Publications

PURPOSE: To evaluate and compare the responses of ChatGPT and Google Gemini to common patient questions about scaphoid fracture and scaphoid nonunion, and to compare responses between hand fellowship-trained orthopedic and plastic surgeons.

METHODS: A list of 30 common patient questions about scaphoid fracture and nonunion was developed and classified using Norman Webb's Depth of Knowledge levels 1-4. Each question was input into ChatGPT-4o and Google Gemini 2.0 Flash. An evaluation guide was created with four domains for each response, each rated on a Likert scale from 1-5: accuracy, clarity, Artificial Intelligence Response Metric, and comparison to an in-person clinician interaction. Responses were evaluated by three orthopedic and three plastic hand surgeons. Statistical comparisons were performed using nonparametric tests to assess differences between AI platforms, domains, question complexity, and surgical specialty.

RESULTS: There were no considerable differences between mean Likert scale scores for ChatGPT and Google Gemini. Plastic surgeons rated responses higher than orthopedic surgeons overall and for ChatGPT. Google Gemini performed better for DOK level 2 and level 3 questions. ChatGPT's responses had greater clarity. For both platforms, ratings for clinician comparability across all DOK levels were considerably lower than scores for all other metrics.

CONCLUSIONS: Our findings suggest that ChatGPT and Google Gemini offer clinical use for patient care regarding scaphoid fracture and nonunion. However, clinician comparability was not a key strength for either platform, highlighting a key area for improvement for AI-based large language models in clinical application.

TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic V.

OBJECTIVE: To determine how sarcopenia and malnutrition affect fracture-healing outcomes and to identify clinical implications for screening and peri-fracture care.

METHODS: A PRISMA-guided search (PubMed/MEDLINE, Cochrane Central, Cochrane Library; last search June 25, 2024; English language) identified in vivo human and animal studies evaluating fracture healing in the presence of sarcopenia or malnutrition. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the MINORS tool.

PRIMARY OUTCOME: nonunion (as defined in each study).

SECONDARY OUTCOMES: time-to-union, surgical complications, mortality, and biomechanical properties. Owing to heterogeneity, a structured narrative synthesis was performed.

RESULTS: Twelve studies met criteria: seven human (four malnutrition; three sarcopenia) and five animal (malnutrition). Large database studies linked malnutrition to higher nonunion risk (e.g., OR ≈2.0) and to post-operative complications and mortality. Definitions of malnutrition and sarcopenia varied widely across studies and included biochemical markers, anthropometric measures, imaging-based muscle assessments, and clinical screening tools. Due to this heterogeneity, associations with fracture healing outcomes were evaluated using study-level definitions rather than standardized diagnostic thresholds. Small clinical cohorts have associated sarcopenia with higher nonunion rates, and in one randomized pilot study, dietary protein/energy, combined with exercise, improved function and reduced pain while modestly shortening the time-to-union. Animal models consistently demonstrated lower BMD/BMC, altered callus composition, and reduced early mechanical strength under protein restriction, with partial reversal after re-feeding. Study heterogeneity and moderate-to-poor quality limited generalizability.

CONCLUSIONS: Across human and animal data, malnutrition and sarcopenia adversely affect fracture healing, increasing the risk of nonunion and complications, and impairing early callus quality. These findings highlight the importance of early identification of sarcopenia and nutritional risk in fracture patients. While emerging data suggest potential benefit from targeted interventions, the current evidence remains limited, underscoring the need for adequately powered randomized trials before routine clinical implementation.

LEVEL OF EVIDENCE: Systematic Review, I.

PURPOSE: To assess and compare the associative value of comorbidity fracture-specific index (CFI) versus the Charlson comorbidity index (CCI) in identifying patients at risk for early complications after open reduction and internal fixation (ORIF) of distal radius fractures (DRFs).

METHODS: We performed a single-center retrospective cohort study including patients ≥40 years who underwent ORIF for closed DRF using a volar locking plate with a minimum of 1 year follow-up. CCI and CFI scores were calculated based on comorbidities over the prior 15 years. The primary outcome was 90-day postoperative complications. We used logistic regression to compare CCI and CFI and their association with complications, adjusting for age, sex, smoking status, and ethnicity. We used Pearson correlation and the intraclass correlation coefficient to assess the relationship and agreement between CCI and CFI.

RESULTS: Among the 317 patients, 16.7% (n = 53) experienced complications. There were no statistically significant differences in CCI or CFI in patients with and without complications. After adjusting for covariates, each increase by 1 in CCI and CFI, increased the odds of complications; however, these effects were not statistically significant. CCI and CFI were strongly correlated and showed high agreement.

