The Journal Of The American Academy Of Orthopaedic Surgeons[JOURNAL]
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200 papers
Open Reduction and Internal Fixation Versus Total Elbow Arthroplasty for Intra-articular Distal Humerus Fractures in Patients 65 Years or Older: A Meta-analysis.
Boutros M, Awad G, Adio A … +6 more , Lawand J, Boufadel P, Khan AZ, Hill BW, Horneff JG, Abboud JA
J Am Acad Orthop Surg · 2026 Apr · PMID 42012370 · Publisher ↗
BACKGROUND: Distal humerus fractures (DHF) in the elderly pose a challenge due to osteoporotic bone, comminution, and potential for poor functional recovery. Surgical management typically involves open reduction and inte...
BACKGROUND: Distal humerus fractures (DHF) in the elderly pose a challenge due to osteoporotic bone, comminution, and potential for poor functional recovery. Surgical management typically involves open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA). However, inconsistent findings across studies have led to uncertainty regarding which intervention optimizes outcomes, underscoring the need for a rigorous meta-analysis to guide clinical decision making. METHODS: A systematic literature search was conducted across PubMed, Scopus, Cochrane Library, and Google Scholar for studies published up to October 28, 2025. Randomized controlled trials and comparative studies evaluating ORIF vs. TEA in patients older than 65 years with DHF were included. Seven studies (1,347 patients aged ≥65 years) met inclusion criteria. Key outcome measures included the DASH score, flexion-extension arc, hospital stay, surgical time, complication rate, infection rate, revision surgery rate, and Mayo Elbow Performance Score. RESULTS: Pooled analysis demonstrated that TEA was associated with a statistically significant improvement in elbow flexion-extension range of motion compared with ORIF (mean difference: -9°, 95% confidence interval, -14.72 to -3.28; P = 0.002). No statistically significant differences were observed between TEA and ORIF about surgical time, hospital length of stay, Mayo Elbow Performance Score, overall complication rates, infection rates, or revision surgery rates (all P > 0.05). CONCLUSION: In elderly patients with intra-articular DHF, TEA provides a modest but statistically significant improvement in elbow range of motion compared with ORIF, although this difference is below commonly reported thresholds for minimal clinically important difference. These findings support an individualized treatment approach, favoring ORIF when durable fixation is achievable, while reserving TEA for carefully selected low-demand or frail patients with fracture patterns unlikely to permit stable reconstruction. Long-term implications of implant-related failure should be considered in surgical decision making. LEVEL OF EVIDENCE: Meta-analysis, Level II.
Assessment of Dose Calculation Accuracy for Bone Cement Implants in Radiation Therapy Planning Systems.
Wu PW, Lai YC, Wang WH
J Am Acad Orthop Surg · 2026 Jul · PMID 42012368 · Publisher ↗
BACKGROUND AND PURPOSE: This study investigated depth-dose alterations caused by bone cement in solid phantoms during vertebroplasty. Dose variations of megavoltage (MV) photon beams after traversing high-density bone ce...
BACKGROUND AND PURPOSE: This study investigated depth-dose alterations caused by bone cement in solid phantoms during vertebroplasty. Dose variations of megavoltage (MV) photon beams after traversing high-density bone cement were measured to estimate the effective density of bone cement. METHODS: A phantom mimicking human anatomy was fabricated with 2.5-cm acrylic embedded with bone cement. An Elekta VersaHD linear accelerator was used with 6 MV and 6 MV flattening filter-free (FFF) photon beams, field sizes ranging from 3 × 3 cm 2 to 10 × 10 cm 2 . Depth dose, planar dose, and point dose were measured using an Advanced Markus chamber, PTW 1600 two-dimensional array, and Semiflex three-dimensional ion chamber. These were compared with calculated doses from treatment plans with various overridden density values for bone cement. RESULTS: Minimal differences in percent depth dose were observed after MV photons (6 MV and 6 MV FFF) penetrated the bone cement. At 1 cm beyond cement, measured versus calculated doses differed by 1.2% to 2.7%. Within 1 to 5 cm behind cement, dose discrepancies were within 3% to 5%. At 3-cm depth behind cement, point-dose differences measured by the Semiflex chamber indicated smaller deviations at lower override densities, with an optimal match at 0.6 g/cm 3 . The two-dimensional array showed near-perfect gamma passing rates (∼100%) at an overridden density of 0.8 g/cm 3 , demonstrating the smallest center-point dose discrepancies. A higher override density of 1.4 g/cm 3 yielded results similar to the plan without density override, suggesting minimal advantage at higher override densities. CONCLUSION: This study revealed that dose perturbations induced by bone cement caused the treatment planning system to underestimate actual delivered doses by approximately 3% to 5%. Optimal density override values for bone cement in treatment planning systems appear to be around 0.6 to 0.8 g/cm 3 . Clinical trials and further data acquisition are necessary to validate precise density values due to variability in cement composition and incomplete cement infusion.
SGLT-2 Inhibitor Effects on Medical and Surgical Complication Rates After Total Shoulder Arthroplasty: A Propensity Matched Cohort Study.
