Clin. Orthop. Relat. Res. [JOURNAL]
Sun
200 papers
Impact Microindentation Evaluates Bone Strength, Bone Quality, and Fracture Susceptibility Across Skeletal Sites: A Cadaver Study.
Vaidya RS, Jahani B, Jin JM … +4 more , Gonzalez CC, Pujari B, Krothapalli S, Tang SY
Clin Orthop Relat Res · 2026 Jul · PMID 42390157 · Publisher ↗
BACKGROUND: Impact microindentation (IMI) is a minimally invasive technique for assessing bone material properties that can be performed clinically. In this study, we aimed to determine how measurements obtained by IMI (...
BACKGROUND: Impact microindentation (IMI) is a minimally invasive technique for assessing bone material properties that can be performed clinically. In this study, we aimed to determine how measurements obtained by IMI (bone material strength index [BMSi]) relate to bone strength, fracture resistance, and susceptibility to fracture. QUESTIONS/PURPOSES: (1) Is BMSi associated with bone strength of the femur, radius, and vertebrae, and does incorporating BMSi alongside bone mineral density (BMD) improve the estimation of strength? (2) Does BMSi evaluate fracture toughness and mechanical properties of the bone tissue? (3) Can BMSi discriminate fracture susceptibility of the hip and wrist? METHODS: This single-site laboratory study included the tibiae, femurs, radii, and L4 vertebrae from fresh-frozen cadavers (n = 67; mean ± SD age 71 ± 13 years). To answer the first question, IMI was performed on the tibia midshaft, dual-energy x-ray absorptiometry (DXA) was used to assess hip and spine BMD, and bone strength (ultimate fracture force) was mechanically determined for each site. To address the second question, stress intensity factor (KC) was quantified from notched cortical bone beam specimens from tibiae using the fracture toughness test. Bone mechanical behavior (ultimate stress, elastic modulus, work-to-fracture), microstructure (cortical porosity, tissue mineral density), and organic matrix quality (percentage of collagen denaturation, concentration of advanced glycation end products) were quantified from beam specimens from the femoral midshaft. To address the last question, hip and wrist fracture susceptibility was defined using the fall-load to fracture-load ratio, where values ≥ 1 indicate susceptibility. Receiver operating characteristic (ROC) curve analyses evaluated the ability of IMI and DXA to discriminate fracture susceptibility. Primary outcomes included evaluating the association between BMSi and BMD with bone strength and ROC analysis for discriminating fracture susceptibility. RESULTS: Higher BMSi values were positively associated with higher bone strength, showing moderate association at the femur (r = 0.62 [95% confidence interval (CI) 0.49 to 0.72]; p < 0.001) and radius (r = 0.52 [95% CI 0.34 to 0.72]; p < 0.001) and weaker association at the L4 vertebrae (r = 0.31 [95% CI 0.03 to 0.53]; p = 0.02). At the femur, BMSi was more strongly associated with strength than total hip BMD (TH-BMD) (r = 0.45 [95% CI 0.3 to 0.62]; p < 0.001), and the inclusion of BMSi in multivariate analyses improved the explained variance in femur strength from 28% to 52% (ΔR2 = 0.24; p < 0.001). At the radius, both BMSi and TH-BMD (r = 0.50 [95% CI 0.31 to 0.71]; p < 0.01) showed moderate association with radius strength, with the combined model improving the explained variance in radius strength from 28% to 39% (ΔR2 = 0.11; p < 0.001). At the vertebrae, strength was weakly associated with BMSi (r = 0.31 [95% CI 0.03 to 0.53]; p = 0.02) but not with BMD. For the hip and wrist of each donor, BMSi discriminated hip fracture susceptibility with moderate accuracy (area under the curve [AUC] 0.75 [95% CI 0.63 to 0.88]; p < 0.001), whereas TH-BMD could not discriminate hip fracture susceptibility. Both BMSi (AUC 0.77 [95% CI 0.63 to 0.90]; p = 0.003) and TH-BMD (AUC 0.78 [95% CI 0.64 to 0.90]; p = 0.002) classified wrist fracture susceptibility with modest discriminatory performance. CONCLUSION: Our study demonstrates that BMSi provides information related to bone strength and discriminates fracture susceptibility of the hip and wrist. CLINICAL RELEVANCE: IMI can be performed at the point of care using an FDA-cleared device and used to evaluate fragility in patients in whom fracture risk or bone strength is uncertain based on BMD alone. Prospective clinical studies are needed to determine whether IMI improves fracture risk prediction and informs patient treatment.
What Is the Effect of Robot Reduction in Displaced Pelvic Fractures? A Multicenter Randomized Clinical Trial.
