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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.

Background: Mastery of hip reduction techniques is a critical skill for emergency medicine physicians and orthopaedic surgeons. Resident physicians often face challenges in acquiring necessary hands-on experience with this procedure, with limited or variable exposure in the clinical learning environment. Soft-embalmed cadavers have unique properties that maintain joint range of motion and may provide an innovative model for training hip reduction techniques in a simulated environment. This project sought to assess the feasibility and physical resemblance of soft-embalmed cadavers as a novel hip dislocation-reduction model.

Methods: The model was created using 2 soft-embalmed cadavers. An orthopaedic surgeon conducted a dissection of the femoroacetabular joint to facilitate repeated dislocations and reductions without compromising the model's integrity. This model was tested by a multidisciplinary group of subject matter experts (SMEs) including 6 physicians specializing in emergency medicine, sports medicine, and orthopaedic surgery who performed hip reductions on the cadaveric model. The experts then completed a survey to assess physical resemblance and utility of the cadaveric model for teaching hip reductions.

Results: All SMEs noted near-complete realism regarding the model's anatomy and range of motion. For replicating a hip dislocation, 83% of SMEs stated the model was realistic. While 66% of SMEs stated the cadaver gave a realistic representation of a hip reduction, only 33% reported the cadaver was able to simulate forces of a real patient. Overall, 66% of SMEs expressed a strong inclination to use this model for teaching learners.

Conclusion: In sum, soft-embalmed cadavers are a feasible model for hip reduction training, limited in their ability to simulate forces required for reduction. In the absence of other available simulators, they may provide learning opportunities for training hip reduction and have potential as a training model for other orthopaedic procedures.

Background: Surgeon selection can influence patient satisfaction, outcomes, and access in total joint arthroplasty (TJA). Awareness of patient preferences enables practices to enhance trust, optimize communication, and improve adherence. While referrals and word-of-mouth recommendations often outweigh online marketing, prospective multicenter research exploring how patients choose their TJA surgeon is limited. The aim of this study was to identify key decision-making factors and how they vary by demographics.

Methods: This prospective, multicenter cross-sectional survey study included patients undergoing elective total joint arthroplasty at 4 high-volume institutions from January 2024 to 2025. Participants completed a survey on surgeon selection, including how they first heard of the surgeon, number of visits before deciding on surgery, and whether other surgeons were consulted. Patients rated 10 factors (1-10 scale) and selected the top 3 most important ones from a list of 7 factors.

Results: Among 808 participants, most selected their surgeon through referrals (44.9%) or word-of-mouth recommendations (18.7%); only 8.4% cited online advertisements. Female patients rated surgeon gender (p = 0.010), ease of communication (p = 0.036), and time spent (P = 0.008) as more important than male patients. Minority patients prioritized gender (p = 0.003), race (p < 0.001), bedside manners (p = 0.013), time spent (p = 0.045), and implant type used (p = 0.004) more than White patients. Patients with a median household income between $30,000 and $70,000 rated insurance acceptance higher than those with household income higher than $300,000 (p = 0.007).

Conclusions: Patients choose their arthroplasty surgeon primarily by way of referrals and word-of-mouth recommendations, underscoring the importance of trust. Female and minority patients value surgeon gender, race, and interpersonal skills, supporting culturally responsive care. Strengthening primary care physician engagement and community outreach may improve trust and promote equitable access.

Background: Muscle rebalancing improves shoulder internal rotation contracture due to brachial plexus birth injury but is less effective for correcting marked glenohumeral dysplasia. For severe cases, combining glenoid anteversion osteotomy (GAO) with subscapularis lengthening and tendon transfers is an alternative to external rotation osteotomy of the humerus. We asked how the addition of glenoid osteotomy affects shoulder motion.

Methods: We defined 2 groups who underwent very similar procedures with the exception of GAO: GAO group-combined GAO, subscapularis slide, and tendon transfers for severe glenohumeral dysplasia, and non-GAO group-subscapularis slide and tendon transfers without GAO for cases of milder dysplasia. We compared active and passive rotation, Active Movement Scale (AMS) and Mallet scores.

Results: We compared 86 children in the GAO group with 74 children in the non-GAO group with median follow-ups of 58 (IQR1-3:22-101) and 46 (IQR1-3: 24-72) months, respectively. Preoperatively, the children in the GAO group were older (median 79 (range 14-210) months vs. 34 (range 6-204) months) and exhibited a relatively severe distribution of glenohumeral dysplasia than those in the non-GAO group, as expected. The extent of active external rotation (ER) in adduction improved postoperatively in the GAO group by 65° (p < 0.05), and in the non- GAO group by 84° (p < 0.05). Despite loss of the mean end range of internal rotation by 31° and 27°, the total arc of rotation increased by 34° and 57° in the GAO and Non-GAO groups, respectively. At final follow-up, active ER at 90° abduction (p = 0.14), passive ER (p = 0.17), total arc of rotation (p = 0.11), AMS ER (p = 0.45), Mallet global ER (p = 0.9), and Mallet composite (p = 0.9) scores were similar between the groups, irrespective of the glenoid osteotomy.

Conclusion: The 2 approaches compared here resulted in similar functional outcomes despite different initial severities of glenohumeral dysplasia. Addition of GAO for severe cases does not obviate improved motion.

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

Background: Geographic access to orthopaedic surgery remains limited in nonmetropolitan regions, where over half of US counties lack an orthopaedic surgeon. Osteopathic physicians (DOs) are nearly twice as likely as allopathic physicians (MDs) to practice in these areas, making them a key component of the rural surgical workforce. However, their representation in orthopaedic training has declined since the ACGME-AOA merger.

Methods: This cross-sectional national study used 2022 Area Health Resource Files, National Residency Matching Program Match data (2020-2024), and USDA Rural-Urban Continuum Codes (RUCC) to evaluate workforce distribution and match outcomes. Statistical analysis included chi-square testing and odds ratios to assess nonmetropolitan representation by degree and state.

Results: Of 30,243 orthopaedic surgeons, 92.9% practiced in metropolitan counties and 7.1% in nonmetropolitan areas. Among DOs, 12.5% practiced in nonmetropolitan regions compared with 6.9% of MDs (OR = 1.92; 95% CI: 1.67-2.19). Eleven states showed significantly higher odds of DOs practicing in nonmetropolitan counties, 9 of these states with longstanding in-state osteopathic schools. From 2010 to 2022, DO presence in nonmetropolitan areas increased by 59%, nearly double the rate of MDs. Despite these contributions, DO match rates in orthopaedic surgery declined from 63.3% to 45.7% between 2020 and 2024, widening the DO-MD gap.

Conclusions: DOs play an important role in orthopaedic coverage, as a percentage of their total, in nonmetropolitan communities. Declining match rates raise concerns about the sustainability of this workforce, particularly in states where DOs help maintain surgical access. Structural reforms in training pathways and residency selection may help preserve geographic workforce diversity.

Clinical relevance: Targeted strategies, such as rural training programs, holistic applicant evaluation, and state-specific recruitment efforts, may strengthen access to musculoskeletal care in underserved regions and support a more equitable orthopaedic workforce.