Haj Shehadeh T, Boufadel P, Abboud JA
J Am Acad Orthop Surg · 2026 Apr · PMID 42012366 · Publisher ↗
INTRODUCTION: Total shoulder arthroplasty (TSA) is being performed with increasing frequency and is projected to rise further in the coming years. Although generally successful, the procedure carries inherent risks. Diab...
INTRODUCTION: Total shoulder arthroplasty (TSA) is being performed with increasing frequency and is projected to rise further in the coming years. Although generally successful, the procedure carries inherent risks. Diabetes is a well-established risk factor for postoperative complications. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are effective antidiabetic agents that are widely used; however, their perioperative safety in the setting of TSA has not yet been evaluated. The objective of this study was to assess the effect of perioperative SGLT2i use on 90-day medical complications and 2-year implant-related complications in diabetic patients undergoing TSA. METHODS: The TriNetX database was queried to identify diabetic patients who underwent TSA. Patients were stratified according to SGLT2i prescription status, and 1:1 propensity score matching was done to adjust for relevant demographic and medical comorbidities. Outcomes of interest included 90-day medical and surgical complications and 2-year implant-related complications. RESULTS: After propensity score matching, each cohort included 2,360 patients. The SGLT2i cohort demonstrated a significantly higher 90-day risk of myocardial infarction compared with control subjects (2.03% vs 0.89%, P = 0.001). No significant differences were observed between groups in the 90-day risk of ketoacidosis, deep vein thrombosis, pulmonary embolism, stroke, pneumonia, acute kidney injury, transfusion, wound disruption, sepsis, or hospital readmission. Similarly, there was no increased risk of implant-related complications at 2 years postoperatively in the SGLT2i cohort. DISCUSSION: SGLT2i use was associated with an increased 90-day risk of myocardial infarction after TSA but appeared safe regarding implant-related outcomes. Additional research is warranted to clarify these associations; however, these findings may aid in preoperative counseling and optimization of surgical outcomes. LEVEL OF EVIDENCE: III.
The Influence of Peripheral Artery Disease on Postoperative Complications Following Open Reduction and Internal Fixation for Ankle Fractures.
Sontam TR, Tummala S, Mittal MM … +1 more , Wukich DK
J Am Acad Orthop Surg · 2026 Apr · PMID 42012357 · Publisher ↗
BACKGROUND: Peripheral artery disease (PAD) has been associated with an increased risk of wound complications and surgical site infection following open reduction and internal fixation (ORIF) for ankle fractures. However...
BACKGROUND: Peripheral artery disease (PAD) has been associated with an increased risk of wound complications and surgical site infection following open reduction and internal fixation (ORIF) for ankle fractures. However, longer-term outcomes, including fracture healing, remain poorly characterized. This study evaluates the association between PAD and short- and long-term postoperative complications following ankle ORIF. METHODS: The TriNetX Research Network was queried to identify patients who underwent isolated unimalleolar, bimalleolar, trimalleolar, or syndesmotic ORIF for ankle fractures. Patients were classified as having PAD if they had a documented diagnosis within 6 months before surgery, whereas patients without PAD served as controls. PAD and non-PAD cohorts were 1:1 propensity score matched for demographics and medical comorbidities. Postoperative complications were assessed at 90 days and 2 years. RESULTS: After propensity matching, 2,159 patients were included in each cohort. At 90 days, patients with PAD had markedly higher rates of surgical site infection (5.5% vs 2.0%), wound disruption (10.2% vs 3.9%), lower extremity cellulitis (7.6% vs 2.1%), and acute osteomyelitis of the ankle or foot (3.1% vs 0.6%) (all P < 0.001). At 2 years, PAD was associated with increased risks of nonunion (RR 3.07, 95% CI, 1.69 to 5.60), chronic osteomyelitis (RR 8.42, 95% CI, 4.64 to 15.27), implant infection (RR 3.19, 95% CI, 2.47 to 4.11), implant removal (RR 1.54, 95% CI, 1.32 to 1.81), and below-knee amputation (RR 10.5, 95% CI, 5.50 to 20.03) (all P ≤ 0.0001). CONCLUSIONS: PAD is associated with markedly increased short- and long-term complications following ankle ORIF, including a sustained risk of impaired fracture healing. These findings underscore the importance of long-term risk stratification in patients with PAD undergoing ankle fracture fixation.
The Effect of Transportation Barriers on the Risk of Relapse for Idiopathic Clubfoot.
Myers AY, Bent MA, Phan T … +3 more , Padilla A, Wren TAL, Goldstein RY
J Am Acad Orthop Surg · 2026 Apr · PMID 42012355 · Publisher ↗
BACKGROUND: Clubfoot is a common orthopaedic birth defect and is affected by both clinical and psychosocial risk factors. The purpose of this study was to evaluate the effect of transportation barriers on the risk of rel...