Zhao C, Ge Y, Cao Q … +10 more , Yang M, Gao F, Xiao H, Liu G, Sun D, Yu B, Jia J, Wu Z, Wang Y, Wu X
Clin Orthop Relat Res · 2026 Jul · PMID 42370806 · Publisher ↗
BACKGROUND: Displaced pelvic fractures present real surgical challenges because of complex three-dimensional deformity patterns and proximity to vital structures, with conventional manual reduction techniques limited by...
BACKGROUND: Displaced pelvic fractures present real surgical challenges because of complex three-dimensional deformity patterns and proximity to vital structures, with conventional manual reduction techniques limited by accuracy constraints and radiation exposure. Although robotic assistance shows promise in preclinical studies, its clinical effectiveness remains unproven in randomized clinical trials (RCTs). QUESTIONS/PURPOSES: (1) Does robotic closed reduction improve reduction quality compared with manual closed reduction in displaced pelvic fractures? (2) Can robotic closed reduction reduce intraoperative radiation exposure while maintaining functional outcomes? METHODS: In this multicenter RCT conducted at six tertiary trauma centers in China involving 10 senior orthopaedic traumatologists, 92 adult patients with acute closed, displaced pelvic fractures (Tile Type B or C) were randomized 1:1 to robotic closed reduction (n = 46) or manual closed reduction (n = 46) groups. At 12 weeks, loss to follow-up for patient-reported outcomes was 9% (4 of 46) in the robotic group and 4% (2 of 46) in the manual group; the remainder were handled in a prespecified per-protocol analysis. In the robot group, reduction was planned using CT-based three-dimensional reconstruction with contralateral pelvic symmetry as the target and executed by a robotic arm with adjunct elastic traction and contralateral pelvic stabilization. In the manual group, reduction was performed using traction and manual manipulation under fluoroscopic guidance. Surgeons and patients were not blinded; radiographic outcome assessors and data analysts were blinded. Primary outcome was reduction quality assessed using Matta criteria (excellent ≤ 4 mm residual displacement, good 5 to 10 mm, acceptable 10 to 20 mm, poor > 20 mm), analyzed as the proportion of excellent to good reductions. Secondary outcomes included intraoperative surgeon fluoroscopic exposure and 12-week Majeed pelvic scores (0 to 100 points across seven domains; higher scores indicate better function). The primary analysis was intention to treat. RESULTS: In the intention-to-treat analysis, a higher proportion of patients who underwent robotic closed reduction achieved an excellent or good reduction than did those who received manual closed reduction (96% [44 of 46] versus 48% [22 of 46], relative risk 2.00 [95% confidence interval (CI) 1.47 to 2.72]; p < 0.001). Median (IQR) intraoperative surgeon fluoroscopic exposure was lower in the robotic closed reduction group (0 [0 to 0] versus 38 [14 to 78] fluoroscopic exposures; p < 0.001). No differences were found in 12-week Majeed functional scores between groups (mean ± SD 69 ± 16 versus 71 ± 17, mean difference -3 [95% CI -11 to 6]; p = 0.55). One superficial infection occurred in the manual closed reduction group, and there were no serious complications in either group. CONCLUSION: Surgeons treating acute displaced pelvic ring fractures should consider robotic closed reduction, when available, to improve reduction quality and reduce intraoperative fluoroscopic exposure, although it did not result in improved patient-reported outcome scores at short term in this randomized trial. Future studies should evaluate longer term functional benefits, define the fracture patterns most likely to benefit, and evaluate implementation factors including learning curve and cost-effectiveness across varied trauma settings. LEVEL OF EVIDENCE: Level I, therapeutic study.
CORR Insights®: Acute or Delayed TKA for Tibial Plateau Fracture? An Observational Study From the Swedish Arthroplasty Register.
Cornell CN
Clin Orthop Relat Res · 2026 Jul · PMID 42370805 · Publisher ↗
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Reply to the Letter to the Editor: Guest Editorial: Recalling a Recall.
Cornell C
Clin Orthop Relat Res · 2026 Jun · PMID 42361822 · Publisher ↗
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Radial Head Fractures Cluster in the Anterolateral and Anteromedial Quadrants and Do Not Correlate With Coronoid Fracture Types.
Azib N, de Klerk HH, Doornberg JN … +4 more , Nettuno N, van den Bekerom MPJ, Chen NC, Bhashyam AR
Clin Orthop Relat Res · 2026 Jun · PMID 42361803 · Publisher ↗
BACKGROUND: Combined radial head and coronoid fractures, including terrible triad injuries, are challenging patterns associated with elbow instability, poor clinical outcomes, and other complications. While both radial h...
