The Journal Of The American Academy Of Orthopaedic Surgeons[JOURNAL]
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200 papers
Management of Pelvic Fractures With Urogenital Injuries.
Cantrell CK, Flanagan CD, Mir HR
J Am Acad Orthop Surg · 2026 May · PMID 42206862 · Publisher ↗
Pelvic ring injuries are frequently associated with concomitant bladder and urethral damage due to the anatomic proximity of the urogenital system. Urogenital injuries occur in approximately 6% to 16% of pelvic fractures...
Pelvic ring injuries are frequently associated with concomitant bladder and urethral damage due to the anatomic proximity of the urogenital system. Urogenital injuries occur in approximately 6% to 16% of pelvic fractures and are linked to increased morbidity and mortality. Diagnosis relies on a combination of physical examination, urinalysis, and imaging, with retrograde urethrogram and cystography serving as benchmarks. Lateral compression and AP compression injuries are both associated with urogenital injuries. Specific fracture characteristics, including pubic symphysis diastasis, are highly predictive of urogenital involvement. Bladder injury management ranges from catheter drainage to surgical repair depending on the degree and location of injury. Urethral trauma is more common in men, particularly affecting the posterior urethra, and is managed with either endoscopic realignment or suprapubic diversion with delayed reconstruction. Long-term consequences include excretory and sexual dysfunction, often linked to fracture displacement, nerve injury, or psychological factors, underscoring the importance of multidisciplinary care. Historically, external fixation was preferred for pelvic stabilization in the setting of bladder injury; however, modern evidence supports selected use of internal fixation without increased infection risk. Coordinated orthopaedic-urologic management remains essential to optimize functional and quality-of-life outcomes.
Computed Tomography Overestimates Roentgenographic Posterior Tilt in Geriatric Garden I/II Femoral Neck Fractures.
Greenhill DA, Jain N, Weiss S … +1 more , Lundy D
J Am Acad Orthop Surg · 2026 May · PMID 42200679 · Publisher ↗
INTRODUCTION: Current best practice is to consider primary arthroplasty for elderly patients with a Garden I/II femoral neck fracture (FNF) when posterior tilt measures greater than 20° on the lateral radiograph. Althoug...
INTRODUCTION: Current best practice is to consider primary arthroplasty for elderly patients with a Garden I/II femoral neck fracture (FNF) when posterior tilt measures greater than 20° on the lateral radiograph. Although this evidence-based threshold stemmed from plain radiographs, clinicians similarly use it using CT when available. The correspondence of posterior tilt measured on radiograph versus CT is unknown. METHODS: Patients older than 65 years presenting with a Garden I/II FNF during a 6.5-year period (January 2018 to August 2024) were retrospectively reviewed. Patients without concomitant radiograph and CT of the affected hip or with inadequate radiographs were excluded. Posterior tilt of the FNF was measured on lateral radiographs (PT-XR) and compared with CT (PT-CT). RESULTS: After review of 1,244 records, a total of 100 patients averaging 82 ± 8 years old met inclusion criteria. Twenty-nine patients underwent internal fixation and 71 hemiarthroplasty. On average, PT-CT was larger than PT-XR (14° vs. 9°; P < 0.001). Lateral radiographs identified two patients (2%) with a posterior tilt ≥20°, while CT identified 17 (17%). For the 15 patients in whom increased posterior tilt was identified only by CT, the mean difference between PT-XR and PT-CT was 24 ± 15°. CONCLUSION: In patients with Garden I/II FNFs, CT often generates larger posterior tilt measurements than plain radiographs. Using CT, an additional 15% of these patients are identified as having posterior tilt ≥20°. Therefore, advanced imaging of Garden I/II FNFs objectively increases the number of fractures considered too unstable for internal fixation. However, its use as an indication for primary arthroplasty is not yet evidence based. LEVEL OF EVIDENCE: III.
Comprehensive Landscape and Future Perspectives of Surgical Therapy for Osteochondral Lesions of the Talus: A Bibliometric Analysis From 1980 to 2024.
Ding M, Zheng C, Liao B … +3 more , Shangguan L, Wang Y, Xu H
J Am Acad Orthop Surg · 2026 May · PMID 42200678 · Publisher ↗
BACKGROUND: 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...
BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.
Effect of Glucagon-Like Peptide-1 Receptor Agonist Use on Fusion Outcomes After First Metatarsophalangeal Arthrodesis in Patients With Type 2 Diabetes Mellitus.
Kayali H, Adio A, Parmar T … +2 more , Sumiyoshi N, Boakye L
J Am Acad Orthop Surg · 2026 May · PMID 42200664 · Publisher ↗
BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) influence bone metabolism by promoting formation and reducing resorption in patients with type 2 diabetes mellitus (T2DM). Although studied in hindfoot an...
BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) influence bone metabolism by promoting formation and reducing resorption in patients with type 2 diabetes mellitus (T2DM). Although studied in hindfoot and midfoot fusion, their effect on forefoot arthrodesis remains unknown. This study evaluated 1-year fusion and complication rates after first metatarsophalangeal joint (MTPJ) arthrodesis in patients prescribed GLP-1 RAs compared with nonusers, with focused analysis in diabetics. METHODS: A retrospective cohort study was conducted using the TriNetX research network. Adults undergoing first MTPJ arthrodesis were identified and stratified by GLP-1 RA use within 1 year before surgery. Glucagon-like peptide-1 (GLP-1) users were compared with nonusers, using a subgroup analysis among patients with T2DM. Propensity score matching (1:1) was conducted using age, sex, obesity, hypertension, peripheral vascular disease, smoking status, and baseline HbA1c. All patients had at least 1 year of follow-up, and relative risks with 95% confidence intervals were calculated. RESULTS: In the primary matched analysis (n = 712 patients per cohort), rates of pseudarthrosis were similar between GLP-1 users and nonusers (7.2% vs. 8.2%; risk ratio, 0.88; P = 0.49), with no significant differences in other complications. However, in the T2DM subgroup (n = 508 patients per cohort), GLP-1 users demonstrated a lower rate of pseudarthrosis compared with diabetic control subjects (7.7% vs. 11.8%; risk ratio, 0.65; P = 0.026), while rates of implant pain, implant removal, and surgical-site infection were comparable between groups. CONCLUSION: Among patients undergoing first MTPJ arthrodesis, GLP-1 RA use was not associated with differences in overall complication rates in the general population. However, among patients with T2DM, GLP-1 use was linked to a markedly lower risk of pseudarthrosis at 1 year postoperatively. These findings suggest that GLP-1 therapy may have a favorable influence on fusion in diabetic patients and warrant additional prospective investigation. LEVEL OF EVIDENCE: III.
Evaluation of Language Diversity Among Orthopaedic Surgeons.
Liu V, Tapp E, Solaiman RH … +3 more , Ortega G, Atkin C, Shapiro LM
J Am Acad Orthop Surg · 2026 Jul · PMID 42200653 · Publisher ↗
INTRODUCTION: 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 prefe...
INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.
Risk of Overdose and Adverse Events With Concomitant Opioids and Gabapentinoid Use After Total Joint Arthroplasty.
Domingo PT, Berger GK, Gray P … +3 more , Chaput R, Navarro R, Singh A
J Am Acad Orthop Surg · 2026 May · PMID 42200647 · Publisher ↗
PURPOSE: We evaluated the safety outcomes of opioids alone versus opioids plus low-dose gabapentinoids in patients naïve to both opioids and gabapentinoids, after total joint arthroplasty (TJA) of the knee, hip, or shoul...
