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Background: Selecting an orthopaedic surgery practice setting is a career-altering decision, yet guidance is often anecdotal. Despite existing resources, no consolidated data compare surgeon experiences across practice models. This study surveys orthopaedic surgeons across Texas and California, to quantify perceived strengths and weaknesses of academic, private, hospital-employed, and privademic practice environments.

Methods: An anonymous survey was distributed through professional networks and organizations between May 2024 and May 2025. Respondents identified their current and prior practice settings, subspecialties, and employment ZIP codes. They rated each practice setting in categories including autonomy, salary, ancillary income opportunities, education, research, administrative burden, reputation, community respect, and work-life balance. Responses were aggregated into a heatmap, with subgroup analysis conducted based on employment history and location.

Results: A total of 100 orthopaedic surgeons responded 45% academic, 30% private, 16% hospital-employed, and 8% privademic. Subspecialty distribution was balanced. Academic surgeons rated research opportunities, professional reputation, and continued education highly (p < 0.001), and ancillary income was rated poorly (p < 0.001). Private practitioners valued autonomy, salary, and ancillary income (p < 0.001), but rated research opportunities and continued education poorly (p < 0.001). Hospital-employed surgeons had no categories rated highly. Privademic surgeons had favorable views on autonomy, salary, and income opportunities (p < 0.001), and no categories were rated poorly. Regional comparison showed California surgeons perceived lower academic autonomy (p = 0.048) and work-life balance (p = 0.037), along with less favorable views on salary and income (p = 0.007).

Conclusions: This survey highlights distinct tradeoffs across orthopaedic practice models and locations. Academic models offer professional and educational benefits but are limited in financial upside, whereas private and privademic settings offer enhanced autonomy and compensation. California surgeons reported less favorable perceptions, especially with compensation, highlighting potential regional influences on employment satisfaction. These findings may inform future decisions in orthopaedic career planning and workforce policy.

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

Pragmatic trials have gained popularity in recent years because of their applicability to practical clinical situations. In contrast to traditional explanatory trials, which are tightly controlled and designed to define the effects of treatments under ideal circumstances, pragmatic trials are intended to reveal differences between established treatments in real-world situations. Although the intention-to-treat principle remains the cornerstone of explanatory trials, it may not reliably identify the treatment effect of greatest relevance in pragmatic trials. The estimand approach to trial design and analysis provides for specification and handling of various important intercurrent events that characterize pragmatic trials and arguably allows clearer definition of the treatment effects of interest for assorted real-world populations. Since pragmatic trials have considerable relevance to orthopaedics, we share the rationale for design and upcoming analysis of the Pulmonary Embolism Prevention after Hip and Knee Replacement Trial using an estimand framework.

» Local antibiotic delivery systems are critical in managing periprosthetic and fracture-related infections, providing high local antibiotic concentrations without systemic side effects. Polymethyl methacrylate (PMMA), the first material to be mixed with antibiotics to perform local antibiotic therapy in orthopaedic history, offers reliable antibiotic delivery above the Minimum Inhibitory Concentration (MIC), typically used with heat-stable antibiotics such as vancomycin, tobramycin, and gentamicin. However, excessive antibiotics can weaken the cement, especially in total joint arthroplasty (TJA). When used for bone defects, a second surgery is often required to replace PMMA with bone grafts. » Calcium sulfate (CaSO₄) and hydroxyapatite (HA) combinations provide high antibiotic delivery, with CaSO₄ dissolving over time and CaSO₄/HA offering better bone conversion than CaSO₄. They are most effective in small, contained defects and can be mixed with relatively heat-unstable antibiotics. » Tricalcium phosphate (Ca₃[PO₄]₂) cements are favored for their biocompatibility and biodegradability, enhancing osteoconductivity and allowing for prolonged antibiotic release. Although clinical studies on Ca₃(PO₄)₂ as an antibiotic carrier are limited, vancomycin is commonly used, showing effective bone formation and infection control with a high bone defect cure and healing rate. » Hydrogels are 3D networks of hydrophilic polymers that absorb water and can form physical barriers against bacterial agents. Defensive antibacterial coatings (DAC) can be loaded with antibiotics and have shown lower postsurgery infection rates in arthroplasty. DACs reduce bacterial adhesion and can promote bone healing when combined with osteogenic factors, while being bioabsorbable and compatible with living tissue. » Antibiotic-impregnated bone grafts combine effective local antibiotic delivery with maximum bone healing potential, particularly for those pretreated with induced membranes. Intramedullary harvest offers an unlimited source of bone graft material.

Background: Osteoporotic fractures pose a critical challenge in patient care, with earlier work pointing to a significant shortfall in preventing subsequent fractures. This study aimed to determine the rate and predictors of bone health evaluations (BHE) before and after an operatively treated first-time fragility fracture and assess the imminent risk of a subsequent fracture.