BACKGROUND: Combined radial head and coronoid fractures, including terrible triad injuries, are challenging patterns associated with elbow instability, poor clinical outcomes, and other complications. While both radial head and coronoid fractures contribute to joint stability, the relationship between their fracture morphologies remains poorly understood. Clarifying these associations may aid in preoperative planning and guide surgical decision-making for restoring elbow stability. QUESTIONS/PURPOSES: (1) In patients with combined coronoid and radial head fractures, what radial head fracture patterns are most common? (2) Are radial head fracture patterns associated with coronoid fracture types? METHODS: This study was a secondary data analysis of a retrospective, multicenter descriptive study of patients with combined coronoid and radial head fractures identified on elbow CT scans. The cohort was derived from two urban tertiary level 1 trauma centers with specialized upper extremity and orthopaedic trauma services. Of 10,016 patients with elbow or forearm injuries who underwent CT imaging, 2% (175) met eligibility criteria for combined coronoid and radial head fractures; eight patients were excluded because of prior pathophysiologic conditions of the elbow, previous surgery, or inadequate imaging quality, leaving 167 patients for analysis, 54% (90) of whom were female, with a mean ± SD age of 50 ± 15 years. The radial head was divided into four quadrants (anterolateral, anteromedial, posterolateral, and posteromedial) using the radial tuberosity as a reference landmark on axial CT images. The anterolateral quadrant corresponds approximately to the surgical "safe zone," the region opposite the radial tuberosity and in line with the radial styloid. Coronoid fractures were classified according to the O'Driscoll classification, which categorizes fractures into Type 1 (tip fractures involving the coronoid apex), Type 2 (anteromedial facet), and Type 3 (basal fractures involving the coronoid base) patterns. Interrater reliability was determined using the Cohen kappa, yielding substantial agreement for the radial head quadrant involvement (κ = 0.715) and O'Driscoll classification (κ = 0.658) and reflecting typical reliability for CT-based fracture classification, with disagreements resolved through consensus. RESULTS: The most common radial head fracture pattern was a single fragment involving both the anterolateral and anteromedial quadrants (31% [51 of 167]), followed by two separate fragments involving the anterolateral and anteromedial quadrants (15% [25 of 167]). Most fractures consisted of one fragment (49% [82 of 167]). Radial head fracture patterns were not associated with coronoid fracture type. CONCLUSION: Radial head fractures in combined coronoid and radial head fractures most commonly involved the anterolateral and anteromedial quadrants, often as a single fragment. We found no association between coronoid fracture types and radial head fracture patterns, suggesting that these injury components occur independently. These findings may help surgeons anticipate fragment location in relation to surgical exposure, while emphasizing the importance of evaluating the radial head and coronoid as separate elements during preoperative planning and intraoperative assessment. LEVEL OF EVIDENCE: Level IV, prognostic study.
Reduced Cerebellar Activation With Eyes Closed Is Associated With Delayed Peroneal Reaction Time in Patients With Chronic Ankle Instability.
Hou Z, Zeng X, Huang W … +1 more , Jiang D
Clin Orthop Relat Res · 2026 May · PMID 42349374 · Publisher ↗
BACKGROUND: Chronic ankle instability (CAI) is a common consequence of lateral ankle sprain and is characterized by recurrent episodes of giving way and impaired neuromuscular control. Neuromuscular control impairments (...
