Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 82 appraisals
The Knee
Artificial intelligence in the management of sports knee injuries: a narrative review.
INTRODUCTION: Sports-related knee injuries are common and debilitating, often leading to chronic pain, early osteoarthritis, and reduced performance. Artificial Intelligence (AI) has emerged as a promising tool to improve their prevention, diagnosis, prognosis, and rehabilitation. This review summarises current evidence on the clinical applications, limitations, and future directions of AI and machine learning in sports-related knee injuries. METHODS: A narrative review of PubMed, Embase, Medline and Web of Science was conducted, examining recent literature on AI-based models in musculoskeletal and sports medicine. The review was categorised into key domains: injury prediction and prevention, diagnostic imaging performance, AI-enabled clinical workflows, alongside postoperative and rehabilitation outcome modelling. RESULTS: AI algorithms demonstrate strong potential across the sports knee injury continuum. Predictive models analysing biomechanical and physiological data have achieved high area under the curve (AUC) values, in some cases above 0.90, in experimental and pilot setting when identifying athletes at risk of ACL rupture or overuse injuries, while machine learning approaches have been used to predict graft failure, revision surgery, and return-to-sport. However, most remain investigational rather than clinically deployable, with limited explainability, insufficient external validation, and training datasets that are often narrow or unrepresentative of broader athletic populations. CONCLUSION: AI has the potential to transform the management of sports-related knee injuries through more predictive, personalised, and precise care. However, wider clinical adoption will require multicentre validation, improved interpretability, and robust ethical and regulatory oversight. With further development, AI may enhance injury prevention, recovery, and improve long-term joint health outcomes in athletes.
3 Aug 2026
Read appraisal →Clinical spine surgery
An Introduction to Machine Learning for the Practicing Spine Surgeon
The applications of new and emerging technologies in spine surgery are constantly expanding. Specifically, machine learning algorithms have seen a rise in utilization in clinical research, allowing for interpretation of large datasets that have the capability of experiential learning. The goal of this work is to present a guide for surgeons to better understand model design, key takeaways, and common pitfalls related to machine learning to ensure accurate and appropriate interpretation of analytical findings in their practice.
2 Aug 2026
Read appraisal →Seminars in musculoskeletal radiology
Artificial Intelligence (Pattern Recognition) in Musculoskeletal Imaging: The Future or Hype?
Artificial intelligence and automated pattern recognition, in particular, have been described as the next frontier in musculoskeletal imaging. However, as the initial hype phase transitions into clinical reality, an essential evaluation of these technologies is required. This narrative review examines the dichotomy between a potential future in which artificial intelligence offers unprecedented efficiency in automatizing multiple tasks in musculoskeletal radiology, from fracture detection, automated segmentation, to automated reporting, versus the hype, characterized by deep learning models that lack generalizability across different scanner vendors and patient populations. We explore the black box nature of deep learning and the ethical implications of automation. By analyzing current barriers to deployment, including workflow integration and regulatory hurdles, this article argues that although artificial intelligence holds transformative potential for musculoskeletal radiology, its success depends on moving beyond narrow diagnostic tasks toward robust multi-institutional validation, to evolve from a speculative trend into an essential clinical copilot tool.
2 Aug 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Shoulder injuries in rugby union: a systematic review and meta-analysis
Shoulder injuries are common in Rugby Union, resulting in prolonged absence and considerable burden. Reported incidence, severity, and mechanisms vary widely, reflecting the multiple high-impact actions in the sport. Various management approaches exist to treat a wide range of pathologies. This systematic review and meta-analysis aimed to synthesise evidence on the epidemiology, mechanisms, and treatment of shoulder injuries in rugby. PUBMED, SCOPUS, and WEB OF SCIENCE were searched from database inception until 1st June 2025. From 1,099 abstracts screened, 37 studies were included. The pooled match incidence was 11.02 injuries/1,000 player-hours (95% CI 7.23-16.82), though heterogeneity was very high (I² = 97%) and the 95% prediction interval was wide (2.11-57.61 injuries/1,000 player-hours), indicating the pooled rate should be read as an average across diverse populations rather than a single representative value. Higher rates were seen in male elite (13.74/1,000 h) and high school/university players (12.28/1,000 h). Training incidence was considerably lower (0.20/1,000 h). Substantial between-study heterogeneity was observed across all incidence analyses, reflecting genuine variation across playing levels, sex, and surveillance methods. Tackling was the predominant injury mechanism, most often affecting the tackler. Bankart, Latarjet, and Bristow procedures all produced favourable reported outcomes for surgical management of anterior shoulder instability. These were indirect comparisons drawn from observational cohorts, however, and comparative effectiveness between techniques cannot be determined from the available evidence. Shoulder injuries in rugby occur far more often in matches than in training, result in prolonged time loss, and are most sustained in tackling. Surgical stabilisation is associated with favourable reported outcomes, though the comparative findings should be regarded as hypothesis-generating, and high-quality comparative studies are warranted. Greater attention to prevention, improved reporting of mechanisms, and focused research on female players should be prioritised.
31 July 2026
Read appraisal →JBJS reviews
One-Stage or Two-Stage Revision for Infected Shoulder Arthroplasty: A Head-to-Head Meta-Analysis of Comparative Studies
BACKGROUND: Periprosthetic joint infection (PJI) following shoulder arthroplasty is a devastating complication associated with substantial morbidity and revision burden. While 2-stage revision has traditionally been regarded as the gold standard for chronic shoulder PJI, single-stage revision has emerged as a potential alternative. The aim of this systematic review was to directly compare infection-related outcomes and complications between single-stage and 2-stage revision arthroplasties for shoulder PJI. METHODS: This systematic review was prospectively registered with PROSPERO (CRD420251159566) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, EMBASE, and Web of Science were searched up to September 22, 2025. Comparative observational studies and randomized controlled trials (RCTs) evaluating single-stage vs. 2-stage revision for shoulder PJI in adults were eligible; no RCTs were identified. Primary outcomes were reinfection and infection control success; overall complications were secondary. Odds ratios (ORs) were calculated within each study and pooled using a random-effects model. Risk of bias was assessed with the Risk of Bias in Non-randomized Studies of Interventions tool, and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Thirteen retrospective comparative studies involving 260 patients (127 single-stage and 133 two-stage) were included. Compared with 2-stage revision, single-stage revision showed a lower, but not statistically significant, odds of reinfection (OR 0.46, 95% confidence interval [CI] 0.21-1.04; p = 0.06; I2 = 0%) and overall complications (OR 0.52, 95% CI 0.18-1.53; p = 0.24; I2 = 0%) and a higher, but nonsignificant, odds of infection control success (OR 1.57, 95% CI 0.45-5.40; p = 0.48; I2 = 17%). CONCLUSION: Single-stage revision demonstrated infection control and complication rates comparable with 2-stage revision for shoulder PJI. Although no statistically significant differences were observed, trends favored single-stage revision. Given that the certainty of the evidence was graded as low, these findings should be interpreted with caution, and high-quality RCTs are required to define optimal patient selection and surgical strategy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
30 July 2026
Read appraisal →PloS one
Hamstring strength assessment methods in sport: A systematic review and meta-analysis of post-activity strength decrements, asymmetry benchmarks, and measurement reliability.
Hamstring strain injuries (HSI) represent one of the most prevalent and recurrent injuries in sport, making reliable strength assessment essential for neuromuscular monitoring in athletic populations. Despite the breadth of available testing modalities, no comprehensive synthesis of assessment methods, their reliability, post-activity strength responses, or normative asymmetry values has been undertaken. This systematic review and meta-analysis aims to evaluate the reliability of hamstring strength assessment methods, quantify the time-course of strength decrements following competition, establish normative inter-limb asymmetry benchmarks, and identify gaps to guide future assessment practices. PubMed, Scopus, SPORTDiscus, and Web of Science were searched from inception to November 1, 2025 following PRISMA guidelines. Methodological quality was assessed using a modified version of the Downs and Black checklist. A total of 161 studies were included in qualitative synthesis and 106 in quantitative analysis. Isokinetic dynamometry was the most frequently used modality, followed by force platform assessments and Nordic hamstring-based devices, with a clear upward trend in field-based testing observed after 2010. Multiple modalities demonstrate good reliability, sensitivity to post-activity fatigue, and comparable patterns to detect inter-limb asymmetries, supporting their use across varied applied settings. Hamstring strength deficits persisted for 24-72 hours following on-field activity, identifying a critical vulnerability window during congested schedules. Minor inter-limb asymmetries of approximately 3-4% appear normative and should not be considered clinically meaningful in isolation. Practitioners should establish individualized baselines and integrate routine monitoring with evidence-based recovery strategies to mitigate HSI risk throughout competitive seasons.
23 July 2026
Read appraisal →American journal of physical medicine & rehabilitation
Virtual Reality-assisted Physiotherapeutic Training for Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis
OBJECTIVE: To evaluate the effectiveness of virtual reality (VR)-assisted physiotherapy in improving pain, physical function, and balance in patients with knee osteoarthritis (KOA) compared with traditional rehabilitation treatments. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs). RESULTS: This analysis included 5 randomized controlled trials (RCTs). The pooled results showed that, compared with consistency rehabilitation, virtual reality (VR)-assisted physiotherapy produced significantly better outcomes in patients with knee osteoarthritis (KOA) for pain relief (SMD = 0.40, 95% CI: 0.14-0.65, P = 0.002), physical function (SMD = 0.37, 95% CI: 0.05-0.70, P = 0.003), and balance (SMD = 0.44, 95% CI: 0.16-0.72, P = 0.002). CONCLUSIONS: Virtual reality-assisted physiotherapy is an effective intervention for patients with knee osteoarthritis, showing superior outcomes in pain reduction, functional improvement, and balance enhancement compared to traditional rehabilitation approaches.
18 July 2026
Read appraisal →The Journal of the American Academy of Orthopaedic Surgeons
Clinical Outcomes and Safety Profile of Open and Arthroscopic Subtalar Joint Arthrodesis: A Systematic Review
BACKGROUND: Open and arthroscopic subtalar arthrodesis are safe and effective surgeries for patients with notable arthritis; however, not an established superiority among them has been found. This systematic review aims to present all of the available literature on studies directly comparing both surgeries. METHODS: Two independent authors completed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol and the Cochrane Handbook guidelines were followed. In addition, the MINORS score was used to evaluate the quality and bias of the nonrandomized controlled trials. Our search criteria included only studies that included both open and arthroscopic subtalar arthrodesis. RESULTS: A total of four studies including 125 open and 130 arthroscopic surgeries met the inclusion criteria for the current systematic review. The mean age and body mass index of patients in the open and arthroscopic groups were 50.0 ± 2.3 and 47.9 ± 1.4 years and 29.0 ± 3.7 and 29.5 ± 2.6 kg/m 2 , respectively. Patients in the open cohort and arthroscopic cohort were followed for a mean of 16.9 ± 6.5 and 15.8 ± 4.7 months, respectively. Union rate was 95.4% ± 4.6% vs. 93.6 ± 4.0%, and the time to fusion was 14 ± 1.6 vs. 10.5 ± 1.6 weeks. The overall complication rate among patients who underwent open arthrodesis was 44.0%, whereas the complication rate was 39% among patients who underwent arthroscopic arthrodesis. Patients stayed in the hospital for 2.2 ± 0.9 days following an open procedure versus 1.1 ± 0.5 days following minimally invasive procedures. CONCLUSION: The current systematic review found a high rate of union among both group of patients. Although trends suggested higher union rates and fewer complications in the arthroscopic cohort, no notable differences were found. Although limited, we hope that this systematic review may help to guide evidence-based decisions when planning the surgical management of patients with severe subtalar arthritis.
17 July 2026
Read appraisal →Proceedings of the National Academy of Sciences of the United States of America
Magnetically actuated microrobotic system for sequential treatment of biofilm
Biofilm-associated infections present a critical therapeutic challenge due to antibiotic resistance and impaired tissue healing. Here, we present a microrobotic system (MZ-8) that integrates real-time human-steered navigation with autonomous, microenvironment-responsive therapy to actively eradicate biofilms and promote tissue regeneration. This microrobotic system features a spine-inspired structure for mechanical biofilm disruption, a pH-responsive ZIF-8 coating for immunomodulatory Zn2+ release, and closed-loop actuation under second near-infrared fluorescence guidance. In a rat model of periprosthetic joint infection, MZ-8 achieved effective biofilm removal, induced a pro-regenerative immune response by polarizing macrophages toward the M2 phenotype, and significantly enhanced tissue regeneration. Transcriptomic analysis further revealed the activation of immunomodulatory pathways and upregulation of M2-associated genes, confirming the system's sequential shift from eradication to repair. Moreover, validation in a rabbit model and human knee joint confirmed its operational feasibility under clinical imaging guidance and excellent biosafety. This work establishes that integrating physical eradication, biochemical immunomodulation, and interactive control within a single system is essential for advancing from infection clearance to functional tissue restoration. Thus, it provides a therapeutic paradigm for biofilm-associated diseases and lays a foundation for future intelligent, clinically adaptive anti-infective systems.
15 July 2026
Read appraisal →Science advances
Motor-free hip exosuit via high-output fibrous dielectric elastomer actuators
Exosuits can assist gait and reduce fatigue for both healthy and pathological populations, yet their bulky, rigid actuators (usually motors or pneumatic actuators) hinder natural, comfortable movement. Dielectric elastomer actuators (DEAs) provide a lightweight, compliant alternative, but are constrained by insufficient force, energy output, and integration challenges. Herein, we propose a motor-free hip exosuit driven by high-output fibrous DEAs, offering a previously unexplored paradigm for lower-limb assistance. We develop high-aspect-ratio fibrous DEAs that deliver high blocked stress (381.6 mN·mm-2), energy density (260 J/kg), and power density (1,664 W/kg), enabled by a dual-polar molecular design of the elastomer to overcome the intrinsic trade-offs between dielectric and mechanical properties. A Lego-like integration strategy is established to efficiently bundle fibers for force amplification. The resulting exosuit reduces the walking metabolic cost by 13.9% compared to no assistance, surpassing most hip exoskeletons. These findings advance DEAs toward practical wearable robotics for real-world human assistance.
12 July 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
Initial surgical management of injuries to the upper extremities for patients with multiple and/or severe injuries - a systematic review and clinical practice guideline update.
PURPOSE: Our objective was to update the evidence-based and consensus-based recommendations for the initial surgical management of upper extremity injuries in patients with suspected multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2025 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to September 2024. Further literature reports were obtained from clinical experts. Randomised controlled trials (RCTs) or observational studies reporting risk-adjusted outcomes were included if they compared early versus delayed surgical treatment for fractures, vascular injuries, or nerve injuries affecting the upper extremities in patients with multiple and/or severe injuries. Studies comparing limb salvage versus amputation or comparing amputation criteria for the upper extremities were also included. We considered patient-relevant outcomes such as mortality and limb salvage, as well as the sensitivity and specificity of scores for predicting upper extremity amputation. Risk of bias was assessed at the outcome level using ROBINS-I for observational studies and AMSTAR-2 for systematic reviews. We used available meta-analyses if possible; alternatively, we synthesised the evidence narratively. We used GRADE to rate the certainty of evidence. Expert consensus was used to develop recommendations and determine their strength. RESULTS: Among 2498 records screened for eligibility, four studies were included. Observational studies addressed the timing of humeral fixation, the timing of revascularisation, or compared limb salvage with amputation. A systematic review evaluated scoring systems for mangled upper limb salvage. Four recommendations were modified, and one consensus-based recommendation was added. All five recommendations achieved strong consensus. CONCLUSION: The timing of surgical intervention for upper extremity injuries in polytrauma patients should be individualized, based on the patient's physiological status, injury pattern, and the risks and benefits of early versus delayed surgery. Although early surgery may improve functional outcomes and reduce complications, adequate patient stabilization is essential before proceeding. Limb salvage should be attempted for patients with a MESS score of less than seven, provided the patient is sufficiently stable and depending on the condition of the amputated limb.Although the guideline addresses patients with multiple and/or severe injuries, the scarce evidence, heterogeneity of the included studies and the limited representation of true polytrauma cohorts may restrict the applicability of the findings to the broader critically injured trauma population.
10 July 2026
Read appraisal →British journal of sports medicine
Comparative effectiveness of physical therapy interventions in adults with rotator cuff tendinopathy: a systematic review and network meta-analysis
OBJECTIVE: To compare the effects of different physical therapy interventions and identify the most effective intervention on pain, function, quality of life (QoL) and adverse events (AEs) in adults with rotator cuff (RC) tendinopathy. DESIGN: Systematic review and network meta-analysis (NMA) of randomised clinical trials (RCTs). DATA SOURCES: Seven databases and two trial registries were searched up to March 2024. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: RCTs comparing physical therapy interventions to any other physical therapy intervention, sham, placebo, waiting list or no treatment on pain, function, QoL and AEs in adults with RC tendinopathy. DATA SYNTHESIS: A frequentist NMA using a random-effects model was performed. Risk of bias and certainty of the evidence were assessed using the revised Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development and Evaluation approach, respectively. RESULTS: 89 RCTs (5532 participants) were included. Exercises targeting the shoulder muscles may reduce pain (standardised mean difference (SMD) -0.79, 95% CI -1.33 to -0.26) and improve function (SMD 0.74, 95% CI 0.34 to 1.14) compared with no treatment but the evidence is very uncertain. Exercises targeting shoulder and scapular muscles in addition to percutaneous electrolysis (SMD -1.58, 95% CI -2.68 to -0.48) and to trigger point dry needling (SMD 3.10, 95% CI 1.99 to 4.22) seem to be the most effective interventions on pain and function at the end of treatment, respectively. CONCLUSION: Most of the interventions identified may not be superior to isolated shoulder exercises alone, which might be considered a reasonable first-line approach, but the evidence is very uncertain and most interventions are informed by limited data. High-quality research is needed to improve evidence of physical therapy interventions in adults with RC tendinopathy. PROSPERO REGISTRATION NUMBER: CRD42024527176.
8 July 2026
Read appraisal →BMJ open
Implementation determinants of a planned machine learning-enabled surgical scheduling system in a high-volume orthopaedic centre in Canada: qualitative findings.
