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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.

Background: The aim of this study was to determine if cancellations within 1 week of surgery are more costly and whether failure to obtain medical clearance is a common reason for nonelective cancellation.

Methods: A retrospective review of 1,684 consecutive scheduled surgeries at 1 surgery center by 1 surgeon was performed. Demographics, including age, gender, and hand dominance; timing of surgical scheduling; and surgery type were recorded. Cancellations within 2 weeks of surgery were recorded including the date and reason, categorized as elective and nonelective, and whether the timeslot was filled or unfilled. Cancellations were analyzed based on number of days prior to surgery: 0 to 7 versus 8 to 14 days versus >14 days from surgery. Estimated revenue and Relative Value Unit (RVU) losses were calculated using values and the average revenue of shoulder surgery found in existing literature. Statistical analysis was used for comparisons between the groups using t-tests, analysis of variance, χ² test, and Fisher exact test.

Results: There were 175 cancellations, 96 occurring within 2 weeks of the scheduled surgery. The average cancellation time was 5.9 ± 4.2 days before surgery. 43.8% (28/64) of cancellations 0 to 7 days before surgery were filled, a significantly lower number compared with those that occurred 8 to 14 days earlier with 93.4% (30/32) of timeslots filled following the cancellation (p = 0.00), and all cancelations >14 days before surgery were filled (79/79). The rate of elective and nonelective cancellations did not differ between the 0 to 7 and 8 to 14 days (p = 0.74). Nonelective cancellations related to lack of medical clearance contributed to 17.2% (11/64) of cancellations that occurred 0 to 7 days before surgery. Approximately $385,624 or 2,990 RVUs of revenue was lost due to unfilled timeslots.

Conclusions: There was an inflection point observed 7 days before scheduled surgery, which marked a statistically significant decrease in the rate at which surgical cancellations were filled with alternative cases at available surgical timeslots. Lack of medical clearance also led to a substantial loss of revenue.

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

Background: Social media is a significant source of medical information for patients, and strategies are needed to enhance the dissemination of accurate orthopaedic content. As prior literature demonstrates that patients prefer simplified language in clinical settings, evaluating the complexity of language in orthopaedic social media posts is crucial for improving online communication.

Methods: Content from 31 American Academy of Orthopaedic Surgeons patient education materials (PEMs) was posted on 2 separate social media accounts. One account shared the original PEMs, while the other posted simplified versions using a validated text simplification protocol that uses artificial intelligence. Engagement metrics, including views, likes, and time spent, were collected. Data were compared using paired t-tests, Wilcoxon signed-rank tests, and Kruskal-Wallis tests.

Results: Original (complex) posts garnered 21,380 views compared with 21,682 views for simplified posts. Despite no significant difference in view counts (p = 0.49), original content received significantly more likes (average 39.58 vs. 22.83 per post, p = 0.003) and longer cumulative viewing time spent per post (86.04 vs. 58.91 minutes per post, p < 0.001). Spine-related posts were the most engaging, achieving the highest average views, likes, and time spent of all orthopaedic subspecialities.

Conclusion: More detailed, complex orthopaedic content garnered higher total likes and longer time spent with posts. Spine-related posts were the most engaging, suggesting social media trends mirror relative clinical prevalence. These findings highlight the importance of striking a balance between content complexity and accessibility to effectively disseminate orthopaedic information on social media platforms.

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

Background: Carpal tunnel release (CTR) or local corticosteroid injection (LCI) is used for the management of carpal tunnel syndrome (CTS). While some practitioners start with CTR right away, others tend to begin with LCI. Both approaches are widely used, and individual randomized controlled trials (RCTs) have disagreed about the superiority of one approach over the other for CTS management. Therefore, a meta-analysis of RCTs would be helpful in informing clinicians.

Methods: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until August 8, 2025. Inclusion criteria consisted of English or non-English language RCTs comparing CTR with LCI in the management of CTS. The studied outcomes were management failure, improvement in symptoms, and improvement in function at several postoperative timepoints.