PURPOSE: We evaluated the safety outcomes of opioids alone versus opioids plus low-dose gabapentinoids in patients naïve to both opioids and gabapentinoids, after total joint arthroplasty (TJA) of the knee, hip, or shoulder. METHODS: This was a multicenter, population-based, retrospective cohort study based in a large, integrated health system. It included opioid-naïve and gabapentinoid-naïve patients who underwent TJA between 2018 and 2024. Patients were categorized into two groups: those dispensed opioids and low-dose gabapentinoids or those dispensed opioids alone postoperatively. The primary outcome was opioid-related overdose events. The secondary outcome was adverse events, including falls, fractures, neurologic/cognitive changes, sedation, and delirium. RESULTS: In total, 36,351 consecutive patients comprised the study cohort, including 29,009 (79.8%) in the opioids-alone group and 7,342 (20.2%) in the opioids plus gabapentinoids group. In total, there were 19 (0.05% total cohort) opioid-related overdose events. Fourteen of these (0.05%) were in the opioids-alone group, and five (0.07%) were in the opioids plus gabapentinoids group (P = 0.3). In addition, 233 patients (0.6%) experienced emergency department or hospital admission due to an adverse event, including 200 patients (0.69%) in the opioids-alone group and 33 patients (0.45%) in the opioids plus gabapentinoids group. No statistically significant difference in adverse event risk was identified between groups. CONCLUSION: Concurrent prescriptions for opioids and low-dose gabapentinoids after TJA were not associated with a statistically significant difference in risk of emergency department or hospital readmission due to opioid-related overdose or adverse events compared with opioids alone. However, the rarity of overdose events limits statistical power, and these findings should be interpreted cautiously.
The Effect of Technological Innovations in Reverse Total Shoulder Arthroplasty on the Rate of Periprosthetic Acromion and Scapular Spine Fractures.
Phillips T, Mousad A, Abdelshaheed JM … +2 more , Beleckas C, Levy J
J Am Acad Orthop Surg · 2026 May · PMID 42190140 · Publisher ↗
INTRODUCTION: Innovations in reverse total shoulder arthroplasty (rTSA) have improved outcomes and mitigated complications through improvements in implant design, surgical techniques, and enabling technologies. The purpo...
INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. LEVEL OF EVIDENCE: III.
A Proposed Preoperative Risk Score for Predicting Surgical Site Complications After Ankle Fracture Fixation in Frail Elderly Patients.
Williamson TK, Verlinsky L, McDonald C … +5 more , Atkison C, Michaeli D, Martin C, Karia R, Hand T
J Am Acad Orthop Surg · 2026 May · PMID 42190138 · Publisher ↗
BACKGROUND: Open reduction and internal fixation (ORIF) of geriatric ankle fractures is associated with infection and wound-related complications, especially in patients with decreased functionality and increased comorbi...
BACKGROUND: Open reduction and internal fixation (ORIF) of geriatric ankle fractures is associated with infection and wound-related complications, especially in patients with decreased functionality and increased comorbidity. The purpose of this study was to propose a risk-related score to anticipate the development of surgical site infection (SSI) and/or wound complications after ORIF of surgical ankle fractures among frail, elderly patients. METHODS: A national database was queried for elderly patients undergoing ORIF for lateral malleolar, bimalleolar, and trimalleolar ankle fractures. Risk indices included age, the revised risk analysis index, and the geriatric nutritional risk index. Outcomes included 30-day SSI, wound dehiscence, and readmission. Established weights were generated for predictive variables (comorbidities, preoperative values) through backstep logistic regression to yield a frail ankle infection risk (FAIR) score for wound and infectious complications. Multivariable analysis assessed associations of indices with outcomes through odds ratio (OR) and confidence interval (CI). Discriminatory accuracy was quantified by receiver operating characteristic curve analysis. RESULTS: A total of 3,383 patients underwent ankle fracture ORIF. 2.4% of patients developed SSI or wound dehiscence. The regression model generated the FAIR score, which demonstrated association with any complication (OR: 2.1; 95% CI, 1.4 to 3.1) and infection-related or wound-related complications (OR: 3.2; 95% CI, 1.9 to 5.4). The FAIR score had good discrimination for wound and infectious complications (area under the curve [AUC] = 0.814), whereas the geriatric nutritional risk index (AUC: 0.500), age (AUC: 0.506), and the revised risk analysis index (AUC: 0.517) demonstrated poor discrimination. CONCLUSIONS: ORIF for ankle fractures is associated with increased rates of wound-related and infection-related perioperative complications among frail patients with predisposing factors. This score may provide additional understanding of the factors associated with complications and expose additional areas for perioperative optimization to include surgical techniques in this patient population. LEVEL OF EVIDENCE: III.
Evaluation of Commonly Utilized Artificial Intelligence Large Language Models in Optimizing Readability, Accuracy, and Comprehension of Orthopaedic Oncology Patient Educational Materials.