OBJECTIVES: Elective non-emergent surgical wait times have increased across countries such as Canada, straining operating room (OR) resources and affecting patient outcomes and healthcare spending. Manual scheduling systems in Ontario orthopaedic centres create wide variations in wait times, with recent declines in meeting benchmark targets despite increased procedure volumes. Challenges stem from fragmented referral processes, outdated scheduling methods and resource constraints. Artificial intelligence and machine learning (ML) offer potential solutions for optimising scheduling; however, their implementation remains inconsistent. This study aims to identify determinants affecting the rollout of a new ML-driven automated scheduling system at a high-volume elective orthopaedic surgery centre. DESIGN: A qualitative description approach supported by implementation science frameworks. SETTING: A high-volume elective orthopaedic surgery unit at a Canadian tertiary care centre. PARTICIPANTS: 17 individuals from clinical, administrative and leadership roles who were directly involved in surgical scheduling. INTERVENTIONS: A new ML-driven automated surgical scheduling system. OUTCOMES: Perceptions of the proposed new surgical scheduling system (barriers and enablers of implementation, recommendations for improvement). RESULTS: Three main themes were identified, capturing challenges and enablers in the existing scheduling system: system functionality, process-related factors and resource constraints.Participants described substantial inefficiencies in the existing manual scheduling system, including outdated software, fragmented information systems, inconsistent communication and resource constraints. Across interest-holder groups, there was broad but variable perceived support for a planned ML-enabled scheduling system, particularly for improving duration prediction, access to scheduling data and reporting, alongside concerns about system complexity, workflow fit, training and resource implications. Interest-holders emphasised the importance of user-friendly design, interoperability, responsive training, phased implementation and ongoing feedback. CONCLUSIONS: This pre-implementation qualitative study identified significant process and resource limitations in manual orthopaedic surgical scheduling, but interest-holder support for a well-designed ML-driven system is strong. While participants anticipated potential benefits for scheduling accuracy, throughput and resource allocation, these perceived advantages will require meaningful user engagement, robust training, phased rollout and evaluation in subsequent implementation and outcome studies.
8 July 2026
Read appraisal →Science advances
Toward autonomous robotic-assisted and microrobotic surgery
Autonomous robotic-assisted surgery (RAS) has emerged as a promising objective in biomedical technology, further enhanced by miniaturization toward microrobotic-assisted surgery (μ-RAS). This reduction in scale promises minimally invasive, partially or fully automated surgical procedures, with the potential to reduce patient recovery times, lower medical costs, and enable previously unavailable procedural options. This perspective highlights the specific advances in RAS that potentially map to the microscale (μ-RAS), organized across five surgical domains: endovascular, endoluminal, laparoscopic, ophthalmic, and orthopedic. We examine both clinical demands and technological advances in surgical robotics and identify the key innovations required for progress across these surgical fields. Our contribution is distinct in combining the perspectives of both surgical experts and bioengineering innovators, outlining a roadmap for the advancement and eventual integration of autonomous RAS and μ-RAS into mainstream surgical practice.
6 July 2026
Read appraisal →Journal of medical Internet research
Sensor-Based Monitoring of Knee Osteoarthritis Symptoms in Free-Living Settings: Scoping Review
BACKGROUND: Knee osteoarthritis is a heterogeneous condition characterized by chronic pain, stiffness, and fatigue that fluctuate rapidly over time. Traditional clinical assessments provide only static diagnoses of disease severity, failing to capture the dynamic, day-to-day symptom variability that impacts patient quality of life. While wearable technologies offer the potential for continuous, high-frequency monitoring, previous reviews have examined general technological interventions for knee osteoarthritis management, yet they lack a specific synthesis of technologies for symptom monitoring. OBJECTIVE: This study aims to synthesize current research on sensor technologies used for the continuous monitoring of knee osteoarthritis symptoms in free-living or simulated daily environments. Specifically, the review seeks to (1) map sensor modalities to specific symptom domains (biomechanical, physiological, and behavioral); (2) evaluate the alignment between objective sensor metrics and patient-reported outcome measures; and (3) identify gaps in current monitoring paradigms. METHODS: A systematic literature search was conducted across PubMed, Embase, Web of Science, and IEEE Xplore. The review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Eligibility criteria included studies involving participants with knee osteoarthritis using wearable or portable sensors capable of continuous monitoring (eg, inertial measurement units and electrocardiography) and assessing clinical symptoms (eg, pain, fatigue, and stiffness). Studies relying solely on stationary laboratory equipment (eg, force plates) without a portable component were excluded to ensure relevance to real-world applicability. Data regarding sensor types, sampling frequencies, monitored symptoms, and the statistical association between objective features and subjective symptom severity (key findings) were extracted. RESULTS: A total of 16 studies met the inclusion criteria. The summary constructed from the results revealed a distinct technological saturation: the majority of studies (n=6) used inertial measurement units to quantify biomechanical deficits (eg, gait asymmetry and range of motion), which showed robust correlations with functional limitations. In contrast, there was a notable scarcity of research using physiological sensors (eg, electrocardiography and bioimpedance) to monitor systemic symptoms. Crucially, findings highlighted a significant discrepancy between subjective and objective data, particularly in sleep monitoring, where poor self-reported sleep quality predicted pain exacerbations despite stable objective actigraphy metrics. Furthermore, most systems operated as passive data loggers, with a lack of integration into active feedback loops. CONCLUSIONS: Unlike previous reviews focused solely on biomechanics, this study innovatively maps the use of sensors across a multidimensional symptom spectrum, revealing a critical gap in the monitoring of fatigue and physiological stress. The findings suggest that current sensor applications are limited by a lack of integration with subjective patient experiences. Real-world implementation requires a hybrid monitoring paradigm that combines the ecological validity of wearable sensors with the clinical relevance of patient-reported outcomes. This approach paves the way for digital phenotyping and active feedback systems, offering a personalized strategy for managing the complex symptom burden of knee osteoarthritis.
3 July 2026
Read appraisal →IEEE transactions on bio-medical engineering
Deep Learning-Based Surrogate Model of Subject-Specific Finite-Element Analysis for Vertebrae
Subject-specific finite-element analysis (FEA) models enable accurate simulation of vertebral biomechanics but are often time-consuming to construct and solve under varying conditions. This study presents a novel deep learning (DL)/machine learning (ML)-based surrogate model that predicts stress distributions in vertebral bodies with high efficiency. The model integrates vertebral shape encoding and employs separate decoding branches for surface and internal nodes. It was trained on 3,960 synthetic L1 vertebrae generated via data augmentation from 42 real computed tomography (CT) scans. Evaluation on independent test samples yielded a mean absolute error (MAE) of 0.0596 MPa and an $\mathrm{R}^{2}$ of 0.864 for von Mises stress. Visualization results confirm strong agreement between predicted and FEA-computed stress patterns, with localized discrepancies observed at the anteroinferior margin and pedicles. Moreover, an end-to-end automated pipeline was established based on the developed model, reducing the total processing time from 90-120min to approximately 134-154s per subject. These findings highlight the potential of the proposed surrogate model to facilitate rapid, subject-specific biomechanical assessments in clinical workflows.
3 July 2026
Read appraisal →Diagnostic and interventional imaging
Artificial intelligence in emergency musculoskeletal imaging: A critical review of current applications.
Artificial intelligence (AI) is increasingly shaping emergency musculoskeletal imaging, where rapid and accurate diagnosis is often challenged by high imaging volumes and time pressure. These constraints increase the risk of missed injuries and underscore the need for tools that support faster and reliable assessments. AI systems show promise in improving workflow efficiency by prioritizing urgent studies, guiding modality selection, and reducing reporting delays. Deep learning models can enhance abnormality detection by identifying fractures, soft tissue injuries, and infectious processes, and can provide structured classifications that support clinical decision making. Pediatric-focused AI systems address age-specific developmental considerations and offer valuable support for clinicians with varying levels of pediatric musculoskeletal expertise. Large language models further expand the role of AI by improving report clarity, generating structured impressions, and facilitating communication with clinicians, patients, and families. Despite these advances, challenges remain, including limited external validation, dataset bias, and medicolegal considerations. This review summarizes current AI applications across these domains and highlights key strengths, limitations, and future directions for safe and effective integration into emergency musculoskeletal imaging.
2 July 2026
Read appraisal →The Orthopedic clinics of North America
Wearable Devices and Artificial Intelligence to Enhance Perioperative Care in Total Knee Arthroplasty
Rapidly evolving wearable devices have the potential to transform health care delivery and enhance outcomes. Applications of wearable smart devices range from activity and motion tracking to real-time monitoring of vital signs and biochemical markers. Recent evidence provides support for the use of wearable devices in chronic disease management, rehabilitation, and perioperative care of patients with total knee arthroplasty. Data derived from these devices may enhance treatment personalization and early identification of complications. Challenges remain regarding accuracy, standardization, privacy, and patient adherence. Future advances must overcome these limitations.
2 July 2026
Read appraisal →Emergency medicine journal : EMJ
Interventions to reduce imaging in children with upper or lower extremity injuries: a systematic review and meta-analysis
BACKGROUND: Radiation exposure, transition delays and costs associated with unnecessary imaging in children have stimulated research into clinical decision rules and other interventions to reduce imaging in the emergency department (ED). The objective of this systematic review is to examine the effectiveness of implementing interventions to reduce imaging in children with upper/lower extremity injuries in the ED. METHODS: Seven databases and the grey literature were searched up to May 2024. Comparative studies assessing interventions to reduce imaging in children with upper/lower extremity injuries implemented in the ED were eligible. Two independent reviewers screened for study eligibility, quality assessment and data extraction, with disagreements settled via third-party adjudication. Changes in imaging are reported as ORs with 95% CIs, using a random effects model. RESULTS: From 9387 citations, eight unique studies enrolling 7793 children were included with the majority using a before-after design. Potential concerns for bias were documented due to a lack of reporting of key quality domains. Decision rules for ankle injuries successfully reduced radiography (OR=0.11; 95% CI 0.07 to 0.16, I2=38%). A decision rule for wrist injuries reduced imaging (OR=0.06; 95% CI 0.03 to 0.11); however, eight injuries were missed. Two studies implementing clinical guidelines reported decreases in radiographs per patient (p<0.001). One trial reported increased imaging in children assessed by triage nurses using an established clinical decision rule (OR=5.44; 95% CI 2.96 to 10.02), with 16 missed injuries identified. CONCLUSIONS: Guidelines incorporating clinical decision rules, particularly decision rules for ankle injuries, can reduce radiography for children with extremity injuries in the ED. Further investigations are warranted to identify other extremity injuries, the components of the intervention and the most efficient clinicians to target. PROSPERO REGISTRATION NUMBER: CRD42016042875.
1 July 2026
Read appraisal →Medicine
Artificial intelligence-guided clavicle fracture detection on plain radiographs: A retrospective diagnostic accuracy study.
Extensive research exists on artificial intelligence (AI)-assisted fracture detection in various anatomical regions, but clavicle fractures remain comparatively understudied. This study aimed to compare the diagnostic performance of AI-guided clavicle fracture detection on plain radiographs with that of an experienced orthopedic surgeon. We retrospectively analyzed all clavicle radiographs obtained at our institution between September 11,2023 and October 31,2024 following the clinical implementation of AI-guided fracture detection. Radiological findings confirmed by a senior radiologist served as the reference standard. AI performance was additionally compared with the assessments of an experienced, blinded orthopedic surgeon. Diagnostic performance metrics included accuracy, sensitivity, specificity, Cohen kappa, F1 score, and Youden index. A total of 367 clavicle radiographs were included, comprising 186 anteroposterior (AP) and 181 second-plane views. The mean patient age was 44.6 ± 26.2 years, and 59.4% were male. According to the reference standard, clavicle fractures were present in 96 AP radiographs (51.6%) and 95 second-plane radiographs (52.5%). On AP radiographs, the AI system achieved an accuracy of 97.31%, sensitivity of 95.83%, specificity of 98.89%, Cohen kappa of 0.95, and F1 score of 0.97. Diagnostic performance on second-plane radiographs was similarly high and overall comparable to that of the experienced orthopedic surgeon. This retrospective diagnostic accuracy study shows that AI-guided clavicle fracture detection is highly accurate and reliable, with performance approaching that of an experienced orthopedic surgeon. These findings support the potential role of AI as a diagnostic support tool in clavicle fracture detection, while prospective and multicenter validation remains warranted.
28 June 2026
Read appraisal →Calcified tissue international
Artificial Intelligence Approaches for Osteoporotic Fracture Risk Prediction Using Administrative Health Data: A Systematic Review
To systematically review Machine Learning (ML) fracture risk prediction models developed solely using administrative data, evaluating their development, performance, risk of bias, and concerns regarding applicability. A systematic search was conducted in PubMed, Embase, IEEE, and Web of Science following PRISMA guidelines (up to November 2025). We included studies developing or validating ML models for osteoporotic fracture risk in adults using administrative data without clinical measurements. Risk of bias and concerns for applicability were assessed using the PROBAST tool. Seven studies were included from 3435 initial records. A range of of ML models were utilized, including Random Forests, XGBoost, LASSO-regularized Logistic Regression and Neural Networks. Discriminative performance was moderate-to-good, with best Area Under the Curve (AUC) values ranging from 0.818 for osteoporotic fractures in general to 0.905 for hip fractures only. While five studies showed low risk of bias, five raised applicability concerns due to using specific subpopulations or features with database characteristics. Only two studies used external validation and none directly evaluated clinical utility of the models. ML models using solely administrative data show some promise as scalable, automated tools for fracture risk prediction without requiring manual clinical input. However, clinical implementation is hindered by limited external validation and a lack of formal utility evaluation of the models. Future research should prioritize more rigorous external validation and recalibration of the existing models, more so than the development of novel models, ensuring they are robust, interpretable, and integrable into future clinical workflows.
28 June 2026
Read appraisal →Acta orthopaedica
Registration and reporting characteristics of trials investigating exercise therapy following total knee arthroplasty: a systematic review.
BACKGROUND AND PURPOSE: Prospectively registering the primary trial outcome is important to reduce selective outcome reporting and increase the trustworthiness of findings, which guide clinical practice. The objectives of our systematic review were to explore and compare the reporting characteristics of prospectively and non-prospectively registered trials investigating exercise therapy following total knee arthroplasty. METHODS: Randomized trials comparing effects of exercise therapy after total knee arthroplasty for osteoarthritis were identified in 4 databases from 2000 to August 12, 2024. One primary outcome per trial was extracted, using a pre-specified hierarchical algorithm, irrespective of outcome domain. Pooled standardized mean differences (SMDs) were calculated on pre-specified outcome domains, and risk-of-bias assessed using the Cochrane Risk-of-Bias tool v2. RESULTS: 94 trials, comprising 9,396 participants, were included, of which 13 were prospectively registered, 33 retrospectively registered, and 48 unregistered. A single primary outcome was defined in 44% of the 94 trials, and 4 trials reported a primary outcome consistent with a prospective registration. The pooled SMD of primary outcomes was 0.06 (95% confidence interval [CI] -0.03 to 0.16) for prospectively registered trials, 0.67 (CI 0.22-1.11) for retrospectively registered trials, and 0.59 (CI 0.32-0.86) for unregistered trials. Lower risk-of-bias ratings and higher proportions of intention-to-treat adherence, dropout reporting, and adverse event reporting were observed among prospectively registered trials. CONCLUSION: Among prospectively registered trials we showed smaller effect size estimates between interventions with lower risk-of-bias ratings, and higher proportions of intention-to-treat adherence, dropout reporting, and adverse event reporting in contrast to trials without prospective registration; furthermore, clear specification of a single primary outcome was uncommon among trials evaluating exercise therapy after total knee arthroplasty.
23 June 2026
Read appraisal →Acta orthopaedica
Predicting persistent pain after total knee arthroplasty using different machine learning algorithms
BACKGROUND AND PURPOSE: After total knee arthroplasty (TKA), 10-20% of patients remain unsatisfied. Well-performing clinical prediction models can provide individualized risk estimates and stratification in terms of poor outcomes, resulting in unnecessary surgeries being avoided and patients being counseled preoperatively. We aimed to create a precise, well-performing prediction model for clinical application using different machine learning algorithms to predict those patients who will have residual pain, a low total Oxford Knee Score (OKS) and the patient group who do not achieve minimally clinical important difference (MCID) in OKS 1 year after TKA. METHODS: We conducted a retrospective cohort study based on patients who had undergone primary TKA at our institution combined with 751 patient-related variables. The multivariable models used were based on the results of univariate analysis. We used the machine learning method Extreme Gradient Boosting (XGBoost). The discrimination capability of the models was measured with the area under the curve (AUC). RESULTS: 11,755 patients were included in this study. There were 850 (7.2%) patients who experienced persistent pain 1 year after TKA. The AUC was 0.67. For the secondary outcomes, the AUC values were similar. The most important variables in the model were lower preoperative OKS, younger age, valgus malalignment, lower preoperative pain OKS, use of mild opioid, neuropathic pain medicine and thyroxine, and higher body mass index. CONCLUSION: The prediction models achieved poor AUCs. It seems clear that the prediction of pain and functional outcome after TKA is difficult, even with a large patient cohort combined with 751 patient-related variables and sophisticated machine-learning algorithms.
23 June 2026
Read appraisal →Science advances
Bioinspired heliconical auxetic biofibers for intelligent biomechanical surveillance
Wearable bio-based fibers are emerging as platforms for biomechanical sensing and physiological interaction. However, achieving high sensitivity to subtle mechanical cues while maintaining flexibility, self-powered output, and distributed perception remains challenging. Inspired by the helical twining mechanics of climbing plant stems, we design a mechano-adaptive auxetic electronic bio-based fiber as an embodied intelligence sensing unit. The dual-modulus helical confinement, achieved by wrapping rigid aramid fiber/polydimethylsiloxane helices around a flexible collagen aggregate/waterborne polyurethane core, enables programmable deformation and a stable negative Poisson's ratio (ν = -0.47). Nonlinear intercomponent coupling facilitates synergistic axial-radial dynamics, amplifying interfacial contact variation under strain. The optimized fiber exhibits ultrahigh sensitivity (strain factor: 11.75), strong electrical output (8.1 volts), and remarkable power density (8.48 milliwatts per square meter) with excellent cyclic stability. Integrated into fiber-sensing arrays, it decodes microstrain patterns linked to lower-limb function, offering a scalable strategy for self-powered, adaptive, and durable biomechanical monitoring.