CONCLUSIONS: CCI and CFI scores did not significantly differ between patients with and without complications after DRF and were not significantly associated with postoperative complications after adjusting for covariates. The strong correlation and agreement between CCI and CFI suggest they capture a similar comorbidity burden in this patient population. Neither CCI nor CFI demonstrated good discriminative ability in identifying patients at risk for early complications after ORIF of DRF.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

BACKGROUND: Prior studies suggest familial clustering of rotator cuff tears (RCT) but are limited by sample size or by approach and no study has estimated narrow-sense heritability of RCT. We perform a comprehensive assessment on the familial heritability of RCT.

METHODS: We utilized data from three studies: the cuffGen study, BioVU and UK Biobank (UKB). In cuffGen, imaging confirmed RCT cases and controls completed a baseline questionnaire inquiring about their family history of RCT. In BioVU and UKB, RCT status was identified using electronic health record (EHR) data, while family relatedness was estimated empirically with genome-wide genetic array data. We then evaluated the association between family relatedness and RCT status in all three studies using multivariable-adjusted logistic regression models while adjusting for age, sex, race/ethnicity, and genetic principal components (when appropriate). Then utilizing genetic data in BioVU and UKB, we estimated narrow-sense/SNP-based heritability for RCT, employing linkage disequilibrium score regression approach.

RESULTS: In the cuffGen study, RCT cases were more likely to report any family history of RCT (Adjusted Odds Ratio [AOR]: 1.82; 95%CI 1.23-2.70) than controls. The association was stronger in first-degree relatives (AOR- 1.59; 95%CI 1.12-2.26), than in second-degree relatives. In BioVU and UKB, familial relatedness is also associated with increased odds of RCT (BioVU: AOR- 1.21; 95%CI 1.13-1.30; UKB: AOR- 1.09; 95%CI 1.04-1.15). However, the strongest associations were observed in third-degree relatives in BioVU (AOR: 1.56; 95%CI 1.10-2.14) and second-degree relatives in UKB (AOR: 1.25; 95%CI 1.12-1.39) rather than first-degree relatives. In SNP-based heritability analyses, we observed less than 1% of heritability of RCT was explained by SNPs (0.2% in BioVU, 0.75% in UKB) suggesting minimal contribution of genetic factors in heritability of RCT.

CONCLUSION: While rotator cuff tears (RCT) cluster within families, SNP-based heritability explains less than 1% contribution to heritability of symptomatic RCT. These data suggest that genetic factors alone may have a minimal impact on symptomatic RCT susceptibility, while non-genetic familial factors, such as environmental or healthcare-related factors represent plausible alternative explanations that warrant further investigation.

LEVEL OF EVIDENCE: Prognostic Level III.

INTRODUCTION: High-velocity gunshot-related humeral fractures are complex injuries often associated with a high rate of nonunion, infection, and poor functional outcome. In low- and middle-income countries these injuries are further complicated by delayed presentation and implant unavailability. Staged management with spanning external fixation followed by internal fixation with intramedullary nail or plate has been well described in the literature; however, the use of a circular frame as a definitive treatment has been very seldom mentioned.

MATERIALS AND METHODS: Six high-velocity gunshot-related humeral fractures cases were treated with a single stack half ring circular external fixator as a definitive surgery performed by a single surgeon. Aspects related to surgical technique, fracture reduction, infection prevention, and restoration of upper limb function using circular frame external fixator are described.

RESULTS: Fracture union was achieved with circular fixation alone in 5 of the 6 patients. One patient developed a nonunion and required a second operation with a lateral compression plate combined with iliac crest autograft. The median circular fixator time was 16 weeks, and the median elbow range of motion was from 0° to 130° of flexion. The median shoulder range of motion was from 0° to 170° of overhead extension. The median Quick-DASH score was 4.5. No patients developed pin site infections.

CONCLUSION: Single-stage definitive treatment with a circular external fixator may be a valid option, not only for surgeons working in resource-constrained environments, for high-velocity gunshot fractures of the humerus. Patients' cultural acceptance and maintenance of the external device far exceeded our expectations.

OBJECTIVE: Although many authors have shown the safety of outpatient spine surgery, few have compared same-day spine surgery in the ambulatory surgical center (ASC) versus the hospital outpatient department (HOPD). The purpose of this study was to compare the safety of anterior cervical arthrodesis/arthroplasty or lumbar decompression with same-day discharge performed at the ASC versus HOPD.