Methods: This retrospective cohort study at a level I trauma center included patients aged 60 years or older who underwent surgery for fragility fractures (hip, pelvis, wrist, humerus, or femur) due to low-energy mechanisms between 2012 and 2022. Patients with a history of pathologic fractures, malignancies, or metabolic and autoimmune diseases affecting bone density were excluded. Demographic data, medical history, and details regarding BHE and fracture characteristics were collected. BHE was defined as a specialist-led management/education session, with or without a dual-energy X-ray absorptiometry scan.

Results: Six hundred two patients (71% female; median age 78 [interquartile ranges {IQR}: 68-87]) with primary fragility fractures were identified. Within this cohort, only 13 (2.2%) had a documented BHE before fracture. Of the remaining 589 patients, 178 (30.2%) were referred for BHE after primary fragility fracture, but only 27 (4.6%) received it. Secondary fragility fractures were diagnosed in 69 patients (11.5%) after an average of 2.2 years (IQR: 1.04-3.75). Among this group, no statistically significant differences were found about patient characteristics or demographics. When comparing patients with and without secondary fragility fractures, there was no statistically significant difference in the overall rate of BHEs. Younger patients (p = 0.015) or those with a family history of osteoporosis (p < 0.001) were more likely to seek BHE.

Conclusion: There is a marked scarcity of BHEs both before and after primary fragility fractures, despite the established risks. Much work needs to be performed to improve referral and patient participation in BHEs after a first-time fragility fracture.

Background: Inflammatory Bowel Disease (IBD) is associated with systemic inflammation and which might influence surgical outcomes. As total joint arthroplasty (TJA) becomes increasingly common in this population as they age, this study aimed to evaluate whether IBD is associated with increased postoperative complications following total hip or knee arthroplasty.

Methods: We performed a systematic review of studies including patients with and without IBD undergoing TJA. Databases searched included PubMed, Scopus, Web of Science, and Embase through February 24, 2025. Eligible studies included adults with a confirmed diagnosis of IBD who underwent TJA. Meta-analyses were conducted using random-effects models with 95% confidence intervals.

Results: Fourteen studies comprising 2,651,318 patients (86,581 with IBD) met inclusion criteria. IBD was significantly associated with increased risks of PJI (OR: 1.47), hospital readmission (OR: 1.39), pneumonia (OR: 1.92), PTE (OR: 1.61), VTE (OR: 1.59), DVT (OR: 1.60), ileus (OR: 5.7), C. difficile infection (OR: 3.3), MI (OR: 2.12), CVA (OR: 2.90), UTI (OR: 2.31), sepsis (OR: 1.83), respiratory failure (OR: 2.17), revision surgery (OR: 1.38), periprosthetic fracture (OR: 1.82), wound (OR: 1.52) and implant complications (OR: 1.62). Length of hospital stay was marginally longer (SMD: 0.06). Mortality and non-home discharge did not differ significantly between groups.

Conclusion: Patients with IBD undergoing TJA are at an elevated risk for some postoperative complications, especially infections, thromboembolic events, and revision surgeries. These findings support personalized management strategies in this population.

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

Introduction: Complex proximal ulna fractures that are associated with radial head dislocation or fracture-dislocation, often referred to as "Monteggia-like" or trans-ulnar fracture-dislocations, constitute a heterogeneous group that poses challenges for classification and treatment. Management often relies on surgeon expertise rather than systematic approaches, leading to poor outcomes, high complication rates, and frequent surgical revisions. We hypothesize that a systematic, coronoid-centric, step-by-step surgical technique could improve outcomes in trans-ulnar fracture-dislocations.

Methods: A retrospective study was conducted on patients with trans-ulnar fracture-dislocations treated between 2017 and 2023. Exclusion criteria included patients younger than 18 years, open fractures beyond Gustilo grade 1, and follow-up shorter than 12 months. Fractures were classified using the coronoid-centric Mayo classification based on preoperative radiographs and CT scans. Two additional fracture patterns, characterized by distinct coronoid detachment features, were identified. Outcomes were evaluated through subjective elbow scores Subjective Elbow Value, Mayo Elbow Performance Score (MEPS), Oxford Elbow Score, QuickDASH, and range of motion (ROM) evaluations.

Results: Among the 39 patients included, the most common fracture pattern was the trans-ulnar basal coronoid fracture-dislocation (49%). At a mean follow-up of 3.9 years (range 1-7), 90% (35/39) of the patients achieved a functional ROM. The mean MEPS was 85 (range 60-100), and the mean QuickDASH was 18 (range 0-45). The revision rate was 13% (5/39), due to coronoid nonunion (n = 1), olecranon fixation failure after a new trauma (n = 1), and elbow stiffness (n = 3). Ulnar nerve neuropathy was recorded in 2 of 39 patients.

Discussion: A systematic, coronoid-centric surgical approach led to satisfactory outcomes in trans-ulnar fracture-dislocation with an acceptable rate of complication and revision rate. Recognizing the prognostic value of the coronoid may reduce complication rates.