21 June 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Association between timing of surgery and postoperative outcomes in older adults with distal femur fractures: a systematic review and meta-analysis
INTRODUCTION: The association between surgical timing and clinical outcomes in older adults with distal femur fractures remains unclear. We conducted a systematic review and meta-analysis to evaluate whether earlier surgery is associated with improved outcomes in this population. MATERIALS AND METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent reviewers searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to October 8, 2024. The primary outcome was 30-day mortality, and secondary outcomes included longer-term mortality and postoperative complications. Risk of bias was assessed using the Quality in Prognosis Studies tool, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Of 6,101 records screened, 16 retrospective cohort studies comprising 31,213 patients met the inclusion criteria. Early surgery was not associated with reduced 30-day mortality (adjusted odds ratio [OR]: 0.77, 95% confidence interval [CI]: 0.56-1.05; low-certainty evidence) or with longer-term mortality at 90 days (crude OR: 0.91, 95% CI: 0.51-1.60), 180 days (crude OR: 0.46, 95% CI: 0.12-1.77), or 1 year (crude OR: 0.61, 95% CI: 0.34-1.09). Similar findings were observed for postoperative complications: cardiac complications (OR: 0.71, 95% CI: 0.48-1.07), pulmonary complications (OR: 1.07, 95% CI: 0.77-1.47), and pulmonary embolism (OR: 1.14, 95% CI: 0.62-2.16). Heterogeneity across outcomes was low to moderate, and definitions of early surgery varied among studies. Overall, this meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Sensitivity analyses consistently suggested lower mortality with earlier surgery, likely reflecting stricter definitions of early surgery and improved control of time-related bias. CONCLUSIONS: This meta-analysis did not demonstrate a clinically meaningful association between surgical timing and short-term clinical outcomes in older adults with distal femur fractures. Given the heterogeneity in definitions and study designs, high-quality prospective studies with standardized timing are warranted.
20 June 2026
Read appraisal →European journal of trauma and emergency surgery : official publication of the European Trauma Society
Pattern of blast injuries. A systematic review: Part 2 - Landmines, unexploded ordnance and terrorism.
PURPOSE: This systematic review analyzes the patterns and distribution of blast injuries from landmine explosions, UXOs and terror attacks including suicide bombing, in civilians and military personnel. METHODS: A search was conducted in two databases on 26. March 2025 for observational studies reporting blast injuries in civilian and military populations of all ages. Studies were clustered by explosion typ. A narrative data synthesis was performed. The JBI tool for case series was used. PROSPERO: CRD42023391736. RESULTS: 126 studies were included in the overall systematic review. 45 studies on terror & suicide bombings and 12 studies on landmines & UXOs are analyzed in the present paper. Studies on landmines from 1980 to 2006 included 13,270 individuals (age: 24.0 years (Range 8.2 years - 32.2 years); mainly male (88.9%)) in post-conflict low- and middle-income countries. Lower extremity injuries including amputations were most frequent, followed by eye injuries. Studies on terrorist attacks with a total of 12,518 mainly civilian victims (average age: 33,1 years; 61.6% males) reported on incidents in post-conflict regions and high-income cities mainly from the early 2000s. The injury pattern was multidimensional, with extremity injuries most frequent (28%-30%), including fractures, lacerations, and traumatic amputations (18%-20%). CONCLUSION: This Systematic Review Part 2 on landmines and terror attacks found that extremity injuries, including traumatic amputations, are the most frequent and dominate injury. However, the injury pattern varies depending on the explosion mechanism. Landmines primarily cause lower extremity injuries, as well as eye injuries. Terror and suicide explosions exhibit multidimensional injury pattern depending on the distance and location of the explosion.
19 June 2026
Read appraisal →Spine
Differentiating Spinal Deformity Versus Leg Length Discrepancy in Patients With Pelvic Obliquity : Systematic Review of Diagnostic Methods, Imaging, and Clinical Management
STUDY DESIGN: Systematic review, PROSPERO ID: (CRD42023112392). OBJECTIVE: We aim to provide physicians with an evidence-based stepwise approach to distinguishing the primary cause of plane pelvic obliquity (PO) to guide treatment. SUMMARY OF BACKGROUND DATA: PO is a frequent clinical finding in both spinal deformity (SD) and leg length discrepancy (LLD) but distinguishing between these etiologies remains challenging due to overlapping clinical and radiographic features and potential multifactorial origins. Misdiagnosis may delay care and worsen patient outcomes. MATERIALS AND METHODS: PubMed, Embase, Scopus, and Web of Science were searched from inception to July 2025 for English-language studies evaluating coronal PO in the context of LLD and/or SD that explicitly compared or differentiated limb-origin from spine-origin obliquity using radiographic, advanced imaging, or validated clinical assessments and reported diagnostic accuracy, discriminative features, or management impact. Two reviewers independently screened studies, extracted data, and performed ROBINS-I risk assessment and Newcastle-Ottawa Scale quality assessment. Owing to marked heterogeneity in populations, measurement protocols, and thresholds, findings were synthesized qualitatively with stratification by age group where possible. RESULTS: Of 436 records, 24 cohort studies met the inclusion criteria. Standing anteroposterior (AP) radiographs reliably quantified both LLD and PO, while advanced imaging provided high reproducibility for subtle or ambiguous cases. Radiographic block or shoe lift correction tests distinguished limb-origin and spine-origin PO through immediate postural correction. Key discriminators included a lumbar curve or PO resolving with block/lift correction suggesting LLD, versus persistent deformity despite correction suggesting spinal etiology. Difficulty remains in diagnosing and treating mixed etiology patients. CONCLUSION: Accurate differentiation of spinal versus limb-driven PO begins with a structured diagnostic approach. AP radiographs, followed by functional block tests, and advanced imaging, may increase diagnostic confidence and decrease unnecessary interventions. Particularly in patients with both LLD and coronal plane SD, prospective studies are required to standardize measurement protocols and improve long-term outcomes. LEVEL OF EVIDENCE: Level IV.
16 June 2026
Read appraisal →British journal of sports medicine
Randomised three-armed trial investigation of the Copenhagen Achilles tendon Rupture Treatment Algorithm (CARTA) for individualised treatment of acute Achilles tendon rupture
OBJECTIVE: To evaluate whether individualised treatment using the Copenhagen Achilles Rupture Treatment Algorithm (CARTA) is superior to default operative or non-operative strategies. METHODS: We conducted a multicentre, three-arm, randomised controlled trial. Adults with acute Achilles tendon rupture were randomised (1:1:1) to individualised CARTA, non-operative or operative treatment. In the CARTA arm, surgery was indicated if ultrasound showed<25% tendon overlap or ≥7% elongation. The primary outcome was the Heel-Rise Work Test (HRWT) at 12 months. Secondary outcomes included HRWT at 6 months, and at both 6 and 12 months, the Heel-Rise Height, Achilles tendon Total Rupture Score (ATRS), Tegner activity scale, Copenhagen Achilles tendon Length Measure, Achilles Tendon Resting Angle (ATRA) and complication recordings. RESULTS: Between May 2018 and June 2023, 970 patients were screened; 300 were randomised (male/female 76%/24%, mean age 41 (SD 1)). At 12 months, data were available for 98 CARTA (64% operated), 100 non-operative and 97 operative patients. There were no significant between-group differences in HRWT at 12 months. However, CARTA significantly reduced rerupture rates by 73% compared with non-operative treatment (3% (95% CI) (1 to 8) vs 11% (6 to 19), p=0.03), improved ATRS by 8 points (1 to 15, p=0.02) and improved ATRA by -2° (-4 to -1), p=0.01). No difference between CARTA and operative treatment was found except 36% less underwent surgery. CONCLUSION: Individualised CARTA did not improve functional outcomes based on the HRWT at 12 months, but among secondary outcomes, it reduced rerupture rates and improved patient-reported outcomes compared with non-operative treatment and with fewer surgeries than routine operative care. TRIAL REGISTRATION NUMBER: NCT03525964.
14 June 2026
Read appraisal →Annals of medicine
Analgesic effect of premixed nitrous oxide in postoperative rehabilitation for ankle fractures: a randomized controlled trial
INTRODUCTION: The global incidence of ankle fractures is on the rise, effective postoperative rehabilitation is a crucial aspect of surgical management. However, the occurrence of severe pain during the rehabilitation continues to pose a substantial clinical challenge. METHODS: The study utilizes a dual-arm, single-center, double-blind, randomized controlled trial design. A total of 100 participants were enrolled. Participants included patients experiencing acute pain (self-reported pain score ≥4) who underwent postoperative rehabilitation for ankle fractures. Participants undergoing rehabilitation training were randomized to receive either 65% nitrous oxide or 100% oxygen. The primary outcome measured was the pain score, while secondary outcomes encompassed anxiety scores, physiological indices, side effects, patient and therapist satisfaction, acceptance, and residual pain. RESULTS: Pain scores were found to be significantly lower in the nitrous oxide group than in the oxygen group (T1: median difference -3.0, [95% CI -3.4 to -2.6]; p < 0.001; T2: median difference -2.0, [95% CI -2.8 to -1.2]; p < 0.001). Compared with the oxygen group, both therapists (p < 0.001) and participants (p < 0.001) in the nitrous oxide group reported significantly higher satisfaction levels. Acceptance rate showed significant intergroup differences (p < 0.001). No severe adverse effects were observed in either group. Anxiety scores between the two groups did not show a significant difference (p = 0.31, η2 = 0.027). CONCLUSION: The safety and analgesic profile of nitrous oxide renders it a suitable option for pain management in postoperative ankle fractures rehabilitation, thus providing a safe and easily manageable alternative to the current available strategies. CLINICAL TRIAL REGISTRATION: We have registered at https://www.chictr.org.cn and the registration number is: ChiCTR2400089379. In comparison with oxygen gas, nitrous oxide has been demonstrated to reduce pain during rehabilitation training following ankle fracture surgery, offering a practical and effective alternative to oral analgesics.The use of nitrous oxide in postoperative rehabilitation training for ankle fractures is relatively safe, with few and mild adverse reactions.Patients and rehabilitation therapists reported high satisfaction with nitrous oxide intervention, and residual pain was significantly reduced.
12 June 2026
Read appraisal →Journal of translational medicine
Mesenchymal stem cell-derived extracellular vesicles for osteochondral defect regeneration: a systematic review and meta-analysis of preclinical studies
BACKGROUND: In recent years, the number of animal studies investigating mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) therapy for osteochondral defects has steadily increased. However, a comprehensive and systematic quantitative analysis is lacking. This meta-analysis aimed to evaluate the efficacy of MSC-EVs in animal models of osteochondral defect through a meta-analysis. METHODS: PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched up to January 31, 2025, to identify and select preclinical studies on MSC-EVs therapy for osteochondral defect models. No restrictions were applied regarding the specific characteristics of MSC-EVs or animal models. A random-effects model was used to perform pooled analyses of osteochondral repair scores, bone structural parameters, and histological scores. Subgroup analyses were conducted to explore potential sources of heterogeneity. Sensitivity analyses, funnel plots, and Egger's test were employed to assess the robustness and stability of the results. RESULTS: A total of 19 studies met the inclusion criteria. MSC-EVs intervention improved International Cartilage Repair Society (ICRS) and Modified O'Driscoll Scale (MODS) scores at both 3 and 6 months, and significantly increased BV/TV, Tb.Th, as well as histological scores of cartilage and subchondral bone. Subgroup analyses indicated that none of the examined subgroups were significant sources of heterogeneity. Sensitivity analyses demonstrated the robustness of the results. CONCLUSIONS: MSC-EVs improved osteochondral repair scores, bone structural parameters, and histological outcomes in preclinical models, indicating their potential for promoting osteochondral regeneration. However, the evidence is primarily derived from small animal models with methodological variability and publication bias. Future studies should focus on large-animal models, standardized EVs preparation and dosing protocols, and long-term safety evaluations to facilitate clinical translation.
31 May 2026
Read appraisal →The Cochrane database of systematic reviews
Surgery for thumb (trapeziometacarpal joint) osteoarthritis
RATIONALE: Surgery is used to treat persistent pain and dysfunction due to osteoarthritis at the base of the thumb, when conservative management is no longer effective. This is an update of a Cochrane review first published in 2005. OBJECTIVES: To evaluate the benefits and harms of different surgeries for people with thumb (trapeziometacarpal) osteoarthritis. SEARCH METHODS: We searched CENTRAL, MEDLINE and Embase up to 19 May 2025. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that compared at least two surgical techniques for trapeziometacarpal osteoarthritis. We excluded studies that used non-surgical interventions as the sole comparator (e.g. splinting). OUTCOMES: Pain, physical function, quality of life, patient global assessment, adverse events, treatment failure and trapeziometacarpal joint imaging. RISK OF BIAS: We assessed risk of bias using the Cochrane Risk of bias 1.0 tool (RoB 1). SYNTHESIS METHODS: Two authors screened studies, extracted data, assessed risk of bias, and judged the certainty of evidence using the GRADE criteria. We synthesised effect estimates for both dichotomous (risk ratio (RR) using Mantel-Haenszel method) and continuous outcomes (standardised mean difference (SMD) or MD using the inverse-variance method) using a random-effects meta-analysis model. INCLUDED STUDIES: We included 25 studies with 1591 participants. We identified 11 surgical procedures: trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint implant, arthrodesis, trapeziometacarpal joint replacement, trapeziectomy and haematoma distraction arthroplasty, trapeziectomy with interpositional arthroplasty with allograft, arthroscopic hemitrapeziectomy, and suture tape suspensionplasty. Other than arthrodesis, no studies compared surgeries that did not involve at least partial trapeziectomy (e.g. first carpometacarpal joint denervation). We found no studies with placebo or non-surgical comparators. SYNTHESIS OF RESULTS: More than 90% of the included studies were at high or unclear risk of performance, detection and selective reporting biases. Below, we summarise the evidence for trapeziectomy with LRTI, the most widely utilised technique. We did not summarise single-study comparisons for trapeziectomy with LRTI. Quality of life, patient global assessment and treatment failure were not reported. Pain was measured on a 100-point visual analogue scale (mm); physical function on a relevant scale (typically the Disabilities of the Arm, Shoulder and Hand questionnaire) presented as a mean difference; adverse events as the proportion of participants who experienced any adverse events; trapeziometacarpal joint imaging as the scapho-metacarpal distance at rest reported in mm. Trapeziectomy with LRTI versus trapeziectomy: compared to trapeziectomy, trapeziectomy with LRTI may make little to no difference to pain (MD -2.80 mm, 95% CI -9.82 to 4.21; I2 = 0%; 3 studies, 162 participants), physical function (SMD 0.01, 95% CI -0.70 to 0.72 translated to an MD of 0.03 points (95% CI -1.95 to 1.98); I2 = 19%; 3 studies, 211 participants), adverse events (RR 1.89, 95% CI 0.96 to 3.73; I2 = 0%; 4 studies, 328 participants) or scapho-metacarpal distance (MD -0.10 mm, 95% CI -0.81 to 0.61; 1 study, 42 participants); all low-certainty evidence. Trapeziectomy with LRTI versus trapeziometacarpal joint replacement: we are uncertain of the effects of trapeziectomy with LRTI compared to trapeziometacarpal joint replacement on pain (MD 1.38 cm, 95% CI 0.7 to 2.07; 2 studies, 206 participants) and physical function (MD 12.53, 95% CI 3.71 to 21.35; I2 = 78%; 2 studies, 207 participants); both very low-certainty evidence. There may be little to no difference in adverse events (RR 0.36, 95% CI 0.12 to 1.06; I2 = 0%; 3 studies, 261 participants; low-certainty evidence). Trapeziectomy with LRTI versus haematoma distraction arthroplasty: compared to haematoma distraction arthroplasty, we are uncertain of the effects of trapeziectomy with LRTI on pain (MD 0.34 cm, 95% CI -1.19 to 1.87; I2 = 97%; 2 studies, 172 participants) and physical function (MD 1.96 points, 95% CI -0.40 to 4.32; I2 = 55%; 2 studies, 172 participants); both very low-certainty evidence). LRTI may make little to no difference to adverse events (RR 16.66, 95% CI 0.99 to 279.94; 1 study, 120 participants) or scapho-metacarpal distance (MD 0.0 mm, 95% CI -2.12 to 2.12; 1 study, 120 participants); both low-certainty evidence. Trapeziectomy with LRTI versus trapeziectomy with interpositional arthroplasty: compared to trapeziectomy with interpositional arthroplasty, trapeziectomy with LRTI may slightly reduce pain (MD -0.57cm, 95% CI -1.10 to -0.04; I2 = 0%; 2 studies, 98 participants), and may make little to no difference to adverse events (RR 1.29, 95% CI 0.49 to 3.44; 2 studies, 146 participants) and scapho-metacarpal distance (MD -0.70 mm, 95% CI -1.44 to 0.04; 1 study, 46 participants); all low-certainty evidence. We are uncertain of the effects of trapeziectomy with LRTI on physical function (MD -6.75 points, 95% CI -15.88 to 2.39; I2 = 70%; 2 studies, 98 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: There are no placebo-controlled trials or studies comparing surgery with non-operative treatment. Low-certainty evidence showed that compared to trapeziectomy, trapeziectomy with LRTI for people with thumb osteoarthritis, may result in little to no difference in pain, function or scapho-metacarpal distance. Compared to trapeziectomy with interpositional arthroplasty, trapeziectomy with LRTI may slightly reduce pain. Trapeziectomy with LRTI may make little to no difference to scapho-metacarpal distance compared to haematoma distraction arthroplasty or trapeziectomy with interpositional arthroplasty. Very low-certainty evidence showed that we are uncertain of the effects of trapeziectomy with LRTI on pain and function compared to trapeziometacarpal joint replacement or haematoma distraction arthroplasty. We are uncertain of the effects of trapeziectomy with LRTI on function compared to trapeziectomy with interpositional arthroplasty. Overall, low-certainty evidence showed that trapeziectomy with LRTI may make little to no difference to adverse events. Low- to very low-certainty evidence from small studies limits our ability to draw conclusions on the benefits and harms of surgical procedures for thumb osteoarthritis. FUNDING: None. REGISTRATION: Protocol (2004) DOI: 10.1002/14651858.CD004631 Original review (2005) DOI: 10.1002/14651858.CD004631.pub2. Review update (2009) DOI: 10.1002/14651858.CD004631.pub3 Review update (2015) DOI: 10.1002/14651858.CD004631.pub4 Review update (2017) DOI: 10.1002/14651858.CD004631.pub5.