Nian PP, Williams CJ, Baidya J … +3 more , Marsh IG, Senthilnathan IS, Maheshwari AV
J Am Acad Orthop Surg · 2026 May · PMID 42190135 · Publisher ↗
INTRODUCTION: 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. A...
INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.
Assessing Large Language Models for Clinical Coding in Hand Surgery: Effect of Note Authorship, Prompt Design, and Diagnosis/Procedure Type.
Schroeder AM, Goldenberg CB, Khaleel MI … +3 more , Nuelle JAV, Kirby BJ, London DA
J Am Acad Orthop Surg · 2026 May · PMID 42171370 · Publisher ↗
BACKGROUND: This study sought to assess large language models' (LLM) ability to generate correct ICD-10 and CPT codes using clinical documentation, and to determine whether note authorship, prompt design, or diagnosis/pr...
BACKGROUND: This study sought to assess large language models' (LLM) ability to generate correct ICD-10 and CPT codes using clinical documentation, and to determine whether note authorship, prompt design, or diagnosis/procedure type affect LLM performance. We hypothesized that LLMs can code hand surgery clinic and surgical notes with greater than 80% accuracy. METHODS: Ninety patients evenly distributed across three orthopaedic hand surgeons and procedure types (cubital tunnel, carpal tunnel, and trigger finger release) were identified. Clinic and surgical notes were deidentified, and correct ICD-10 diagnosis and CPT procedure codes were recorded. "Zero-shot," "one-shot," "multishot," and "chain-of-thought" prompts instructed LLMs to assign ICD-10 codes and CPT codes based on note content. Each prompt was posed to Chat GPT 3.5, Chat GPT 4.0, and Gemini. Rates of coding correctness were calculated across attendings, diagnosis/procedure, prompt type, and LLM. Chi-square analysis determined statistical significance for these comparisons (P < 0.05). RESULTS: No differences in LLM coding performance were observed between note authors (P = 0.09 ICD-10, P = 0.48 CPT) or prompt types (P = 0.27 ICD-10, P = 0.62 CPT). Chat GPT 3.5 provided less accurate ICD-10 codes than Chat GPT 4.0 or Gemini (P < 0.0001). All LLMs better predicted CPT codes (91.5% correct) than ICD-10 codes (23.9% correct). The most common error was incorrect or omitted ICD-10 laterality. Prompts updated to emphasize ICD-10 laterality demonstrated improved accuracy (40%). DISCUSSION: Variation in note content and writing style did not markedly affect LLM performance. Public-facing LLMs require additional optimization to interpret clinical documentation for coding purposes and are not ready for independent use.
Impact of Obesity, Sarcopenia, and Nutritional Status on Spine Surgery Patients.
Daniels AH, Kim J, Nassar JE … +1 more , Diebo BG
J Am Acad Orthop Surg · 2026 May · PMID 42171350 · Publisher ↗
Obesity, sarcopenia, and malnutrition are increasingly recognized as key determinants of outcomes in spine surgery. Reliance on body mass index alone does not capture variations in fat distribution, muscle quality, or nu...
Obesity, sarcopenia, and malnutrition are increasingly recognized as key determinants of outcomes in spine surgery. Reliance on body mass index alone does not capture variations in fat distribution, muscle quality, or nutritional status, each of which affects perioperative risk. Central adiposity and sarcopenic obesity are independent predictors of wound complications, mechanical failure, and delayed recovery. Nutritional deficiencies in obese and postbariatric patients, including low levels of vitamin D, iron, and protein, can further impair bone healing and fusion. Emerging evidence supports structured preoperative optimization through dietary counseling, resistance-based prehabilitation, and coordinated multidisciplinary management. Glucagon-like peptide-1 receptor agonists represent a promising pharmacologic option that improves metabolic control and facilitates weight reduction without the malabsorption associated with bariatric surgery. This review summarizes current understanding of obesity phenotypes, sarcopenic obesity, and nutritional deficiency in spine patients and presents a practical framework for preoperative optimization to reduce complications, enhance fusion rates, and improve long-term surgical outcomes.
Remain-In or Opt-Out: An Economic Evaluation of Medicare Opt-Outs in Orthopaedic Surgery.