Results: Twelve RCTs representing a total of 1799 patients, with 880 undergoing CTR and 919 undergoing LCI, were included. There was no difference in failure rates between the 2 groups at 1, 3, and 6 months; function improvement at 3 and 6 months; and symptoms improvement at 3 months. However, the LCI group had a higher rate of failure at 1 year (odds ratio [OR] = 18.41; p = 0.01) and latest follow-up (OR = 5.38; p = 0.003), and the CTR group had a better improvement in symptoms at 6 months (standardized means difference [SMD] = 0.39; p = 0.03) and 1 year (SMD = 0.30; p = 0.01).

Conclusion: This meta-analysis revealed that CTR and LCI were equivalent management options for CTS for the first 6 months after treatment. However, CTR was superior at longer follow-up.

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

Background: Periprosthetic joint infections (PJI) caused by Cutibacterium spp. are frequently observed in total hip arthroplasty (THA) using the direct anterior approach (DAA). The microbiological spectrum of PJI after DAA differs from that of a lateral based approach. The aim of this study was to compare a dual-antibiotic (AB)-prophylaxis with cefuroxime (CEF) and doxycycline (DOX) to mono-AB-prophylaxis with CEF alone in DAA THA.

Methods: A total of 4,430 primary THAs receiving CEF prophylaxis were compared with 3,487 THAs receiving CEF+DOX prophylaxis. The institutional AB-prophylaxis was changed from cefuroxime 1.5-3 g (CEF group) alone to cefuroxime 1.5-3 doxycycline 300 mg (CEF+DOX group). A multivariable binary logistic regression analysis to evaluate the association between CEF vs. CEF+DOX and the occurrence of PJI (according to the International Consensus Meeting 2018) was performed with dropping 3 months before and after the change (covariates: American Society of Anesthesiologists, Charlson Comorbidity -Index, age, body mass index [BMI], smoking status, and diabetes mellitus [DM]). The primary outcome was the incidence of PJI following THA after a minimum follow-up of 1 year, with an accompanying analysis of the microbiological spectrum.

Results: In total, 7,917 (age: 65.8 (65.5; 66.0) years; female: 61.2%; male: 38.8%) THA were analyzed for this study. After a median follow-up of 4.3 years (interquartile-range: 2.0-6.2), no significant difference in the incidence of septic revision was observed between the CEF and CEF+DOX therapy with an infection rate of 1.3% and 1.0%, respectively (p = 0.172). The septic-free revision rate at 1 year was 99.0% in the CEF group and 99.1% in the CEF+DOX group (p = 0.541). Due to the longer follow-up, the CEF group experienced more THA with aseptic loosening compared to the CEF+DOX group. The type of AB prophylaxis was not associated with a clinically relevant higher risk of PJI (odds ratio [OR] = 1.03; 95% CI: 0.99-1.07; p = 0.052). Only BMI demonstrated a significant association with PJI (OR = 1.12; 95% CI: 1.09-1.16; p < 0.001). In the CEF+DOX group, Cutibacterium avidum was more frequent (15.7% vs. 8.1%) and Cutibacterium Acnes was less frequent (9.8% vs. 12.3%) compared with the CEF group (p = 0.143 and p = 0.809, respectively).

Conclusion: This study showed no superiority in the rate of PJI between CEF+DOX and CEF alone in DAA THA. DOX does not prevent Cutibacterium-positive PJIs. There are factors other than AB prophylaxis that influence the risk of PJI.

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

Background: Chronic posterior hip dislocations are rare and diffcult to treat. Open reduction is exceptionally challenging given the significant amount of scar tissue and muscle contractures, and need to preserve the blood supply to the femoral head while obtaining a stable, concentric reduction. The goal of this article was to describe the outcomes of two different novel surgical techniques for open reduction of chronic posterior hip dislocations.

Methods: This was a retrospective review of two different surgical techniques for the reduction of chronic posterior hip dislocations that were completed at a single tertiary referal center. All patients with chronic (>6 weeks) posterior hip dislocations treated with either a keyhole approach or a Ganz trochanteric flip osteotomy. Clinical outcomes included ability to ambulate without an assistive device and rates of complications. Patient-reported outcomes included the modified Harris-Hip Score (mHHS). Radiographic outcomes included rate of avascular necrosis.