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

Background: Osteoarthritis is the most common joint disorder in the United States, and total knee arthroplasty (TKA) is among the most frequently performed surgeries. Although randomized controlled trials (RCTs) are essential for guiding treatment, their clinical usefulness remains uncertain. This study assessed the utility of TKA RCTs published between 2020 and 2024 using the van't Hooft usefulness framework.

Methods: We systematically reviewed RCTs of knee arthroplasty published between 2020 and 2024, identified through MEDLINE and Embase (April 2, 2025). Utility was assessed using the 13-item van't Hooft framework. Linear regression analyzed associations between utility scores and study characteristics, including funding, sample size, and journal impact factor.

Results: Of 184 studies, 29.3% met the problem-base criterion. Although 86.4% included patient-centered outcomes, most were secondary. Pragmatism was rare (1.1%). 23.9% were prospectively registered, and 4.9% provided raw data. Transparency and clinical utility were moderately correlated (r = 0.28, p < 0.001).

Conclusion: Most RCTs showed internal validity but limited real-world relevance. Narrow eligibility, short follow-up, and poor transparency limit clinical impact. These findings should not be interpreted as a dismissal. Rather, they highlight opportunities to strengthen future trials so that they remain a cornerstone of evidence-based orthopaedics.

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

Introduction: Orthopedic surgery is highly competitive, requiring strong performance in research, exams, and clinical skills. Despite required competency on standardized exams, many students report low confidence in musculoskeletal (MSK) knowledge. These exams often fail to prepare students for the clinical demands of orthopedic rotations, which require a strong foundation in MSK anatomy and radiographic interpretation. This study aimed to assess medical student perceptions of preparedness and exposure to MSK anatomy and radiology during preclinical training.

Methods: A cross-sectional survey was conducted at a local orthopedic research conference to evaluate self-reported preparedness among medical students planning to apply for orthopedic residency. The 13-question survey used a 1-5 Likert scale ("strongly disagree" to "strongly agree"). Eligible participants were students who had completed preclinical training but had not begun orthopedic away rotations. The survey was voluntary, anonymous and distributed via QR code. 41 of 48 students responded (85%). Data was collected via Qualtrics and analyzed using descriptive statistics.

Results: Responses were grouped into five categories: curriculum evaluation, self-driven preparation, resource access, x-ray interpretation, and supplemental course value. While 67.6% felt well-prepared in MSK anatomy, only 23.5% felt prepared to interpret MSK radiography, while 55% felt unprepared. Most students (79.4% and 85.3%) spent extracurricular time on MSK x-rays and anatomy, respectively, and 76.5% struggled to find high-quality resources. Only 35.3% of respondents reported feeling somewhat confident in their ability to interpret x-ray if they were to be placed in an orthopedic away rotation, with zero respondents strongly agreeing and 41.2% feeling unconfident. All students agreed that formal MSK x-ray instruction would benefit them, and 91% endorsed a dedicated anatomy course.

Conclusion: Students report low confidence and insufficient preparation in MSK radiology and anatomy, despite its importance for orthopedic success. Unanimous support for supplemental instruction highlights the need for improved educational resources. Clinical Relevance: Enhancing MSK anatomy and radiology training may improve student confidence, clinical performance on orthopedic rotations, and match success in orthopedic residency.

Background: Ossification of the posterior longitudinal ligament (OPLL) is relatively common in East Asian populations, with a recently revealed link to obesity. However, evidence linking OPLL with visceral fat obesity, which is prevalent in the Asian population, is insufficient. We aimed to examine the association between visceral fat obesity and the development of OPLL.

Methods: In a single-center case-control study, data were collected from 120 Japanese patients diagnosed with OPLL and 91 controls without spinal ligament ossification identified during health screenings. From 2020 to 2023, all participants underwent computed tomography to assess visceral fat content and spinal ligament ossification. OPLL was classified as localized (cervical spine) or diffuse (thoracic/lumbar spine). Multivariable logistic regression was conducted to assess the effect size (odds ratio [OR]) of body mass index on the incidence of OPLL and to compare outcomes between groups with a high and low visceral/subcutaneous fat area (V/S) ratio.

Results: The proportion of patients with visceral fat obesity was significantly higher in both the localized and diffuse OPLL groups than in the controls (58.9% vs. 64.1% vs. 25.2%, p < 0.05). Patients with OPLL had a higher rate of comorbid visceral fat obesity than the propensity score-matched controls did (56.8% vs. 18.1%, p < 0.001). The effect of BMI on the development of diffuse OPLL was 2.6-fold greater in the high V/S ratio group (OR, 9.50; 95% confidence interval [CI], 2.11 to 42.71) than in the low V/S ratio group (OR, 3.56; 95% CI, 1.51-8.37).

Conclusions: Visceral fat obesity was associated with the development of OPLL, particularly diffuse OPLL. The modifying effect of visceral fat accumulation with overweight status was more strongly associated with diffuse OPLL than was that of subcutaneous fat combined with an overweight status.

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