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Background: Total knee arthroplasty (TKA) clinical trials inform surgical decisions by reporting adverse events (AEs), including serious adverse events (SAEs), other adverse events (OAEs), and deaths. However, concerns persist regarding discrepancies in AE reporting between trial registries, such as ClinicalTrials.gov, and peer-reviewed publications, even after the implementation of Food and Drug Administration Amendments Act Section 801 and the Final Rule of 2017, laws introduced to mitigate selective reporting and enhance public transparency.

Methods: We conducted a systematic registry-to-publication comparison of 92 TKA-focused clinical trials with posted results on ClinicalTrials.gov between 2009 and 2024. Data on SAEs, OAEs, and deaths were extracted from registries and matched peer-reviewed publications using a pre-registered protocol. Descriptive statistics were used to evaluate discrepancies and trends over time. Regression analysis was used to assess the impact of the Final Rule and variables associated with changes in reporting score.

Results: AE reporting was consistently more complete in ClinicalTrials.gov entries than in publications. SAE count mismatches were present in 95% of trials, and mortality data were omitted from 87% of pre-Final Rule Applicable Clinical Trial (ACT) publications. Post-Final Rule trials continued to underreport SAEs and deaths in publications, with no significant improvement in reporting completeness. Only 15% of trials listed AEs as formal outcomes in registries, and 66% of post-Final Rule ACTs omitted SAE reporting in the publication.

Conclusion: Despite regulatory mandates, AE reporting in TKA trials remains inconsistent and incomplete across publications. These discrepancies risk undermining surgical decision-making and evidence-based guidelines. Enhanced enforcement, editorial accountability, and stricter adherence to reporting standards such as Consolidated Standards of Reporting Trials Harms are necessary to improve transparency and patient safety in orthopaedic research.

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

Background: Plate fixation in skeletally immature children can cause angular deformity with longitudinal growth even when the plate does not overlie the adjacent physis. While this phenomenon has been described for the distal femur, angular deformity has not been reported following plating in other long bones. The aim of the study was to characterize whether sagittal-plane deformity occurs following volar plating of radius fractures in skeletally immature children and to determine associated risk factors.

Methods: A retrospective review of volar plating of acute radius fractures in children with an open distal radius physis at a single institution was completed. In patients with at least 4 months of follow-up, the first radiograph and the last follow-up radiograph were evaluated for any change in sagittal angulation distal to the plate. Demographic information was obtained from the electronic medical record. Linear regression analysis was used to determine if distance from the plate to the physis, follow-up time, age, or coexisting ulnar fracture was predictive of any observed changes in angulation.

Results: Sixty-one acute radius fractures treated with volar plating at a mean age of 12.1 years (67% male, 70.5% White, 90.2% non-Hispanic) were included. When analyzing by fracture location, 78% (21/27) of the distal-third radius fractures with appropriate follow-up developed at least 10° of apex volar angular deformity, with 44% (12/27) exhibiting greater than 20°. Middle-third and proximal-third fractures did not exhibit similar degrees of angulation (only 13% [4/30] and 0% [0/4] of included patients developed more than 10° of deformity, respectively). Linear regression analysis revealed distance of the plate to the physis and follow-up time to be strong predictors of angulation (both p < 0.0001).

Conclusions: Children with radius fractures, particularly those in the distal-third, treated with a volar plate may develop apex volar angular deformity. While the exact rate of this phenomenon is unclear, these findings underscore the importance of strict surgical indications and vigilant postoperative monitoring beyond fracture healing, and represent a paradigm shift in understanding growth modulation following plating.

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

Background: Venous thromboembolism (VTE) poses significant risk of morbidity and mortality in orthopaedic trauma patients. Thromboelastography (TEG) analysis has been demonstrated to provide value in demonstrating hypercoagulability and predicting the risk of post-injury VTE. The primary aim was to investigate if TEG analysis at the time of admission following severe extremity trauma predicts thromboembolic events. We hypothesized that previously described elevations in maximal amplitude (MA) on initial TEG would correlate with an increased risk of VTE.

Methods: This was a secondary study of PREVENT CLOT, a multicenter, randomized trial that enrolled adult patients with an extremity fracture (from hip to midfoot or shoulder to wrist) treated operatively or any pelvic or acetabular fracture. TEG at admission was performed according to local protocols. The primary outcome of this analysis was postoperative VTE. We assessed the association between admission TEG values and VTE using bivariate and multivariable regression analyses. Statistical significance was set at p < 0.05.

