Jahn J, Dean KK, Travis LM
… +4 more, Ramos-Pascua LR, García de la Blanca JC, Temple HT, Pretell-Mazzini J
J Bone Joint Surg Am
· 2026 Mar · PMID 41880536
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BACKGROUND: Unplanned excisions (UEs) of soft-tissue sarcoma are resections performed without appropriate preoperative imaging or biopsy confirmation. These procedures represent a large proportion of referrals to sarcoma...BACKGROUND: Unplanned excisions (UEs) of soft-tissue sarcoma are resections performed without appropriate preoperative imaging or biopsy confirmation. These procedures represent a large proportion of referrals to sarcoma centers and can negatively influence oncologic outcomes. Limited evidence exists regarding the impact of consultation timing after UE. This study aimed to compare oncologic outcomes of patients evaluated early versus late at a sarcoma center following UE. METHODS: Of 397 patients treated for soft-tissue sarcoma from 2012 to 2020 at 2 tertiary centers, 117 underwent UE followed by later tumor bed excision and were analyzed. Consultation with a sarcoma specialist was defined as the patient's first visit with a multidisciplinary sarcoma team member, marking entry into the coordinated cancer center. Patients were stratified into early (≤2 months) and late (>2 months) consultation groups. Demographic, clinical, and tumor characteristics were collected. Primary outcomes included local recurrence-free survival (LRFS), metastasis-free survival (MFS), and overall survival (OS). Chi-square and t tests were used for univariate comparisons, and Kaplan-Meier analyses were performed. Multivariable Cox regression and logistic regression analyses were performed, adjusting for patient age, sex, and comorbidities; tumor size, depth, grade, stage, and margin status; and/or follow-up duration. RESULTS: Among the 117 patients (mean age, 56 years; 55% female; 84% White; 65% non-Hispanic), 26 were seen early and 91 late. The rate of metastasis was significantly higher in the late cohort (48.4% versus 11.5%, p = 0.0016), as was mortality (30.8% versus 3.8%, p = 0.0109). Five-year Kaplan-Meier survival outcomes favored early consultation, including LRFS (84.6% versus 63.7%, p = 0.041), MFS (88.5% versus 50.5%, p = 0.003), and OS (96.2% versus 64.8%, p = 0.005). On multivariable analysis, late consultation was independently associated with inferior LRFS (hazard ratio [HR] = 1.95, p = 0.046), MFS (HR = 2.76, p = 0.004), and OS (HR = 2.53, p = 0.022). Logistic regression showed increased odds of metastasis (odds ratio [OR] = 7.11, p = 0.0027) and mortality (OR = 11.29, p = 0.021) at 5 years in the late group. CONCLUSIONS: Delayed consultation after UE was associated with significantly worse outcomes, including higher rates of metastasis and mortality and lower LRFS, MFS, and OS. These results emphasize the importance of timely referral to sarcoma centers for early multidisciplinary management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Imbeault R, Shen J, Alzakri A
… +4 more, Barchi S, Roy-Beaudry M, Turgeon I, Parent S
J Bone Joint Surg Am
· 2026 Mar · PMID 41875234
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BACKGROUND: Vertebral body tethering (VBT) aims to gradually correct scoliosis using patients' growth while preserving spinal motion. We report 5 to 8-year outcomes and complications in skeletally immature patients. METH...BACKGROUND: Vertebral body tethering (VBT) aims to gradually correct scoliosis using patients' growth while preserving spinal motion. We report 5 to 8-year outcomes and complications in skeletally immature patients. METHODS: This prospective single-center cohort study included 74 patients who had idiopathic scoliosis and a ≥5-year follow-up. Preoperative, first postoperative visit, 1-year, 2-year, and ≥5-year radiographs were analyzed. A ≥5° increase in the interscrew angle suggested tether breakage. RESULTS: All 74 patients (5 male and 69 female) were