Lee B, Levin AS
J Am Acad Orthop Surg · 2026 May · PMID 42159374 · Publisher ↗
BACKGROUND: 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 i...
BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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. CLINICAL RELEVANCE: 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.
Stress Ulcer Prophylaxis in Orthopaedic Surgery.
Maitra S, Hii JL
J Am Acad Orthop Surg · 2026 Jul · PMID 42159356 · Publisher ↗
Although rare, stress-related gastrointestinal complications, such as perforated peptic ulcer (PPU) and upper gastrointestinal bleeding, can result in notable morbidity and mortality following orthopaedic surgery, partic...
Although rare, stress-related gastrointestinal complications, such as perforated peptic ulcer (PPU) and upper gastrointestinal bleeding, can result in notable morbidity and mortality following orthopaedic surgery, particularly in elderly or critically ill patients. Despite widespread implementation of stress ulcer prophylaxis (SUP) in critical care, its role in orthopaedic surgical populations remains ill defined. A narrative review of the literature reveals a low incidence of PPU following orthopaedic procedures (0.054% after elective spine surgery); however, associated mortality may reach as high as 25% in cases of PPU. Identified risk factors include NSAID use, advanced age, notable comorbidities, and critical illness. SUP with proton pump inhibitors or histamine-2 receptor antagonists has been shown to reduce upper gastrointestinal bleeding in critically ill patients, leading to guideline-based recommendations for selective prophylaxis in high-risk individuals. Given the potential severity of these complications, orthopaedic surgeons should maintain vigilance and consider SUP in at-risk patients, while avoiding routine prophylaxis in low-risk cases. Tailoring prophylactic strategies to patient-specific risk factors aligns with best practices from critical care and may help mitigate preventable postoperative complications.
Reduction of Electronic Medical Record Documentation Time and Burden Using an Artificial Intelligence Scribe Tool in an Orthopaedic Clinic.
Vallabhaneni N, Ingawa HS, Blackburn BE … +1 more , Pelt CE
J Am Acad Orthop Surg · 2026 May · PMID 42153705 · Publisher ↗
INTRODUCTION: With an aging population in the United States, the demand for joint arthroplasty procedures continues to rise. As patient volumes increase in arthroplasty clinics, the documentation burden for each clinic d...
INTRODUCTION: With an aging population in the United States, the demand for joint arthroplasty procedures continues to rise. As patient volumes increase in arthroplasty clinics, the documentation burden for each clinic day also grows, creating a demand for tools that can help alleviate this workload. Artificial intelligence (AI)-powered tools, such as automated charting assistants, may enhance provider efficiency by reducing documentation time. This study evaluates whether implementing an AI scribe in an orthopaedic clinic decreases documentation time for providers. METHODS: A retrospective, nonexperimental analysis was conducted after the adoption of a commercially available Health Insurance Portability and Accountability Act (HIPAA)-compliant AI scribe software tool. Active electronic medical record time per clinic day was measured for a team comprising one orthopaedic surgeon, one physician associate, and one orthopaedic surgery fellow. Resident physicians were excluded because of frequent rotation changes. RESULTS: Before AI implementation, providers saw an average of 38.7 patients (±2.2) over 34 clinic days, compared with 39.9 patients (±2.3) over 27 clinic days after implementation (P = 0.043). Total active EMR time per clinic day significantly decreased by 26.1% after implementation (after: 339.1 ± 78.7 vs. before: 458.8 ± 95.6 minutes; P < 0.0001). Average EMR time per patient decreased by 35.3% (after: 7.7 ± 2.9 vs. before: 11.9 ± 2.5 minutes; P < 0.0001). Total EMR time per clinic day (P = 0.0046) and per patient (P = 0.0002) demonstrated a significant, continual decline throughout the postimplementation period. CONCLUSION: The use of an AI-powered scribing assistant markedly reduced documentation time in an orthopaedic clinic, enhancing provider efficiency. These findings suggest a promising strategy for alleviating documentation burden, potentially improving clinic workflow as patient volume increases. Larger, multicenter studies are needed to confirm these benefits and explore long-term effects on provider workload and patient care.