30 May 2026
Read appraisal →European radiology experimental
Enhancing resolution and image quality in musculoskeletal MRI using deep learning reconstruction
OBJECTIVE: Deep learning-based noise reduction enhances image quality, overcoming the tradeoff among acquisition time, spatial resolution, and signal-to-noise ratio (SNR). We implemented deep learning reconstruction (DLR) into a 1.5-T musculoskeletal (MSK) magnetic resonance imaging (MRI) protocol to improve image quality without compromising SNR. MATERIALS AND METHODS: We retrospectively analyzed 39 MRI examinations performed on a 1.5-T scanner using standard-resolution (SR) sequences and sequences with higher resolution reconstructed with DLR (HR-DLR). Exams of the knees, shoulders, ankles, and hips were evaluated. The included sequences were: three-dimensional T2-weighted fast advanced spin-echo; T1-weighted and proton density-weighted fast spin-echo. One expert reader and two junior readers in agreement evaluated the visibility of various structures using a 5-point Likert scale in a blind manner. A fourth reader estimated the SNR and contrast-to-noise ratio (CNR) in bone and muscle. A mixed model was used to compare HR-DLR versus SR measures. The agreement between radiologists was assessed with the Kendall τ coefficient. RESULTS: The HR-DLR sequences globally had a smaller pixel size and shorter acquisition time. A good inter-reader agreement was obtained for SR sequences (0.613 ≤ τ ≤ 0.788) and even higher levels of agreement for HR-DLR sequences (0.682 ≤ τ ≤ 0.961). All the structures had higher or similar Likert scores in HR-DLR sequences (p < 0.001), regardless of joint and sequence contrast. Apparent SNR and CNR of HR-DLR and SR were similar. CONCLUSION: Incorporating DLR into 1.5-T MSK MRI protocols enhances resolution and maintains SNR and CNR, improving MSK structure visualization. RELEVANCE STATEMENT: This study demonstrated the effectiveness of deep learning reconstruction in improving the efficiency of 1.5-T musculoskeletal MRI exams. Despite shorter acquisition times, the visibility of key MSK structures was consistently rated as superior or similar in higher-resolution images with DLR. KEY POINTS: MRI is one of the primary diagnostic tools for evaluating MSK injuries and disorders. Deep learning reconstruction (DLR) implemented in a 1.5-T MSK protocol improved resolution, still preserving SNR and CNR. Higher scores were assigned by different raters to the DLR images, showing image quality improvement.
29 May 2026
Read appraisal →Journal of robotic surgery
Robot-assisted percutaneous pelvic channel screw placement for unstable pelvic ring injuries: a systematic review and meta-analysis with narrative technical comparison of multi-platform differences
Percutaneous pelvic channel screw fixation is a key technique for the minimally invasive treatment of pelvic ring injuries. Robotic-assisted systems aim to improve accuracy and reduce radiation, but direct comparative studies across platforms are lacking. This systematic review and meta-analysis primarily compares robot-assisted versus conventional fluoroscopy-guided pelvic channel screw placement, with a secondary narrative comparison of technical differences across TiRobot, Mazor X, and ROSA platforms. We systematically searched PubMed, Web of Science, Embase, Cochrane Library, CNKI, Wanfang, and CBM databases up to April 2026. Comparative studies of robot-assisted versus conventional fluoroscopy-guided pelvic channel screw placement in adult pelvic ring injury patients were included. Primary outcomes were screw accuracy (Gras classification) and radiation exposure. Secondary outcomes included operative time, functional recovery (Majeed score), complications, and cost. No direct head-to-head studies comparing different robotic platforms for pelvic screw placement were identified; therefore, platform comparisons are primarily narrative and indirect, with spine surgery data presented as hypothesis-generating only. Risk of bias was assessed using ROBINS-I and RoB-2, and evidence was graded using the GRADE system. Fifteen studies (1,247 patients, 2,893 screws) were included. Primary meta-analysis showed that robot-assisted placement significantly improved screw accuracy (excellent/good rate: 98.2% vs. 86.4%; OR = 5.32, 95%CI: 3.18-8.89, p < 0.001; GRADE: Low certainty due to risk of bias) and reduced radiation exposure (SMD=-1.84, 95%CI: -2.43 to -1.25; GRADE: Low certainty due to serious inconsistency). Operative time showed no significant difference in studies by experienced surgeons (MD=-5.2 min, 95%CI: -11.0 to 0.6). Functional outcomes (Majeed score) were comparable between groups (MD = 0.8, 95%CI: -0.7 to 2.3). Overall complications were significantly reduced with robotic assistance (OR = 0.46, 95%CI: 0.30-0.71; GRADE: Low certainty due to risk of bias). For platform comparisons, TiRobot has the strongest pelvic trauma-specific evidence from 11 studies (847 patients). Evidence for Mazor X and ROSA in pelvic trauma is limited to technical descriptions and indirect spine surgery data; no direct pelvic trauma validation is available. Robot-assisted pelvic channel screw placement is superior to conventional methods in accuracy and radiation reduction, with comparable functional outcomes and fewer complications. TiRobot demonstrates the strongest pelvic trauma-specific evidence based on available comparative studies. Mazor X and ROSA require direct pelvic trauma validation before their performance can be reliably compared. TiRobot may have lower acquisition costs in Chinese healthcare settings, but formal cost-effectiveness analyses are lacking for all platforms. Significant evidence gaps remain, including lack of high-quality RCTs, absence of direct platform comparisons in pelvic trauma, and insufficient cost-effectiveness analyses.
28 May 2026
Read appraisal →JMIR mHealth and uHealth
Reducing Sedentary Time After Knee Replacement Using a Multicomponent mHealth Intervention: Randomized Controlled Trial
BACKGROUND: Total knee replacement (TKR) is a common surgery for end-stage knee osteoarthritis. Although reductions in pain and improvements in mobility occur after surgery, physical activity levels often do not change. Given the challenges of increasing physical activity in this population, targeting reductions in sedentary behavior may be a first step; however, no prior studies have examined the feasibility and effects of a sedentary reduction intervention after TKR. OBJECTIVE: This study examined the effects of a 2-month multicomponent mobile health sedentary reduction intervention (NEAT!2) on sedentary time in adults with TKR. METHODS: Adults (N=83; mean age 65.3, SD 9.4 years; mean BMI 32.7, SD 6.9 kg/m2; 62/83, 74.7% female; 64/83, 77.1% White) with a TKR ≤1 year ago were randomized to the NEAT!2 group (n=42, 50.6%) or the attention-matched control group (n=41, 49.4%). The NEAT!2 intervention focused on reducing sedentary time via a smartphone app designed to interrupt prolonged bouts (≥30 minutes) of sedentary behavior and through 5 coaching calls emphasizing goal setting and problem solving. The control group focused on surgery recovery via an app or website and 5 educational calls. Sedentary time, total physical activity, physical function, and pain were measured at 2 and 5 months. Linear mixed-effects models examined intervention effects and differences between groups at each time point. RESULTS: Retention was 96% and 95% at 2 and 5 months, respectively, with no differences between groups. Participants in the NEAT!2 group completed an average of 4.95 (SD 0.2) calls, used the app on an average of 40.3 (SD 13.8) days (out of 56 days), and received an average of 9.6 (SD 6.0) notifications per day. At 5 months, there was a significant increase in sit-to-stand transitions in the NEAT!2 group and a substantial decrease in the control group, resulting in a significant difference between groups (mean difference 4.06, 95% CI 0.13-7.99; P=.04); however, the NEAT!2 intervention did not result in significant effects on any of the other study outcomes at 2 or 5 months. Additionally, more days of app use were associated with greater increases in moderate-to-vigorous intensity physical activity (r=0.335; 95% CI 0.017-0.585; P=.04). CONCLUSIONS: This study highlights the challenges of reducing sitting time in adults with TKR. Future studies should explore alternative behavior change techniques across different levels of influence (eg, environmental and social) to support interventions implemented within the first year after TKR. TRIAL REGISTRATION: ClinicalTrials.gov NCT04482400; https://clinicaltrials.gov/ct2/show/NCT04482400.
28 May 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Comparative analysis of the improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty compared to open reduction and internal fixation: a systematic review and meta-analysis
PURPOSE: To compare the clinical and functional outcomes of open reduction and internal fixation (ORIF) and reverse shoulder arthroplasty (RSA) in patients aged ≥ 65 years with complex proximal humeral fractures (PHFs). METHODS: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. PubMed, Web of Science, ScienceDirect, EBSCO, and the Cochrane Library were searched for randomized controlled trials (RCTs) and cohort studies published in English without date restrictions. Eligible studies compared RSA and ORIF in elderly patients with PHFs and reported functional, radiographic, or complication outcomes. Pooled data were analyzed using a random-effects model. RESULTS: Twenty-two studies involving > 34,000 patients were included. RSA was associated with greater forward flexion and a trend toward improved abduction, whereas internal rotation favored ORIF without reaching significance. No significant differences were observed in external rotation. The functional scores (Constant-Murley, Oxford Shoulder Score) were similar, and the complication and reoperation rates did not differ significantly between the groups. CONCLUSION: RSA offers modest advantages in forward flexion compared with ORIF but does not consistently improve overall functional scores or reduce complications. RSA may be preferred in elderly patients with poor bone stock or rotator cuff pathology, whereas ORIF remains appropriate for patients in whom joint preservation is feasible. High-quality RCTs with standardized outcome reporting are needed to clarify the optimal surgical management.
28 May 2026
Read appraisal →JBJS reviews
Reconstruction of the Proximal Tibia and Extensor Mechanism After Tumor Resection: A Systematic Review and Meta-Analysis
BACKGROUND: Proximal tibia reconstruction after tumor resection is technically challenging due to the dual requirement of skeletal stability and extensor mechanism restoration. Multiple reconstruction methods exist, but comparative data on complications, survival, and functional outcomes remain limited. This study aimed to compare complication rates and implant survival across different proximal tibia reconstruction methods (megaprostheses, osteoarticular allografts [OAs], intercalary allografts [ICAs], and allograft-prosthetic composites [APCs]) and to evaluate how extensor mechanism reconstruction technique influences functional outcomes. METHODS: A systematic review and meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and Embase databases were searched through September 2025. Studies reporting outcomes of proximal tibia and/or extensor mechanism reconstruction for oncologic indications were included. Complications were classified using the Henderson system. Random-effects meta-analysis was performed for complication rates, implant survival, and extension lag. Subgroup analyses were performed by reconstruction type. RESULTS: Seventy-eight studies including 2,825 patients were analyzed (mean age 25.9 years, mean follow-up 84.7 months). Prosthetic reconstruction demonstrated the lowest overall complication rate (39.2%, 95% confidence interval [CI] 32%-45%) compared with OAs (69.6%, 95% CI 55%-82%), APCs (52.7%, 95% CI 32%-73%), and ICAs (53.4%, 95% CI 34%-70%) (p = 0.004). Biological reconstructions had significantly higher structural failure rates (OA 31.0%, ICA 24.5% vs. prosthesis 5.5%, p < 0.001). Five-year implant survival showed no significant differences between prosthesis (75.3%), OA (67.4%), and APC (74.3%). At 10 years, survival rates converged across all methods (63%-71%). Extensor mechanism reconstruction technique significantly influenced extension lag: direct tendon-to-metal reattachment (11.0°) resulted in worse outcomes than synthetic augmentation (5.7°), allograft reattachment (4.6°), or autograft reconstruction (2.3°) (p < 0.001). CONCLUSION: While prosthetic reconstruction offers lower short-term complication rates, long-term implant survival is comparable across reconstruction methods. Extensor mechanism reconstruction technique is a critical determinant of functional outcome. Surgeons should consider techniques beyond simple direct reattachment, particularly synthetic augmentation or biological reconstruction, when feasible to optimize extension function. Individual patient factors should guide selection between prosthetic and biological reconstruction. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.
27 May 2026
Read appraisal →Biomedical physics & engineering express
Acoustic-based intraoperative assessment of femoral stem initial stability in cementless THA via sensitive frequency band identification
Intraoperative assessment of femoral stem initial stability in cementless total hip arthroplasty (THA) predominantly relies on subjective tactile and auditory feedback, which lacks standardization and increases complication risks. This study develops a quantitative framework to identify sensitive acoustic frequency bands characterizing the bone-implant fixation state. Specifically, we acquired high-fidelity acoustic signals from 118 primary cementless THA procedures. Utilizing a statistical difference analysis framework, we identified two distinct sensitive bands (640-1920 Hz and 3460-3560 Hz) to extract band power fraction features. Machine learning evaluation demonstrated that these bands significantly outperform traditional empirical partitioning, achieving a classification accuracy of 0.816±0.028, which improved to 0.834±0.042 after feature fusion. Furthermore, stratified validation confirmed high consistency across diverse bone qualities and implant designs (Summit and Corail). While robust under steady-state Gaussian noise, the system exhibited sensitivity to non-steady-state speech interference. In conclusion, the identified sensitive bands effectively reflect the mechanical evolution of the bone-implant interface, providing a physically interpretable decision-support tool for enhancing surgical safety.
27 May 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Loop versus anchor tenodesis of the long head of the biceps tendon: a prospective randomized controlled pilot study
BACKGROUND: The long head of the biceps tendon is a frequent source of anterior shoulder pain, often treated with tenodesis. While anchor tenodesis is well established, it carries risks of implant-related complications. This study evaluates an implant-free "loop tenodesis" technique as a potentially safer and cost-effective alternative. METHODS: In this prospective, double-blinded, randomized exploratory study, 48 patients undergoing arthroscopic biceps tenodesis were randomized to either loop (n = 24) or anchor (n = 24) tenodesis. Clinical outcomes were assessed using ASES, Constant, and DASH scores, as well as range of motion, supination strength, satisfaction, aesthetic appearance, and return-to-sport. Statistical analysis was performed using the Mann-Whitney U and Wilcoxon signed-rank tests to compare non-parametric data. RESULTS: Both groups showed significant improvements with similar gains in functional scores. Supination strength recovery was greater in the loop group (103% vs. 93%). There were no significant differences in range of motion or complications. Notably, only the anchor group showed cases of Popeye deformity (2 patients). Return to sport was achieved in 95.3% of patients, typically within 3 months. No revision or implant-related issues occurred. CONCLUSION: Loop tenodesis offers equivalent clinical outcomes to anchor-based techniques, with fewer aesthetic concerns and no implant-associated risks, making it a safe, reliable, and cost-effective alternative for biceps tenodesis.
25 May 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Extracorporeal shockwave therapy in bone fractures: a systematic review
INTRODUCTION: The increasing incidence of fractures and cases of delayed union or nonunion has encouraged the search for non-invasive therapies. Extracorporeal shockwave therapy (ESWT) has been proposed as a strategy to stimulate bone regeneration and improve fracture healing. MATERIALS AND METHODS: A systematic review was conducted following PRISMA guidelines, with searches performed in PubMed, Scopus, Web of Science, and Embase (2005-2025). Clinical studies evaluating ESWT for fracture treatment with radiographic assessment of bone healing and the presence of a control group were included. RESULTS: A total of 834 studies were initially identified, of which 7 were included in the final analysis. Most studies demonstrated positive effects of ESWT, including improved bone healing, pain reduction, and functional recovery. However, there was considerable heterogeneity in treatment protocols and relatively small sample sizes. CONCLUSION: ESWT shows potential as a non-invasive therapy to stimulate fracture healing, particularly in cases of delayed union or nonunion. However, further controlled clinical trials and standardized protocols are needed to confirm its clinical effectiveness.
25 May 2026
Read appraisal →Medicine
Predicting poor wrist function recovery after internal fixation of distal radius fractures: A retrospective study based on multivariate analysis and machine learning models
This study aimed to identify independent risk factors associated with poor wrist function recovery 6 months after internal fixation of distal radius fractures (DRF) and develop machine learning models for early risk prediction. This retrospective study included 328 patients who underwent internal fixation for DRF at our hospital between January 2022 and June 2025. Wrist function was evaluated using the Cooney Wrist Score at 6 months postoperatively. Poor recovery was defined as a Cooney score <75. The overall incidence of poor wrist function recovery was 21.56% (71/328). Clinical variables including demographic characteristics, comorbidities, laboratory indicators, fracture type, postoperative pain scores, and rehabilitation compliance were collected. Rehabilitation compliance referred to patients' adherence to prescribed postoperative functional training and follow-up plans. Variables with P <.05 in univariate analysis were entered into multivariate logistic regression to identify independent risk factors. These variables were subsequently used to construct random forest (RF), XGBoost, and backpropagation (BP) neural network models. Model performance was evaluated using ROC curves and classification metrics. Multivariate analysis identified low rehabilitation compliance, age ≥65 years, AO type C fractures, postoperative visual analogue scale scores >3 at 1 week, and decreased serum albumin levels as independent predictors of poor wrist function recovery. Among the machine learning models, the RF model demonstrated the best performance (AUC = 0.939, accuracy = 0.946), followed by the BP neural network (AUC = 0.924). The XGBoost model showed comparatively lower predictive performance (AUC = 0.876). Poor wrist function recovery after internal fixation of DRF is influenced by multiple clinical factors. Machine learning models based on identified independent risk factors, particularly the RF model, show strong predictive ability and may assist clinicians in early risk stratification and individualized rehabilitation planning.
25 May 2026
Read appraisal →Calcified tissue international
Performance of Large Language Models in Answering Osteoporosis-Related Frequently Asked Questions: A Systematic Comparative Evaluation Based on International Associations
To systematically evaluate and compare the performance of large language models (LLMs) in answering osteoporosis-related frequently asked questions (FAQs) derived from international osteoporosis-related associations. A standardized question bank was constructed based on FAQs summarized from three international osteoporosis-related associations. Six LLMs were prompted to generate responses to all questions under uniform conditions. Two osteoporosis experts independently and blindly evaluated all responses using 5-point Likert scales for accuracy and comprehensiveness. Inter-rater reliability was assessed using Cohen's κ coefficient. Nonparametric statistical analyses, including Kruskal-Wallis tests with Dunn's post hoc comparisons and Wilcoxon signed-rank tests, were performed to compare models' performance. A total of 528 responses were generated from 88 association-based questions. Inter-rater agreement was good for both accuracy and comprehensiveness (κ = 0.668 and 0.702, respectively). Significant differences were observed among models, with Claude Sonnet 4.5 demonstrating the highest overall performance on association-based FAQs. Although most models showed solid medical knowledge and basic reasoning ability, substantial variability was observed across question types and prompt formulations. Current LLMs demonstrate promising potential as auxiliary tools for osteoporosis-related health management. However, it is necessary to optimize the strategies for integrating medical knowledge and designing prompts, so as to better improve the accessibility of its clinical application.