skeletally immature at surgery. The mean age at surgery was 11.8 ± 1.3 years, and the mean follow-up time was 63.4 ± 8.4 months. Of the 74 patients, 68 patients were White, 4 were Black, and 2 were Middle Eastern or North African. VBT was performed on a mean of 7.4 vertebral levels. The maximum Cobb angle was 47.9° ± 9.4° preoperatively, whereas the instrumented Cobb angle measured 17.2° ± 12.3° at 2 years and 25.7° ± 14.0° at ≥5 years postoperatively. An unplanned return to the operating room occurred in 16 patients (21.6%). Forty-nine patients (66%) had a suspected broken tether at the final follow-up. The mean time of the first tether breakage was 38.1 ± 15 months. Forty-nine patients (66%) also had a curve of <40° without an unplanned return to the operating room at a minimum of 5 years postoperatively. CONCLUSIONS: In our cohort, 66% (49 patients) had a radiographically suspected tether breakage after 5 years and 13.5% (10 patients) required posterior spinal fusion to date. VBT yielded significant correction in the coronal plane (p < 0.001) and transverse plane (p = 0.006) postoperatively, with a reoperation rate of 21.6%. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Stewart H, Watkins A, Ahlawat S
… +3 more, Fayad LM, Skaggs DL, Sponseller PD
J Bone Joint Surg Am
· 2026 May · PMID 41875228
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➢ Computed tomography (CT) remains the gold standard for bone imaging, but radiation risks, especially in children, are driving interest in alternatives. ➢ Magnetic resonance imaging (MRI)-based techniques are emerging a...➢ Computed tomography (CT) remains the gold standard for bone imaging, but radiation risks, especially in children, are driving interest in alternatives. ➢ Magnetic resonance imaging (MRI)-based techniques are emerging as a radiation-free alternative to CT, using sequences such as zero echo time, ultrashort echo time, and 3-dimensional (3D) gradient recalled echo, along with deep learning-based synthetic CT. ➢ Zero echo time MRI stands out for its high-resolution and silent imaging, whereas 3D gradient recalled echo offers widespread availability and minimal requirements for implementation. ➢ Early studies have shown high agreement of all modalities with CT across multiple anatomical sites, supporting broader clinical use, especially in pediatrics, surgical planning, and cost-reduction efforts. ➢ Deep learning-based synthetic CT demonstrates strong potential given its ability to improve over time and to generate highly accurate CT-like images, although current applications are limited by existing training data.
Wang Z, Janney CA, Guo E
… +3 more, Carender CN, Hallstrom BR, Kheir MM
J Bone Joint Surg Am
· 2026 Mar · PMID 41875225
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BACKGROUND: The U.S. Centers for Medicare & Medicaid Services (CMS) requires the collection of patient-reported outcome measures (PROMs) after primary total joint arthroplasty (TJA), with penalties for noncompliance affe...BACKGROUND: The U.S. Centers for Medicare & Medicaid Services (CMS) requires the collection of patient-reported outcome measures (PROMs) after primary total joint arthroplasty (TJA), with penalties for noncompliance affecting all Medicare reimbursement. The CMS will publish risk-standardized improvement rates based on substantial clinical benefit (SCB) thresholds of 22 points for the HOOS JR (Hip disability and Osteoarthritis Outcome Score for Joint Replacement) and 20 points for the KOOS JR (Knee injury and Osteoarthritis Outcome Score for Joint Replacement). Our aims were to determine if preoperative scores predicted postoperative PROMs, to externally validate the SCB thresholds, and to analyze them with different anchors. METHODS: We retrospectively identified patients who underwent TJA at our institution between 2015 and 2023. The HOOS JR and KOOS JR were prospectively collected in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI); all other