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Background: Diffuse tenosynovial giant cell tumor (DTGCT) is a locally aggressive benign tumor of the synovium. Patients often initially present with pain, stiffness, and swelling of the affected joint with varying levels of severity. Treatment traditionally involved surgical resection exclusively; however, this could be complicated by high disease recurrence rates. New research has introduced several targeted systemic therapies onto the market changing the treatment paradigm and necessitating a multidisciplinary treatment approach in specialized centers to optimize patient outcomes.

Methods: This review synthesizes the current literature on DTGCT including its pathophysiology, classification, diagnosis, and available treatment options. There is a particular focus on the newer systemic therapies available and how these medications may be used in conjunction with surgery to enhance disease control.

Results: DTGCT most commonly affects young to middle-aged adults, with a slight female predominance, and is most frequently found in the knee. Arthroscopic and even open synovectomy can have disease recurrence rates exceeding 50%. Colony stimulating factor 1 (CSF1) receptor inhibitors have proven effective at symptom palliation and reducing tumor burden in approximately 40% of patients. While these medications improve the quality of life for patients with unresectable disease, they may also be effective in the neoadjuvant setting to downstage surgical approaches and possibly improve disease control in otherwise highly morbid cases.

Conclusions: Surgery alone, the traditional standard for DTGCT, is often insufficient due to high recurrence rates. Systemic therapies can restore function and improve quality of life in patients with advanced disease with rare-but potentially serious-adverse effects. Combining surgical resection with neoadjuvant CSF1R inhibition may provide superior outcomes. Further research is needed to refine the role of systemic agents and develop multidisciplinary protocols. Although initial symptoms often lead patients to community providers, optimal care for patients with DTGCT is best delivered at referral centers with dedicated musculoskeletal oncology programs.

Level of evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.

Background: The prevalence and characterization of specific types of musculoskeletal (MSK) conditions associated with menopausal transition remains unclear and is often underreported. Our objectives were twofold: (1) to systematically review, and conduct meta-analysis whenever appropriate, to compare the prevalence of MSK symptoms across the different stages of menopause and (2) to characterize the specific MSK conditions associated with transition to menopause.

Methods: We searched Medline, EMBASE, CENTRAL, and PubMed from inception to May 2024. Articles were eligible for inclusion if they included perimenopausal women and reported any primary data on MSK symptoms or pathology. The outcomes we aimed to find included muscle and joint pain, back pain, and the prevalence of various MSK conditions. A pairwise meta-analysis was performed using a DerSimonian-Laird random-effects model for all comparative data, and subgroup analyses were used to explore heterogeneity.

Results: After screening 5,556 relevant records, 37 observational studies across 22 countries enrolling 93,021 women were included in the quantitative analysis. Four in 10 women experienced muscle or joint pain during the premenopausal phase (40% [95% confidence interval {CI}: 32%-49%]). Whereas over half of perimenopausal women (57% [95% CI: 48%-65%]) and postmenopausal women (59% [95% CI: 50%-67%]) experienced muscle or joint pain, representing a 1.35-fold increased risk (risk ratio [RR] 1.35, 95% CI: 1.25-1.46, p < 0.001, I² = 88.6%; absolute risk difference 130 more per 1,000 [95% CI: 93-171]) and a 1.40-fold increased risk (RR 1.40, 95% CI: 1.28-1.53, p < 0.001, I² = 95.0%; absolute risk difference 148 more per 1,000 [95% CI: 104-197]) on pairwise comparison with premenopausal women, respectively. Geographic study location nor measurement scale explained the considerable heterogeneity in the pooled analyses. There was underreporting of specific MSK conditions beyond the generic descriptors of muscle and/or joint pain.

Conclusion: Women transitioning to menopause appear to be at increased risk of developing muscle or joint pain. However, as these findings are based on observational studies, specific causes of MSK pain are underreported, and there is significant heterogeneity. Further high-quality research is needed to confirm and clarify this association.

Level of evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS) is an alternative to posterior fusion. There are limited prospective, multicenter data available on VBT following US Food and Drug Administration approval. We hypothesize that curve correction on first postoperative standing (first erect, FE) imaging is associated with higher rates of successful correction at final follow-up.

Methods: All qualifying patients with AIS who underwent thoracic and lumbar VBT between 2019 and 2022 were prospectively enrolled from 9 institutions. Radiographic and clinical data were compared preoperatively, at FE, and at final follow-up with minimum of 2 years. Success was defined as major curve magnitude of ≤35° at final follow-up and no fusion surgery.

Results: One hundred twenty-seven patients were enrolled (79.5% female), with mean follow-up 2.4 years. Mean age at surgery was 12.9 ± 1.4 years, most had bone age of Sanders 4 or lower (93/112, 83.0%). In average, 7.6 ± 1.7 levels were tethered. Mean preoperative major curve magnitude was 50 ± 8°, with mean initial correction at FE of 29 ± 8° (% correction, 39 ± 18%). At final follow-up, mean curve magnitude was maintained at 26 ± 11° (% correction, 45 ± 23%) despite 29% of tether breakage. Patients who had mean FE curve magnitude of ≤35° were 88% successful compared with only 60% in those with >35° on FE (p = 0.0021). Patients showed stable sagittal alignment across all timepoints. Scoliosis Research Society-22 scores improved significantly by 2 years (p < 0.0001).