Results: Twelve patients with chronic posterior, native hip dislocations were included with an average age of 27.3 years (range 8-38) and average follow-up of 0.9 months (range 0.25-3.5). The average time of dislocation before surgical reduction was 5.5 months (range 3-11). Four patients were reduced with a keyhole approach and 8 patients with a Ganz osteotomy. Two femoral shortening osteotomies were required for initial reduction, both in the keyhole group. All patients ambulated independently and had satisfactory mHHS at final follow-up (mean 92.5 months, range 83-100).

Conclusions: In the treatment of chronic (>6 weeks) posterior hip dislocations, both the keyhole and the Ganz trochanteric flip osteotomy approaches have acceptable outcomes in regard to functional and patient-reported outcome measures. The Ganz osteotomy offers improved access to the acetabulum and mitigated the need for a femoral shortening osteotomy. Longer-term follow-up will provide information on the viability of hip preservation in patients suffering chronic posterior hip dislocations.

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

Background: This study aimed to investigate the incidence of perioperative myocardial infarction/injury (PMI) and mortality and to identify associated risk factors, in patients undergoing surgical treatment for proximal femur fractures (PFFs).

Methods: We performed a post hoc analysis of a prospective cohort study and included consecutive patients undergoing surgery for PFFs (femoral neck, intertrochanteric, or subtrochanteric fractures) at a tertiary center between 2014 and 2018. All patients underwent systematic PMI screening using serial high-sensitivity cardiac troponin T measurements. The primary outcomes were incidence of PMI and all-cause mortality at 1 year. Univariable logistic regression identified risk factors for PMI and mortality.

Results: Among 348 patients, 23% developed PMI. PMI incidence did not differ significantly between arthroplasty and osteosynthesis groups (22.0% vs. 24.0%, p = 0.7). A history of myocardial infarction and hypertension was associated with increased PMI risk. One-year mortality was 17.8% overall and higher in patients with PMI compared with those without (27.5% vs. 14.9%, p = 0.013). Significant risk factors for 1-year mortality included low body mass index, history of atrial fibrillation, low preoperative hemoglobin, and higher anesthesiologists class. No associations were found between PMI or mortality and fracture type, implant type, use of bone cement, or anesthesia type.

Conclusions: PMI is common after surgical treatment of PFFs and is associated with increased mortality. Systematic screening improves detection, enabling optimization of perioperative management. We recommend routine PMI screening in high-risk patients undergoing PFF surgery to reduce adverse outcomes.

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

Background: Musculoskeletal trauma accounts for a major share of global disability, yet access to orthopaedic care in low- and middle-income countries remains severely limited. This narrative review explores the systemic disparities in Nigeria, the most populous country in Africa, based on semistructured interviews with orthopaedic surgeons, field observations from a multinational clinical collaboration, and analysis of published literature and policy data.

Methods: Semistructured interviews were conducted with attending and resident orthopaedic surgeons at a national referral hospital in Lagos. Observational data were gathered during a multi-institutional orthopaedic site visit. Themes were triangulated with the literature from peer-reviewed journals, health policy documents, and global health reports to construct a multilevel review of structural, sociocultural, and economic barriers to musculoskeletal care.

Results: We identified 3 major drivers of orthopaedic inequity. First, economic constraints: more than 90% of patients pay out-of-pocket and with implant and surgery costs often exceed annual household income, care is often delayed or forgone. Second, sociocultural barriers: Patients often first seek treatment from traditional bone setters whose unregulated practices result in complications such as malunions, infections, and delayed presentation. Third, workforce-related limitations: Nigeria has fewer than 500 orthopaedic surgeons for more than 200,000,000 people. Many providers report burnout, limited access to advanced training, and a growing desire to emigrate because of low salaries and resource scarcity.

Conclusions: Proposed reforms include national insurance expansion, rural trauma center development, regulation of informal care networks, and global-academic partnerships. Orthopaedic equity in Nigeria will require both local leadership and sustained international investment that prioritizes capacity building. This review highlights a scalable collaboration model that may inform future global orthopaedic engagement strategies.