Comparison of Costs and Postoperative Complications Between Carbon Fiber and Titanium Intramedullary Nails in the Treatment of Impending or Completed Pathologic Femoral Fractures: A Propensity-Matched Study.
Rizk PA, Gonzalez MR, Morse AS … +1 more , Lozano-Calderón SA
J Am Acad Orthop Surg · 2026 May · PMID 42148749 · Publisher ↗
AIMS: Despite the benefits of carbon fiber (CF) implants, concerns over their higher cost relative to titanium implants have limited their broader adoption in orthopaedic oncology. Our study compared the costs and postop...
AIMS: Despite the benefits of carbon fiber (CF) implants, concerns over their higher cost relative to titanium implants have limited their broader adoption in orthopaedic oncology. Our study compared the costs and postoperative complications associated with titanium and CF intramedullary nails (IMNs) in patients with femoral bone metastases. METHODS: We conducted a retrospective analysis of patients treated with titanium or CF IMNs for impending or completed pathologic femoral fractures due to metastatic bone disease between 2016 and 2023. Inpatient costs, 30-day costs, and 30-day postoperative complications were assessed. Mean and median total, direct, and indirect costs were evaluated using cost units. Propensity-score matching was conducted to minimize potential confounders. RESULTS: After propensity-score matching, we included 91 and 45 patients treated with titanium and CF femur IMNs, respectively. No differences in age, sex, primary tumor, or comorbidity profile were found between groups. Mean and median total costs, direct costs, and indirect costs during the inpatient stay and at 30 days postoperatively were similar between the titanium and CF groups. The mean length of stay was 8 days in both groups (P = 0.70). Thirty-day complication rates were 25% and 20% in the titanium and CF group, respectively (P = 0.50). No differences in 30-day readmission (25% in both; P = 0.35), mortality (4% versus 9%; P = 0.29), and revision surgery (1% versus 2%; P = 0.61) rates were observed between the titanium and CF groups. CONCLUSION: We found comparable inpatient costs, 30-day costs, and short-term postoperative complications between titanium and CF IMNs for impending or completed pathologic femoral fractures. LEVEL OF EVIDENCE: III.
Osteochondritis Dissecans of the Capitellum in the Young Athlete.
Tramer JS, Haley RM, Saluan PM
J Am Acad Orthop Surg · 2026 Jun · PMID 42138432 · Publisher ↗
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, suc...
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.
The Open Versus Closed Access Publication Advantage in Orthopaedic Surgery.
Kothari SK, Nemirov D, Shamith S … +2 more , Kothari NK, Ilyas AM
J Am Acad Orthop Surg · 2026 May · PMID 42133992 · Publisher ↗
BACKGROUND: As scientific publishing has shifted to digital platforms, two primary article-publishing modalities have emerged: open access and closed access. Open access is freely accessible with an article processing ch...
BACKGROUND: As scientific publishing has shifted to digital platforms, two primary article-publishing modalities have emerged: open access and closed access. Open access is freely accessible with an article processing charge (APC) paid by authors, whereas closed access lies behind paywalls, with low to no APC for authors. As the academic community increasingly relies on digital dissemination, it is critical to evaluate how these models influence research visibility and impact. This study compared open versus closed access randomized control trials (RCTs) across five prevalent orthopaedic conditions by analyzing attention scores, social media metrics, readership, and citations. The study hypothesis was that open access publications would have higher attention and readership, whereas closed access articles would yield more citations. METHODS: A PubMed search was conducted in May 2025 to identify RCTs on rotator cuff tears, carpal tunnel syndrome, hip fractures, anterior cruciate ligament tears, and Achilles tendon ruptures. Altmetric Attention Scores, X mentions, Facebook mentions, news mentions, Mendeley readers, and Dimensions citations were collected for each article using the Altmetric Explorer database. A negative binomial regression, adjusted for time since publication, was used to compare metrics between open and closed access publications. RESULTS: Of 1,223 articles studied, 53.8% of the articles were open access and 46.2% were closed access. Open access articles had significantly higher Altmetric Attention Scores (44.1 ± 197 vs 17.2 ± 52.0), X mentions (32.2 ± 27.1 vs 17.4 ± 38.4), Facebook mentions (1.2 ± 4.3 vs 1 ± 2.5), news mentions (4.1 ± 25.2 vs 1.0 ± 7.2), number of Mendeley readers (136.6 ± 127.9 vs 113.4 ± 108), and, notably, number of Dimensions citations (36.8 ± 88.9 vs 30.1 ± 45.6) compared with closed access articles ( P < 0.05). CONCLUSION: Contrary to our initial hypothesis, open access articles had higher attention metrics and citation numbers when compared with closed access publications. These findings suggest that open access publishing not only enhances visibility and engagement but also may increase academic impact across multiple orthopaedic subspecialties.