BACKGROUND: Clubfoot is a common orthopaedic birth defect and is affected by both clinical and psychosocial risk factors. The purpose of this study was to evaluate the effect of transportation barriers on the risk of relapse in patients undergoing treatment for idiopathic clubfoot. METHODS: Patients diagnosed with idiopathic clubfoot were enrolled in a prospective registry at a single tertiary care center between May 2019 and August 2022. A prospective survey was administered regarding demographics and transportation, and a retrospective chart review was conducted. Zip codes were also used to query a health needs database. RESULTS: A total of 97 patients who met inclusion criteria underwent the Ponseti treatment method, with a median of eight serial casts. Eighty patients (83.3%) underwent an Achilles tenotomy. A total of 46 patients (47.4%) experienced a relapse, and 27 patients (27.8%) experienced multiple relapses. For the first episode of relapse, 27 of 46 patients (58.7%) underwent repeat casting, 15 of 46 (32.6%) underwent a surgical procedure, and 4 of 46 (8.7%) underwent both.Patients with a longer commute to our clinic were significantly more likely to experience relapse (median 38 versus 52.5 minutes; P = 0.031). In addition, patients from areas with higher rates of households without vehicles and patients from areas with more households below the federal poverty level were more likely to experience relapse (P = 0.008 and P = 0.037, respectively). CONCLUSION: Transportation barriers correlate with higher relapse rates in patients with clubfoot. These findings underscore the importance of addressing social determinants of health, particularly transportation access, to optimize treatment outcomes for patients with idiopathic clubfoot. LEVEL OF EVIDENCE: III.
Ultrasonography in Orthopaedic Surgery: An Update on Current Evidence and Emerging Technologies.
Immerman I, Hatamiya N, Lalchandani G … +1 more , Berrigan W
J Am Acad Orthop Surg · 2026 Jul · PMID 42012351 · Publisher ↗
Ultrasonography has become an integral tool in orthopaedic practice, offering real-time, high-resolution imaging for both diagnostic and interventional procedures. Ultrasonography enhances the diagnosis and management of...
Ultrasonography has become an integral tool in orthopaedic practice, offering real-time, high-resolution imaging for both diagnostic and interventional procedures. Ultrasonography enhances the diagnosis and management of entrapment neuropathies, traumatic nerve injury, tendon and ligament injury, fractures, and a variety of other soft-tissue pathologies. It has high utility in the assessment of joint subluxation or dysplasia in pediatrics. Ultrasonography guidance improves the accuracy and safety of musculoskeletal injections and enables minimally invasive interventions, including nerve decompressions, tenotomies, tendon sheath releases, and fasciotomies. A growing body of literature supports the noninferiority of these techniques, with some demonstrating superior outcomes relative to standard, open procedures. Recent innovations such as elastography and ultrasound tissue characterization (UTC) show potential for increasing its diagnostic utility even further.
Outpatient Management of Slipped Capital Femoral Epiphysis Is Common, Safe, and Saves Costs: A Single-Institution Analysis and Results From a National Database Survey.
Brown EA, Wilson DR, Lawrence HW … +4 more , Rainwater RR, Siegel ER, Rabenhorst BM, Schoenleber SJ
J Am Acad Orthop Surg · 2026 Jul · PMID 42007901 · Publisher ↗
INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a condition requiring surgical fixation on a semiurgent basis. Although recent studies have evaluated the safety of outpatient SCFE management, none have examined...
INTRODUCTION: Slipped capital femoral epiphysis (SCFE) is a condition requiring surgical fixation on a semiurgent basis. Although recent studies have evaluated the safety of outpatient SCFE management, none have examined cost in this population. Furthermore, it is unclear what percent of in situ SCFE fixation is done on an outpatient basis nationally. METHODS: A retrospective chart review of patients treated between the years 2015 to 2024 was conducted at a large tertiary-care children's health system. Patients undergoing in situ fixation for stable SCFE and a minimum 90 days follow-up were included. Demographics, outcomes, and charges were compared between patients treated as outpatients or inpatients. A review of the national PearlDiver database was performed to determine frequency of inpatient versus outpatient settings for this procedure. RESULTS: A total of 95 patients with stable SCFE were included. The mean age was 11.6 ± 1.9 years. Thirty patients were admitted through the emergency department, 19 of which underwent admission, surgery, and discharge on the same day. In total, 65 patients were scheduled as outpatients from clinic, 58 of which were true outpatient procedures. There was no difference in 90-day complications between groups. There was, however, a significant difference in patient charges for scheduled outpatients versus ED admissions ($10,052.40 vs $13,285.14; P = 0.001). In addition, scheduled outpatient surgery was less expensive than treatment through the ED, even if fixation and discharge occurred the same day ($9,669.90 vs $11,585.78; P = 0.041). On a national level, outpatient SCFE management is more frequent than inpatient management ( P = 0.0016). CONCLUSION: This study suggests that stable SCFE can safely be an outpatient procedure with significant cost savings. A national trend toward outpatient SCFE management is evident, mirroring general healthcare trends.
Postoperative Noncompliance in the Early Postoperative Period Is a Strong Negative Predictor of Patient-Reported Outcomes at 2 Years After Hip Arthroscopy.
Garden AR, Finerty JT, Everhart JS
J Am Acad Orthop Surg · 2026 May · PMID 41995396 · Publisher ↗
INTRODUCTION: Existing literature supports weight-bearing and activity restriction following hip arthroscopy, as well as early participation in physical therapy. However, there is a knowledge gap surrounding how failure...