variables were obtained from electronic medical records. Logistic regression analyses and anchor-based receiver operating characteristic curves were generated to determine threshold values and the efficacy of using preoperative and postoperative scores as predictors of patient improvement, satisfaction, and willingness to repeat surgery. RESULTS: In total, 3,465 cases (1,498 total knee arthroplasties [TKAs] and 1,967 total hip arthroplasties [THAs]) were included. Preoperative scores failed as predictors (area under the curve [AUC], <0.6) of patient improvement, satisfaction, and willingness to repeat surgery. The change in scores for TKA, particularly at 1 year postoperatively, was predictive of improvement (AUC, 0.79), satisfaction (AUC, 0.77), and willingness to repeat surgery (AUC, 0.71); and the change in scores for THAs was predictive of improvement (AUC, 0.85), satisfaction (AUC, 0.82), and willingness to repeat surgery (AUC, 0.77). The Youden index indicated that change thresholds of 24 points for patient improvement, 24 points for satisfaction, and 26 points for willingness to repeat surgery provided the best predictions at 1 year after THA. Similarly, change thresholds of 21 points for patient improvement, 22 points for satisfaction, and 24 points for willingness to repeat surgery provided the best predictions at 1 year after TKA. Twenty percent of patients did not achieve CMS-proposed SCB thresholds. CONCLUSIONS: Although preoperative scores were not predictive of patient-reported outcomes, the degree of score improvement postoperatively was strongly associated with patient improvement, satisfaction, and willingness to repeat surgery. CMS-proposed SCB thresholds appear to be validated in our population and compare favorably with the thresholds produced in this study. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Yang L, Mulford KL, Girod-Hoffman MM
… +8 more, Khela M, Khosravi A, Crossman DM, Kanabar A, Saniei S, Ulrich MN, Taunton MJ, Wyles CC
J Bone Joint Surg Am
· 2026 Mar · PMID 41875224
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BACKGROUND: We aimed to develop automated data extraction pipelines with large language models (LLMs) to extract registry data from total hip arthroplasty (THA) operative notes and compare the performance with that of ex...BACKGROUND: We aimed to develop automated data extraction pipelines with large language models (LLMs) to extract registry data from total hip arthroplasty (THA) operative notes and compare the performance with that of existing natural language processing (NLP) algorithms. METHODS: We randomly sampled 1,000 primary THA cases from our institutional registry. Two human annotators manually reviewed each operative note for 3 data points: surgical approach, bearing surface, and fixation technique. All labeled THA notes were split into the development set (n = 239) and the testing set (n = 719). We developed a custom data extraction pipeline for each data point by combining an iteratively customized prompt with an LLM. The performance was compared with that of existing rules-based NLP algorithms. RESULTS: The accuracy of LLMs was superior to that of NLP algorithms for all data points: surgical approach (96% compared with 94%), bearing surface (89% compared with 74%), and fixation technique (96% compared with 95%). Furthermore, the LLM accurately inferred the bearing surface for 80% of the notes that were ambiguous about the bearing surface. CONCLUSIONS: We developed LLM pipelines for extracting 3 registry-relevant data points from THA operative notes, demonstrating superior performance to existing NLP algorithms. CLINICAL RELEVANCE: LLMs have the potential to impact clinical care, including the evaluation of electronic medical record free-text data. As registries serve as a cornerstone of orthopaedic evidence, this work demonstrates promise for LLMs to simplify, improve, and democratize the construction of registry databases from operative notes.
