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Background: This randomized controlled trial evaluates low-dose oral corticosteroids for improving pain and function after total knee arthroplasty (TKA), leveraging their potent anti-inflammatory effects.

Methods: A total of 102 patients who underwent primary unilateral TKA were randomized to receive either 400 mg of celecoxib plus 10 mg of oral prednisolone daily or 400 mg of celecoxib alone. Oral medications started after discharge (24-48 hours after surgery) and continuing for 2 weeks. Follow-up visits were conducted at 1, 2, 4, 12, and 24 weeks postsurgery. The Visual Analog Scale, range of motion (ROM), Knee Society Score, Oxford Knee Score, and sleep quality were evaluated.

Results: Demographic data were similar, except for age, with celecoxib alone group being older (p = 0.005). The celecoxib + prednisolone group experienced significantly lower Visual Analog Scale pain scores at 1 week (mean difference [MD]: -0.81; 95% confidence interval [CI]: -1.59 to -0.03) and 2 weeks (MD: -0.99; 95% CI: -1.87 to -0.09) postoperatively. Age-adjusted results confirmed the reduction in pain with a slight difference, although it was not statistically significant. Knee function scores showed statistically significant improvement in the celecoxib + prednisolone group at 2 weeks (MD: 12.96; 95% CI: 0.21-26.13). Improvement in knee function scores was reduced by about half in age-adjusted analysis and was not statistically significant (MD: 6.25, p = 0.35). ROM demonstrated significant difference at 4 weeks (MD: 6.66; 95% CI: 0.44-12.86). Sleep quality showed significant improvement in the celecoxib + prednisolone group at 2 weeks (MD: 0.84; 95% CI: 0.05-1.64). Improvement was clinically confirmed by controlling for the effect of age with borderline significance. Uncertainty was observed due to wide CIs in some results.

Conclusion: Oral low-dose prednisolone administered early after TKA resulted in significant reductions in pain and improvements in sleep quality, ROM, and Knee Society Score during the early postoperative period. However, these improvements did not consistently reach the minimal clinically important difference. Adjusted analyses accounting for age suggested modest benefits, but wide CIs and small effect sizes warrant cautious interpretation. To optimize dosing regimens and assess the long-term effects of oral corticosteroids in TKA recovery protocols, large-scale randomized controlled trials are necessary.

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

Background: The optimal use of primary hemiarthroplasty (HA) or total hip arthroplasty (THA) for treating displaced femoral neck fractures (FNFs) remains controversial. This study aims to compare the outcomes of HA and THA in ambulatory patients 80 years or older, at 4- and 10-year postsurgery.

Methods: In a prospective, randomized, single-blind trial, patients with acute displaced FNFs with a mean age of 85 (range 80-94) years were randomly allocated to receive either HA or THA. The primary end points were hip function (Harris Hip Score, HHS) and health-related quality of life (European Quality of Life-5 Dimensions [EQ-5D]). Secondary end points included hip-related complications, reoperations, mortality, pain in the affected hip, activities of daily living, a radiographic evaluation of acetabular erosion, and general complications.

Results: At the 4-year follow-up, 39 patients in the HA and 39 in the THA group were available. At 10 years, 10 HA patients and 16 THA patients were available for follow-up. No differences were observed in the HHS at 4 and 10 years. The EQ-5D Index was statistically significant in favor of THA at 4 years, but no difference was observed at 10 years. No differences were found between the groups regarding hip-related complications, reoperations, mortality, activities of daily living, and pain in the operated hip. Hip function, activities of daily living, and pain in the operated hip deteriorated over time.

Conclusion: Up to 10 years after surgery, both HA and THA demonstrated comparable outcomes in hip function and health-related quality of life in ambulatory octogenarians and nonagenarians with displaced FNFs. This suggests that both interventions are suitable for this group of older patients.

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

Background: Externally controlled intramedullary lengthening nails (IMNs) have reduced the soft-tissue morbidity associated with external fixation. However, these complex devices introduce specific risks related to their motorized and telescopic mechanisms. Existing literature often conflates structural fatigue fractures with internal mechanism dysfunction. This systematic review aims to analyze the incidence, etiology, and management of intrinsic mechanism failures in lengthening IMNs.

Methods: A comprehensive search of PubMed, Embase, and Scopus was conducted from January 2000 to July 2025 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The review included human studies reporting mechanism-related failures (e.g., jamming, backtracking, and motor failure) in externally controlled IMNs. Studies describing only structural fatigue fractures or nonexternally controlled devices were excluded (e.g., Intramedullary Skeletal Kinetic Distractor [ISKD]). Data were stratified by implant generation and material.