Results: Thousand one hundred eighty-three patients enrolled participants in the PREVENTion of CLots in Orthopedic Trauma (PREVENT CLOT) trial had TEG analysis performed on initial presentation. Of these patients, 47 (3.97%) had a symptomatic postoperative VTE at a median of 9 days (interquartile range, 4-18 days). There were no differences in VTE rates when examining MA of ≥65, ≥69, or ≥72 (p = 0.12, 0.21, and 0.19, respectively). However, on admission TEG, reaction time (R-time) was significantly higher among those who experienced a postoperative deep venous thrombosis (2.45 vs. 1.79, p < 0.01). After controlling for confounders, R-time of ≥2.0 was associated with a 2.1-fold increased odds of VTE (OR 2.13, 95% confidence interval 1.06-4.28, p < 0.001).

Conclusion: In contrast to previous smaller retrospective studies, elevated admission-TEG MA values were not predictive of VTE following operative orthopaedic extremity trauma in this secondary analysis of a large multicenter prospective study. Our findings suggest that an increased R-time on the admission TEG, which is thought to be indicative of a longer time to form a clot, may be paradoxically associated with an increased VTE risk in orthopedic trauma patients.

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

Background: Conversion total hip arthroplasty (THA) is performed as a salvage operation for patients who develop symptomatic posttraumatic arthritis following open reduction internal fixation (ORIF) of displaced acetabular fractures. Historically, high failure rates in this patient population were related to acetabular loosening. Recent studies, however, have demonstrated improved outcomes with modern techniques. This study aims to evaluate the outcomes and survivorship of early conversion THA after high-energy acetabular fractures at our institution.

Methods: A retrospective review was performed of all patients who underwent acetabular ORIF and subsequent conversion THA at a Level I trauma center between 2002 and 2022. Patients with less than 1 year follow-up after conversion THA without complication were excluded. Patient demographics, injury characteristics, perioperative details of ORIF and THA, complications, and subsequent reoperations and revisions were recorded.

Results: A total of 144 cases were included. The average age was 51.3 years at the time of ORIF with transverse posterior wall (46.5%) and posterior wall (30.6%) fracture patterns predominating. The median time from ORIF to conversion THA was 1.1 years (interquartile range [IQR], 0.7-1.8). Complications occurred in 47 THAs (32.6%), with dislocation (n = 19, 13.2%) and periprosthetic joint infection (n = 17, 11.8%) being the most common. The reoperation and revision rate following conversion THA was 21.5% and 18.1%, respectively. The median time from conversion THA to revision THA was 0.5 years (IQR, 0.1-1.3), with 69.2% of revisions occurring within the first year.

Conclusions: Early conversion THA following acetabular ORIF in our cohort was associated with a marked rate of complication and revision surgery. Although aseptic loosening was less prevalent, instability and infection rates were significant concerns. These findings underscore the need for continued improvements in managing this challenging patient population.

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

Background: The growth of value-based purchasing programs has increased interest in understanding risk factors for readmission and preventing unplanned readmissions. The aim of this study was to estimate rates and risk factors for 30-day readmission following inpatient total shoulder arthroplasty (TSA) in Pennsylvania between 2010 and 2018.

Methods: We examined inpatient TSA between 2010 and 2018 in Pennsylvania using a statewide administrative discharge data set. Readmissions were for any cause and to any hospital in the state, and not only to the operating hospital. Potential risk factors included patient demographics, comorbidities, and discharge destination. Logistic regression was used to identify significant risk factors.

Results: Among 14,333 patients receiving TSA, 469 (3.27%) were readmitted within 30 days. Patients admitted on an urgent or emergent basis had 65% greater odds (odds ratio [OR] = 1.65, p = 0.009) than patients treated on an elective basis. While patients covered by commercial insurance had 24% lower odds of readmission (OR = 0.76, p = 0.04), patients covered by Medicaid had twice (OR = 1.95, p = 0.002) the odds of readmission. Relative to patients with no comorbidities, patients with 1 to 2 comorbidities had 54% greater odds (OR = 1.54, p < 0.0001), and patients with 3+ comorbidities had triple the odds (OR = 3.14, p < 0.0001) of readmission within 30 days. Discharge destination was a significant predictor of readmission, with patients discharged with home health having 50% greater odds (OR = 1.49, p < 0.0001) and patients discharged to a skilled nursing facility having more than twice the odds (OR = 2.19, p < 0.0001) of readmission within 30 days.