Conclusion: This was the first prospective, multicenter study to assess outcomes of VBT for patients with AIS. VBT shows promise, but optimal results may depend on careful patient selection and surgical technique. FE major curve magnitude of ≤35° was associated with 88% success rate compared with only 60% success for those with poor correction.

Level of evidence: Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Blount disease is growth disorder of the proximal tibia, resulting in genu varum, internal rotation, and procurvatum. Three different forms of the condition are described: infantile, or early onset, juvenile onset, and adolescent or late onset. Although several hypotheses exist, the etiology of Blount disease remains unknown. The best-founded hypothesis is the "increased mechanical force hypothesis". In particular, the relation between obesity and Blount disease. Although, most studies supporting this hypothesis are conducted in high income countries. However, unlike in the Western population that was studied to establish this hypothesis, Blount disease is relatively common in African countries and obesity is not.

Methods: This study is a retrospective, case control study in a rural hospital in Ghana (2012-2021). Demographic information, body weight, and age at presentation were collected. The World Health Organization (WHO) weight-for-age growth standard was used. Overweight was defined as a percentile between 85th and 97th. Obese as a percentile between 97th and 99th. Above the 99th percentile was defined as severely obese.

Results: In total 96 patients with infantile Blount disease were included, all of black Ghanaian descent. The mean age of onset of Blount disease in our patients was 1.7 (±0.9) years, and the mean age at presentation was 6.3 (±3.4) years. This was not different between boys (n = 27) and girls (n = 69). The mean weight for age percentile in our population was 56.8th (±35.3th), and 68% was of normal weight, 15% overweight, 8% obese, and 9% severely obese. Our study population had a significant (p < 0.05) higher mean weight percentile compared with the local control group (n = 79, 37.0th ± 26.0th).

Conclusion: Although our study population of patients with infantile Blount was significantly heavier compared with the control group, the mean weight (56.8th ± 35.3th) was well within normal values. Obesity might have a role in the development of infantile Blount disease, but it is shown to be not as an important factor in the Ghanaian population (18% obese) compared with the more extensively studied US population with much higher obesity rates.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Suicide is the second leading cause of death among American children aged 10 to 18 years, and those with medical conditions have a 20% increase in suicidal ideation (SI) relative to healthy peers. Despite this, suicidality in children with musculoskeletal problems is largely unstudied. This study aims to determine the prevalence of SI in pediatric orthopaedic patients and identify risk factors for suicidality.

Methods: A retrospective review of patients aged older than 10 years presenting for outpatient orthopaedic evaluation to a tertiary pediatric institution over a 1-year period was conducted. Demographic information, chief complaint, pain symptomatology, treatment history, primary orthopaedic diagnosis, and responses on the Ask Suicide-Screening Questionnaire were reviewed.

Results: Of 19,631 individual patient encounters, 470 children (2.4%) endorsed SI with 23 (4.9%) experiencing active SI. Patients endorsing suicidality were predominantly assigned female sex at birth (66.2%), Black (2.9%), with a mean age of 14.1 years. They were also more likely to present with a chief complaint of pain (2.7% vs. 2.2%, p = 0.0188) and were ultimately more likely to receive a nonstructural, nonmechanical pain diagnosis (4.4% vs. 2.1%, p < 0.0001). Those presenting for pain who screened positive for SI were more likely to characterize their pain as persistent/chronic than acute (59.3% vs. 40.7% p < 0.0001). Multivariate analyses revealed that patients taking psychotropic medications (odds ratio [OR] = 3.4, 95% confidence interval [CI]: 2.6-4.3) and carrying a preexisting psychological diagnosis (OR = 2.5, 95% CI: 2.0-3.1) were more likely to report SI. Patients with underlying mental health disorders presenting with a chief complaint of pain without an identifiable structural/mechanical etiology were 2.5 times more likely to screen positive for SI (OR = 2.5, 95% CI: 2.0-3.1).

Conclusion: SI was identified in 2.4% of adolescent pediatric orthopaedic patients presenting for outpatient care. Black female patients with chronic pain and preexisting mental health diagnoses appear be at higher risk.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Dual-mobility cups (DMCs) are increasingly used in total hip arthroplasty (THA) because of their low dislocation rates. However, a unique complication associated with DMCs is femoral neck notching (FNN), which is believed to result from impingement between the metal liner and the femoral stem neck. The risk factors for FNN, however, remain poorly understood. This study aimed to identify the risk factors associated with FNN in patients undergoing THA with DMCs.