24 May 2026
Read appraisal →Medicine
Global, regional, and national burden of clavicle, scapula, or humerus fracture in 204 countries and territories, 1990 to 2021: A systematic analysis from the Global Burden of Disease Study 2021
Clavicle, scapula, or humerus fracture represent a major public health challenge, yet their epidemiology and health burden remain poorly characterized. Using the Global Burden of Disease 2021 framework, we quantified incidence, prevalence, and years lived with disability (YLDs) of clavicle, scapula, or humerus fractures across 204 countries from 1990 to 2021. Estimates were stratified by age, sex, region, and socio-demographic index (SDI), and reported with 95% uncertainty intervals (UIs) from Bayesian models. Globally, the age-standardized incidence rate (ASIR) declined from 276.68 (95% UI: 219.06-346.71) per 100,000 person-years in 1990 to 220.94 (95% UI: 172.60-280.99) per 100,000 person-years in 2021, with an estimated annual percentage change of -0.78% (95% UI: -0.82% to -0.73%). High SDI regions showed the greatest ASIR (300.30 per 100,000 person-years), age-standardized prevalence rate (112.03 per 100,000 person-years), and age-standardized YLDs rate (3.72 per 100,000 person-years). In 2021, Eastern Europe had the highest ASIR (465.06 per 100,000 person-years), while Australasia led in age-standardized prevalence rate (151.42 per 100,000 person-years) and age-standardized YLDs rate (5.04 per 100,000 person-years). China ranked first in absolute prevalence (1.21 million, 95% UI: 1.04-1.39 million) and YLDs (40,235, 95% UI: 24,471-61,196). Despite declines in age-standardized rates, absolute cases increased substantially, highlighting demographic and regional disparities. Priority populations for targeted prevention include women aged ≥60 years and residents of high-SDI regions, as these strata accounted for the highest burden across incidence/prevalence/YLD rates.
24 May 2026
Read appraisal →The journal of trauma and acute care surgery
Cognitive dysfunction after polytrauma in the absence of traumatic brain injury: A systematic review of incidence.
BACKGROUND: Polytrauma patients frequently experience long-term health impacts, including cognitive impairments. While traumatic brain injury (TBI) is a recognized nonmodifiable cause, polytrauma patients are likely to face cognitive challenges potentially linked to systemic inflammation and multiple surgical interventions even in the absence of TBI. This review aims to describe the incidence and identify factors associated with cognitive dysfunction in adult multiple injury patients without Frank TBI. METHODS: A systematic search was conducted across MEDLINE, CINAHL, EMBASE, and Scopus databases on August 17, 2023, to identify studies reporting on cognitive dysfunction in adults with polytrauma, excluding brain injuries. The Critical Appraisal Skills Programme checklists guided study appraisal, and findings were narratively synthesized. RESULTS: From 2719 articles identified (including one through citation searching), 47 were fully screened, yielding 10 cohort studies for inclusion. The reported incidence of cognitive dysfunction among multiple injury patients without TBI varied widely, from 0% to 60%, with a majority (eight out of ten studies) noting incidences of 30% or higher. No consensus was found for a relationship of other studied factors with cognitive dysfunction. Injury Severity Score was found to not be associated with cognitive dysfunction in selected studies which analyzed this factor. CONCLUSION: This review suggests a high prevalence of cognitive dysfunction in multiple injury patients without TBI. The evidence base is limited by heterogeneity of the inclusion criteria, and the cognitive outcome measures. IMPLICATIONS OF KEY FINDINGS: Multiple injury is associated with long term cognitive dysfunction even without primary brain injury. This aspect of the disease of multiple injury needs further characterization to identify predictors and potential preventive and therapeutic interventions. Standardized reporting is also required to be able to monitor incidence and prevalence. ( J Trauma Acute Care Surg . 2026;100: 973-981. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Systematic Review; Level II.
23 May 2026
Read appraisal →Neurosurgical review
The safety and efficacy of perioperative nefopam for analgesia in spine surgery: A systematic review and meta-analysis of randomised controlled trials
OBJECTIVE: Moderate-to-severe pain is common after spine surgery. While opioids remain standard analgesia, their adverse effects have prompted opioid-sparing strategies. This systematic review evaluates the safety and efficacy of nefopam, a non-opioid and non-NSAID, as adjuvant perioperative analgesia in spine surgery. METHODS: Medline, Embase, Scopus and Cochrane databases were searched from inception to May 9, 2025. RevMan V5.4 was used to analyse mean differences (MD) or standardised mean differences (SMD) and 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RR) with 95% CIs for dichotomous outcomes. The GRADE framework was used to assess the certainty of evidence. RESULTS: Seven randomised controlled trials (n = 553) were included. Nefopam did not reduce 24-hour morphine use (MD -1.47 mg; 95% CI: -3.86 to 0.92 mg; GRADE moderate), 24-hour incisional pain (SMD, -0.01; 95% CI -0.22 to 0.20; GRADE moderate), 48-hour incisional pain (SMD, -0.24; 95% CI -0.50 to 0.02; GRADE low), 24-hour neuropathic pain (SMD, -0.19; 95% CI -0.49 to 0.10; GRADE low), 72-hour neuropathic pain (SMD, -0.33; 95% CI -1.02 to 0.36; GRADE very low), or length of stay (MD, 0.08days; 95% CI -0.73 to 0.88days; GRADE Low). There were no significant differences in drug-related adverse effects (sedation (RR 1.30), nausea/vomiting (RR 1.03), dizziness (RR 1.14), and urinary retention (RR 2.36)), (GRADE: very low to low). CONCLUSION: Perioperative nefopam did not reduce acute morphine use, pain scores, hospital stay, or drug-related adverse events in spine surgery, though most studies used doses below the median effective dose, limiting conclusions on its efficacy and safety.
23 May 2026
Read appraisal →Surgical and radiologic anatomy : SRA
Proximal femoral morphometry and its association with hip fracture patterns: a systematic review with meta-analysis
PURPOSES: Proximal femoral fractures (PFFs) represent a major cause of morbidity and mortality in the elderly population. Beyond bone mineral density, proximal femoral (PF) and hip joint (HJ) morphometry have been implicated in fracture susceptibility and fracture pattern. However, the relative contribution of individual geometric parameters remains incompletely defined. The purpose of this study was to systematically evaluate the association between PF and HJ morphometry and hip fracture (HF) patterns, and to assess the predictive value of radiographic morphometric parameters derived from standard anteroposterior radiographs. MATERIALS AND METHODS: A systematic review with meta-analysis was conducted in accordance with PRISMA guidelines. PubMed and MEDLINE databases were searched up to September 2025 for observational studies reporting radiographic morphometric parameters in patients with unilateral PFFs. Statistical meta-analysis was performed with random-effect models to compare intracapsular-ICF/subcapital-SCF fractures with intertrochanteric (ITF) and extracapsular (ECF) fracture patterns. RESULTS: Twenty-two studies comprising 4184 patients (77.8% female; pooled mean age 77.4 years) were included. Meta-analysis using a random-effects model revealed that ITF were significantly associated with a smaller femoral head diameter (p < 0.001) and increased medial neck cortex thickness (p = 0.021) compared with ICF. ECF demonstrated significantly longer femoral neck axis length (p = 0.012), increased horizontal offset (p = 0.048), smaller absolute offset (p = 0.026) and shorter hip axis length (p = 0.026) than ICFs. Angular parameters provided the most robust stratification. ITFs and ECFs exhibited significantly lower (more varus) neck-shaft angles (p < 0.001) and significantly higher Wiberg angles (p < 0.001) compared with the ICF group. CONCLUSIONS: PF and HJ morphometry are associated with distinct HF patterns, independently of bone mineral density. Simple linear and angular measurements obtained from standard anteroposterior radiographs may assist fracture pattern stratification, risk assessment, and preoperative planning in elderly patients.
22 May 2026
Read appraisal →Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
Cephalosporins Versus Non-cephalosporin Antibiotics for Perioperative Prophylaxis in Primary Arthroplasty: A Systematic Review and Meta-Analysis
BACKGROUND: The number of arthroplasty procedures and infection-related complications, including prosthetic joint infections (PJIs) and surgical site infections (SSIs), continues to rise. Although current guidelines recommend cefazolin or cefuroxime as the first-line perioperative prophylactic antibiotic, substitutions with non-cephalosporins remain common, especially among patients with reported β-lactam allergies. These substitutions may increase infection risk and healthcare costs. Evidence comparing outcomes across antibiotic classes remains variable. METHODS: We conducted a systematic review and meta-analysis of studies comparing single-agent cephalosporin versus single-agent non-cephalosporin prophylaxis in adults undergoing primary arthroplasty. Cochrane, Embase, Medline, Scopus, and Web of Science were searched from database inception through January 2025. Random-effect or fixed-effect models were used to estimate pooled odds ratios (OR) and 95% confidence intervals (CI). Subgroup analyses stratified results by cephalosporin type, study era, and risk of bias. RESULTS: Twenty-three studies (7 randomized controlled trials and 16 observational studies) were included, encompassing 191 527 arthroplasties in the cephalosporin arm and 20 058 in the non-cephalosporin arm. The odds of PJI were lower with cephalosporins (OR 0.59; 95% CI, .46-.75). No overall difference was observed for SSI (OR 0.70; 95% CI, .36-1.36), though post-2013 studies and the cefazolin subgroup demonstrated a significant protective effect. Randomized trial estimates were limited and heterogeneous and did not reach statistical significance. Certainty of evidence was graded as moderate. CONCLUSIONS: Cephalosporins, particularly cefazolin or cefuroxime, remain the preferred prophylactic agents for primary arthroplasty. This quantitative synthesis reinforces their protective association against prosthetic joint infection and supports adherence to guideline-endorsed prophylaxis.
22 May 2026
Read appraisal →JBJS reviews
Medial Parapatellar vs. Transpatellar Approach in Tibial Intramedullary Nailing: A Systematic Review and Meta-Analysis of Pain and Function
BACKGROUND: Tibial intramedullary nailing (IMN) is the standard treatment for tibial shaft fractures, yet anterior knee pain (AKP) remains common, affecting nearly 47% of patients. Despite the reported advantages of suprapatellar techniques, infrapatellar approaches-medial parapatellar (MPP) and transpatellar (TP)-remain the most commonly used methods for tibial IMN. This systematic review and meta-analysis compares MPP and TP approaches regarding pain, AKP incidence, range of motion (ROM), knee function, and fracture healing. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, Embase, Scopus, and Web of Science were searched up to November 2024. Randomized clinical trials (RCTs) and comparative observational studies in adults undergoing tibial IMN via MPP or TP approaches were included. Outcomes were AKP incidence, pain intensity, knee function, ROM, and union-related variables. Pooled mean differences (MDs) and risk ratios (RRs) were calculated using random-effects and common-effects models. RESULTS: Twelve cohort studies (782 patients) and 9 RCTs (462 patients) were included. Across cohort studies, MPP was associated with a significantly lower AKP risk at latest follow-up (RR = 0.76 [0.63; 0.90]) and at 6 months. Visual analog scale pain at 3-month postoperative also favored MPP (MD = -1.27 [-1.94; -0.60]) but did not reach the minimal clinically important difference. RCTs demonstrated similar trends toward lower pain and AKP with MPP, but without statistical significance. Functional outcomes and ROM generally favored MPP across both study designs, though findings were inconsistent and unsuitable for pooling. Fracture healing and union rates were comparable between approaches. CONCLUSION: The MPP approach for tibial IMN was linked to a lower incidence of AKP compared with the TP approach, while offering comparable or better functional outcomes, ROM, and pain intensity. These findings suggest MPP as the preferred infrapatellar approach in appropriate clinical settings. Nonetheless, high-quality studies with standardized outcome measures are essential to validate these findings. LEVEL OF EVIDENCE: Level III (systematic review of RCTs and retrospective comparative studies). See Instructions for Authors for a complete description of levels of evidence.
21 May 2026
Read appraisal →Neurosurgical review
The impact of augmented reality on radiation exposure during spine surgery: a systematic review
BACKGROUND: Augmented reality (AR) has rapidly emerged as an important navigational technology in spine surgery, with growing interest in its potential to reduce dependence on fluoroscopy and mitigate radiation exposure for both patients and operating room staff. METHODS: This systematic review examined current evidence on radiation-related outcomes of AR-assisted spine procedures. A PRISMA-guided search of PubMed, Embase, and Scopus identified twelve eligible studies, including randomized trials, prospective and retrospective clinical cohorts, and cadaveric or synthetic-model investigations. RESULTS: Across the included studies, AR was consistently associated with reduced fluoroscopy use, with several studies demonstrating statistically significant reductions in exposure time compared with conventional fluoroscopy. Two clinical studies directly measured occupational radiation and reported substantially lower staff doses when AR-based navigation and optimized shielding strategies were employed. Patient radiation exposure was similarly decreased in most studies, particularly when AR was integrated with low-dose cone-beam CT protocols. Operative time findings were mixed, reflecting early learning curves and variability in AR systems, but accuracy remained high across platforms. CONCLUSION: Current evidence suggests that AR may reduce intraoperative radiation exposure without compromising workflow or surgical precision, available studies are limited by small sample sizes, heterogenous methodologies, and a paucity of direct staff-dosimetry data. Larger, high-quality multicenter studies are needed to clarify the magnitude of AR's radiation-sparing benefits and to define its role in modern spine surgery.
19 May 2026
Read appraisal →Spine
Identifying Predictors of Failed Back Surgery Syndrome Following Lumbar Spine Surgery: A Machine Learning Approach
STUDY DESIGN: Retrospective cohort study from a tertiary academic medical center. OBJECTIVE: To build a prognostic machine learning model to predict 1-year FBSS incidence after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: A minority of patients who undergo degenerative lumbar spine surgery will have persistent postoperative pain, characterized as "Failed Back Surgery Syndrome" (FBSS). Adequate preoperative identification of patients at risk of having an undesirable outcome after surgery is an essential part of a spine surgeon's workflow. Although several studies have proposed mechanisms and risk factors for FBSS, no studies have developed a prognostic machine learning model to quantify and functionalize predictions. METHODS: A cohort of lumbar fusion and lumbar decompression surgeries was queried from a tertiary academic medical center from 2002 to 2022. Patient and operative characteristics were systematically extracted for each surgery. Several machine learning algorithms were used and optimized to predict FBSS occurrence within 1 year of surgery. SHAP feature importance values were computed for the top-performing model. RESULTS: A total of 10,128 unique lumbar decompression surgeries and 2890 unique lumbar fusion surgeries were included. The Random Forest model had the highest performance of tested models (AUROC of 0.715 for lumbar decompression, 0.701 for lumbar fusion). For lumbar decompression, the top three predictors of FBSS were absence of microdiscectomy, lack of preoperative immunosuppressant usage, and preoperative benzodiazepine usage. For lumbar fusion, prior FBSS diagnosis, lack of preoperative immunosuppressant usage, and operating room duration were the most important predictors. Other key variables spanned several domains, including preoperative medication usage, patient demographics, and operative indications and characteristics. CONCLUSION: This study demonstrates the successful creation of a prognostic machine learning model for prediction of FBSS within one year postoperatively. These models, after external validation, have the potential to be instrumental aspects of a spine surgeon's workflow. LEVEL OF EVIDENCE: Level III.
16 May 2026
Read appraisal →Spine
Automated Classification of Cervical Spinal Stenosis Using Deep Learning on Computed Tomography Scans
STUDY DESIGN: Retrospective study. OBJECTIVE: To develop and validate a computed tomography-based deep learning (DL) model for diagnosing cervical spinal stenosis (CSS). BACKGROUND: Although magnetic resonance imaging (MRI) is widely used for diagnosing CSS, its inherent limitations, including prolonged scanning time, limited availability in resource-constrained settings, and contraindications for patients with metallic implants, make computed tomography (CT) a critical alternative in specific clinical scenarios. The development of CT-based DL models for CSS detection holds promise in transcending the diagnostic efficacy limitations of conventional CT imaging, thereby serving as an intelligent auxiliary tool to optimize health care resource allocation. MATERIALS AND METHODS: Paired CT/MRI images were collected. CT images were divided into training, validation, and test sets in an 8:1:1 ratio. The 2-stage model architecture employed: (1) A Faster R-CNN-based detection model for localization, annotation, and extraction of regions of interest (ROI), (2) Comparison of 16 Convolutional Neural Network (CNN) models for stenosis classification to select the best-performing model. The evaluation metrics included accuracy, F1-score, and Cohen κ coefficient, with comparisons made against diagnostic results from physicians with varying years of experience. RESULTS: In the multiclass classification task, 4 high-performing models (DL1-b0, DL2-121, DL3-101, and DL4-26d) achieved accuracies of 88.74%, 89.40%, 89.40%, and 88.08%, respectively. All models demonstrated >80% consistency with senior physicians and >70% consistency with junior physicians. In the binary classification task, the models achieved accuracies of 94.70%, 96.03%, 96.03%, and 94.70%, respectively. All 4 models demonstrated consistency rates slightly below 90% with junior physicians. However, when compared with senior physicians, 3 models (excluding DL4-26d) exhibited consistency rates exceeding 90%. CONCLUSIONS: The DL model developed in this study demonstrated high accuracy in CT image analysis of CSS, with a diagnostic performance comparable to that of senior physicians.
16 May 2026
Read appraisal →Annals of medicine
Impact on analgesia, diaphragmatic function, and recovery between erector spinae plane block versus superior trunk block in arthroscopic shoulder surgery: a randomized controlled trial
BACKGROUND: Effective analgesia and preservation of diaphragmatic function are key considerations in analgesia for shoulder surgery. The superior trunk block provides analgesia with reduced phrenic nerve involvement, while the erector spinae plane block offers minimal impact on diaphragm motion. This randomized controlled trial compared the analgesic efficacy, impact on diaphragmatic motion, and postoperative recovery between the two blocks. METHODS: Sixty patients undergoing arthroscopic shoulder surgery were randomized to receive either erector spinae plane block or superior trunk block. Primary outcomes were postoperative VAS and changes in diaphragmatic excursion. Secondary outcomes included Quality of Recovery-15 (QoR-15) scores, morphine-equivalent consumption, and the handgrip strength motor blockade. RESULTS: The superior trunk block resulted in significantly lower dynamic VAS at 1-h postoperatively (0.1 [0.0, 0.2] vs. 5.7 [4.0, 7.6]; p < 0.001) and reduced 24-h morphine consumption (7.8 [2.5, 15.0] mg vs. 12.7 [7.5, 17.3] mg; p = 0.038) compared to the erector spinae plane block. However, diaphragmatic excursion was better preserved in the erector spinae plane block group (8.37% ± 20.7% vs. -20.09% ± 22.2%; p < 0.001), with a lower incidence of partial hemidiaphragm paresis (3.3% vs. 46.7%; p < 0.001). At 24 h postoperatively, QoR-15 scores were higher in the superior trunk block group (p = 0.047), and no patient in either group developed handgrip motor blockade. CONCLUSIONS: Superior trunk block offers superior early postoperative analgesia and better overall recovery, while erector spinae plane block minimizes diaphragmatic impairment. However, the erector spinae plane block may represent an option only in carefully selected patients at high respiratory risk, acknowledging its significantly poorer early analgesic profile.