BACKGROUND: Chronic ankle instability (CAI) is a common consequence of lateral ankle sprain and is characterized by recurrent episodes of giving way and impaired neuromuscular control. Neuromuscular control impairments (such as decreased postural stability and delayed muscle responses) are dominant during reduced vision. However, the neural mechanisms underlying impaired sensorimotor integration under reduced vision remain unclear. As a key structure involved in sensorimotor processing, the role of the cerebellum during vision-related neuromuscular control impairments has not been well defined. QUESTIONS/PURPOSES: (1) Are there any differences in cerebellar activation across different visual conditions in patients with CAI compared with a control group? (2) Are there any associations between vision-related cortical activation changes and static and dynamic neuromuscular control deficits in patients with CAI? METHODS: This cross-sectional study enrolled physically active adults with unilateral CAI and control participants matched for age, sex, and activity level. Between May and September 2025, a total of 55 individuals were screened. Of these, 64% (35 of 55) were considered eligible based on the inclusion criteria, consisting of 57% (20 of 35) in the CAI group (nine females, mean ± SD age 28 ± 7 years) and 43% (15 of 35) in the control group (eight females, mean age 25 ± 4 years). To assess cerebellar activation and its relation to neuromuscular control, all participants underwent task-based functional MRI (fMRI) and laboratory-based neuromuscular assessments. During fMRI, participants performed repetitive ankle dorsiflexion and plantarflexion movements using an MRI-compatible device under alternating eyes-open and eyes-closed conditions in a block design. Neuromuscular control was assessed during single-leg stance and a sudden ankle inversion (trapdoor) task. Postural stability was quantified using the Romberg ratio derived from center-of-pressure measures. Dynamic neuromuscular response was evaluated by peroneal reaction time using surface EMG synchronized with motion capture. Ankle function and perceived instability were assessed using questionnaires (Cumberland Ankle Instability Tool [CAIT], Foot and Ankle Ability Measure [FAAM], and Ankle Ligament Reconstruction-Return to Sport After Injury [ALR-RSI] tool). Whole-brain analyses were conducted to identify between-group differences in vision-related activation (eyes closed minus eyes open) using a general linear model with Gaussian random field correction. Clusters greater than 50 voxels were considered to be the minimum clinically important difference. Correlation analyses were performed to examine associations between neural activation patterns, neuromuscular outcomes, and clinical measures, with age and sex included as covariates. RESULTS: Compared with controls, individuals with CAI demonstrated reduced activation when eyes changed from open to closed in bilateral cerebellar regions including lobule VI (left hemisphere: cluster size 156 voxels, group mean difference -25.1 [95% confidence interval (CI) -40.1 to -10.1]; p < 0.001; right hemisphere: cluster size 153 voxels, group mean difference -21.7 [95% CI -36.3 to -7.6]), vermis VI (cluster size 51, group mean difference -26.6 voxels [95% CI -44.8 to -8.4]), and crus I (cluster size 112 voxels, group mean difference -21.9 [95% CI -35.8 to -8.1]), as well as in the left fusiform gyrus (cluster size 54 voxels, group mean difference -18.1 [95% CI -29.3 to -6.8]). Correlation analyses revealed that reduced activation in cerebellar and fusiform gyrus in both eyes-open and eyes-closed states was moderately associated with delayed peroneal reaction time in both visual conditions (eyes open: r = -0.38; p = 0.03; eyes closed: r = -0.40; p = 0.02) and worse self-reported ankle stability and function, as measured by the CAIT (r = 0.34; p = 0.046) and ALR-RSI (r = 0.38; p = 0.02). No correlations were observed between cerebellar activation and Romberg ratio. CONCLUSION: Patients with CAI demonstrated reduced cerebellar activation across visual conditions, which was associated with delayed dynamic muscle responses and worse perceived ankle stability. CLINICAL RELEVANCE: These findings suggest that patients with CAI had vision-related central activation strategies, such as reduced cerebellar activation when eyes were closed compared with controls. Such neural alterations were associated with decreased neuromuscular control and diminished ankle function. These vision-specific central alterations may be important in designing future interventions aimed at enhancing central sensorimotor integration.
CORR Insights®: Reduced Cerebellar Activation With Eyes Closed Is Associated With Delayed Peroneal Reaction Time in Patients With Chronic Ankle Instability.
Guyton GP
Clin Orthop Relat Res · 2026 Jun · PMID 42339845 · Publisher ↗
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Residency Diary: Saying Goodbye.
Friedman LGM
Clin Orthop Relat Res · 2026 Jun · PMID 42339840 · Publisher ↗
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Virtue Ethics in a Value-driven World: Soliciting Donations From Grateful Patients.
Humbyrd CJ
Clin Orthop Relat Res · 2026 Jun · PMID 42333595 · Publisher ↗
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Editorial Comment: Selected Proceedings From the 2025 Musculoskeletal Infection Society Meeting.
Zalavras CG
Clin Orthop Relat Res · 2026 Jun · PMID 42333543 · Publisher ↗
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Are Social Determinants of Health Disparities Associated With Worse Completion Rates for Patient-reported Outcome Measures After Total Joint Arthroplasty?
Meacock S, Hohmann A, Sellig MT … +2 more , Sherman M, Fillingham YA
Clin Orthop Relat Res · 2026 Jun · PMID 42333542 · Publisher ↗
BACKGROUND: Patient-reported outcome measures (PROMs) are important markers to assess patient improvement after total joint arthroplasty (TJA). PROMs are increasingly relevant because of new PROM-reporting requirements f...