Methods: This retrospective analysis included 766 patients who underwent THA with DMCs between 2013 and 2023. Patients with follow-up durations of less than 1 year and those with mixed-manufacturer components (i.e., an acetabular cup and a femoral stem from different manufacturers) were excluded. Cup positioning angles and the presence of FNN were assessed using standard radiographs. Spinopelvic alignment was evaluated in a subgroup of 204 patients using EOS imaging.

Results: FNN was identified in 24 of 766 patients (3.1%). Among these, 14 patients underwent EOS imaging, compared with 190 patients without FNN. Patients with FNN demonstrated significantly higher cup anteversion (31.4° ± 6.1°) than those without FNN (15.2° ± 4.8°, p < 0.0001). Logistic regression analysis showed that increased cup anteversion was significantly associated with FNN, with an odds ratio of 1.62 (95% confidence interval: 1.32-2.27, p < 0.0001), identifying it as the primary risk factor for FNN formation.

Conclusions: Cup anteversion was identified as a significant risk factor for FNN following THA with DMCs. These findings suggest that careful attention to cup positioning may help reduce the incidence of FNN in DMC-THA.

Level of evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Mechanical alignment total knee arthroplasty (TKA) in valgus knees requires soft tissue releases and complex techniques that are unnecessary with kinematic alignment (KA). Few studies have evaluated the outcomes of KA in valgus knees, and fewer have studied KA with medial-pivot (MP) implants. This study compared the clinical outcomes of KA-TKA with MP implants (KA/MP-TKA) in patients with preoperative varus versus valgus alignment. We hypothesized that outcomes following KA/MP-TKA would be equivalent.

Methods: A prospective database was queried to identify patients who underwent primary KA-TKA with MP implants. Patients were included if they had a preoperative hip-knee-ankle angle ≤177° (varus, n = 302) or ≥183° (valgus, n = 51). A total of 353 consecutive patients were identified. The Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcome Score (KOOS-JR), Knee Society Score (KSS), and range of motion were collected preoperatively and at 6-week, 6-month, and 1-year visits.

Results: Patients with preoperative valgus alignment had worse KSS Function and KOOS-JR scores preoperatively (p = 0.04 and p = 0.02, respectively); all other baseline outcomes were comparable. Postoperatively, the valgus group demonstrated better KOOS-JR at 6 weeks (p = 0.004), KSS Pain-Motion at 6 months (p = 0.02), and FJS at 1 year (p = 0.03). The varus group showed better KSS Function at all postoperative visits (p < 0.02). There were no statistically significant differences in flexion or extension between the groups.

Conclusions: Patients with valgus alignment undergoing KA/MP-TKA achieved postoperative outcomes that were clinically equivalent or superior to those of patients with varus alignment. These findings support KA-TKA using MP implants as an appropriate surgical approach for preoperative valgus alignment.

» Limited evidence is available within shoulder arthroplasty literature to fully assess if an association exists between the presence of metal allergies and outcomes after total shoulder arthroplasty. » Several systems are available for both anatomic and reverse total shoulder arthroplasty to provide patients with a nickel-free implant if a history of a metal allergy is present. » The results of this scoping review as well as extrapolating results from total knee arthroplasty literature suggest hypoallergenic implants produce similar results as standard cobalt-chromium implants and may present an appropriate option for patients with metal allergies.

Background: Unicompartmental knee arthroplasty (UKA) improves recovery, but optimizing load remains challenging. This study measures tibiofemoral contact pressures after conventional and robotic UKA in cadavers and validates a finite element (FE) model against experimental data.

Methods: Sixteen fresh-frozen cadaveric lower limbs underwent medial UKA with conventional cutting guides (n = 8) or CORI robotic assistance (n = 8). Medial (implanted) and lateral (native) compartment pressures were recorded from 0° to 90° using pressure film sensors. The FE model replicated and was validated against these measurements.

Results: Medial compartment pressure decreased significantly from 1.864 MPa at 0° to 0.252 MPa at 90° (p < 0.05). The lateral compartment showed a similar significant decrease from 0.733 MPa to 0.320 MPa (p < 0.05). No significant differences were observed between conventional and robotic-assisted techniques (p > 0.05). The FE model demonstrated strong agreement with the measured data, with r² values of 0.9994 (medial) and 0.9962 (lateral).

Conclusion: Conventional and robotic-assisted UKA techniques demonstrated similar contact pressure profiles. However, increased force and area in the native lateral compartment may predispose to postoperative degeneration. The FE model reliably predicted contact behavior and may be especially useful in refining conventional UKA techniques.

Level of evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic surgery remains one of the most competitive specialties in the National Residency Matching Program. Despite the large number of medical students who do not match into orthopaedics, limited guidance exists for mentors to support these applicants. This review provides mentors with possible pathways and strategies to help ensure that applicants are best positioned to obtain a structured interim year that strengthens their research productivity, clinical experience, and faculty advocacy in preparation for reapplication. Mentors should also help applicants realistically assess their competitiveness and consider alternative specialties or parallel career pathways as part of early contingency planning. Although reapplicants face lower success rates in the orthopaedic surgery match, resilience, preparation, and mentorship can maximize their chances of a successful outcome.