty English-speaking patients described their symptoms to an LLM prompted to provide a single most likely diagnosis. Clinician diagnoses were recorded after the visit. Patients completed a survey assessing perceptions of the LLM interaction, demographics, and psychosocial factors-including measures of unhelpful thoughts and distress (eg, catastrophic thinking, misperception of pain as necessarily signifying injury, rumination about pain, and fear of losing cherished roles). Linear regression sought associations between personal factors, diagnostic concordance, and experience with the LLM. Discordance between clinician and LLM diagnoses was common 45% (67 of 140), but was not associated with any factors. Discordance often reflected diagnostic ambiguity (eg, knee osteoarthritis and meniscal tear) or clinician use of specific diagnoses for nonspecific symptoms (eg, myofascial pain syndrome, complex regional pain syndrome, and piriformis syndrome). Hispanic ethnicity, unmarried status, lower educational attainment, and lower annual income were associated with more favorable patient-rated experience with the LLM. Clinician use of speculative and ambiguous diagnostic labels may limit the usefulness of LLM-clinician discordance as a signal of patient unhelpful thinking and distress. LLMs may support personal health agency, particularly in the setting of social disadvantage.
Bone graft is commonly used to promote joint arthrodesis. Currently, the bone graft options used surgically include autograft, allograft, and bone graft substitutes (BGS). Limited availability, potential morbidity (associated with autograft harvest), efficacy concerns, costs, and the theoretical risk of disease transmission have led to an increased use of BGS. Although there are numerous BGS available, it remains unclear which BGS provide the best clinical outcomes. This systematic review is intended to evaluate the quantity and quality of published BGS clinical outcome studies in non-spinal orthopaedic arthrodesis surgery. A comprehensive literature search of PubMed, Embase, and the Cochrane Library identified 1,751 studies of which 15 met inclusion criteria. All of these studies were of the foot and ankle and represented eight commercially available BGS. Among them, Augment had the most evidence and received a grade A recommendation. All other BGS received grade I recommendations due to insufficient published clinical outcome data. These findings highlight the limited published evidence on the clinical outcomes associated with the use of BGS in non-spinal orthopaedic arthrodesis surgery. Surgeons should continue to use the best available evidence when selecting BGS while recognizing the need for additional high-quality clinical studies.
There is a paucity of literature on the short-term clinical significance and patient-reported outcome measures (PROMs) after arthroscopic stabilization for anterior shoulder instability. (1) To define the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds for arthroscopic anterior shoulder stabilization at a minimum 2-year follow-up. (2) To investigate predictive factors, including preoperative, demographic, and intraoperative variables, for achieving MCID and PASS. Case-control study. Patients who underwent primary arthroscopic stabilization for anterior-inferior labral tears from March 2018 to December 2021 with a minimum of 2-year follow-up were retrospectively identified through a prospectively maintained institutional database. MCID thresholds were determined by a distribution-based method, while PASS thresholds were established using an anchor-based method. The PROMs analyzed included the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE), Patient-Reported Outcomes Measurement Information System Upper Extremity (PROMIS UE), and the Veterans Rand-12 (VR-12) score. Multivariate logistic regression was performed to identify factors associated with achieving MCID and PASS. A total of 65 patients were included. The thresholds for MCID achievement and achievement rates were as follows: WOSI, 12.8 (84.6%); SANE, 14.4 (81.5%); PROMIS UE 4.4 (90.8%); VR-12 Physical, 3.9 (76.9%). The thresholds for PASS achievement and achievement rates were as follows: WOSI, 40.2 (80%); SANE, 74.9 (86.2%); PROMIS UE 40.5 (84.8%); VR-12 Physical, 49.9 (83.1%). Symptom duration >6 months was predictive of failing to achieve MCID for the WOSI and PASS for the WOSI and SANE. Preoperative hyperlaxity was predictive of failing to achieve PASS for the WOSI and PROMIS UE. A lower body mass index (BMI) was predictive of achieving PASS for the WOSI, PROMIS UE, and VR-12. The presence of an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion was predictive of failing to achieve PASS for the WOSI and failing to achieve MCID and PASS for the WOSI, PROMIS UE, and VR-12 simultaneously. This study defines thresholds for MCID and PASS achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization. Factors including symptom duration, hyperlaxity, BMI, and ALPSA lesions were found to be predictive of MCID and PASS achievement on multiple PROMs at short-term follow-up.