Clinical relevance: This study highlights critical barriers to orthopaedic care delivery in Nigeria, including financial hardship, workforce shortages, and infrastructure deficits, which contribute to delayed treatment and poor surgical outcomes. By identifying locally grounded, cost-effective strategies-such as integrating traditional providers, expanding telemedicine, and building global partnerships-this work offers a scalable framework for improving musculoskeletal care access in low-resource settings worldwide.

Background: The increasing utilization of magnetic resonance imaging has facilitated the detection of intraspinal abnormalities in congenital scoliosis (CS) caused by hemivertebra. However, the risk of intraspinal abnormalities across different hemivertebra patterns remains unclear. The aim of this study was to compare the prevalence of intraspinal abnormalities between single hemivertebra and multiple hemivertebra and identify key associated risk factors.

Methods: A total of 1,048 patients with CS caused by hemivertebra who received surgical correction were included. The radiographic and clinical data for each patient were collected and analyzed.

Results: Intraspinal abnormalities were present in 16.5% of patients, including syringomyelia (9.2%), lipoma filum terminale (6.0%), low-lying conus medullaris (3.1%), tethered spinal cord (2.9%), diastematomyelia (2.4%), and Chiari malformation (1.9%). Patients with multiple hemivertebra demonstrated a significantly higher intraspinal abnormalities incidence than those with single hemivertebra (24.4% vs. 14.1%, p < 0.001). In single hemivertebra (HV), 51 of 114 patients (44.7%) have intraspinal abnormalities located outside the region of bony HV, while the figure is 26 of 59 (44.1%) in patients with multiple HVs. Multivariate logistic regression showed that female sex [odds ratio (OR) = 1.800, p = 0.001], semisegmented/nonsegmented morphology (OR = 1.499, p = 0.003), and multiple hemivertebra (OR = 1.957, p = 0.001) are the risk factors of intraspinal abnormalities in all cases. Although 12.1% of all patients with intraspinal abnormalities had positive neurological findings, this was not statistically significant compared with those without intraspinal abnormalities (9.0%).

Conclusion: Patients with multiple hemivertebra have a 1.96-fold higher risk of intraspinal abnormalities compared with those with a single hemivertebra. Importantly, intraspinal abnormalities are associated with female sex, multiple hemivertebra, and nonsegmented morphology, but not neurological symptoms, and caution should be paid to the intraspinal abnormalities outside of the bony lesions.

Background: The decision to reconstruct or amputate a limb after high-energy lower extremity trauma is influenced by time-dependent factors including evolution of the extent of injury and complications. The purpose of this study was to introduce a time-dependent classification of limb condition and assess its association with amputation.

Methods: This was a secondary analysis of OUTLET, a multicenter study of participants aged 18 to 60 with a Gustilo-Anderson Type III pilon, talar, calcaneal, IIIB or C ankle fracture, or an open or closed blast/crush foot injury. The primary outcome was amputation within 18 months. The Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) was modified to score the evolving condition of the injured limb postoperatively throughout the treatment course to create a time-dependent OFC (OFC-P). Cox proportional hazards models were fit to estimate the hazard of amputation associated with OFC-P domains over time and compared with models using the baseline OTA-OFC.

Results: 568 participants comprised the study sample, of which 99 underwent amputation. The average age was 38, 33% female, and 68% White. Using the least injured state (score = 1) as the referent, the highest adjusted hazard ratios for amputation were estimated for 2-point changes in the skin (6.1-fold; 95% confidence interval [CI]: 3.1-12.0), muscle (28-fold; 95% CI: 6.8-117), arterial (12.9-fold; 95% CI: 7.1-23.2), and contamination (7.2-fold; 95% CI: 2.9-18.0) domains of the OFC-P. When the relationship of the OFC-P with amputation was allowed to change after 2 weeks from injury, further improvements in model fit were found for skin (p = 0.03) and muscle domains (p = 0.005). The time-dependent models outperformed baseline models, with the largest effect sizes observed within 14 days after injury.

Conclusions: A longitudinal modification of the OTA-OFC is more strongly associated with amputation, especially among skin and muscle domains. Dynamic, quantitative limb viability assessment more accurately reflects clinical practice and patient management but requires prospective validation.

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