Results: Twenty-nine studies encompassing 2,495 nails were included. The overall reported mechanism-related failure rate was 4.3% (n = 107/2,495). Distinct failure phenotypes emerged based on the implant material. Titanium-alloy nails (PRECICE P1/P2) demonstrated a 4.2% failure rate (n = 74/1,761), predominantly characterized by mechanical jamming or gear slippage due to load-induced yield. Stainless steel nails (STRYDE) exhibited a significantly higher failure rate of 12.9% (n = 12/93), primarily driven by tribocorrosion and biological reactions at the telescopic junction. The FITBONE system had a reported failure rate of 3.3% (n = 21/641). Management required surgical intervention in 97.2% of failure cases, with exchange nailing being the primary salvage strategy (94.4%). Despite the need for reoperation, the target limb length was reportedly achieved in the majority of studies where quantitative outcomes were specified.

Conclusion: Mechanism failure in externally controlled lengthening IMNs is a clinically significant complication with a reported incidence of approximately 1 in 24 cases. A material trade-off is evident: Titanium implants are susceptible to mechanical gear yield, whereas stainless steel implants are prone to tribocorrosion-induced failure. While these failures necessitate revision surgery, they typically do not preclude successful limb reconstruction if managed with timely nail exchange.

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

Background: Successful applications of artificial intelligence (AI) in healthcare have increased interest in how it could be integrated into orthopaedic surgery. However, orthopaedics surgeons' current use of AI and attitudes toward its incorporation remain largely unexplored. The 2025 American British Canadian Travelling Fellowship Survey on AI in Orthopaedic Surgery aimed to assess AI use, knowledge, training, and attitudes among orthopaedic surgeons.

Methods: The survey was administered from May 7 to September 4, 2025 to orthopaedic surgeons across Australia, New Zealand, the United Kingdom, and North America. Questions addressed demographics, AI training and use, and attitudes toward AI. Descriptive statistics summarized responses, chi-square tests compared AI use by geography and attitudes by career stage, and linear regression explored associations between demographics, AI behaviors, and outlook on AI.

Results: Among 350 participants, most were trainees (45.1%) and from North America (42.9%). AI use exceeded training, and 79.9% rated their AI knowledge as average or poor. Trainees reported significantly more favorable attitudes toward AI than late-career respondents. Higher self-rated AI knowledge and AI use in clinical and research settings were associated with a more positive outlook on the future of AI in orthopaedics.

Conclusions: These findings highlight the need for formal AI education, as use is widespread despite limited training, particularly among later-career surgeons. Future studies should reduce self-selection and career-stage imbalance and include additional demographic variables to improve generalizability.

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

Background: Since the Match began in 1952, residency interviews were traditionally conducted in person. This abruptly changed in 2020 when virtual interviews became mandatory. In 2024, the Association of American Medical Colleges (AAMC) recommended retaining the virtual format. However, the Council of Orthopaedic Residency Directors left interview formats up to individual programs for the 2024 to 2025 cycle. This study examined what format orthopaedic surgery residency programs chose to interview their candidates for the 2024 to 2025 interview season.

Methods: The list of orthopaedic surgery residency programs in the United States was compiled from the AAMC Electronic Residency Application Service Directory website. Each program's interview format (virtual, hybrid, or in-person) was detailed using the Orthopaedic Residency Information Network, individual program websites, and direct communication with program coordinators. Programs' geographic locations (state and region) and class size (small <4, medium 5-8, and large ≥9 residents) were also recorded.

Results: Interview format data were obtained for 182 of 198 (92%) total orthopaedic surgery residency programs. Of these, 128 programs (70%) held in-person interviews, while 46 (25%) opted for virtual and 8 (4%) used a hybrid format. There was high variability in interview choices across states, ranging from all in-person interviews to exclusively virtual interviews (p = 0.03). Interview formats varied slightly by region. The West (43%) held a higher proportion of virtual interviews than the Northeast (27%), Midwest (21%), Southeast (23%), or Southwest (16%). However, regional differences were not statistically significant. Finally, programs with small class sizes conducted virtual interviews (38%) more frequently than medium (13%) or large (0%) programs (p = 0.002).

Conclusions: Orthopaedic surgery residency programs favored in-person interviews in the 2024 to 2025 interview season. Program state and class size were associated with choice of interview format, whereas regional differences were not statistically significant.