J Bone Joint Surg Am
· 2026 Mar · PMID 41875223
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BACKGROUND: Carpal tunnel syndrome (CTS) diagnosis has traditionally relied on electrodiagnosis (EDX) to confirm the diagnosis and to assess severity. Ultrasound has shown potential in measuring median nerve cross-sectio...BACKGROUND: Carpal tunnel syndrome (CTS) diagnosis has traditionally relied on electrodiagnosis (EDX) to confirm the diagnosis and to assess severity. Ultrasound has shown potential in measuring median nerve cross-sectional area (CSA) for CTS diagnosis, and magnetic resonance imaging (MRI) can be used for wrist soft-tissue evaluation. This study explored the correlation between CTS diagnosis and median nerve CSA measured on MRI at different wrist levels. METHODS: A retrospective review of an electronic medical record database identified patients who underwent both wrist MRI and EDX within a 90-day interval between January 2000 and December 2022. Median nerve CSA was measured on axial T2-weighted images at 3 levels: proximal to the carpal tunnel inlet (the distal radioulnar joint [DRUJ]), the inlet, and the outlet. Continuous variables are presented as means ± standard deviations. A logistic regression model was constructed to evaluate the diagnostic accuracy of median nerve CSA, at the 3 anatomical levels, in identifying CTS. Empirical cut point estimation determined optimal cutoffs and corresponding areas under the receiver operating characteristic curve (AUCs). RESULTS: Sixty-eight patients (76 wrists; mean age, 51.4 ± 14.2 years; male-to-female ratio, 26 to 50; 59 White patients, 8 Hispanic patients, and 1 Asian patient) were included. The mean median nerve CSA in the EDX-negative group compared with the EDX-positive group was 10.6 ± 3.4 versus 11.7 ± 4.0 mm2 (p = 0.248) at the DRUJ level, 11.1 ± 3.1 versus 14.4 ± 5.1 mm2 (p = 0.007) at the inlet level, and 9.8 ± 2.4 versus 11.0 ± 5.2 mm2 (p = 0.833) at the outlet level. The inlet CSA cutoff for CTS was 11.3 mm2 (AUC = 0.67), with a sensitivity of 74% and a specificity of 60%. CONCLUSIONS: MRI-based measurements of median nerve CSA, particularly at the inlet level, suggest that relying solely on CSA measurements may not be an optimal diagnostic strategy for CTS in patients with equivocal clinical symptoms. Even with MRI and highly standardized measurement protocols, only poor-to-fair diagnostic accuracy was achieved. This study raises questions about the diagnosis of CTS based on CSA measurements. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Werthel JD, Walch G, Gauci MO
… +4 more, Bauer S, Ogor J, Morvan Y, Walch A
J Bone Joint Surg Am
· 2026 Mar · PMID 41875222
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BACKGROUND: Recent evidence suggests that variations in overall scapular morphology may predispose individuals to specific shoulder pathologies. The purposes of this study were to provide a comprehensive 3D analysis of s...BACKGROUND: Recent evidence suggests that variations in overall scapular morphology may predispose individuals to specific shoulder pathologies. The purposes of this study were to provide a comprehensive 3D analysis of scapular anatomy in a healthy population and to investigate potential age-related differences and associations with pathological thresholds described in the literature. METHODS: This study included computed tomography scan data from 369 healthy scapulae of subjects ≥18 years of age without shoulder pathology. The scapulae were analyzed to measure key morphological parameters, including glenoid version, acromial coverage, posterior acromial height, coracoid angles, and scapular spine angle. Scapulae of individuals <60 years old were compared with those of individuals ≥60 years old. Morphological thresholds described in previous studies were used to identify the percentage of healthy scapulae that demonstrated values exceeding pathological thresholds. RESULTS: Significant differences were observed between the scapulae of patients <60 years old and those ≥60 years old, with younger patients generally exhibiting scapular morphologies more closely resembling those reported in pathological cases. Key differences included posterior acromial height, posterior acromial coverage, scapular spine angle, and coracoacromial coverage (p < 0.05 for each). Across the cohort, a small percentage of healthy scapulae exceeded pathological thresholds published in the literature for posterior instability (posterior acromial height: 12.2%; posterior acromial coverage: 12.7%), anterior instability (coracoid pillar angle 2: 9.5%; scapular spine angle 2: 13.3%; glenoid rotation: 0.5%), and primary osteoarthritis (anterior coracoid plane coverage: 6.5%; coracoacromial plane coverage: 10.8%; posterior acromial coverage: 10.3%; critical shoulder angle: 6.0%). CONCLUSIONS: This study provides a comprehensive reference for the 3D morphology of the healthy scapula. The results reveal relatively low variability in shape among healthy scapulae; however, specific morphological variations appear to predispose individuals to certain pathologies. As degenerative conditions develop over time, younger subjects with such predispositions may gradually transition out of the healthy cohort. Conversely, individuals who remain healthy beyond 60 years of age likely possess a "healthy" anatomy that does not favor pathology, representing the true cohort of healthy subjects. CLINICAL RELEVANCE: Understanding the 3D morphology of the healthy scapula could enhance our knowledge of the etiology of conditions such as posterior and anterior instability and primary osteoarthritis, potentially improving their surgical management.