15 May 2026
Read appraisal →BMJ open
Prediction of Oswestry Disability Index and Numeric Rating Scale scores after lumbar spine surgery: machine learning model development and fairness assessment
BACKGROUND: One-third of patients operated for degenerative conditions in the lumbar spine do not report substantial improvement after 12 months. Most previous outcome prediction models are classifiers. This constrains nuances in prediction and use for decision support. OBJECTIVES: To develop and test models for the prediction of continuous outcome scores and retrieval of similar patients' outcomes, and to evaluate the models' fairness. SETTING: Norwegian public and private specialist healthcare. PARTICIPANTS AND DATA SOURCE: All cases recorded with an elective operation for lumbar disc herniation (LDH, n=18 377) or lumbar spinal stenosis (LSS, n=24 540) in the Norwegian Registry for Spine Surgery from 1 January 2007 to 23 May 2023. OUTCOME MEASURES: All outcomes were patient-reported 12 months after the operation. The primary outcome was the Oswestry disability index (ODI), modelled on a scale ranging from 0 to 100. Numeric Rating Scale scores (range 0-10) for back and leg pain were secondary outcomes. MODEL BUILDING AND PERFORMANCE: We selected 22 predictors recorded preoperatively by patients and clinicians based on Shapley Additive Explanations values. Data were split into 80%/20% training/test samples for LDH and LSS. Six machine learning methods for regression, that is, with a continuous outcome (extreme gradient boosting (XGBoost), Gaussian process regression, gradient boosting regression, artificial neural networks and linear regression), were trained for both conditions using fivefold cross-validation. We report the magnitude and distribution of errors as mean absolute error (MAE) with 95% CIs, and explanatory power as the coefficient of determination (R2). Fairness and calibration were assessed with violin and calibration plots of error. We developed a patient-similarity function that uses a K-nearest neighbour model to retrieve the individual outcomes of the 50 most similar patients and evaluated it by calculating L1 distances (Manhattan distances) across subgroups. RESULTS: XGBoost regression performed best for both conditions. The models showed good calibration and predicted ODI with MAE 11.32 (95% CI 11.00 to 11.63) and R2 0.27 (95% CI 0.24 to 0.29) for LDH and MAE 12.05 (95% CI 11.76 to 12.32) and R2 0.31 (95% CI 0.28 to 0.34) for LSS. The MAEs for back and leg pain were 2.09 (95% CI 2.04 to 2.15) and 1.95 (95% CI 1.90 to 2.00) for LDH and 2.33 (95% CI 2.28 to 2.38) and 2.13 (95% CI 2.08 to 2.16) for LSS. All models were fair with differences in error between subgroups for sex, age, education level and native language. In the patient-similarity function, distances at baseline were evenly distributed across subgroups. CONCLUSIONS: Our machine learning models predicted continuous outcomes with MAEs close to the SEs of measurements. The models were fair across sociodemographic subgroups. We succeeded in developing a patient-similarity function which supplements the predictions.
15 May 2026
Read appraisal →JAMA
Intrawound Tobramycin Plus Vancomycin to Prevent Surgical Site Infection in Tibial Fractures: The TOBRA Randomized Clinical Trial
IMPORTANCE: Previous research has suggested that intrawound vancomycin powder reduces deep surgical site infections among patients with periarticular tibial fractures at high risk of infection. It is unknown whether the addition of tobramycin powder further decreases infection rates. OBJECTIVE: To compare whether the combination of tobramycin plus vancomycin vs vancomycin alone delivered as intrawound powder at the time of definitive fixation reduces deep surgical site infections. DESIGN, SETTING, AND PARTICIPANTS: Open-label, assessor-masked, randomized clinical trial conducted at 39 US trauma centers. Eligible patients were adults with an operatively treated periarticular tibial fracture (either tibial plateau or pilon) who met 1 of 3 criteria for elevated infection risk. Enrollment occurred between June 18, 2021, and December 12, 2024 (final follow-up, July 15, 2025). INTERVENTIONS: Intrawound tobramycin (1.2 g) plus vancomycin (1.0 g) powder vs intrawound vancomycin (1.0 g) powder delivered at the time of definitive fixation. MAIN OUTCOMES AND MEASURES: The primary outcome was a deep surgical site infection requiring surgical management within 182 days of definitive fracture fixation. Secondary outcomes included deep surgical site infections with pathogens that were gram-negative only, deep surgical site infections with at least 1 pathogen that was gram-positive, deep surgical site infections with polymicrobial cultures, deep surgical site infections with negative culture results, and cellulitis or skin infections treated only with antibiotics. RESULTS: Among the 1660 participants randomized, 1528 (mean age, 47.0 [SD, 14.3] years; 603 female [39.5%]; 925 male [60.5%]) were included in the primary analysis. Deep surgical site infections occurred in 51 of 753 participants (182-day probability, 7.4%) in the tobramycin plus vancomycin group and 47 of 775 participants (182-day probability, 6.6%) in the vancomycin alone group (hazard ratio, 1.11; 95% bayesian credible interval, 0.75-1.66; posterior probability of superiority, 29.7%). The threshold required for superiority was not reached for any secondary outcome. CONCLUSIONS AND RELEVANCE: Among patients with operatively treated periarticular tibial fractures at high risk of infection, adding intrawound tobramycin powder to vancomycin powder at the time of definitive fixation did not reduce deep surgical site infections compared with vancomycin powder alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02227446.
14 May 2026
Read appraisal →Journal of investigative surgery : the official journal of the Academy of Surgical Research
Meta-Analysis of PENG+LFCN versus FICB on ERAS-Related Outcomes: Postoperative Pain, Motor Function and Recovery in Hip Surgery
OBJECTIVE: To compare pericapsular nerve group block combined with lateral femoral cutaneous nerve block (PENG+LFCN) with fascia iliaca compartment block (FICB) for postoperative analgesia and functional recovery after hip surgery within Enhanced Recovery After Surgery (ERAS) pathways. METHODS: PubMed, Embase, the Cochrane Library, CNKI, Wanfang Data, and CQVIP were searched through January 2026. Comparative studies of PENG+LFCN versus FICB in hip surgery were included. Data were pooled using a random-effects model, with assessment of bias, heterogeneity, and publication bias. RESULTS: Sixteen studies were included. The PENG+LFCN group had significantly lower resting VAS (MD = -0.54; p < 0.00001) and dynamic VAS (MD = -0.98; p < 0.00001) scores. It also showed a lower incidence of postoperative muscle weakness (OR = 0.10; p = 0.0001), better preservation of quadriceps muscle strength, shorter time to first ambulation (MD = -9.22 h; p < 0.0001), and reduced length of stay (MD = -0.75 days; p < 0.00001). Additionally, morphine consumption (MD = -24.22 mg; p = 0.001) and PCA pump activations (MD = -2.46; p < 0.00001) were lower in the PENG+LFCN group. CONCLUSION: PENG+LFCN may be a more favorable regional analgesic strategy than FICB for hip surgery within ERAS pathways. PROTOCOL REGISTRATION: This systematic review and meta-analysis was registered at PROSPERO https://www.crd.york.ac.uk/PROSPERO/view/CRD420261295309.
13 May 2026
Read appraisal →Biofabrication
Resolving the multiscale design trade-off in bone tissue engineering: from generative design to digital twins
The clinical translation of bone tissue engineering is constrained by a severe multiscale design trade-off: the requirement for load-bearing mechanical strength competes directly with the need for vascular-permissive porosity. Conventional approaches address scaffold geometry, material formulation, and fabrication in a sequential, decoupled manner and therefore fail to navigate this multi-objective conflict. To overcome this limitation, we propose an 'AI-Driven Holistic Intelligence' framework. It spans the entire pipeline from generative inverse design to digital twin (DT)-based predictive maturation. The framework integrates gradient scaffold optimization, closed-loop adaptive manufacturing, and virtual clinical trial within a unified workflow. This architecture is designed to co-optimize the boundary conditions of stiffness and perfusion simultaneously, rather than in isolation. Nonetheless, realizing this vision as a clinically viable autonomous regeneration pathway will require bridging persistent translational gaps in data standardization, algorithm interpretability, and regulatory alignment. Importantly, the core innovation of this framework is not merely to navigate the empirical 'trade-off' along a fixed Pareto front, but to resolve it through multiscale co-optimization that expands the accessible design space, enabling simultaneous improvements in mechanical strength and vascular perfusion beyond the limits achievable by conventional single-objective approaches.
13 May 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Healthcare utilization following hip fractures based on social vulnerability status in the US: an analysis of 2016-2020 nationwide readmissions data
INTRODUCTION: Social vulnerability (SV) influences rehabilitation and postoperative care for patients with hip fracture. However, most previous work relies on area-level measures that overlook interindividual variation. The recent adoption of ICD-10 Z-codes allows clinical identification of patient-level SV and may offer a better understanding of its impact. This study aimed to evaluate healthcare utilization, including readmissions, discharge disposition, and length of stay (LOS) in surgically treated hip fracture patients with and without clinically acknowledged SV. METHODS: Adults surgically treated for hip fracture between 2016 and 2020 were included from the Nationwide Readmissions Database. SV was defined as having at least one documented relevant ICD-10 Z-code. Primary outcome measures included complications, LOS, discharge disposition, and 30- and 90-day readmissions, stratified by SV and evaluated using chi-square analyses. Multivariable logistic regression assessed long LOS (≥ 5 days) and discharge to home, adjusting for age, insurance/income status, and substance use. RESULTS: Patients with SV were younger (35.6% with SV vs. 50.1% without SV were 81+), had a lower median household income (38.8% with SV vs. 25.7% without SV were in the lowest quartile), and were more often insured by Medicaid (19.3% vs. 3.8%). Alcohol/drug use disorders were significantly more prevalent in patients with SV (18.5% vs. 4.5%). SV was associated with 47% higher odds for long LOS (1.47, 1.41-1.54) and 23% higher odds for discharge to home (1.23, 1.16-1.30) but comparable 90-day readmissions (21.2% vs. 19.8%). CONCLUSION: Among surgically treated hip fracture patients, SV was associated with higher odds of long LOS and discharge to home but no meaningful difference in readmissions. The small number of patients with clinically documented SV highlights the limited reporting by healthcare workers. This analysis of a nationwide all-payer database highlights the need to identify these higher risk patients and implement appropriate care pathways to reduce healthcare utilization.
10 May 2026
Read appraisal →Biomedical physics & engineering express
Enhancing CNN regressors with contour encoding and self-supervision for improved 3D/2D x-ray to CT registration in spinal surgery navigation
With advances in deep learning, regression-based methods have shown promising results in 3D/2D medical image registration. However, strict intraoperative radiation dose constraints produce low-dose x-ray images with severe blur and reduced contrast, significantly degrading registration accuracy and limiting precise image-guided spinal interventions. We propose the Contour Encoding Regressor (CER), a novel end-to-end CNN framework that extracts highly discriminative features directly from binary contour masks of intraoperative x-rays without any restrictions on contour length, shape, or morphology. These contour features are efficiently encoded by a dedicated module and seamlessly fused into the regression pipeline to improve robustness against image degradation. To further enhance pose estimation, CER employs a dual-branch architecture that explicitly decouples rotational and translational parameters, thereby reducing mutual interference and improving overall accuracy. In addition, a self-supervised fine-tuning strategy with a tailored multi-component loss function is introduced to adapt the model to blurred low-dose conditions and minimize residual errors. On low-dose x-ray images, CER achieves a mean target registration error of 1.39 mm-a clinically acceptable threshold-while outperforming state-of-the-art methods in accuracy and enabling real-time performance (0.03-0.06 s per frame on clinically accessible GPUs). These improvements meet the stringent precision and speed requirements of intraoperative navigation, offering strong potential to enhance surgical safety and outcomes in minimally invasive spinal procedures.
10 May 2026
Read appraisal →Current osteoporosis reports
The Use of Statistical Shape and Appearance Modelling for Predicting Osteoporotic Fracture Risk
PURPOSE OF REVIEW: Osteoporotic fractures remain a major cause of morbidity and mortality worldwide. Current clinical assessment metrics (e.g., bone mineral density) are limited in their ability to identify fracture risk and bone strength. Statistical Shape and Appearance Modelling (SSAM) offers a method to quantify anatomical geometry and density patterns. This review examines advancements in SSAM for osteoporosis research. RECENT FINDINGS: Recent literature demonstrates that SSAM can capture detailed bone geometry and internal density distribution. Increasingly, these models are combined with computational analytics, including finite element analysis and machine learning, to assess the mechanical and structural behavior of bone. SSAM provides a robust quantitative framework for bone research. Notably, SSAM is used to reconstruct 3D subjects from clinical 2D images for biomechanical evaluation. Although clinical adoption remains limited by generalizability, the advancement of deep learning and complex SSAM pipelines supports its potential for osteoporosis screening and fracture risk prediction.
10 May 2026
Read appraisal →Neurosurgical review
Sequesterectomy versus standard micro‑/open discectomy for lumbar disc herniation: a systematic review and meta-analysis
Lumbar disk herniation is a common clinical entity affecting about 1% of the entire population every year. The purpose of the present work is to provide a systematic review and meta-analysis comparing the safety and efficiency of sequesterectomy and discectomy in the management of lumbar disk herniation. A systematic review and meta-analysis using the random effects method was performed. This search was applied through the 6th of March 2025 to PubMed, Scopus, Cochrane Central Register of Controlled Trials and the Directory of Open Access Journals. The data collected included patient demographics, spinal level at which the operation occurred, duration of operation and hospital stay, outcome, recurrence rate as well as potential immediate and delayed complications. A total of 18 original studies with a cumulative number of 4394 patients were identified. No statistically significant difference was found in the re-herniation and complication rate between the two groups (OR: 1.058, 95% CI: 0.726-1.541, p=.769 and OR: 1.399, 95% CI: 0.964-2.032, p=.077 respectively). The same applied for mean hospital stay (standard difference in means: 0.206, SE = 0.167, p= .219). In contrast, mean operating time was found to be significantly shorter in the sequesterectomy group than in the discectomy group (mean 58.086 min versus 72.885 min respectively). As or the patient reported outcomes, VAS score for back pain two years after the operation was the only index that was significantly higher in patients with discectomy (standard difference in means: 0.348, SE = 0.172, p= .04). Based on the available data, the two approaches do not differ in terms of risk of reherniation, reoperation rate and postoperative complications. Nevertheless, patients that have undergone sequesterectomy could potentially benefit from a more significant reduction in back pain in the long run.
10 May 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Defining orthoplastic limb salvage centers: a systematic review
INTRODUCTION: Limb salvage centers have increased in number over time, but lack standardized defining criteria. This systematic review aimed to assess organizational features of limb salvage centers and determine whether orthoplastic centers, in comparison to vascular limb salvage centers, represent a distinct care model that may benefit from standardization. METHODS: We conducted a systematic review of publications related to limb salvage centers by searching MEDLINE, Embase, Web of Science, and Cochrane databases from their inception through 2024. We quantified binary data extraction as a reporting score of 26 organizational features across six structural care domains for limb salvage centers, based on a validated quality measurement framework. Organizational features differentiating distinct center types were identified to establish a quality framework for orthoplastic centers. Statistical comparisons between center types were performed using appropriate tests (p < 0.05). RESULTS: Of 118 included studies, orthoplastic (n = 43) and vascular (n = 48) centers represented 77% of all studies. Recent increases in orthoplastic publications show substantial variability in organizational features. Orthoplastic center literature more frequently reported plastic surgery consultation criteria (p < 0.001), surgical outcomes (p < 0.001), and centralized network integration (p ≤ 0.006), highlighting acute reconstructive approaches. Vascular center studies documented significantly more organizational team features (p < 0.001) and quality systems (p = 0.033), reflecting established care frameworks for chronic disease management. Six organizational features characterized orthoplastic centers with > 70% prevalence, providing a benchmark framework with standardization priorities. CONCLUSION: Orthoplastic limb salvage centers demonstrate distinct care paradigms that benefit from standardization. Our findings suggest structural benchmarks to support the need for standardized development of orthoplastic limb salvage centers.
10 May 2026
Read appraisal →Joint diseases and related surgery
High diagnostic accuracy of a resnet50-based deep learning model for osteochondral lesions of the talus on magnetic resonance imaging
OBJECTIVES: This study aims to evaluate the diagnostic performance of a ResNet50-based convolutional neural network (CNN) in detecting osteochondral lesions of the talus (OLTs) on magnetic resonance imaging (MRI) and to compare its efficacy between T1- and T2- weighted sequences. MATERIALS AND METHODS: A total of 219 ankle MRI scans were reviewed retrospectively, including 60 with confirmed OLTs and 159 without lesions. From each study, coronal and sagittal T1- and T2-weighted images were extracted and standardized to 224 × 224 pixels. Augmentation techniques were applied to strengthen model training. Data were divided into training, validation, and test sets in a 60:20:20 split. A ResNet50 model initialized with ImageNet weights was fine-tuned using crossentropy loss with class weighting. Diagnostic performance was summarized with accuracy, precision, recall, and F1-scores. RESULTS: The model performed better on T1 sequences, achieving an accuracy of 94.1% (95% confidence interval [CI] 88.3-97.1%) and an area under the curve [AUC] of 0.93 (95% CI 0.87-0.97), with patient cases classified at 0.92 precision and 0.82 recall. Healthy controls in the T1 group were recognized with 0.95 precision and 0.98 recall. In contrast, T2 sequences were less reliable, showing an accuracy of 87.2% (95% CI 80.5-91.9%) and an AUC of 0.91 (95% CI 0.85-0.95). Precision for patient cases in the T2 group was notably lower (0.65) despite a recall of 0.81. Misclassifications were more frequent in the T2 dataset, as evidenced by the confusion matrices. CONCLUSION: Even with a relatively modest dataset, the ResNet50 model delivered strong results for T1-weighted MRI. While T2 images proved more challenging, suggesting that deep learning can add value to routine assessment of OLTs.
5 May 2026
Read appraisal →Physics in medicine and biology
Confounding factors in the generalisation of synthetic CT to diagnostic spine MRI
Objective. Generalisation of synthetic CT (sCT) generation to diagnostic MRI data in the spine faces many challenges, particularly when aiming at accurate visualisation of pathologies for orthopaedic treatment management. In this study we assessed the effect of potential confounding factors on the performance of sCT generation from diagnostic MR images.Approach. Paired spinal diagnostic MR and CT scans from two centres (51 patients) were collected retrospectively, spanning multiple spinal pathologies and regions. Each patient's dataset contained 3D T1-/T2-weighted and 2D T1- and T2-weighted scans. 3D U-Nets were trained per centre on the 3D MR data and CT using a mean absolute error (MAE) loss. The performance was assessed on sCTs derived from original 2D and 3D data and from simulated 2D data with varying orientation (axial/coronal/sagittal) and slice spacing (1.1-6.6 mm). The sCTs were compared to the CTs using MAE, peak signal-to-noise ratio, and dice similarity coefficient.Main results. We identified MR resolution, orientation and contrast as confounding factors for sCT generation from diagnostic MR. Additionally, CT noise and CT-to-MR registration were identified to influence the performance evaluation. Performance degraded with larger slice spacings and significant differences between orientations occurred more often at larger slice spacings. The effect of slice spacing and orientation was stronger inside the vertebrae than outside. While the networks performed better overall on contrasts more similar to the training contrasts, they demonstrated promising performance when trained on 3D T2w images and tested on 2D T1w images. Finally, higher CT noise levels resulted in worse sCT performance metrics, reflected in a significant correlation between noise and MAE.Significance. This work demonstrates that generalisation of sCT generation to diagnostic spine MRI data is hampered primarily by MRI acquisition related aspects including MR resolution, orientation and contrast, which provides guidance for future work on generalisable sCT from diagnostic MR.