Introduction: Implicit gender biases in letters of recommendation (LoRs) may differentially influence the success of applicants to residency positions. With the inevitable use of large language models (LLMs) such as ChatGPT to draft LoRs, concerns have emerged regarding whether these models reproduce human biases in their writing. The purpose of this study was to examine whether ChatGPT exhibits gender bias when drafting LoRs for hypothetical orthopaedic surgery residency applicants.

Methods: Thirty paired prompts were created describing a variety of mentor-mentee relationships, manipulating only the applicant's gendered name and pronouns while holding all other factors constant. Prompts were sequentially input into ChatGPT-5.0, and output LoRs were saved. Linguistic Inquiry and Word Count (LIWC) software was used to characterize LoRs across 4 summary measures and 28 word categories. Paired t tests were used to compare the composition of male and female letters across these dimensions. Word counts were compared similarly.

Results: The mean length of recommendations for men was 304 ± 53 words. For women, the mean length was 310 ± 47 words. There was no significant difference in word count between groups (p = 0.364). However, recommendations for women were composed of more auxiliary verbs (4.67% ± 1.10% vs. 4.17% ± 1.02%; p = 0.045), communication-related words (0.80% ± 0.51% vs. 0.59% ± 0.46%; p = 0.047), and personal pronouns (10.48% ± 1.18% vs. 9.82% ± 0.87%; p = 0.005) than recommendations for men. A follow-up analysis using a gender-neutral name, while only varying pronouns between prompts demonstrated that recommendations for women were composed of more "prosocial" words than recommendations for men (3.27% ± 1.16% vs. 2.79% ± 1.00%; p = 0.003).

Conclusion: ChatGPT-assisted drafting of LoRs includes nuanced and systematic gender-based linguistic differences. For orthopaedic letter writers, the use of LLMs must be accompanied by structured review, bias-aware training, and standardized templates to avoid inadvertently perpetuating inequities.

» Chronic Charcot arthropathy results from the convergence of genetic predisposition (OPG/RANKL/RANK polymorphisms), metabolic disturbances (AGEs, vitamin D deficiency affecting 84.2% of patients), and inflammatory dysregulation (RANKL/OPG axis, IL-17 family cytokines), explaining why only 0.08-1% of diabetic neuropathy patients develop this devastating complication. » The receptor activator of nuclear factor kappa-B ligand (RANKL)/receptor activator of nuclear factor kappa-B (RANK)/osteoprotegerin (OPG) axis dysregulation drives excessive osteoclastogenesis and bone resorption in the acute phase, while impaired Wnt/β-catenin signaling and advanced glycation end products-modified collagen compromise healing quality in the chronic phase, resulting in malunion and permanent deformity. » Magnetic resonance imaging is the best non-invasive imaging modality for differentiating chronic Charcot from osteomyelitis (single bone involvement beneath ulcer, sinus tract, and abscess favor infection; periarticular distribution favors Charcot), though bone biopsy remains the gold standard when diagnostic uncertainty persists. » Current management relies primarily on mechanical interventions (accommodative footwear, bracing, surgical reconstruction for unbraceable deformities), but emerging molecular therapies targeting RANKL (denosumab), pro-inflammatory cytokines (IL-17 inhibitors), and Wnt pathway (romosozumab) show promise for disease modification. » Integrated risk stratification models combining genetic risk scores, serum biomarkers (RANKL/OPG ratio, vitamin D levels), and clinical factors can identify high-risk individuals (AUC 0.89), enabling targeted preventive interventions including vitamin D supplementation, prophylactic off-loading, and potentially pharmacological prevention.

Background: Hip displacement (HD), common in cerebral palsy (CP), is reportedly less prevalent for spastic hemiplegia. Patients with a Winter-Gage-Hicks (WGH) type IV gait pattern are believed at increased risk of HD, but true prevalence is unknown. This study aimed to analyze the rates of HD according to the sagittal plane-based WGH classification and identify associated risk factors.

Methods: Patients with hemiplegic CP, ≥1 instrumented gait analysis (IGA), hip surveillance radiograph(s), and minimum 2-year follow-up were included. The primary outcome was presence of an "unsuccessful hip" defined as a migration percentage ≥30% and/or undergoing reconstructive osteotomies for HD. Secondary outcome variables included WGH type, previous surgery, sex, scoliosis, epilepsy, ventriculoperitoneal shunt, gastrostomy tube, and IGA-derived hip kinematics.