Conclusions: In this statewide analysis, there were several significant risk factors for 30-day readmission following inpatient admission for TSA, many of which may be useful targets for hospitals to prevent costly orthopaedic surgery readmissions.

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

» Arthroplasty outcomes are fundamentally tied to the accuracy of bone preparation and subsequent implant positioning. » Laser bone shaping represents a paradigm shift from mechanical cutting to controlled thermomechanical ablation. » Integration with real-time optical sensing and robotic targeting enables execution of patient-specific surgical plans with unprecedented accuracy and a pathway to autonomous procedures. » Clinical adoption is dependent on achieving clinically relevant bone removal rates and seamless surgical workflow integration. » These capabilities enable bone-preserving resurfacing procedures that move beyond conventional planar reconstruction.

Background: Unicompartmental knee arthroplasty (UKA) is an effective treatment for unicompartmental end-stage knee arthritis. Simultaneous bilateral UKAs for patients with bilateral knee arthritis can reduce costs, number of anesthetics, and overall rehabilitation time. It is unknown how the long-term outcomes of unilateral and simultaneous bilateral UKAs compare.

Methods: In total, 1,939 unilateral and 1,939 simultaneous bilateral medial mobile-bearing UKAs (n = 3,878) from the National Joint Registry were propensity score matched. Kaplan-Meier and Cox regression were used to compare implant survival, revision indications, and mortality.

Results: The 10-year implant survival in the simultaneous bilateral group was 92% (95% confidence interval [CI] 90-94) and in the unilateral group was 90% (95% CI 88-92). The simultaneous bilateral group had a lower revision risk (hazard ratio [HR] 0.73, p = 0.01). Revisions for pain were lower in the bilateral group (0.5% vs. 1.2%, p = 0.01). There were no differences in patient mortality. Subgroup analyses found similar trends in 10-year implant survival and revision risk with both cementless (simultaneous bilateral 98% CI 95-99; unilateral 95% CI 91-98; HR 0.66, p = 0.27) and cemented fixation (simultaneous bilateral 91% CI 89-93; unilateral 90% CI 88%-92%; HR 0.85, p = 0.28).

Conclusions: Simultaneous bilateral UKAs had better 10-year implant survival and similar mortality to compared with single-unilateral UKAs. For patients with severe symptomatic bilateral unicompartmental knee osteoarthritis, simultaneous bilateral UKAs could be considered to be a safe and effective procedure, particularly as only one operation and postoperative recovery is required.

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

Background: Generative artificial intelligence (AI) large language model (LLM) chatbots, such as ChatGPT, are increasingly used to answer medical questions. This study sought to assess the accuracy and quality of evidence cited in ChatGPT-4o mini responses to questions pertaining to hip fracture care.

Methods: Prompt questions regarding hip fracture management that aligned with each of the 19 recommendations published in the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline (CPG) for Management of Hip Fractures in Older Adults were posed to the ChatGPT-4o mini LLM asynchronously by 4 independent medical student graders. Three prompt variations were applied for each recommendation, reflecting the perspectives of a physician, a patient, and a general information seeker. Graders then requested from the LLM a reference list with PubMed Identifier (PMID) numbers supporting each recommendation. Accuracy and clarity of responses were assessed using a standard rubric for overlap with CPG citations, fabrications, and inaccurate citations.

Results: ChatGPT-4o mini returned 228 responses to prompts seeking advice on AAOS CPG hip management recommendations. 76.3% of responses were "accurate" to the CPG recommendation. 88.2% of responses received a clarity rating of "excellent". ChatGPT-4o mini provided 228 responses citing 2,556 publications when prompted for supporting evidence, of which 1.1% overlapped with AAOS CPG references, and 7.9% were fabricated. Of the publications cited by the LLM which exist in the PubMed index, 91.7% were given with incorrect authors, 91.5% incorrect titles, 91.4% incorrect pages, 91.0% incorrect PMIDs, 90.9% incorrect journals, 90.3% incorrect journal volumes, and 20.0% incorrect publication years. Responses for an AAOS CPG strong recommendation strength were significantly more likely to be "accurate" (p < 0.001), and responses for an AAOS CPG limited strength recommendation were significantly more likely to be "unsupported" (p < 0.001).