27 Apr 2026
Read appraisal →Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews
Academic Influence and Industry Funding in Platelet-Rich Plasma Injections: Coauthorship Network Analysis
BACKGROUND: Platelet-rich plasma (PRP) injections have gained popularity in the fields of orthopaedics and sports medicine despite inconsistent evidence regarding clinical efficacy. Concerns have placed a role on industry funding in shaping the development of PRP injection literature. Therefore, the aim of this study is to investigate the relationship between industry funding and academic influence in PRP injection research. METHODS: A systematic review was done of PRP injection literature published between 2017 and 2024, all from Q1 (top quartile) peer-reviewed journals based on Scopus journal ranking metrics. Overall, 81 studies were included in final analysis. Authors were linked to the Open Payments Database (OPD) and were identified through their national provider identifier (NPI) number. A coauthorship network analysis was used to map patterns of collaboration among authors in the field. RESULTS: The majority of studies identified were randomized control trials (38.3%). From 2017 to 2024, total industry funding to PRP authors totaled $36.1 million. Markedly more general payments than research payments were there (P < 0.05). Funding did not markedly correlate with publication count (r = 0.368, P = 0.40). No notable association was found between funding type and study outcome for either general (P = 0.482) or research (P = 0.481) payments. A centralized structure of 621 unique authors revealed that the top 10% of contributors accounted for more than 40% of all betweenness activity among these authors. CONCLUSION: The majority of industry funding in PRP injection research is directed as general payments. A small cohort of authors hold disproportionate influence over the community.
26 Apr 2026
Read appraisal →Archives of orthopaedic and trauma surgery
Analysis of mental health outcomes in major versus minor upper extremity amputations: a retrospective national database study
BACKGROUND: Upper extremity amputations are associated with developing psychiatric conditions. The aim of this study is to identify differences in mental health outcomes for patients undergoing major versus minor upper extremity amputations. METHODS: Data were obtained from the PearlDiver database between 2010 and 2022 using Current Procedural Terminology and International Classification of Diseases codes. Patients aged 10 and above without prior mental health diagnoses or antidepressant prescription records who underwent upper extremity amputations were stratified by major (shoulder disarticulation, arm, forearm, wrist, transmetacarpal) versus minor (single metacarpal, digit, phalanx) amputations. Demographic characteristics and rates of mental health diagnoses, antidepressant prescriptions, and psychotherapy care were assessed for 90 days and one year postoperatively, using Welch's T-tests and Pearson's chi-squared tests. RESULTS: Patients with major amputations had increased risk of mental health diagnoses at 90 days (OR: 3.29, p < 0.001) and at one year (OR: 2.01, p < 0.001). Both groups had higher rates of mental health diagnoses than the general population. Patients undergoing major amputations had higher odds of starting antidepressants at 90 days (OR 3.82, p < 0.001) and at one year (OR 2.38, p < 0.001). Psychotherapy care was significantly increased after major amputations at 90 days (OR 5.47, p < 0.001) and at one year (OR 4.18, p < 0.001). CONCLUSIONS: Mental health disorders, antidepressant use, and psychotherapy care are significantly higher for major upper extremity amputations compared to minor amputations. Surgical teams should provide mental health resources to mitigate negative effects from mental health needs after upper extremity amputation. LEVEL OF EVIDENCE: III.
26 Apr 2026
Read appraisal →PloS one
Controlled comparative study of YOLOv8-Pose, YOLOv11-Pose, and Detectron2 for vertebrae detection and keypoint estimation
Accurate vertebrae detection with precise keypoint localization is essential for medical image analysis and clinical applications, such as spinal alignment assessment. This study presents a controlled, task-driven comparison of four pose-based deep learning models for vertebrae detection and keypoint estimation: YOLOv8n-Pose, YOLOv11n-Pose, and Detectron2 (Keypoint R-CNN) with ResNet-50 and ResNet-101 backbones. A single-class vertebrae dataset with bounding box annotations and four anatomically meaningful keypoints per vertebra was evaluated under consistent training settings. Performance was assessed in terms of keypoint localization accuracy, detection precision, inference speed, and vertebrae-specific prediction behavior, including detection completeness and duplicate detections, which are critical for clinical usability. Results show that YOLOv11n-Pose provides the best balance between keypoint accuracy and inference efficiency, while YOLOv8n-Pose achieves the fastest inference with competitive performance. Detectron2-based models exhibit lower keypoint accuracy, slower inference, and frequent duplicate predictions that obscure correct anatomical landmarks. Additional experiments indicate that larger YOLO variants (particularly YOLOv8l-Pose) improve accuracy, albeit at increased computational cost. Overall, the results demonstrate that model capacity or architectural recency alone does not guarantee superior performance in vertebrae keypoint detection, highlighting the importance of anatomy-aware model selection for spine imaging applications.
23 Apr 2026
Read appraisal →BMJ open
Patients' experiences of the path to sarcoma diagnosis: a qualitative systematic review and thematic synthesis
OBJECTIVE: To explore existing qualitative research on patients' experiences from the onset of symptoms to the diagnosis of sarcoma, with the purpose of identifying patient-perceived barriers at both patient and healthcare system levels and to highlight opportunities for improvement. DESIGN: Systematic review of qualitative studies using thematic synthesis. METHODS: We systematically searched Medline [Ovid], Embase [Ovid], PsycINFO [EBSCOhost] and CINAHL [EBSCOhost] from database inception to 11 April 2025 for qualitative studies reporting sarcoma patients' experiences during their diagnostic trajectory. The final search was conducted on 11 April 2025. All articles were screened against predefined inclusion and exclusion criteria and methodological quality was appraised using the Critical Appraisal Skills Programme qualitative checklist. Six studies conducted in Australia, the Netherlands and the UK were included. Data were analysed using a thematic synthesis approach guided by Thomas and Harden (2008). Confidence in the synthesised findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation - Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERqual) approach. RESULTS: Four overarching themes emerged: patients' experience and interpretation of symptoms, diagnostic pathways, healthcare system factors, and reflections and recommendations. Key contributors to delayed diagnosis were symptom normalisation, misattribution by both patients and healthcare professionals, limited continuity of care and communication challenges. These findings were consistent across multiple countries, indicating relevance and validity in many settings. Patients emphasised the importance of disease awareness, persistence of patients and coordinated care. CONCLUSIONS: Diagnostic delays in sarcoma are influenced by both patient and healthcare systemic factors. Addressing these factors requires increased disease awareness among healthcare professionals and the public, improved coordination within the healthcare system, and targeted research to guide future interventions. This review provides cross-country insights into barriers to early sarcoma diagnosis, informing future priorities in clinical practice and research. PROSPERO REGISTRATION NUMBER: CRD420251030726.
18 Apr 2026
Read appraisal →PloS one
High-versus conventional-volume pericapsular nerve group (PENG) block for total hip arthroplasty: A randomized, controlled trial
BACKGROUND: Currently, the optimal volume of pericapsular nerve group (PENG) block for analgesia after total hip arthroplasty (THA) has not been clarified. In this trial, we investigated whether a high-volume PENG block has a superior analgesic effect than a conventional PENG block for primary THA. METHODS: Forty patients receiving primary THA under spinal anesthesia were enrolled and randomly divided into the high-volume PENG group (40 mL of 0.375% ropivacaine) and the conventional-volume PENG group (20 mL of 0.375% ropivacaine). Dexamethasone (5 mg) was added to the local anesthetic in both groups. A blinded researcher performed pain scores and lower limb sensory and motor block assessments at 3, 6, and 24 h after surgery. The time of first walking, time of first opioid consumption, total opioid consumption within 48 h, nerve block, opioid-related complications, and length of hospital stay were recorded. The primary outcome was the dynamic pain scores at 6 h post-surgery. RESULTS: Thirty-seven patients were included in the final analysis, among whom 18 were in the high-volume group and 19 in the conventional-volume group. There were no significant differences between the two groups in dynamic pain scores at 6h after surgery [median and interquartile range (p25, p75) 5(4,6) vs 4 (4,5)] and other secondary outcomes. CONCLUSIONS: The high-volume PENG block is not superior to conventional-volume PENG block in improving post-operative analgesia in patients undergoing primary THA and does not increase the risk of quadriceps weakness. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR, https://www.chictr.org.cn). Clinical trial registration number: ChiCTR2300077281.
18 Apr 2026
Read appraisal →Acta orthopaedica
Migration patterns of uncemented femoral stems in hip replacement: a systematic review and meta-analysis of clinical radiostereometric analysis cohort studies
BACKGROUND AND PURPOSE: We conducted a systematic review and meta-analysis of radiostereometric analysis studies of primary uncemented femoral stems to investigate their subsidence and retroversion patterns and the migration patterns according to implant, patient, and study characteristics. METHODS: A systematic search of PubMed, Web of Science, Cochrane, and Embase databases to identify all radiostereometric analysis studies on femoral stem migration following primary uncemented total hip replacement was performed. Clinical studies with 2 or more postoperative radiostereometric measurements within 2 years were included. Subsidence and retroversion at 6 weeks, 3 and 6 months, 1, 2, 5, and 10 years were included for analysis. Extracted implant characteristics included implant design, coating, and surgical approach. Data was analyzed using a random effects model. RESULTS: 73 studies on 120 cohorts and 2,970 uncemented stems were included. 119 cohorts reported on subsidence and 91 on retroversion. The pooled subsidence at 3 months was 0.29 mm (95% confidence interval [CI] 0.19-0.39) and 0.32 mm (CI 0.21-0.43) at 2 years. The pooled retroversion at 3 months was 0.51° (CI 0.33-0.70) and 0.70° (CI 0.48-0.93) at 2 years. Hydroxyapatite-coated stems showed the least migration (subsidence 0.26 mm; CI 0.13-0.40; retroversion 0.51°; CI 0.22-0.80) among different coating types. The anterior approach showed more migration (subsidence 1.04 mm, CI 0.53-1.55; retroversion 1.52°, CI 1.08-1.95) than other surgical approaches. CONCLUSION: Our study shows that most subsidence and retroversion of uncemented femoral stems occurs during the first 3 months. Stabilization of subsidence occurred after 3 months, and retroversion stabilized after 2 years. Migration patterns differ based on stem type, coating, surgical approach, the time period when inclusion started, and timing of baseline measurement.
18 Apr 2026
Read appraisal →Acta orthopaedica
Intraoperative single-dose methadone significantly affects postoperative morphine consumption in older patients with a hip fracture: the MetaHip randomized controlled trial
BACKGROUND AND PURPOSE: Effective pain management in older patients with a hip fracture is critical for postoperative recovery. Our primary objective was to compare intraoperative methadone with placebo on postoperative morphine consumption over 72 hours. METHODS: Patients aged ≥ 60 years with hip fractures were randomized to receive methadone (0.10 mg/kg) or placebo intraoperatively. The primary outcome was postoperative morphine consumption measured in 24-hour intervals over 72 hours. Secondary outcomes included pain scores, time to mobilization, and discharge. Harms were assessed as adverse and serious adverse events. RESULTS: 129 patients were included. The primary endpoint analysis demonstrated that postoperative morphine consumption over 72 hours differed significantly between groups (likelihood-ratio test, P = 0.02). Model-based estimates suggested lower morphine consumption in the methadone group at 0-24 hours (least square mean [LSM] 7.1 [SE 1.2] vs placebo 10.1 [SE 1.7] mg) and at 24-48 hours (4.1 [SE 0.8] vs placebo 5.3 [SE 0.9] mg). At 48-72 hours, the model suggested lower morphine consumption in the placebo group (3.2 [SE 0.6] vs methadone 4.6 [SE 0.9] mg). Secondary outcomes were similar between groups, except that time to hospital discharge was longer in the methadone group (LSM 5.6 vs 4.5 days; mean difference -1.3 days, 95% confidence interval -2.3 to -o.4; P < 0.01). Harms appeared comparable, although the low event rate precluded formal analysis. CONCLUSION: A single intraoperative dose of methadone significantly alters postoperative morphine consumption over 72 hours after hip fracture surgery, without major safety concerns.
17 Apr 2026
Read appraisal →Spine
Predictors for Unsuccessful Outcome of Lumbar Spinal Stenosis Surgery: A Secondary Analysis of the 2 Randomized NORDSTEN Trials
STUDY DESIGN: Observational cohort study. OBJECTIVE: To evaluate potential predictors of unsuccessful outcomes after surgery in patients with lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is a common cause of disability in adults and the leading indication for spine surgery in Norway. Despite advances in surgical techniques, nearly one-third of patients report either minor or no improvement or worsening of symptoms after surgery. Identifying predictors of unsuccessful outcomes is essential for improving patient selection and shared decision-making. MATERIALS AND METHODS: This secondary analysis used data from the 2 NORwegian Degenerative spondylolisthesis and spinal STENosis (NORDSTEN) randomized trials, which included 704 surgically treated patients with LSS, with (n=267) or without (n=437) degenerative spondylolisthesis. The Oswestry Disability Index (ODI) was the primary outcome measure. A reduction in ODI score of <30% from baseline to 2 years postoperatively was defined as an unsuccessful outcome. Multivariable logistic regression analysis was used to evaluate whether carefully selected baseline variables were associated with an unsuccessful outcome at 2-year follow-up. RESULTS: Longer duration of radiating pain (>12 mo; OR: 2.58, 95% CI: 1.54-4.29), psychological distress (HSCL-25 ≥1.75; OR: 1.60, 95% CI: 1.01-2.53), and advanced disc degeneration (Pfirrmann grades 4-5; OR: 1.98, 95% CI: 1.26-3.12) were independently associated with an unsuccessful outcome. Commonly discussed factors such as age, BMI, smoking, ASA grade, and predominant back pain did not reach statistical significance for association with the outcome. CONCLUSION: Among patients undergoing surgery for LSS, longer symptom duration, psychological distress, and advanced disc degeneration were associated with a higher risk of unsuccessful postoperative outcomes.
16 Apr 2026
Read appraisal →European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
Memantine as a pain management strategy post-total knee arthroplasty: a randomized controlled trial
INTRODUCTION: Total knee arthroplasty (TKA) provides significant pain relief and improved function for patients with knee osteoarthritis. Despite its effectiveness, postoperative pain remains a major challenge. Effective management of this acute postoperative pain is critical for enhancing recovery. The study investigates the effectiveness of memantine in reducing postoperative pain in patients undergoing TKA. METHODS: This double-blind, randomized controlled trial aimed to evaluate the efficacy of memantine for managing postoperative pain after TKA. Conducted from April to September 2022, eligible participants over 18 years with ASA grades I or II were recruited. Exclusions included patients with substance abuse histories, chronic opioid use, significant comorbidities, or contraindications to memantine. Participants were randomly assigned to receive either memantine (20 mg daily preoperatively for three days and 10 mg daily postoperatively for two weeks) or a placebo. Both groups received standard analgesics during hospitalization and upon discharge. Pain levels were assessed using Visual Analog Scale (VAS) scores and Short-Form McGill Pain Questionnaire (SF-MPQ) at various time points. Secondary outcomes measured included opioid usage and nocturnal awakening. RESULTS: Memantine did not significantly lower pain levels compared to placebo, as measured by VAS (mean difference: 0.138, CI 95%: - 0.468-1.103, P = 0.418) and SF-MPQ (mean difference: 1.962, CI 95%: - 1.013-4.936, P = 0.190). Patients receiving memantine needed opioid analgesia (2.85 ± 0.67 times) significantly (P < 0.001) less frequently than the Placebo patients (4.14 ± 1.06 times). Nocturnal awakening did not differ significantly between the two groups (Memantine: 3.59 ± 2.15, Placebo: 2.33 ± 2.12, P = 0.067). CONCLUSION: The comparison of pain levels between oral memantine and placebo indicates that memantine does not significantly reduce pain in patients undergoing TKA. However, it significantly lowers the need for opioids postoperatively.
10 Apr 2026
Read appraisal →European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
Predicting minimal clinically important difference after hip arthroscopy: logistic regression versus machine learning
PURPOSE: Hip arthroscopy outcomes for femoroacetabular impingement (FAI) remain heterogeneous, with 30-40% of patients failing to achieve meaningful improvement. We aimed to develop and validate a predictive model for achievement of minimal clinically important difference (MCID) using routine preoperative variables, and to compare logistic regression with machine learning algorithms. METHODS: We retrospectively analyzed 310 consecutive patients undergoing hip arthroscopy for FAI (2010-2024) at a single institution. Predictor variables included age, sex, body mass index (BMI), morphological etiology, preoperative pain (VAS), and Hip Outcome Score-Activities of Daily Living (HOS-ADL). The outcome was achievement of MCID (≥ 9-point improvement in HOS-ADL). We developed logistic regression, random forest, and gradient boosting models. Internal validation used 10-fold stratified cross-validation. Temporal external validation used 80% of patients for training and 20% for testing. RESULTS: Mean age was 39.7 ± 12.0 years; 59.7% were male. MCID was achieved by 213 patients (68.7%). Lower preoperative HOS-ADL (OR 0.911, 95% CI 0.883-0.940, p < 0.001) and lower BMI (OR 0.846, 95% CI 0.771-0.928, p < 0.001) independently predicted MCID achievement. Logistic regression achieved AUC 0.804 (95% CI 0.76-0.85) on internal validation and AUC 0.819 on temporal external validation (accuracy 81.4%). Logistic regression outperformed random forest (AUC 0.787) and gradient boosting (AUC 0.777). Calibration was excellent. CONCLUSION: A parsimonious logistic regression model using routine preoperative variables demonstrated excellent and externally validated discriminative ability for predicting MCID after hip arthroscopy. The model outperformed machine learning algorithms while maintaining superior interpretability. The developed nomogram provides a practical tool for individualized outcome prediction.