Mobility Outcomes Testing Following Total Knee Arthroplasty: Improving on Subjective Outcomes Reporting: A Pilot Study.
Harper K, Sullivan T, Park K … +3 more , Clyburn T, Incavo S, Lambert B
J Am Acad Orthop Surg · 2026 May · PMID 42133986 · Publisher ↗
BACKGROUND: Patient-reported outcome measures (PROMs) are widely used to assess recovery following total knee arthroplasty (TKA) but are limited by subjectivity and recall bias. This initial pilot study introduces a nove...
BACKGROUND: Patient-reported outcome measures (PROMs) are widely used to assess recovery following total knee arthroplasty (TKA) but are limited by subjectivity and recall bias. This initial pilot study introduces a novel Mobility Outcomes Testing Battery (MOTB) designed to objectively evaluate functional recovery using real-time movement and pain assessments. METHODS: Thirty-six patients undergoing primary TKA completed MOTB and PROMs (Knee injury and Osteoarthritis Outcome Score Jr, Pain Catastrophizing Scale, TSK-11) preoperatively and at 3 and 6 months postoperatively. MOTB included eight functional tasks (walking, sit-to-stand, stair ambulation) scored on performance (0 to 2 scale) and real-time pain (VAS 0 to 10). Composite MOTB scores were calculated by combining function and pain metrics. Dual-energy radiograph absorptiometry was used to assess body composition and skeletal dimensions. Radiographic limb alignment and demographic data were also collected. An analysis of variance was used to detect changes in measures over time, Pearson correlations examined the relationship between MOTB and standard PROM scores, and stepwise linear regression identified predictors of 6-month MOTB performance. RESULTS: MOTB scores improved markedly from baseline to 3 months (0.001) and from 3 to 6 months ( P = 0.008), demonstrating greater sensitivity than PROMs for detecting functional change. MOTB correlated with Knee injury and Osteoarthritis Outcome Score Jr. (r = 0.715, P < 0.001), Pain Catastrophizing Scale (r = -0.445), and TSK-11 (r = -0.359). Movement-specific analysis revealed stair descent as the most challenging task, with only 50% of patients achieving optimal scores at 6 months. Regression analysis identified higher preoperative lean mass and leg length as predictors of better stair performance, whereas increased body fat, valgus alignment, and cardiovascular disease were associated with poorer outcomes. Limb alignment classification (varus vs. valgus) had the strongest influence on cumulative MOTB scores. CONCLUSION: The MOTB offers a practical, objective, and movement-specific alternative to PROMs, with greater sensitivity to functional changes and reduced subjectivity. Easily implemented in minutes with no large equipment required, its potential in-clinic utility may enable individualized rehabilitation tracking and guide recovery by identifying movement deficits and modifiable risk factors.
Impact of an Orthopaedic-Driven Perioperative Protocol to Optimize Social and Medical Risk (SAFE) following Elective Total Joint Arthroplasty in a Health Safety-Net Hospital.
Abdeen A, Olszewski N, Bemis K … +3 more , Kain MS, Freccero DM, Tornetta P
J Am Acad Orthop Surg · 2026 May · PMID 42133981 · Publisher ↗
BACKGROUND: Preoperative optimization of medical risk factors before total joint arthroplasty of the hip and knee improves outcomes. Arthroplasty programs in health safety-net hospitals have increased risk of complicatio...