INTRODUCTION: Existing literature supports weight-bearing and activity restriction following hip arthroscopy, as well as early participation in physical therapy. However, there is a knowledge gap surrounding how failure to adhere to these instructions affects long-term outcomes. This study aims to evaluate how noncompliance with postoperative protocol after hip arthroscopy affects patient-reported outcomes at 2 years after surgery. METHODS: Seventy-nine patients who underwent hip arthroscopy for femoroacetabular impingement between January and December 2022 were identified, with 52 in the compliant group and 27 in the noncompliant group. Patient noncompliance was defined as loss to follow-up (n = 4), delayed or lack of physical therapy (n = 12), and nonadherence to weight-bearing and activity restrictions (n = 17) within 3 months following surgery. Symptom and functional status were assessed at 2 years with the international Hip Outcomes Tool (iHOT-12), the Physical Function Short Form of the Hip Disability and Osteoarthritis Outcome Score (HOOS-PS), and the single-item patient-acceptable symptom state. RESULTS: The average iHOT and HOOS-PS scores were lower for noncompliant patients (iHOT, 50.67; SD, 28.9; HOOS-PS, 60.9; SD, 23.8) compared with compliant patients (iHOT, 71.95; SD, 26.8; P = 0.002; HOOS-PS, 79.0; SD, 23.0; P = 0.002). Noncompliant patients had lower rates of reaching Patient Acceptable Symptom State at 2 years (compliant: 69%, noncompliant: 37%; OR = 3.86; 95% CI [1.42, 10.0] 0.006). Multivariate analysis revealed independent predictors of lower iHOT scores were history of a mental health disorder (-12.0 points SD, 2.9; P = 0.001) and noncompliance (-8.6 points SD, 3.0; P = 0.01). No baseline demographic differences were identified between compliant and noncompliant patients. CONCLUSION: Noncompliance with functional restrictions and postoperative physical therapy is a strong independent risk factor for poor patient-reported outcomes at 2 years after hip arthroscopy.
Complex Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Assessment, Approach, and Outcomes.
Wing CW, Mika AP, Springer BD … +1 more , Ledford CK
J Am Acad Orthop Surg · 2026 May · PMID 41995395 · Publisher ↗
The incidence of posttraumatic knee osteoarthritis occurs in nearly one-third of patients sustaining intra-articular fracture and/or ligamentous knee injury. As a result, complex total knee arthroplasty may become the be...
The incidence of posttraumatic knee osteoarthritis occurs in nearly one-third of patients sustaining intra-articular fracture and/or ligamentous knee injury. As a result, complex total knee arthroplasty may become the best treatment option for these patients. Several challenges must be considered when planning and executing the surgery, including exposure with prior incisions, implant retention or removal, angular deformity, bone defects, stability, and the use of enabling technologies. Although these patients demonstrate notable improvement in pain and function after complex total knee arthroplasty, higher complication rates, increased revision risk, and inferior patient-reported outcomes have also been shown comparatively. This review will summarize how to effectively approach these complicated cases and report contemporary outcomes.
Meniscal Transplantation-Update on Indications, Techniques, and Outcomes.
Knapik DM, Smith MV, Matava MJ … +1 more , Brophy RH
J Am Acad Orthop Surg · 2026 Jun · PMID 41989310 · Publisher ↗
Meniscal tears are a very common clinical condition, often treated with surgery. While indications for meniscal repair are expanding, most meniscal tears are still treated with arthroscopic resection. Meniscal allograft...
Meniscal tears are a very common clinical condition, often treated with surgery. While indications for meniscal repair are expanding, most meniscal tears are still treated with arthroscopic resection. Meniscal allograft transplantation (MAT) is an evolving treatment option for young, active patients with symptomatic meniscal-deficient knees. There is a growing body of evidence for good long-term outcomes from MAT, although the long-term chondroprotective potential is still unproven. This article reviews the latest evidence regarding the indications, surgical techniques, complications, rehabilitation, and reported outcomes after MAT.
Declining Medicare Reimbursement for Total Ankle Arthroplasty: A Comparison of Podiatrists and Orthopaedic Surgeons, 2014 to 2023.
Ferdon RJ, Minerva AJ, Moore JW … +5 more , Jacques B, George KD, Ravinsky RA, Gross CE, Silvestre J
J Am Acad Orthop Surg · 2026 Apr · PMID 41983469 · Publisher ↗
BACKGROUND: Total ankle arthroplasty (TAA) is a well-established motion-preserving treatment for end-stage ankle arthritis. Although utilization has increased, declining Medicare payments for orthopaedic procedures remai...