BACKGROUND: Patient-reported outcome measures (PROMs) are important markers to assess patient improvement after total joint arthroplasty (TJA). PROMs are increasingly relevant because of new PROM-reporting requirements for elective inpatient TJA from the Centers for Medicare & Medicaid Services. Social determinants of health (SDOH) disparities have been associated with various worse outcomes after TJA, but to our knowledge, it is not yet known how PROM completion may be affected by SDOH disparities. QUESTIONS/PURPOSES: Among patients undergoing TJA, (1) are there SDOH disparities (such as insurance, transportation access, and living alone) that are associated with differences in PROM completion? (2) Are there neighborhood metrics, including Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI), that are associated with differences in PROM completion? METHODS: This study was a retrospective, comparative single-institution study of 12,842 patients who underwent primary, unilateral TJA for osteoarthritis between 2019 and 2022. Study participants had a mean ± SD age of 67 ± 10 years, 45% (5745) were men, and 86% (10,131 of 11,833) were White. Mean ± SD national ADI score was 34 ± 21, and SVI score was 0.4 ± 0.3. PROMs were collected within the first year preoperatively and at 6 months, 1 year, and 2 years postoperatively per institutional protocol. Patient demographic and socioeconomic factors were collected from the institutional medical record. We examined whether PROM noncompletion and completion differed in terms of SDOH, including living alone, transportation access, and insurance type. Race and ethnicity were self-reported by patients. We additionally examined whether PROM noncompletion and completion differed in terms of neighborhood metrics including SVI and ADI scores. For proportions, a clinically important difference was defined by a 15% change. RESULTS: We found no clinically important differences regarding SDOH disparities in terms of PROM noncompletion and completion; specifically, there were no differences in PROM completion based on Black race (preoperative: 13% [312 of 2332] versus 9% [884 of 9501]; p < 0.001; 1 year: 11% [886 of 8015] versus 8% [310 of 3818]; p < 0.001), lack of transportation access (preoperative: 3% [67 of 2002] versus 2% [199 of 8494]; p = 0.01; 1 year: 3% [205 of 7050] versus 2% [61 of 3446]; p = 0.001), living alone (preoperative: 23% [466 of 1988] versus 21% [1750 of 8452]; p = 0.01; 1 year: 23% [1577 of 6999] versus 19% [639 of 3441]; p < 0.001), and commercial insurance preoperatively (62% [1577 of 2563] versus 65% [6675 of 10,279]; p < 0.001). For neighborhood-level metrics, we found no clinically important difference for PROM noncompletion and completion in terms of mean ± SD ADI scores nationally (preoperative: 36 ± 23 versus 34 ± 21; p = 0.004; 1 year: 39 ± 21 versus 33 ± 20; p < 0.001) and SVI scores (preoperative: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.53 to 0.73]; p < 0.001; 1 year: 0.4 ± 0.3 versus 0.4 ± 0.3, mean difference 0.1 [95% CI 0.61 to 0.80]; p < 0.001). CONCLUSION: No clinically important difference was found for various SDOH disparities and neighborhood metrics investigated in this study. Considering these findings, lack of transportation access, living alone, race, insurance type, and address-related neighborhood disadvantage may not be strong indicators of PROM completion after TJA. However, SDOH disparities still require further investigation to understand the relationship between other SDOH disparities and different populations outside of our urban institution. LEVEL OF EVIDENCE: Level III, prognostic study.
A Conversation With ... Malcolm Willett, Cartoonist Who Looks at Us With a Wry Smile.
Leopold SS
Clin Orthop Relat Res · 2026 Jun · PMID 42333539 · Publisher ↗
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Reply to the Letter to the Editor: Can Nutritional and Inflammatory Markers Be Combined to Develop an Accurate Survival Model for Surgical Decision-making in Patients With Lung Cancer Bone Metastases?
Yan Y, Zhang Y
Clin Orthop Relat Res · 2026 Jun · PMID 42328747 · Publisher ↗
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Are Age-based Cutoffs for THA Logically Consistent?
Bernstein J, Lee A, Kandel L … +2 more , Vadhera AS, Sheth NP
Clin Orthop Relat Res · 2026 Jun · PMID 42328737 · Publisher ↗
BACKGROUND: Although THA is routinely offered to patients age 85 years and older, surgeons might hesitate to operate on patients deemed "too young." This study tests whether such hesitancy reflects a consistent standard....