BACKGROUND: Preoperative optimization of medical risk factors before total joint arthroplasty of the hip and knee improves outcomes. Arthroplasty programs in health safety-net hospitals have increased risk of complications because of increased medical complexity and disparities of social determinants of health. We propose a novel, orthopaedic team-driven perioperative optimization protocol to comprehensively and systematically address medical and social risk factors before total joint arthroplasty. We aim to evaluate the effect of optimizing medical and social risk factors on outcomes after hip and knee arthroplasty in a health safety-net hospital. METHODS: A retrospective case-control series was done in a single, academic, tertiary-care, urban, safety-net hospital to compare complications (primary outcome) readmissions, length of stay (LOS), discharge disposition and escalation of care to intensive care unit (ICU), revision surgeries, and mortality (secondary outcomes) in patients who underwent hip or knee arthroplasty by a single surgeon before and after implementation of the optimization protocol. Follow-up duration was 12 months. Social determinants of health (SDOH) burden between groups were compared. RESULTS: Of 808 primary total joint arthroplasty patients, 409 had surgery after the optimization protocol was implemented and 399 control subjects had surgery before implementation. Study patients had lower 90-day deep infection rate (0.24% vs 1%; P = 0.017) and 1-year deep infection rate (0.24 vs 2.01%; P = 0.017) compared with control subjects, respectively. Study patients versus control subjects: LOS (3.0 vs 3.5 days, P = 0.012), discharge to skilled nursing facility (SNF) (11.0 vs 17.0%, P = 0.015), escalation to ICU care (0.25 vs 2.5%, P = 0.006), and 1-year mortality (0.24 vs 2.5%, P = 0.074), respectively. SDOH burden was similar between control and study groups. CONCLUSION: Implementation of an orthopaedic-driven, standardized protocol designed to address modifiable medical and social risk factors before elective primary hip and knee arthroplasty was associated with reduced infection, LOS, discharge to SNF, and escalation of ICU care in a health safety-net hospital. LEVEL OF EVIDENCE: Level III.
A Comparison of Postoperative Patient-reported Outcomes After Hallux Surgery With a Modified Lapidus Versus a Metaphyseal Extra-articular Transverse and Akin Osteotomy.
Jackson JB, Ventresca H, Eaton K … +2 more , Altobello S, Gonzalez TA
J Am Acad Orthop Surg · 2026 May · PMID 42133977 · Publisher ↗
BACKGROUND: The modified Lapidus procedure (MLP) and metaphyseal extra-articular transverse and Akin osteotomy (META) are acceptable surgical treatment options for treating hallux valgus. The current literature is evolvi...
BACKGROUND: The modified Lapidus procedure (MLP) and metaphyseal extra-articular transverse and Akin osteotomy (META) are acceptable surgical treatment options for treating hallux valgus. The current literature is evolving when comparing the different procedures' effects on patient-reported outcomes and postoperative complications. This study aims to compare postoperative outcomes, radiographic outcomes, and patient-reported outcomes using the Patient-reported Outcome Information System for MLP and META. METHODS: This study retrospectively reviewed patients who underwent an MLP or META for the treatment of moderate to severe hallux valgus without associated first tarsometatarsal (TMT) instability between February 2020 and February 2022. Demographic data, radiographic outcomes, and Patient-reported Outcome Information System scores, including pain interference, physical function (PF), and mobility scores, were collected. The paired Student T- test and Wilcoxon rank sum test were used to compare continuous variables and the chi-squared test for categorical variables. RESULTS: A total of 145 patients were included in the study. The average follow-up for MLP and META patients was 61.3 and 52.2 weeks, respectively. META patients had significantly higher improvements in PF (5.3 vs. 2.2, P = 0.03) and mobility (5.5 vs. 2.9, P = 0.02) scores compared with MLP patients. META patients also had a significantly lower nonunion rate (2.6% vs. 14.3%, P = 0.02), implant failure rate (0% vs. 10.4%, P < 0.01), recurrence rate (0% vs. 7.4%, P = 0.02), and greater improvement in hallux valgus angle (18.6° vs. 15.8°, P = 0.03) compared with those treated with MLP. CONCLUSION: META was found to improve patient-reported outcomes markedly more than MLP, with a lower radiographic nonunion rate, implant failure rate, and recurrence rate, and higher improvement in hallux valgus angle. These findings suggest META is a viable option in patients with mild, moderate, or severe HV deformity without TMT instability. LEVEL OF EVIDENCE: III.
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