BACKGROUND: Total ankle arthroplasty (TAA) is a well-established motion-preserving treatment for end-stage ankle arthritis. Although utilization has increased, declining Medicare payments for orthopaedic procedures remains a growing concern. Limited data exist comparing Medicare reimbursement trends for TAA between orthopaedic surgeons and podiatrists performing this procedure. METHODS: A retrospective analysis of the Centers for Medicare & Medicaid Services Medicare Physician and Other Practitioners database was done from 2014 to 2023 using Current Procedural Terminology code 27702. Providers billing ≥10 TAA procedures annually were included and stratified by specialty. Provider demographics, geographic distribution, mean reimbursement (average Medicare standardized amount), and annual procedural income (API) were analyzed. All payments were adjusted to 2023 US dollars using the Consumer Price Index. Statistical comparisons were made with t-tests and Chi-squared analyses with alpha set at 0.05. RESULTS: A total of 388 providers (351 orthopaedic surgeons, 37 podiatrists) performed 6,263 TAAs for Medicare beneficiaries over the study period. Podiatrists represented 9.5% of all providers and 8.3% of all TAA procedures. Podiatrists were reimbursed $61 (7.4%) more per TAA than orthopaedic surgeons ($890 ± $138 vs. $829 ± $167; P = 0.033) and had a higher mean payment ratio (0.25 ± 0.07 vs. 0.21 ± 0.11; P = 0.004). No notable differences existed in mean APIs between podiatrists and orthopaedic surgeons (P = 0.409). After inflation adjustment, reimbursement decreased 24% for podiatrists and 18% for orthopaedic surgeons, corresponding to API declines of 36% and 22%, respectively, over the study period. CONCLUSIONS: Between 2014 and 2023, Medicare reimbursement for TAA declined markedly for foot and ankle surgeons. Continued reductions in Medicare payments may threaten practice sustainability and patient access to specialized foot and ankle reconstructive care.
Thoracolumbar Instrumentation Options: Biomechanical Implications.
Rawall S, Hiatt LA, Theiss S … +1 more , Rajaram SM
J Am Acad Orthop Surg · 2026 Apr · PMID 41983464 · Publisher ↗
Pedicle screws and rods are the cornerstone of spine instrumentation. This article focuses on the practical usage of these implants in contemporary spine practice. Furthermore, we discuss strategies to optimize fixation...
Pedicle screws and rods are the cornerstone of spine instrumentation. This article focuses on the practical usage of these implants in contemporary spine practice. Furthermore, we discuss strategies to optimize fixation in osteoporotic spine and implant-related considerations in preventing proximal junctional kyphosis. Cross-sectional imaging helps select the longest screws with maximum outer diameter that can be safely placed. Conical inner diameter with V-shaped thread provides best pullout strength. Dual-core, dual-thread screws are biomechanically superior to conventional screws. For pedicle screw placement, undertapping or no tapping and convergent trajectory is recommended. Polyaxial, uniaxial, and monoaxial screws have shown similar clinical and radiologic results. Cortical bone trajectory screws and sublaminar bands can provide alternative fixation options to pedicle screws. Cement augmentation through cannulated fenestrated screws is the most reliable method of pedicle screw augmentation in osteoporotic spine. Alternatively, biodegradable cement augmentation, HA-coated screws, and expandable screws can be used. Both titanium and cobalt-chromium rods have shown similar clinical and radiologic results. Precontoured rods are recommended to prevent notching. Multiple rods are recommended at L5-S1 and osteotomies to prevent complications. "Soft landing" using hooks or sublaminar band, and vertebroplasty at the cranial end of the construct may prevent proximal junctional kyphosis.
Scaphotrapeziotrapezoid Joint Osteoarthritis: Differentiating SOAC Wrist From SLAC Wrist.
Rodriguez Fontan F, Netscher DT
J Am Acad Orthop Surg · 2026 Apr · PMID 41983463 · Publisher ↗
Scaphotrapeziotrapezoid (STT) osteoarthritis (OA) is the third most common osteoarthritic joint in the wrist. Recent research challenges prior assumptions about the STT OA relationship with scapholunate dissociation (SLA...
Scaphotrapeziotrapezoid (STT) osteoarthritis (OA) is the third most common osteoarthritic joint in the wrist. Recent research challenges prior assumptions about the STT OA relationship with scapholunate dissociation (SLAC) and proposes a new progression model leading to scaphotrapeziotrapezoid osteoarthritis advanced collapse (SOAC) wrist. Normal wrist mechanics enable the scaphoid and proximal carpal row to move synchronously for optimal motion. STT arthrodesis may have adverse effects if midcarpal instability is unrecognized. Understanding outcomes from early clinical studies of STT arthrodesis provides insight into the natural progression of STT OA. Altered wrist mechanics, particularly disruption of synchronous scaphoid and proximal row motion, demonstrate how instability and load redistribution can contribute to progressive arthritic degeneration and advanced collapse. This article emphasizes the importance of identifying and managing midcarpal instability. The purpose of this article is threefold: (1) It reviews the pathophysiology of STT OA and its progression to SOAC, (2) highlights surgical options for different stages, and (3) proposes a modified classification system for early awareness and to guide treatment.
Comparing Conservative and Surgical Treatment of Acute Nondisplaced Fractures of the Scaphoid Based on Fracture Location: A Systematic Review and Meta-Analysis.
