Increasing attention has been directed towards the fragility index (FI) and reverse fragility index (RFI) in orthopaedic surgery. The purpose of this study was to amalgamate the FI and RFI literature in orthopaedic surgery, and critically appraise its clinical impact.
Three databases were searched from inception to 22 March 2025, for articles evaluating either the FI or RFI across orthopaedic surgery. Median and mean FI and RFI were presented as ranges with median values. Findings from correlation analyses assessing the impact of study characteristics on FI were consolidated. Citation analysis was performed to assess the uptake of FI/RFI literature.
Eighty-four studies were included in the final analysis. Sports medicine was the most represented subspeciality (25.0%). Median FI of subspeciality-specific studies ranged from 1 to 6, and RFI from 3 to 7. Median FI of pathology-specific studies ranged from 0 to 12, and RFI from 2 to 10. The RFI exceeded the FI in most pathology-specific studies (93.3%). Decreasing p-value (88%), increasing sample size (50%) and increasing study power (50%) were commonly found to be associated with increasing fragility index. The median number of citations was 11.5 (interquartile range [IQR], 3.0–27.0) with a median citation density of 3.1 (IQR, 1.2–6.2). Sports medicine publications had the highest collective median citation density of 4.3 (IQR, 1.0–6.6). The h-index for all included studies was 25, indicating 25 studies had at least 25 citations. Earlier publication year (p < 0.001) and increasing journal impact factor (p = 0.007) were associated with increased citations.
The majority of fragility index research is concentrated across a few orthopaedic subspecialties with redundant findings indicating low statistical robustness. Recurring methodologic recommendations based on correlation analyses include increasing patient sample size to increase study power. Methodological recommendations from this body of research should be integrated into future original studies to strengthen statistical robustness.
Level III.
High tibial osteotomy (HTO) is frequently used to treat knee malalignment in younger patients. Given the rise in online health information-seeking behaviour, this study aimed to evaluate the quality of ChatGPT-generated responses to frequently asked questions (FAQs) about HTO and to assess the reliability of two scoring systems used by orthopaedic surgeons.
Twenty-four FAQs were submitted to ChatGPT (GPT-4-turbo). Four orthopaedic surgeons independently rated the responses at two time points using: (1) a 4-point categorical scale (1 = excellent, 4 = poor), and (2) a 100-point numerical scale (0 = worst, 100 = best). Intra-observer reliability was assessed using weighted kappa (κ) and intraclass correlation coefficients (ICC); inter-observer agreement was measured using ICC values.
Most responses were rated positively, with over 70% considered ‘excellent’ or requiring minimal clarification. Intra-observer agreement was variable, ranging from κ = 0.333 to 0.864 and ICC = 0.690–0.922. Inter-observer agreement was consistently low across both scales (ICC ≤ 0.390).
ChatGPT responses to HTO-related FAQs were rated as high quality by most evaluators. However, the low inter-observer agreement highlights the need for standardised evaluation tools and suggests that expert oversight remains essential when integrating AI-generated content into patient education.
Level V.
The posterolateral region of the knee or so-called posterolateral corner of the knee or posterolateral angle is an anatomical entity that remains relatively unknown. A clinical consensus relative to the evaluation, diagnosis and treatment of posterolateral corner injuries has recently been published. However, there are still knowledge gaps as to the precise anatomy and variability of all the structures that are part of this anatomical region. There is also paucity relative to their precise histological characteristics and their function. In addition, the nomenclature used in the literature for the posterolateral corner structures is sometimes confusing. A narrative review of the research focused on the posterolateral corner of the knee over the last hundred years was conducted. The main objective of this work was to synthesize and to bring order to the existing knowledge of the main ligamentous and tendinous components of the posterolateral corner of the knee. Twenty fresh-frozen human knees from a body donor programme were dissected to obtain anatomical images from each one of the posterolateral corner structures. Currently, there is no consensus regarding the anatomical descriptions of some of the posterolateral corner structures. Their nomenclature is still confusing, and the anatomical descriptions are not sufficiently complete. However, the images taken of each of the posterolateral corner structures show their main morphological characteristics. This work will help to develop a common framework and a consensus on the anatomy of these structures. Currently, the lack of consensus relative to the anatomy of the posterolateral region of the knee makes it difficult to resolve issues around injuries to them, their diagnosis, and the treatment of these structures.