Balu AR, Kalainov D, Edelstein A
… +3 more, Divi S, Simon JE, Thirukumaran C
J Bone Joint Surg Am
· 2026 May · PMID 41875221
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➢ The Medicare Transforming Episode Accountability Model (TEAM) is a 5-year payment model that started on January 1, 2026, with mandatory participation from >700 U.S. hospitals in 5 surgery categories, 3 of which are ort...➢ The Medicare Transforming Episode Accountability Model (TEAM) is a 5-year payment model that started on January 1, 2026, with mandatory participation from >700 U.S. hospitals in 5 surgery categories, 3 of which are orthopaedic. ➢ The TEAM encompasses a specified operation from the day of the admission or outpatient procedure to 30 days after discharge, with payment based on a hospital-specific target price that is adjusted for hospital demographic characteristics and a Composite Quality Score multiplier. ➢ Although hospitals hold the financial risk and benefit, orthopaedic surgeons will drive the TEAM's success, making their strategic engagement with leadership essential. ➢ Robust data infrastructure, along with timely collection and analysis, forms the foundation for the TEAM implementation and compliance. ➢ Many hospitals are unprepared for the TEAM, and the inclusion of high-variability procedures, such as the surgical treatment of hip and femoral fractures and spinal fusion, heightens financial risk, underscoring the need for a clear strategic framework and orthopaedic surgeon leadership.
Shu HT, Hoveidaei AH, Reider LM
… +12 more, Vallier HA, Quinnan S, Gary JL, Carroll EA, Carlini AR, Higgins TF, Bosse MJ, Shafiq B, Tornetta P, O'Toole RV, Castillo RC,
METRC (Major Extremity Trauma Research Consortium)
J Bone Joint Surg Am
· 2026 May · PMID 41849563
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BACKGROUND: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. METHODS: We performed a secondary analysis of data from the FIXIT study. Adults with severe o...BACKGROUND: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. METHODS: We performed a secondary analysis of data from the FIXIT study. Adults with severe open tibial fractures were randomized to undergo definitive modern external ring fixation (n = 122) or internal fixation (n = 132). Primary outcomes were pain intensity and interference at 6 and 12 months, measured by the Brief Pain Inventory. Secondary outcomes were Numeric Pain Rating Scale (NPRS) scores and the incidence of moderate to severe pain. Post hoc subanalysis compared pain in patients with and without pin-site infections and with and without external fixation removal. RESULTS: At 6 months, median pain intensity did not differ significantly between the external fixation group (4.1 [interquartile range (IQR), 2.2 to 5.5]) and the internal fixation group (3.0 [IQR, 1.8 to 5.8]) (p = 0.11); however, patients who underwent external fixation had greater median pain interference (6.0 [IQR, 3.3 to 8.0]) than patients who underwent internal fixation (4.0 [IQR, 1.9 to 7.4]) (p = 0.01). At 12 months, pain intensity, pain interference, and NPRS scores did not differ by treatment type. The overall incidence of moderate to severe pain was 33% at 6 months and 35% at 12 months. At 6 months, pin-site infections were associated with greater pain intensity (p = 0.01) but not greater interference (p = 0.10). At 12 months, the presence of external fixation was associated with greater pain intensity (p = 0.01) and interference (p < 0.01). CONCLUSIONS: At 6 months after a severe open tibial fracture, patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation, partly because of pin-site infections. No differences in pain interference or intensity were seen at 12 months. At 12 months, patients with external fixation in place had greater pain intensity and interference than those whose external fixation had been removed, but this was not the case at 6 months. Approximately one-third of all patients had moderate to severe pain at both time points, highlighting that persistent pain is common, regardless of treatment type. These findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.