Hawkins SD, Al-Kharabsheh Y, Li J … +3 more , Leary E, Nuelle JAV, London DA
J Am Acad Orthop Surg · 2026 Apr · PMID 41983461 · Publisher ↗
INTRODUCTION: Treatment of nondisplaced scaphoid fractures with either nonsurgical or surgical methods ideally involves shared decision making. To date, no meta-analysis has explicitly reported differences in healing rat...
INTRODUCTION: Treatment of nondisplaced scaphoid fractures with either nonsurgical or surgical methods ideally involves shared decision making. To date, no meta-analysis has explicitly reported differences in healing rates between fracture locations and treatment choices, making this conversation challenging. We aimed to report the nonunion risk in nondisplaced scaphoid fractures when stratified by both treatment type and fracture location. METHODS: We searched PubMed, SCOPUS, CINAHL, SportsDiscus, HAND, Journal of Hand Surgery, and Plastic and Reconstructive Surgery for outcome studies of nonsurgical or surgical treatment of acute, nondisplaced scaphoid fractures. Meta-analyses were conducted for the pooled proportion of fracture nonunion of each fracture location and treatment modality. RESULTS: We screened 2019 articles, and 29 were included in the final data analysis. The pooled proportion of scaphoid fracture nonunions was higher among those treated nonsurgically than surgically, although prediction intervals were overlapping and significance was not established. We found that, regardless of the treatment method, proximal fragment fractures have the highest rate of nonunion. When evaluating only proximal scaphoid fractures, the proportions of nonunion were similar between nonsurgical and surgical subgroups. DISCUSSIONS: Our review indicates that surgical treatment results in overall fewer nonunions than nonsurgical treatment, but with overlapping prediction intervals. However, when analyzing subgroups, we found that this association is less clear for proximal scaphoid fractures. Our review highlights a distinct lack of literature on scaphoid fractures of the distal pole. CONCLUSIONS: The results of this study can be used to inform shared decision making when discussing treatment for a nondisplaced scaphoid fracture.
Insurance Type Matters Most: An Analysis of Risk Factors for Poor Physical Therapy Adherence After Anterior Cruciate Ligament Reconstruction in an Urban Population.
Hanelin DG, Volaski HA, Lo Y … +3 more , Chan FJ, Voleti PB, Levy BJ
J Am Acad Orthop Surg · 2026 Jun · PMID 41979131 · Publisher ↗
INTRODUCTION: Physical therapy (PT) after anterior cruciate ligament (ACL) reconstruction is critical for recovery. Despite this, adherence to PT protocols remains inconsistent, and although socioeconomic barriers are th...
INTRODUCTION: Physical therapy (PT) after anterior cruciate ligament (ACL) reconstruction is critical for recovery. Despite this, adherence to PT protocols remains inconsistent, and although socioeconomic barriers are thought to influence PT attendance, there are a paucity of data quantifying compliance rates and the influence of these proposed barriers. METHODS: A total of 128 consecutive patients who underwent ACL reconstructions between January 2023 and December 2024 at a single urban academic medical center were studied. Three months postoperatively, patients completed a questionnaire regarding their PT compliance. Demographic, socioeconomic, and behavioral factors were collected. RESULTS: 35.9% of patients missed >15% of sessions. Reported barriers included time commitments (58.6% of respondents), transportation (50%), appointment availability (46.1%), cost (36.7%), and insurance issues (21.9%). Despite difficulties, 93.0% of patients thought PT was necessary. Government-sponsored insurance was associated with poor PT adherence ( P = 0.006). By contrast, historically described barriers to healthcare access, including Area Deprivation Index (ADI) ( P = 0.195), primary language other than English ( P = 1.0), and lack of car ownership ( P = 0.690), were not associated with poor attendance. CONCLUSION: Having state-sponsored/government-sponsored insurance is an independent risk factor for poor PT adherence, despite near unanimous strong desire of patients to attend therapy. Previously described barriers including higher ADI, primary language other than English, and not owning a car were not notable risk factors.
Impact of Preoperative Heel Ulceration on Surgical Outcomes Following Open Reduction and Internal Fixation of Rotational Ankle Fractures.
Tummala S, Wood BA, Wukich DK
J Am Acad Orthop Surg · 2026 Apr · PMID 41960717 · Publisher ↗
BACKGROUND: As surgical treatment with open reduction and internal fixation (ORIF) becomes more common, attention to preoperative risk stratification has grown. Although multiple modifiable risk factors and comorbidities...
BACKGROUND: As surgical treatment with open reduction and internal fixation (ORIF) becomes more common, attention to preoperative risk stratification has grown. Although multiple modifiable risk factors and comorbidities have been associated with adverse outcomes, the impact of preexisting decubitus heel ulcers in this context remains yet to be defined. METHODS: Using a nationally representative multi-institutional database, a retrospective analysis was conducted on adults undergoing ORIF for rotational ankle fractures between 2010 and 2022. Patients with a documented decubitus heel ulcer within 4 weeks before surgery were compared with ulcer-free controls. After applying strict exclusion criteria and employing 1:1 propensity score matching for key demographic and clinical variables, 90-day medical complications and 1- and 3-year surgical outcomes were evaluated. RESULTS: The presence of a preoperative heel ulcer was associated with markedly higher risks of 90-day surgical site infection, sepsis, pneumonia, urinary tract infection, mortality, and deep infection (all P < 0.005). At 1 and 3 years postoperatively, the ulcer cohort demonstrated markedly elevated rates of nonunion, revision surgery, and below-knee amputation (all P < 0.0125). CONCLUSIONS: Preoperative decubitus heel ulceration is associated with elevated risks of both short-term complications and long-term surgical failure following ORIF for ankle fractures. These findings underscore the importance of thorough preoperative foot assessment and may inform surgical planning and perioperative management in this high-risk population. LEVEL OF EVIDENCE: Therapeutic Level III, Retrospective Cohort Study.