N/A.
Ulnar shortening osteotomy (USO) is the primary surgical intervention for the treatment of ulnar impaction syndrome (UIS), requiring high precision. Conventional techniques face challenges in achieving optimal outcomes. This study evaluates whether 3D-printed patient-specific osteotomy guide plates can improve surgical precision and functional recovery.
A retrospective comparative study was conducted on patients who underwent USO, divided into the USO group (n = 37) and the 3D-USO group (n = 20). Perioperative outcomes, radiographic precision (ulnar variance and osteotomy angle), functional recovery (visual analog scale, disability of the arm, shoulder and hand, modified mayo wrist score, grip strength and range of motion) and medical cost were assessed.
The 3D-USO group demonstrated significant advantages, including reduced operative time, fluoroscopy frequency and hospital stay. Radiographically, the 3D-USO group achieved superior precision in ulnar variance correction (−0.14 vs. −3.52 mm) and osteotomy angle (3.0° vs. 6.9°). Clinically, this group exhibited significantly better early functional recovery scores and grip strength at the 6 week and 3-month follow-ups. No significant difference was noted between the two groups in terms of the incidence of complications or the reoperation rates.
3D printed osteotomy guide plates improved surgical precision and early functional recovery without increasing postoperative risks. These findings corroborate the potential of the 3D-printed osteotomy guide plate as a translational and therapeutic tool for the effective, accurate, and personalised treatment of patients with UIS.
Level IV.
The purpose of the study was to compare time to return to sport between patients undergoing isolated medial patellofemoral ligament reconstruction (MPFL-R) and patients undergoing MPFL-R and concomitant TTO (MPFL-TTO) for recurrent patellofemoral instability.
A retrospective chart review of prospectively collected data was conducted to identify consecutive patients who underwent primary isolated MPFL-R or MPFL-TTO. Exclusion criteria included concomitant cruciate ligament surgery, multi-ligament surgery, failed previous surgery and <1 year follow-up. Patient demographic information, surgical data, radiographic data, return to sport, and re-dislocation rates were recorded. Pre-operative and post-operative functional outcome scores (Kujala, IKDC), activity level (Pedi-FABS), and health-related quality of life (KOOS-PS, KOOS-QOL) were compared.
One hundred and seventy-eight patients were included in the study. One hundred and nineteen patients (74% female) underwent isolated MPFL-R, and 59 patients (85% female) underwent MPFL-TTO. Patients who underwent MPFL-R returned to sport at 9.5 ± 3.9 months, and patients who underwent MPFL-TTO returned to sport at 12.9 ± 11.0 months (p = 0.011). Patients who underwent isolated MPFL-R had a significantly higher return to the same or higher level of sport compared to MPFL-TTO (85% vs. 66%, p = 0.018). Both cohorts showed significant improvement in KOOS, IKDC, and Kujala scores at all follow-ups (p < 0.001).
Patients who underwent both isolated MPFL-R and MPFL-TTO had excellent return to sport rates, with isolated MPFL-R patients reporting significantly higher rates of return to the same or higher level of sport. The MPFL-R group returned to sport faster than those who had a concomitant TTO, with no difference in rates of recurrent instability. Patient-reported outcomes for both groups were significantly improved at 5 years postoperatively. The results of this study contribute to the growing body of literature supporting excellent long-term functional recovery with low rates of recurrent instability after isolated MPFL-R or MPFL-TTO.
Level III, cohort study.
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