METHODS: After IRB approval, a retrospective, propensity-matched, comparative cohort analysis of a statewide, prospective, multicenter, spine-specific database (Michigan Spine Surgery Improvement Collaborative [MSSIC]) was undertaken. Patients who underwent lumbar decompression or anterior cervical arthrodesis/arthroplasty (1 or 2 levels) with same-day discharge from January 1, 2021, to June 30, 2023, were reviewed. The HOPD/ASC matched cohorts were created at a ratio of 4:1 based on BMI, American Society of Anesthesiologists physical status class (ASA), and operative levels. The primary outcome variables investigated included any complication, return to operating room (OR) within 90 days, and emergency department (ED) visit or readmission within 30 and 90 days. Secondary outcome measures investigated included patient-reported outcome (PRO) measures at 90 days and 1 year and return to work at 90 days and 1 year. Differences between HOPD and ASC patients were tested using univariate comparisons for both the anterior cervical and lumbar decompression cohorts. Multivariate analysis was performed for the lumbar decompression group.

RESULTS: After matching, 3351 patients who underwent outpatient lumbar decompression (2679 HOPD and 672 ASC) and 806 patients who underwent anterior cervical arthrodesis/arthroplasty (644 HOPD and 162 ASC) were included in the analysis. In the univariate analysis for anterior cervical arthrodesis/arthroplasty, there were no differences between HOPD and ASC groups in terms of any complication, PROs at 90 days or 1 year, and return to work at 90 days and 1 year (p > 0.05). In the univariate analysis of the lumbar decompression group, there were higher rates of complications and return to the OR for the ASC group compared to the HOPD group (8% vs 5.5% [p = 0.01] and 4.9% vs 2.1% [p < 0.001], respectively), which remained in the multivariate analysis (incidence rate ratio [IRR] 1.5 [p = 0.001] and IRR 2.3 [p < 0.001], respectively). There were no differences between the groups in terms of PROs at 90 days and 1 year.

CONCLUSIONS: Although both outpatient anterior cervical surgery and lumbar decompression can be performed safely and effectively in ASC and HOPD, there is a slightly higher risk of return to the OR for patients who undergo lumbar decompression in the ASC. Given similar outcomes, future studies should focus on patient and payer cost differences between ASC and HOPD.

Survivors of focal neurological injuries experience accelerated bone loss, particularly in the paretic upper extremity, substantially increasing the risk of fragility fractures. Mechanical unloading, neuromuscular impairment, and altered bone remodeling contribute to rapid reductions in bone mineral density and unfavorable changes in bone geometry within the first year after stroke and brachial plexus palsy. Despite growing evidence, bone health assessment is rarely incorporated into routine poststroke care, and referrals often occur only after fracture. This article discusses the role of hand surgeons and proposes practical screening, multidisciplinary care strategies, and interventions to improve early detection, prevention, and management of upper extremity fragility fractures.

PURPOSE: Depression, a leading cause of disability, is a known predictor of poorer outcomes in upper-extremity procedures. Associated mood and somatic symptoms may interfere with the assessment of postoperative recovery, making it difficult to distinguish between postoperative-related symptoms and those linked to depression. This study examines the impact of depression on patient-reported outcomes following carpometacarpal (CMC) arthroplasty (trapeziectomy with ligament reconstruction and tendon interposition) for basilar thumb arthritis. We hypothesized that patients with a diagnosis of major depressive disorder or active antidepressant treatment before surgery will have poorer upper-extremity outcomes at 1 year compared with patients without depression.

METHODS: Patients who underwent isolated thumb CMC arthroplasty at a single academic center were screened for inclusion. Baseline demographic data, psychiatric history, and antidepressant use at the time of surgery were collected retrospectively. Patients with concomitant psychiatric diagnoses other than depression, those undergoing multiple procedures at the time of thumb CMC arthroplasty, or individuals with additional chronic upper-extremity pathology were excluded. The Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) questionnaire was administered before surgery to establish baseline scores and at 3, 6, and 12 months after surgery. Quick Disability of the Arm, Shoulder, and Hand scores were analyzed using an independent samples t test and a linear mixed effects model to adjust for the time from surgery, sex, race, and body mass index at the time of surgery.

RESULTS: Seventy-three (22.3%) of 328 patients had a diagnosis of depression or were receiving antidepressant treatment at the time of surgery. Before surgery, the average QuickDASH score was 41.4 for the patients with depression and 40.3 for patients without. At 1 year after surgery, these averages were 28.8 and 24.0, respectively. No significant difference in QuickDASH scores was observed between patients with depression or receiving antidepressant treatment and those without at any time point.