Large Language Models Outperform PGY-5 Residents on the Orthopaedic In-Training Examination: A Comparative Analysis of Six Cutting-Edge Large Language Models.
Dave R, Vediya N, Sharma N … +3 more , Shah A, Whelan D, Wolfstadt J
J Am Acad Orthop Surg · 2026 Jul · PMID 41949048 · Publisher ↗
INTRODUCTION: Large language models (LLMs), such as ChatGPT, are becoming increasingly prevalent, particularly in medical education and clinical assessments. Previous LLMs were seen to perform at the level of a first-yea...
INTRODUCTION: Large language models (LLMs), such as ChatGPT, are becoming increasingly prevalent, particularly in medical education and clinical assessments. Previous LLMs were seen to perform at the level of a first-year resident on the 2022 Orthopaedic In-Training Examination (OITE). With exponential advances in LLMs over the past 3 years, the true capabilities of these models remain unexplored. In addition, the addition of image processing further increases their clinical applicability. The purpose of this study was to evaluate the performance of six LLMs on the 2024 OITE. METHODS: Six LLMs were evaluated in this study: ChatGPT (GPT-4o), Gemini 2.0 Flash, Grok 3, Mistral Large 2.7, DeepSeek R1, and Llama. ChatGPT, Gemini, Grok, and Mistral could evaluate images and text while DeepSeek and Llama were limited to text. Accuracy, image interpretation, and logical consistency were assessed in 203 multiple-choice questions, stratified by difficulty and type of the question. Statistical analyses involved chi-square tests, Fisher exact tests, z-tests, and Cohen κ tests. RESULTS: ChatGPT performed with the highest accuracy (74.9%), followed by DeepSeek, Llama, Grok, Mistral, and Gemini. ChatGPT also led in logical consistency (72.4%) and image interpretation (73.8%). Logical consistency strongly correlated with accuracy and correctness ( P < 0.00001). As difficulty increased, performance declined across all models. CONCLUSION: ChatGPT consistently scored the highest in terms of accuracy across all metrics while also maintaining reasoning quality. Compared with resident averages, ChatGPT performed at a postgraduate year five level which indicates its potential for integration into orthopaedic clinics, electronic medical records, and surgical planning. Further development models would allow for better performance on difficult questions and creating orthopaedic focused models could enhance these results.
Mortality Risk of Upper Extremity Amputation in Patients With Peripheral Artery Disease.
Kim SW, Bank NC, Perle SJ … +3 more , Brown P, Patterson JMM, Draeger RW
J Am Acad Orthop Surg · 2026 Apr · PMID 41949035 · Publisher ↗
INTRODUCTION: The mortality risk of patients with peripheral artery disease (PAD) undergoing upper extremity amputation (UEA) remains poorly understood. The aim of this study was to clarify the mortality risk associated...
INTRODUCTION: The mortality risk of patients with peripheral artery disease (PAD) undergoing upper extremity amputation (UEA) remains poorly understood. The aim of this study was to clarify the mortality risk associated with upper extremity amputation in patients with PAD. METHODS: The TriNetX database was retrospectively queried to identify patients with PAD who did or did not undergo UEA, using International Classification of Diseases, 10th Revision, and Current Procedural Terminology codes. Patients were divided into two cohorts: PAD with UEA and PAD without UEA. Propensity score matching was conducted on a 1:1 ratio based on age, sex, body mass index, diabetes, and other comorbidities. Subgroup analyses were conducted based on level of amputation. Kaplan-Meier survival analyses, along with hazard ratios (HRs) and 95% confidence intervals (CIs), were used to assess mortality at 1, 5, and 10 years after UEA. RESULTS: A total of 1,802,975 patients with PAD were identified (1,862 with UEA; 1,801,113 without UEA). Each cohort included 1,862 patients after propensity score matching. Patients who underwent UEA had higher mortality rates at 1 year (24.1% vs. 14.1%), 5 years (54.3% vs. 36.6%), and 10 years (72.5% vs. 54.8%). UEA was associated with increased mortality risk at all time points: 1 year (HR 1.767, 95% CI, 1.500 to 2.081), 5 years (HR 1.739, 95% CI, 1.544 to 1.958), and 10 years (HR 1.705, 95% CI, 1.524 to 1.908). Long-term survival was poor across both digit-level and forearm-level amputation groups, with no statistically significant differences in mortality risk over time. DISCUSSION: These findings demonstrate an increased mortality risk among patients with PAD who undergo UEA compared with those who do not. Given the high prevalence of diabetes and vascular disease in the United States, these results underscore the importance of early recognition, patient education, and implementation of preventive strategies to reduce disease progression and the potential need for amputation.