Results: Included were 144 patients (39.6% female), classified as Gross Motor Function Classification System I (45.1%) or II (54.9%), mean follow-up 9.6 ± 4.6 years. Seventeen patients (11.8%) had an unsuccessful hip outcome (age 11.6 ± 3.6 years). Stratified by WGH type, unsuccessful hip outcome rates were I: 9.5% (2/21), II: 9.4% (6/64), III: 6.7% (2/30), and IV: 24.1% (7/29); age at onset was not different between WGH types (p = 0.8). Multivariate analysis identified hip internal rotation (odds ratio [OR]: 4.7, confidence interval [CI]: 1.2-18.1, p = 0.02) and hip adduction (OR: 5.2, CI: 1.2-22.1, p = 0.02) as significant independent risk factors.

Conclusion: The rates of HD in spastic hemiplegia were higher than expected for all WGH types, particularly IV. A high index of suspicion and regular hip surveillance radiographs is required for patients with hip internal rotation and adduction, starting during preadolescence.

Level of evidence: III-Retrospective cohort observational study. See Instructions for Authors for a complete description of levels of evidence.

Background: Orthopaedic surgery still has one of the lowest representations of female physicians of all specialties. This investigation evaluated the association of female non-orthopaedic surgeon faculty (NOSF) and female orthopaedic surgeon faculty (OSF) with female resident composition in orthopaedic surgery residency programs. A secondary objective was to evaluate the association between female leadership and female residents. It was hypothesized female NOSF, OSF, residency program leadership, and departmental leadership are positively correlated with female resident composition.

Methods: Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs for the 2024 to 2025 academic year were included. Military residencies and residency programs that did not report residents and faculty were excluded. The total number of OSF and female OSF was recorded from both program websites (W-OSF) and programs' self-reported data (SR-OSF) in 2 publicly available databases. The number of female residents, NOSF, and leadership was extracted from program websites. Gender identity was confirmed using the National Provider Identifier database. Univariate, multivariate, and correlation statistics between female residents, OSF, NOSF, total faculty, and other program characteristics were examined.

Results: In all, 198 programs reported residents and faculty and were included. The percentage of female residents was significantly correlated with the number of female W-OSF (r_s = 0.495, p < 0.001), female NOSF (r_s = 0.489, p < 0.001), and female SR-OSF (r_s = 0.401, p < 0.001), and the percentages of female W-OSF (r_s = 0.402, p < 0.001) and female SR-OSF (r_s = 0.339, p < 0.001). Programs with female faculty had significantly larger resident cohorts (23.4 vs. 14.1, p < 0.001) and percentages of female residents (22 vs. 12.7, p < 0.001). Programs with female residents had more total residents (23.1 vs. 12.8, p = 0.002), OSF (32.6 vs. 17.4, p = 0.014), and percentage of female OSF (12.2 vs. 4.9, p = 0.011). Programs with female program directors had significantly more female residents (6.9 vs. 5, p = 0.021) and higher percentages of female W-OSF (17.9 vs. 11.1, p = 0.003) and female residents (25.1 vs. 20.6, p = 0.048).

Conclusion: Female non-orthopaedic surgeon faculty were associated with female resident diversity. Female orthopaedic surgeon faculty and program directors were also associated with more female residents. Efforts to increase female faculty and leadership may be associated with increased female trainees.

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

Background: Entrapment of the lateral cutaneous nerve of the forearm (LCNF), the terminal sensory branch of the musculocutaneous nerve, is rare and often overlooked in the differential diagnosis of lateral forearm paresthesia and anterior elbow pain. This study describes a cohort of competitive weightlifting athletes with LCNF neuropathy due to biceps tendon compression, who underwent surgical decompression after failed conservative treatment.

Methods: We reviewed cases treated between 2009 and 2019 at a single orthopaedic center. Inclusion criteria were a clinical diagnosis of LCNF neuropathy (based on a positive Tinel sign lateral to the biceps tendon and paresthesia in the lateral forearm), a magnetic resonance imaging scan excluding other conditions, participation in competitive weightlifting, and failure of conservative treatment lasting ≥3 months. Outcome measures included symptom resolution, Tinel sign status, return to sport, and complications.

Results: There were 5 male athletes (mean age, 28 years; range, 23-34) with LCNF entrapment lateral to the biceps tendon at the antecubital fossa. The mean interval from symptom onset to surgery was 12.8 months (range, 8-18). Mean follow-up was 74 months (range, 50-100). Within a month of the operation, all patients had complete symptom resolution and a negative Tinel sign and resumed competitions at their preinjury level. No complications occurred.

Conclusions: LCNF entrapment should be considered in athletes performing repetitive elbow extension and pronation who present with unexplained lateral forearm paresthesia. When conservative measures fail, surgical decompression is safe, reproducible and has excellent long-term outcomes.

Level of evidence: Level IV, Case Series, Prognostic study. See Instructions for Authors for a complete description of levels of evidence.