BACKGROUND: Although THA is routinely offered to patients age 85 years and older, surgeons might hesitate to operate on patients deemed "too young." This study tests whether such hesitancy reflects a consistent standard. QUESTIONS/PURPOSES: (1) How much utility (net benefit) can be expected from THA, as a function of patient age and operation-related clinical variables? (2) What relative cost must be attributed to revision of a THA such that the imposition of this penalty renders the expected utility of the operation too low to justify it in younger people? METHODS: A calculator was programmed using a state-transition Markov model to estimate the expected lifetime benefit of THA as a function of patient age and other user-specified parameters. A novel unit of benefit, the joint-adequate life year (JALY), was defined. One JALY is earned in each postoperative year that the patient has an intact prosthesis and adequate clinical outcome. JALYs can also be forfeited when a patient enters a revision state. Thus, previously accumulated JALYs may be partially or completely offset, resulting in a net lifetime total that is lower than the total years of an adequate outcome. Users of the calculator specify patient sex and age at the time of THA (we modeled sex rather than gender in order to be able to derive life expectancy from sex-specific life tables published by the Social Security Administration), the anticipated fraction of patients expected to have a clinically adequate outcome (termed here the "satisfaction fraction"), prosthetic life expectancy, the expected annual risk of revision attributed to catastrophic events such as fracture or infection, and a discount rate, which is used to convert future gains and losses to their net present value. The prosthetic life expectancy parameter was used to calculate an annual risk of needing revision for wear. Users also assign a negative value to the revision state, representing the number of JALYs that a patient would be willing to forgo to avoid that state. This penalty was applied in the first instance the failure state was encountered, and a value 1.5 times this penalty was applied for any subsequent encounter. The model was then interrogated to provide the expected JALYs earned as a function of failure-state penalties ranging from 0 to 40 JALYs. For this calculation, prosthetic life expectancy was set to 15 years, the anticipated satisfaction fraction was set to 90%, the annual rate of catastrophic failure was set to 0.5%, and no temporal discounting was applied. Sensitivity analyses were then performed for different values of prosthetic life expectancy, satisfaction fraction, catastrophic failure rate, second-revision penalty ratio, and with 2% and 10% temporal discounting applied. Based on the common use of THA in 85-year-old patients (a group with a life expectancy of about 6 years after THA), a benchmark of six JALYs was established, as logically no patient can have more "adequate joint years" than total years of life. We then determined the penalty that must be assigned to the revision state, such that a 45-year-old male's expected benefit would fall below this six-JALY benchmark. RESULTS: A cohort of 45-year-old males can be expected to earn 25 lifetime JALYs under the base case assumptions and a revision penalty of five JALYs. Lifetime JALYs for this cohort do not drop below the threshold of six until the revision penalty reaches 25 JALYs. Sensitivity analysis demonstrated that this finding was robust across wide variation in clinically plausible values for prosthetic life expectancy, satisfaction, failure rates, and discounting. CONCLUSION: Hesitation to offer THA to 45-year-old patients with impairing hip disease is logically inconsistent with the procedure's broad acceptance in 85-year-old patients. This is because under plausible assumptions of the clinical parameters, 45-year-old patients stand to accrue considerably more lifetime benefit. Indeed, even accounting for the inevitable failures younger patients may encounter (and the penalties these failures impose), such patients can expect to accrue more than six JALYs across their lifetimes unless implausibly large failure penalties are assumed. LEVEL OF EVIDENCE: Level II, Economic and Decision Analyses.
Clinical Presentation Patterns and Outcomes of Decompression for Suprascapular Neuropathy: A Retrospective Surgical Series.
McCarthy CF, Bishop KR, Lansford JL … +5 more , Rocchi VJ, Susmarski AJ, Dickens JF, Kilcoyne KG, LeClere LE
Clin Orthop Relat Res · 2026 Jun · PMID 42328728 · Publisher ↗
BACKGROUND: Suprascapular neuropathy caused by nerve compression or tension at the suprascapular notch is an uncommon but often underappreciated source of shoulder pain and weakness, with limited reporting of presentatio...