Exploring Bias Patterns in Systematic Reviews and Meta-Analyses of Bone Marrow Aspirate Concentrate.
Dhunna DP, Gazula P, Nguyen KT … +7 more , Fink J, Yendluri A, Brown EL, Corvi JJ, Kelly JD, Li X, Parisien RL
J Am Acad Orthop Surg · 2026 Jun · PMID 41945672 · Publisher ↗
INTRODUCTION: Bone marrow aspirate concentrate (BMAC) is increasingly used in orthopaedics for its regenerative potential. As clinicians rely on systematic reviews and meta-analyses to guide clinical decision making, con...
INTRODUCTION: Bone marrow aspirate concentrate (BMAC) is increasingly used in orthopaedics for its regenerative potential. As clinicians rely on systematic reviews and meta-analyses to guide clinical decision making, concerns remain regarding methodologic rigor and reporting bias (spin). This study evaluated the prevalence and types of spin within systematic reviews and meta-analyses investigating the use of BMAC and assessed study quality using the AMSTAR 2 tool. METHODS: A systematic search of PubMed, Scopus, and EMBASE was conducted in May 2025 per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Eligible studies were systematic reviews or meta-analyses of BMAC in clinical orthopaedic contexts. Each study was assessed for 15 predefined spin types grouped as misleading interpretation, misleading reporting, or inappropriate extrapolation. Methodologic quality was appraised using AMSTAR 2. Associations between study characteristics and spin were analyzed using t -tests, analysis of variance, Fisher test, and Spearman correlation. RESULTS: Of the 156 studies screened, 28 met inclusion criteria. Spin was identified in 21 abstracts (75.0%), with the most frequent types being selective reporting of outcomes (type 3, 64.3%), claims of benefit despite high risk of bias (type 5, 53.6%), and selective emphasis on notable outcomes (type 11, 50.0%). Across spin categories, misleading interpretation was most common (67.9%). AMSTAR 2 rated 67.9% of studies as critically low confidence, 17.9% as low, and only 7.1% as high confidence. No notable association was found between spin prevalence and publication year, level of evidence, or journal impact factor. CONCLUSION: Most review studies on BMAC demonstrated low methodologic quality and frequent use of spin, with three spin types accounting for the most reporting bias. These findings suggest a consistent overstatement of BMAC efficacy and highlight the need for improved transparency, adherence to reporting standards, and rigorous methodology in future reviews to better inform clinical decision making. LEVEL OF EVIDENCE: IV.
Factors Associated With Outcome Response Frequency in a Knee Replacement Registry.
Kaadan A, Molino J, Aaron R
J Am Acad Orthop Surg · 2026 Apr · PMID 41930980 · Publisher ↗
INTRODUCTION: Nonresponse can potentially introduce bias in arthroplasty registries, compromising confidence in outcome data, diminishing both internal validity and generalizability. Patient-reported outcome measures can...
INTRODUCTION: Nonresponse can potentially introduce bias in arthroplasty registries, compromising confidence in outcome data, diminishing both internal validity and generalizability. Patient-reported outcome measures can be critical tools in evaluating clinical outcomes after total knee arthroplasty; however, patient-reported outcome measure data can be skewed when subsets of the population are nonresponsive. This study investigates sociodemographic and clinical factors associated with 12-month nonresponse after total knee arthroplasty and the effects of comprehensive multimodal follow-up methods. METHODS: A prospective cohort of 2,508 total knee arthroplasty patients enrolled in the Function and Outcomes Research for Comparative Effectiveness registry between 2018 and 2023 was analyzed. Sociodemographic and clinical data were collected preoperatively, and comprehensive multimodal follow-up methods were implemented. Hierarchical cluster analysis identified characteristics associated with nonresponse, and logistic regression was used to validate these findings. RESULTS: At 12-month follow-up, 735 of 2,508 patients (29%; P < 0.0001) were nonresponsive. Nonresponders, represented by cluster 5, which had a 45.8% response rate, were more likely to be female (P < 0.0001), non-White or mixed race (P < 0.0001), Hispanic or Latino (P < 0.0001), have less than a college education (P < 0.0001), public insurance (P < 0.0001), greater comorbidity (P < 0.0001), and lower preoperative knee injury and osteoarthritis outcome scores (P < 0.0001). The highest response rate (76.9%) was found in cluster 1, which primarily included well-educated males (P < 0.0001), with private insurance (P < 0.0001), and a lower body mass index (P < 0.0001). CONCLUSION: (1) Persistent and multimodal follow-up methods, through e-mail, paper mailings, and phone calls are needed to achieve high response rates above international registry standards of 60%. (2) Identifying patient characteristics linked to nonresponse provides an opportunity to help with targeted response strategies. These strategies may help reduce selection bias, improve data collection through improved response rates, and enhance the long-term utility of arthroplasty registries.
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