CONCLUSIONS: This study demonstrates no significant difference in postoperative QuickDASH scores between patients with a diagnosis of depression or antidepressant treatment and those without following thumb CMC arthroplasty. These findings suggest that a history of depression may not adversely affect patient-reported outcomes after thumb CMC arthroplasty.

LEVEL OF EVIDENCE: Prognostic IV.

➢ Open fractures are a critical global health challenge that disproportionately affect individuals in low- and middle-income countries (LMICs), primarily due to road traffic collisions. Surgical management of open fractures is 1 of the 3 essential bellwether procedures identified by The Lancet Commission on Global Surgery.➢ We developed and evaluated a novel hybrid course on open fracture management for surgical trainees and practicing surgeons in Rwanda, combining a self-directed, virtual, pre-course curriculum with a live, in-person workshop in Kigali in June 2025 that was simultaneously live-streamed for virtual attendees. Prerecorded multilingual lectures (English and French) and curated peer-reviewed articles provided foundational knowledge in advance and prepared learners for in-person didactics, case discussions, and skills training.➢ The in-person workshop included didactic sessions and discussions of local clinical cases from Rwanda related to open fracture management and other orthopaedic emergencies, along with hands-on practice in fracture external fixation and negative pressure wound therapy using affordable devices designed for resource-constrained practice.➢ The workshop engaged 160 active learners (37 in-person, 123 virtual) and demonstrated high overall satisfaction among 84 survey respondents, with an average rating of 4.6 out of 5.➢ Self-reported confidence in managing open fractures increased substantially following the course, from a mean rating of 3.83 to 4.69 on a 5-point scale (p < 0.001). Most survey respondents reported that the course moderately or significantly improved their knowledge (96.4%) and would change their clinical practice (96.5%).➢ Participant feedback highlighted opportunities for improvement, including extending the workshop duration to increase hands-on time, expanding the content on complex soft-tissue management, and improving the engagement of remote learners through mechanisms such as the provision of low-cost external fixation models for at-home practice.➢ Future directions include integrating the course into medical student and general practitioner education in Rwanda, adapting it for major surgical conferences regionally and internationally, and continuing to prioritize hands-on training modules. Iterative refinement of the course is planned on the basis of participant feedback.

BACKGROUND: Optimal management of acetabular fractures remains controversial. Open reduction and internal fixation (ORIF) may be followed by post-traumatic degeneration and late conversion arthroplasty, whereas acute total hip arthroplasty (THA) may introduce implant-related risks. We compared short- and long-term outcomes after ORIF versus acute THA in a large, multicenter electronic health record cohort.

METHODS: We performed a retrospective cohort study using the TriNetX Network. Adults with isolated, closed, acute acetabular fractures treated with either ORIF or acute primary THA were identified. Patients were propensity score-matched (PSM) 1:1 on demographics and comorbidities. Outcomes were assessed at 90 days and at 1, 2, 5, and 10 years, including mortality, complications, health care utilization, and procedure-specific failures (for ORIF: nonunion, post-traumatic osteoarthritis, and conversion to THA; for THA: periprosthetic fracture, prosthetic joint infection [PJI], instability/dislocation, and mechanical complications).

RESULTS: After PSM, 3700 matched pairs comprised the early follow-up cohorts. At 90 days, ORIF was associated with higher mortality (5.2% vs 3.5%; OR 1.5; p < 0.0001) and higher rates of stroke, respiratory failure, venous thromboembolism, and ICU admission, whereas acute THA had higher emergency department visits (9.1% vs 5.3%; p < 0.0001) and hip pain (23.2% vs 13.2%; p < 0.0001). Over long-term follow-up, acute THA demonstrated higher implant-related complications at 2 years, including periprosthetic/implant fracture (3.0% vs 0.8%), PJI (6.8% vs 3.8%), instability (7.7% vs 3.0%), and mechanical complications (6.3% vs 3.5%) (all p < 0.0001), while overall reoperation rates were similar at 2 years (11.8% vs 11.2%; p = 0.53) and remained comparable through 10 years. In the ORIF cohort, nonunion reached 11.3%; conversion to THA increased from 4.3% at 2 years to 5.8% at 10 years; and post-traumatic osteoarthritis (PTOA) increased from 21.2% at 2 years to 27.2% at 10 years. Pre-index hip disease was markedly more common among acute THA patients (OA 51% vs 10%; AVN 14% vs 1%).

CONCLUSIONS: In this study, ORIF was associated with higher early mortality and systemic complications, whereas acute THA was associated with higher implant-related complications. Despite these differing complication profiles, cumulative reoperation rates were similar through long-term follow-up. Progressive PTOA and conversion to THA remain important sequelae after ORIF.