9 Apr 2026
Read appraisal →JBJS reviews
Treatment Outcomes for Distal Radius Fractures: A Meta-Analysis
BACKGROUND: Distal radius fractures (DRFs) are among the most prevalent in upper-extremity injuries, particularly in older adults and individuals with osteoporosis. The common treatment options include surgical interventions such as volar locking plate (VLP) fixation and percutaneous pinning, as well as conservative strategies like splinting and bracing. However, the comparative effectiveness of these modalities remains unclear. This study aims to compare the functional outcomes and complication rates associated with VLP, percutaneous pinning, bracing, and splinting in the treatment of DRFs. METHODS: A systematic search of PubMed, Google Scholar, and the Cochrane Library (September 2001-February 2025) identified randomized controlled trials, prospective cohort studies, and retrospective cohort studies comparing DRF treatments. Functional outcomes and complication rates (superficial infection, malunion, nonunion, delayed union) were analyzed. Data were analyzed using Review Manager Web with significance set at p ≤ 0.05. RESULTS: Twenty-seven studies involving 3,200 patients met inclusion criteria: VLP fixation (n = 896), percutaneous pinning (n = 666), splinting (n = 718), and bracing (n = 903). No significant differences were observed between VLP and splinting or between bracing and splinting for Disabilities of the Arm, Shoulder, and Hand (DASH); Patient-Rated Wrist Evaluation (PRWE); or grip strength. Compared with VLP, percutaneous pinning demonstrated better PRWE scores but a higher infection rate. Compared with bracing, percutaneous pinning showed significantly better DASH, PRWE, and grip strength outcomes, although with substantial heterogeneity. Compared with bracing, VLP fixation yielded significantly better DASH, PRWE, and grip strength outcomes and a lower malunion rate. CONCLUSION: All 4 treatments achieved acceptable outcomes, but with key trade-offs: Percutaneous Pinning had the best functional results but a higher infection risk. VLP provided better function and lower malunion rates than bracing. Splinting and bracing were effective conservative options, often yielding results similar to VLP, but were inferior in some specific measures. The findings suggest that a perfect anatomic repair is not always necessary for a good recovery. Ultimately, the choice of treatment must be individualized, weighing the functional benefits against the risks of complications, while considering patient health factors and preferences. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
8 Apr 2026
Read appraisal →Medical science monitor : international medical journal of experimental and clinical research
Ultrasound-Guided Modified Clavipectoral Fascial Plane Block With Superficial Cervical Plexus Block for Midshaft Clavicular Surgery: A Prospective Randomized Controlled Trial
BACKGROUND This study evaluated the efficacy and safety of modified clavipectoral fascial plane block (mCPB) plus superficial cervical plexus block (SCPB) compared with interscalene brachial plexus block (ISBP) in midshaft clavicular fracture surgery. MATERIAL AND METHODS Fifty-six patients scheduled for midshaft clavicular surgery under regional anesthesia were randomly allocated to a control (ultrasound-guided ISBP plus SCPB) or experimental (mCPB plus SCPB) group at a 1: 1 ratio. The primary outcome was the Numerical Rating Scale (NRS) score at 12 hours postoperatively. Secondary outcomes were NRS scores at 4, 8, and 24 hours; rescue analgesic administration frequency; block success rate; procedural and onset times; and hemidiaphragmatic paralysis incidence. RESULTS Block success was 100% in both groups, without differences in performance time or onset time. A significant group × time interaction was observed (P<0.001). Compared with the control group, the experimental group had significantly lower NRS scores at 12 hours (estimated mean difference -1.29; P<0.001) and 24 hours (estimated mean difference -2.36; P<0.001). No significant differences occurred at 4 or 8 hours. Rescue analgesic requirements within 24 hours were significantly reduced in the experimental group (P=0.002). Hemidiaphragmatic paralysis incidences were 71.4% in the control group and 0% in the experimental group (P<0.001). CONCLUSIONS In midshaft clavicular fracture surgery, mCPB plus SCPB provided effective anesthesia with procedural characteristics comparable to ISBP, while avoiding hemidiaphragmatic paralysis and demonstrating superior analgesia at 12 and 24 hours. These findings require validation in larger multicenter trials.
8 Apr 2026
Read appraisal →The bone & joint journal
Robotic-assisted surgery and functional alignment in total knee arthroplasty: the RASKAL registry-nested 2 × 2 factorial randomized trial
AIMS: Robotic-assisted surgery and functional alignment are increasingly being adopted in total knee arthroplasty (TKA). This study assessed the individual and combined effectiveness of robotic-assisted surgery and functional alignment in improving outcomes in TKA, compared with computer-assisted surgery and mechanical alignment, respectively. METHODS: A registry-nested, multicentre, blinded, 2 × 2 factorial, randomized trial was performed with 303 TKA patients randomized to robotic-assisted or computer-assisted surgery, and functional or mechanical alignment. The primary outcome was the between-group differences in postoperative change over two years in the mean Knee Injury and Osteoarthritis Outcome Score (KOOS-12). Secondary outcomes included knee-specific and general patient-reported outcome measures (PROMs), operative and functional outcomes, and adverse events. Primary modified intention-to-treat and secondary per-protocol analyses were performed. RESULTS: There were no differences comparing robotic-assisted with computer-assisted surgery in KOOS-12 at three months, six months, one year, and two years (mean two-year difference -2.8; 95% CI -6.4 to 0.9; p = 0.137), and no differences comparing functional with mechanical alignment at three months, six months, one year, and two years (mean two-year difference 0.3 (95% CI -3.4 to 4.0); p = 0.867). No differences were found in Oxford Knee Score, Forgotten Joint Score, EuroQol five-dimension five-level visual analogue scale, patient satisfaction, joint-related improvement, and pain comparing technology or alignment groups at three months, six months, one year, and two years. Robotic-assisted surgery had a shorter mean operating time by 11.5 minutes (95% CI 7.3 to 15.9; p < 0.001) and better mean posterior cruciate ligament macroscopic soft-tissue injury score (mean difference 0.7 (95% CI 0.3 to 1.1); p = 0.001) compared with computer-assisted surgery. Mechanical alignment had a higher soft-tissue release rate compared with functional alignment (44.8% vs 8.1%; OR 9.2 (95% CI 4.6 to 18.3); p < 0.001). In most cases, surgeons preferred the use of robotics and functional alignment. CONCLUSION: Robotic-assisted surgery and functional alignment were not superior to computer-assisted surgery and mechanical alignment, respectively, in improving clinical and functional outcomes up to two years post-TKA.
8 Apr 2026
Read appraisal →Medicine
Comparison of costoclavicular with infraclavicular block for upper limb surgeries: A meta-analysis
BACKGROUND: The influence of costoclavicular versus infraclavicular nerve block on the analgesia for upper limb surgeries remains elusive. This meta-analysis and systematic review aim to study the analgesic efficacy of costoclavicular versus infraclavicular nerve block for upper limb surgeries. METHODS: We have searched several databases, including PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases from inception to January 2024, and randomized controlled trials (RCTs) assessing the effect of costoclavicular versus infraclavicular nerve block for upper limb surgeries were included. The inclusion criteria were presented as follows: study design was RCT, patients underwent upper limb surgeries, and intervention treatments were costoclavicular nerve block versus infraclavicular nerve block. Studies without English abstracts were excluded. The methodological quality of the included studies was evaluated by the modified Jadad scale. Standard mean difference with 95% confidence interval (CI) was used to assess continuous outcomes, while odds ratio (OR) with 95% CI was applied to evaluate dichotomous outcomes. RESULTS: Six RCTs and 434 patients were included in this meta-analysis. Compared with infraclavicular nerve block for upper limb surgeries, costoclavicular nerve block was able to significantly decrease block onset time (SMD = -0.29; 95% CI = -0.53 to -0.05; P = .02), but demonstrated no influence on performance time (SMD = -0.26; 95% CI = -0.85 to 0.34; P = .40), number of passes (SMD = -0.08; 95% CI = -0.40 to 0.24; P = .61), vascular puncture (OR = 0.25; 95% CI = 0.04 to 1.56; P = .14) or Horner syndrome (OR = 1.02; 95% CI = 0.04 to 27.64; P = .99). CONCLUSION: Costoclavicular nerve block may need shorter block onset time for upper limb surgeries compared to infraclavicular nerve block, but more RCTs were needed to confirm these findings.
5 Apr 2026
Read appraisal →Nanoscale
A machine learning-assisted Ag-TiO2 SERS platform for intraoperative osteomyelitis diagnosis
Osteomyelitis is a progressive bone infection with high disability and recurrence rates. However, current diagnostic approaches, including bacterial culture, imaging, and serological assays, suffer from poor sensitivity, low specificity, and delayed turnaround, making intraoperative evaluation particularly challenging. Here, we present an Ag-TiO2-based surface-enhanced Raman scattering (SERS) platform for rapid, label-free detection of osteomyelitis using minimal volumes of wound saline irrigation fluid (WSIF). Benefiting from the synergistic interplay between electromagnetic field amplification and enhanced interfacial charge-transfer interactions, the Ag-TiO2 substrate provides ultrasensitive detection with high spectral reproducibility, enabling reliable identification of subtle biochemical changes in complex clinical samples. Quantitative analysis indicates that strengthened charge-transfer processes significantly enhance molecular Raman responses, while plasmonic electromagnetic effects remain essential for overall signal amplification. Distinct Raman fingerprints of infected, non-infected, and recovered patients were successfully classified using artificial intelligence (AI) models, revealing metabolic alterations in amino acids, purines, proteins, and lipids associated with bacterial infections and immune response. This integration of SERS with AI not only elucidates the mechanistic basis of spectral enhancement but also demonstrates clinical feasibility for intraoperative osteomyelitis diagnosis, offering a promising strategy to improve surgical precision and reduce recurrence risk.
5 Apr 2026
Read appraisal →BMJ open
Development and acceptability of a patient decision aid for people with degenerative cervical myelopathy: an international mixed-methods study
OBJECTIVES: To develop and user-test a patient decision aid for people diagnosed with degenerative cervical myelopathy and who are considering surgery. DESIGN: Mixed-methods study describing the development of a patient decision aid. SETTING: A draft decision aid was developed by a multidisciplinary steering group (including study authors with degenerative cervical myelopathy, health professionals and researchers) informed by the best available evidence, authorship consensus and existing patient decision aids. PARTICIPANTS: Patient-participants and health professional-participants who manage people with degenerative cervical myelopathy were recruited through social media and the steering group's research and practice network. Quantitative questionnaires were used to gather baseline data, descriptive feedback, refine the decision aid and assess its acceptability. Qualitative semi-structured interviews were conducted online to gather feedback on the decision aid and were analysed using reflexive thematic analysis. RESULTS: We conducted 32 interviews: 19 patient-participants and 13 health professional-participants who manage people with degenerative cervical myelopathy (neurosurgeons, neurologists, physiotherapists, orthopaedic surgeons, general practitioners, rehabilitation and pain specialists and consultant occupational physicians and chiropractors). Participants were from 10 countries (Australia, Canada, Cyprus, Germany, Ireland, New Zealand, Sweden, Switzerland, United Kingdom and USA). Most participants rated the decision aid's acceptability as good-to-excellent and agreed with most aspects of the decision aid (eg, defining degenerative cervical myelopathy, management recommendations, potential benefits and harms, questions to consider asking a health professional). CONCLUSION: Our patient decision aid was rated as an acceptable tool by both health professional-participants who treat degenerative cervical myelopathy and patient-participants with lived experience of degenerative cervical myelopathy. This decision aid can be used by clinicians and people with degenerative cervical myelopathy to help with shared decision making following a diagnosis of degenerative cervical myelopathy. A study testing the potential benefits of this decision aid in a clinical setting is recommended.
5 Apr 2026
Read appraisal →European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
Radiological and surgical outcomes after graduation to posterior spinal fusion surgery following magnetically controlled growing rod treatment for early-onset scoliosis: a systematic review and single-arm meta-analysis
PURPOSE: Early-onset scoliosis (EOS) is a challenging condition for spinal surgeons. Growing rods represent the standard treatment for patients requiring surgery, and magnetically controlled growing rods (MCGR) are increasingly adopted. Many patients ultimately transition to posterior spinal fusion (PSF), although the necessity of definitive fusion remains debated. This systematic review and single-arm meta-analysis aimed to evaluate radiographic and surgical outcomes of PSF following MCGR treatment. METHODS: A systematic literature search was conducted in PubMed, Google Scholar, Medline, Scopus, Embase, and the Cochrane Library up to April 2025, following PRISMA guidelines. Eligible studies were identified using a PIO (Population, Intervention, Outcome) framework. Extracted data included demographic, radiographic, and surgical outcomes, including complications. A single-arm meta-analysis compared pre- and post-PSF radiographic parameters (main curve magnitude, thoracic kyphosis (TK), T1-T12 and T1-S1 lengths). Risk of bias was assessed using the MINORS tool. RESULTS: Eight retrospective studies were included (370 patients), of which six were eligible for quantitative synthesis. The meta-analysis demonstrated significant improvements in all radiographic parameters (main curve magnitude, TK, T1-T12 and T1-S1 lengths, p < 0.05). The pooled overall postoperative complication rate after PSF was 17.2%. CONCLUSIONS: PSF appears to be a viable treatment option following MCGR, providing significant deformity correction with a relatively acceptable complication rate. Nevertheless, the current evidence is limited by small, retrospective cohorts. Larger, prospective studies with standardized reporting of surgical variables and clinical outcomes are needed to better define the role of final fusion and to optimize treatment protocols.
4 Apr 2026
Read appraisal →Ann Anat
Epiphyseal interfaces.
This work explores interconnected articular and growth plate osteochondral interfaces, via complementary anatomical, biomechanical and structural analyses that combine benchtop micro-computed tomography (microCT) and high-resolution synchrotron CT (sCT) imaging approaches. We show that bony sclerosis, well-documented in late-stage OA in humans, and the osteoarthritic STR/Ort mouse model, is preceded by the amplified regionalised expansion of articular calcified cartilage (ACC) where vulnerability load-induced failure is greatest. We further observed marked alterations in the number and size of resident osteocyte lacunae in pre-OA and OA regions in comparison to controls, which age healthily, underscoring the value of CT-based approaches for elucidating early OA-related changes. Notably, our findings imply that excessive ACC formation is an early consequence of disrupted endochondral ossification that precedes and potentially drives OA sclerosis, osteophytosis and indeed, articular cartilage lesions. By applying digital volume correlation (DVC) to sCT images of loaded murine knee joints under physiological conditions, we demonstrate that the joints from a healthy parental control strain of CBA mice efficiently dissipate compressive strain, whereas OA-prone STR/Ort exhibit high strain foci in the epiphyseal compartment prior to cartilage degeneration; suggesting that early strain accumulation may therefore promote early joint vulnerability and subsequently prime degenerative progression with age. Finally, we examined how the cartilaginous growth plate (GP), responsible for all longitudinal bone growth, contributes to mechanical epiphyseal stability for articulation. Analysis of mineralised trans-physeal GP structures (bridges), revealed their dynamic and sexually dimorphic character as well as their regulation by mechanical loading and osteotropic agents. DVC analyses of sCT-imaged murine knee joints subjected to identical physiologically oriented load, identified that regionally heterogeneous load-induced strain patterns in the GP are spatially synchronised to bridge location; a relationship substantiated by finite element simulation. Together, these findings establish intra-physeal GP bridges as regulatable and mechanically sensitive structures that coordinate the transfer of local GP strains, while enhancing epiphyseal stability by distributing compressive and shear strains to thereby permit cessation of longitudinal growth.
1 Apr 2026
Read appraisal →Am Surg
Neurogenic Thoracic Outlet Syndrome: A Current Literature Review
Neurogenic Thoracic Outlet Syndrome (nTOS), the most prevalent type of thoracic outlet syndrome, results from compression of the compression of the brachial plexus as it traverses the scalene triangle and rectopectoralis minor space. It typically presents with upper extremity pain, hand weakness, paresthesia, and muscle atrophy that is often exacerbated by arm elevation or overhead activity. Etiology commonly includes congenital anatomical variants, trauma, and repetitive overhead activity. Diagnosis remains challenging as a result of significant symptom overlap with cervical radiculopathy, brachial plexopathies, and entrapment neuropathies. Work up involves a combination of thorough history and physical with electrophysiologic testing, diagnostic injections and imaging such as MRI or duplex ultrasonography. Initial therapy indicates physical therapy with a focus on decompression and postural correction. In patients with persistent symptoms, motor deficits or failed conservative management, surgical decompression using transaxillary, supraclavicular or minimally invasive techniques is indicated. Rib-sparing surgical decompression is increasingly favored given lower complication rates. Postoperative rehabilitation focuses on restoring range of motion and shoulder girdle strength. This review serves to outline clinical presentation, diagnostic strategies and operative options for nTOS while emphasizing an individualized, stepwise approach to optimize outcomes and minimize risk.
1 Dec 2025
Read appraisal →Int J Surg
Multi-omic profiling reveals age-specific blood biomarkers and aging-driven B cell remodeling in osteoarthritis
BACKGROUND: Osteoarthritis (OA) pathogenesis involves age-related immune dysregulation, yet non-invasive diagnostic tools and mechanistic insights remain limited. METHODS: We integrated transcriptomic profiling of four OA-affected joint tissues with machine learning to identify potential peripheral blood biomarkers. Weighted gene co-expression network analysis was employed to explore gene modules and pathways associated with OA. Single-cell RNA sequencing was performed on 217 983 joint cells to delineate B cell differentiation trajectories. Flow cytometry was used to validate age-associated B cell imbalances in peripheral blood. RESULTS: We identified five peripheral blood biomarkers: MAPK1, MAP3K8, ING1, LDLR, and NUP153 in distinguishing OA patients from controls (the area under the curve [AUC] = 0.966). Importantly, these markers exhibited age-specific expression profiles; ING1, NUP153, and MAP3K8 were elevated, while MAPK1 was reduced in elderly compared to younger OA patients. A refined predictive model based on these age-specific markers demonstrated superior performance specifically for elderly Knee OA (KOA, AUC: 0.8 vs. 0.7 for younger KOA). These biomarkers correlated with immune cell infiltration and inflammatory cytokines. In osteoarthritic joint tissues, B cells predominantly originated from subchondral bone and synovium. Single-cell analysis identified age-specific B cell differentiation patterns, with elderly KOA patients enriched in an activated B cell cluster (C1). Furthermore, B cells from elderly KOA patients showed altered energy metabolism and increased proportions in peripheral blood, and functionally promoted chondrocyte damage. CONCLUSION: Our findings establish a novel blood-based diagnostic framework for OA and uncover aging-driven B cell remodeling as a key contributor to elderly OA pathogenesis. These findings offer non-invasive diagnostics and immunomodulatory targets for age-specific OA therapy.
1 Nov 2025
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