BACKGROUND: Suprascapular neuropathy caused by nerve compression or tension at the suprascapular notch is an uncommon but often underappreciated source of shoulder pain and weakness, with limited reporting of presentation types, diagnostic algorithms, and outcomes of surgical treatment. QUESTIONS/PURPOSES: (1) How does suspected suprascapular nerve compression without rotator cuff tear or space-occupying lesion present in a predominantly young and active military population? (2) How does arthroscopic suprascapular nerve decompression affect VAS pain scores, shoulder motor grading, and return to military duty or sport in this population? METHODS: Between 2013 and 2020, two surgeons treated 29 patients for symptoms attributed to suprascapular nerve lesions with arthroscopic suprascapular nerve decompression. The diagnosis was made by a combination of history, physical examination, MRI, and selective use of EMG and diagnostic injection. Ultrasound-guided suprascapular nerve injection at the suprascapular notch with local anesthetic was performed in all patients presenting predominantly with pain to support the diagnosis. Patients who had positive findings from this work-up were offered surgical decompression, with patients presenting predominantly with pain having completed at least 7 months of nonoperative treatment at the time of final diagnosis. Although we do not have the exact numbers, the large majority of patients whose work-up suggested the presence of these nerve lesions underwent surgical decompression. We excluded nine of the original 29 patients because they had concomitant procedures and/or were over the age of 60 years. The remaining 20 patients (median [IQR] age 23 years [21 to 28]; 15 were men) were treated with isolated arthroscopic suprascapular nerve decompression at the suprascapular notch with necessary concomitant subacromial decompression, and all of them had follow-up of a minimum of 2 years (median [range] 6 years [2 to 10]) with respect to the endpoint of VAS pain, motor grading, and return to duty or sport. To answer our first research question, we characterized the patients' presentations descriptively based on whether they presented principally with pain or with weakness. Patients presenting predominantly with pain had VAS pain scores ranging from 4 to 8 with motor grades no worse than 4+ of 5, while patients presenting predominantly with weakness had a motor grading of 4 of 5 or worse and VAS pain scores ranging from 0 to 5 (median and mode 0). To answer our second research question, we collected the following outcome measures: return to active-duty military service, shoulder abduction and external rotation strength (by motor grade), and VAS pain score (worst level at rest or activity). These outcomes were compared with Wilcoxon rank sum tests. RESULTS: We found two clinical patterns. A primary symptom of weakness was present in 10 of 20 patients, and pain was the main symptom in 10 of 20 patients. Supraspinatus and/or infraspinatus edema and/or atrophy were present on MRI in 10 of 10 patients with weakness and 0 of 10 patients with pain. EMG had denervation changes in 8 of 8 patients with weakness and 0 of 4 patients with pain. Postoperatively, patients who primarily reported pain had improvement in median (IQR) VAS scores (6 [4 to 7] to 1 [0 to 1]; p = 0.009), whereas those who primarily reported weakness had improvement in abduction and external rotation motor grading (4.0 [3.6 to 4.0] to 5.0 [4.8 to 5.0] and 3.3 [3.0 to 3.9] to 4.3 [4.0 to 5.0], respectively; p = 0.004 and p = 0.008). Return to duty or sport occurred in 8 of 10 patients presenting predominantly with pain and 9 of 10 patients presenting predominantly with weakness at a median (IQR) of 13 weeks (13 to 17) and was maintained past at least 1-year follow-up. CONCLUSION: In this young, active cohort, suspected suprascapular neuropathy caused by compression at the suprascapular notch presented with one of two primary symptoms: pain or weakness. Diagnosis can be supported by concordant findings on history, physical examination, and MRI, with selective use of EMG for weakness and diagnostic injection for pain. Outcomes after arthroscopic suprascapular nerve release with necessary concomitant subacromial decompression involved successful pain relief and strength improvement in patients presenting with pain and weakness, respectively. Future studies could provide valuable insight into the epidemiology of suprascapular neuropathy and further define thresholds for surgical treatment, especially for patients presenting predominantly with pain. LEVEL OF EVIDENCE: Level III, therapeutic study.
Letter to the Editor: What Is the Association Between Radiographic Measurements of Initial and Residual Fracture Displacement, Tibial Alignment, and Recovery in Terms of Patient-reported Outcome After Surgical Treatment of Tibial Plateau Fractures?
Qin K, Chen D, Sun P … +1 more , Liang W
Clin Orthop Relat Res · 2026 Jun · PMID 42328727 · Publisher ↗
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Letter to the Editor: Only Nine Percent of Orthopaedic Clinical Trials Report and One Percent Analyze a Social Determinant of Health: A Systematic Review.
Lee TC
Clin Orthop Relat Res · 2026 Jun · PMID 42328726 · Publisher ↗
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What Are the Substantial Clinical Benefit Thresholds for KOOS Pain, Physical Function, and Joint Replacement Scores After Primary TKA?
Elmenawi KA, Pasqualini I, Khan ST … +3 more , Hadad MJ, Piuzzi NS, Cleveland Clinic Adult Reconstruction Research Group (CCARR)
Clin Orthop Relat Res · 2026 Jun · PMID 42328725 · Publisher ↗
BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) have mandated the collection of patient-reported outcome measures (PROMs) for inpatient TKA with a submission deadline of September 2025. Not achieving a 20-...
BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) have mandated the collection of patient-reported outcome measures (PROMs) for inpatient TKA with a submission deadline of September 2025. Not achieving a 20-point improvement in substantial clinical benefit (SCB) on the Knee Injury and Osteoarthritis Outcome Score (KOOS) for joint replacement (JR) will negatively impact hospital reimbursement. However, SCB thresholds for KOOS subscales and factors associated with not achieving SCB remain poorly defined. QUESTIONS/PURPOSES: We retrospectively analyzed a large TKA database at a multisite tertiary healthcare system and asked: (1) What are the SCB thresholds for the KOOS pain, physical function short form (PS), and JR subscales at 1 year after primary TKA? (2) What patient factors are associated with failure to achieve the SCB on these KOOS subscales? METHODS: This was a retrospective analysis of a longitudinally maintained institutional registry, which evaluated the results of 15,638 patients who underwent primary TKA from 2016 to 2022. Of these, 89% (13,850) of patients completed baseline PROMs, and 79% (10,988 of 13,850) of patients completed 1-year follow-up; data from those patients were used in this analysis. Demographics, comorbidities, as well as baseline and 1-year KOOS scores were recorded. The median (IQR) age of these patients was 67 years (61 to 73), 60% (6615 of 10,988) of patients were women, and the median (IQR) BMI was 31.0 kg/m 2 (27.2 to 35.5). The SCB thresholds were calculated using anchor-based methodology, utilizing item 8 from the Veterans RAND 12-Item Health Survey at 1 year postoperatively as an anchor question: "Compared to one year ago, how would you rate your physical health in general now?" The optimal threshold, defined as the value that maximized the Youden index, was used as the SCB threshold to distinguish patients who had substantially improved in terms of end point versus those who had not. Multivariable logistic regression identified factors that were associated with not achieving the SCB. It should be noted that race was identified by self-report and grouped as White and non-White per our database. RESULTS: The SCB thresholds were 33 of 100 for KOOS pain (sensitivity 0.80, specificity 0.53, area under the receiver operating characteristic curve [AUC] 0.72), 16 of 100 for KOOS PS (sensitivity 0.82, specificity 0.47, AUC 0.69), and 23 of 100 for KOOS JR (sensitivity 0.82, specificity 0.51, AUC 0.72), achieved by 59% (6483) of patients for each subscale. For KOOS pain, factors associated with not achieving the SCB included older age (OR 0.84 [95% confidence interval (CI) 0.78 to 0.9]; p < 0.001), non-White race compared with White race (OR 1.7 [95% CI 1.59 to 1.93]; p < 0.001), a higher Charlson comorbidity index (CCI) (OR 1.11 [95% CI 1.05 to 1.17]; p < 0.001), and commercial insurance (OR 0.80 [95% CI 0.72 to 0.89]; p < 0.001). For KOOS PS, factors associated with not achieving the SCB included older age (OR 0.82 [95% CI 0.76 to 0.89]; p < 0.001), non-White race (OR 1.82 [95% CI 1.59 to 2.1]; p < 0.001), a higher CCI (OR 1.08 [95% CI 1.02 to 1.15]; p < 0.01), commercial insurance (OR 0.77 [95% CI 0.68 to 0.87]; p < 0.001), and lower education level (OR 0.89 [95% CI 0.83 to 0.96]; p < 0.01). For KOOS JR, factors associated with not achieving the SCB included older age (OR 0.84 [95% CI 0.78 to 0.90]; p < 0.001), non-White race (OR 1.77 [95% CI 1.56 to 2.01]; p < 0.001), a higher CCI (OR 1.07 [95% CI 1.01 to 1.12]; p = 0.01), commercial insurance (OR 0.8 [95% CI 0.72 to 0.90]; p < 0.001), and lower education level (OR 0.92 [95% CI 0.86 to 0.98]; p < 0.01). CONCLUSION: As TKA outcomes are increasingly judged by achievement of the 20-point SCB threshold on the KOOS JR under new CMS policies, determining SCB thresholds is of utmost importance. This study found SCB thresholds of 33 for KOOS pain, 16 for KOOS PS, and 23 for KOOS JR, with only 59% (6483) of patients achieving these thresholds 1 year after TKA. More at-risk populations, including older, non-White, less educated, and patients with medically complex conditions, were at higher risk of not achieving the SCB. These results suggest that SCB nonattainment after TKA is likely found in a meaningful subset of patients-especially those with greater baseline symptom burden and medical complexity. These findings can guide perioperative support to increase the likelihood that all patients achieve the reduction in pain and improvement in function that they seek from arthroplasty, as healthcare systems prepare for the implementation of the new PROM policy for TKA from the CMS. LEVEL OF EVIDENCE: Level III, Therapeutic study.
Behind the Mask: Setting Expectations.
Zhang SE
Clin Orthop Relat Res · 2026 Jun · PMID 42328724 · Publisher ↗
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CORR Insights®: Are LGBTQ+ Allyship Symbols Associated With Patient Trust in the Orthopaedic Surgeon? A Dual Cohort Survey.
McAllister Nolan B
Clin Orthop Relat Res · 2026 Jun · PMID 42328717 · Publisher ↗
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