Conclusions: ChatGPT-4o mini provided clear, moderately accurate responses with rampantly erroneous and occasionally fabricated citations to queries about hip fracture care derived from the AAOS Clinical Practice Guideline on Management of Hip Fractures in Older Adults.

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

Background: Total hip and knee arthroplasty (THA/TKA) are among the most common and costly orthopedic procedures in the United States. While hospital-level pricing drivers are known, the influence of community socioeconomic and geographic factors remains unclear. This study aimed to evaluate both hospital-level and community-level predictors of THA/TKA pricing.

Methods: A retrospective cross-sectional analysis used commercially negotiated THA/TKA inpatient hospital prices (Medicare Severity-diagnosis-related group 470) from 2,286 US hospitals encompassing 5,946 prices across 5 major commercial payers (Turquoise Health, March 2024). Prices are defined as claims costs reimbursed by payers, excluding surgeon, anesthesia, and outpatient fees. Hospital price data were linked to county-level socioeconomic, clinical need (e.g., arthritis prevalence), and hospital structural characteristics (e.g., bed count). Multivariate linear regression assessed associations between hospital/community factors and log-transformed prices.

Results: Negotiated THA/TKA prices were significantly higher in rural than urban counties. Multivariate analysis found that higher prices were associated with larger hospital bed count (+5.20% per standard deviation [SD], p < 0.001), higher Case Mix Index (+5.34% per SD, p = 0.002), and counties with minority population populations (+3.19% per SD, p = 0.001) and uninsured rates (+2.91% per SD, p = 0.019). By contrast, higher arthritis prevalence (-3.13% per SD, p < 0.001) and Social Deprivation Index scores (-7.23% per SD, p < 0.001) were associated with lower prices, which suggests that high-need populations face lower hospital reimbursement or reflect price adjustments in response to local economic capacity.

Conclusions: Commercially negotiated THA/TKA prices are influenced by both hospital structural factors and the demographics of the surrounding community. Higher prices in areas with larger minority populations and more uninsured residents may reflect systemic drivers of geographic and demographic disparities in healthcare pricing.

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

Background: Large Language Models (LLMs) are increasingly used for health information, but concerns exist regarding performance disparities for non-English speakers, potentially exacerbating health inequities. Appropriate information is critical for patients with limited English proficiency undergoing orthopedic procedures such as total hip arthroplasty (THA). This pilot study evaluated differences in the clinical reliability of English and Spanish responses to common THA questions generated by leading LLMs.

Methods: Three widely accessible LLMs (ChatGPT-4o, Gemini 2.0 Flash, and Microsoft Copilot) were evaluated using 10 standardized frequently asked questions on THA, posed in English and Spanish. Responses were independently graded by language-fluent medical experts using a 4-point rubric (1 = Unsatisfactory to 4 = Excellent) assessing clinical reliability and appropriateness. Nonparametric statistics, including Wilcoxon signed-rank, Kruskal-Wallis, and effect sizes (Cliff's Delta, η²), were used for comparisons.

Results: A statistically significant main effect of language was found (p = 0.014, η² = 0.151), indicating significantly lower clinical reliability scores for Spanish responses in all LLMs. A nonsignificant within-model score decline was observed across all 3 LLMs.

Conclusion: Leading LLMs exhibit significant difference in clinical reliability when providing THA information, performing less reliably in Spanish compared with English. This linguistic gap suggests a potential risk for difference in response interpretation and could potentially worsen health inequities for Spanish-speaking populations. Efforts are needed to improve multilingual capabilities and manage biases in medical artificial intelligence (AI). Clinicians and patients should exercise caution when using LLMs for health information in languages other than English until cross-lingual reliability is demonstrably improved.

Clinical relevance: This study highlights a significant linguistic disparity in AI-generated health information for THA. Improving LLMs' multilingual capabilities is essential to promote equitable access to reliable medical education and prevent the exacerbation of health inequities for non-English speaking patients.

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

1 to 2 sentence description: This study evaluates LLMs in providing THA information in English and Spanish, revealing that Spanish responses are clinically less reliable. The findings highlight linguistic gap in AI healthcare tools, raising potential concerns for patient safety, and widening health inequities for non-English speakers.