Postcapsulorrhaphy arthropathy (PCA) may result as a long-term sequela of instability surgery, eventually necessitating shoulder arthroplasty. Alterations to the soft tissue and bony anatomy during the index surgery may lead to unique wear patterns of the glenohumeral joint compared with what is observed in primary glenohumeral osteoarthritis (GHOA). We sought to characterize the three-dimensional glenoid morphology of patients with PCA to understand whether arthritic wear patterns are distinct from those observed in GHOA. Patients diagnosed with GHOA or PCA were retrospectively propensity matched in a 4:1 ratio by age and sex. Radiographic measurements-including glenoid inclination, version, humeral head subluxation, glenoid vault loss, and maximum erosion depth-were assessed using Materialise Surgicase Preoperative Planner. The presence of biplanar glenoid deformity, defined as glenoid inclination and version ≥10° was assessed. The PCA cohort was further stratified by capsulorrhaphy technique (open vs. arthroscopic). Univariate analysis was conducted to compare glenoid morphology between cohorts and subcohorts. After matching, the GHOA and PCA cohorts consisted of 264 and 67 patients, respectively, with no notable differences in age (GHOA 64.9 ± 7.0 years vs. PCA 63.6 ± 8.1 years; P = 0.236) or sex (85.0% male GHOA vs. 82.1% male PCA; P = 0.714). The PCA cohort demonstrated a markedly greater degree of superior inclination compared with the GHOA cohort (7.5 ± 5.4 vs. 4.3 ± 5.7; P = <0.001), although this is not likely clinically relevant. No other notable differences in any of the other radiographic measurements or parameters between GHOA and PCA cohorts were found. The arthroscopic and open PCA subcohorts consisted of 34 and 25 patients, respectively, with no notable differences in radiographic parameters observed between the open and arthroscopic cohorts (P > 0.05). Arthritic glenoid wear patterns in patients with PCA and GHOA demonstrate no notable differences despite the altered soft tissue and bony anatomy inherent to instability surgery. Subcohort analysis of open versus arthroscopic capsulorrhaphy revealed no notable differences in glenoid morphology. Although PCA presents unique surgical challenges, these may be more closely tied to soft-tissue alterations than to variations in glenoid morphology. Level III; Retrospective Comparative Study.
Osteochondritis dissecans of the capitellum is an uncommon but notable cause of elbow pain in the young athlete. Although the exact pathogenesis of this condition is not completely understood, repetitive microtrauma, such as in throwing athletes or gymnasts, can predispose these groups to developing osteochondral lesions. Patients may present with laterally based elbow pain, swelling, or loss of range of motion. Initial screening radiographs can often detect these lesions, with MRI key to determining the exact lesion size, location, and stability. Treatment depends on multiple factors and may include a period of rest, particularly in stable lesions. Surgery is more often recommended in patients with unstable lesions or loose bodies or those who have persistent lesions despite a course of nonsurgical management. Historically, isolated osteochondritis dissecans removal and débridement yielded suboptimal results in the medium to long term, especially in larger and more laterally based lesions. Osteochondral autograft or allograft transplantation allows for more anatomic restoration of capitellar anatomy and has become the preferred treatment for larger, unstable defects with promising outcomes and return to activity.
Poor nutritional status is a modifiable risk factor that has been shown to have adverse outcomes in spine surgery, including higher rates of complications, poorer functional outcomes, longer hospital stays, and increased healthcare costs. As such, interest has emerged in clinical practice regarding the use of tools and important nutrient profiles that can be used to assess nutritional status both pre- and postoperatively. The purpose of this review is to synthesize the current evidence surrounding the clinical utility of various nutritional screening tools, as well as to evaluate the importance of targeted interventions. These strategies include protein and amino acid supplementation, vitamin D optimization, and preoperative carbohydrate loading; prior studies have associated these interventions with improved fusion rates, lower infection risk, and accelerated recovery. Furthermore, economic analyses in the setting of nutritional optimization are explored. Despite these benefits, substantial barriers like inconsistent protocols and patient nonadherence remain. In addition, reliance on single markers like albumin may be misleading due to inflammatory confounding, highlighting the need for multifactorial assessment that incorporates surrogates of bone quality and baseline health status. As the spine surgical population ages and procedures grow more complex, preoperative nutritional optimization represents a low-risk strategy with potential for substantial advancements in patient recovery. This review advocates for the standardization of multidisciplinary nutritional protocols as a key component of comprehensive perioperative spine care.