Publications

Vascularized lymph node transplant (VLNT) is widely performed for chronic upper and lower extremity lymphedema. However, ideal recipient sites for the transplant are still under debate. The placement of VLNTs distally in an extremity can be challenging as the small cross-sectional area of the limb at this level does not allow for flap inset without gross contour deformity, which can adversely impact aesthetic outcomes and preclude fitting of an adequate compression garment. In this article, we introduce the Kager triangle as a potential distal lower extremity VLNT recipient site for the lower extremity. The Kager triangle is bordered by the Achilles tendon, the flexor hallucis longus, and the calcaneus, which accommodates the Kager fat pad, the largest adipose structure in the lower extremity. We transferred an omentum lymph node flap to the Kager triangle, and the posterior tibial artery and the anterior lateral malleolar artery were utilized as recipient vessels in a flow-through fashion. The incisions were directly closed with excellent cosmesis.

The prevalence of musculoskeletal diseases such as osteoarthritis, osteoporosis, sarcopenia, and rheumatoid arthritis is rising sharply with global ageing, increasing disability rates among older adults (aged ≥60 years), diminishing quality of life, and burdening health-care systems. Current musculoskeletal care for older adults faces multiple limitations, including comorbidities, frailty, and fragmented care. High osteoarthritis prevalence in individuals older than 55 years, the mounting economic burden of osteoporotic fractures, the growing concern of muscle mass decline, and insufficient guideline implementation collectively underscore these challenges. In the USA, musculoskeletal diseases affect over 121 million people and account for the highest rate of disability among all disease groups, underscoring the need for targeted strategies. Although promising solutions encompassing advanced pharmacological therapies, regenerative medicine, and digital health technologies (including artificial intelligence) are available, they remain underutilised in existing care models. This Personal View discusses the need for personalised, multidisciplinary approaches to address these issues, advocating for collaboration among the orthopaedic, geriatric, and health-care sectors in the USA. We propose that prevention of musculoskeletal diseases is key to its effective management in ageing populations, alongside a holistic, scalable approach that integrates diagnostics, therapy, and telemedicine. Early intervention, interdisciplinary collaboration, and personalised care are essential to improving patient outcomes and addressing the growing musculoskeletal disease burden in the USA.

AUDIENCE: This didactic session on distal radius fracture diagnosis and management is designed for Emergency Medicine (EM) residents of all levels.

INTRODUCTION: With an incidence of 1,130 upper extremity injuries per 100,000 persons per year,1 distal radius fractures (DRFs) are the most common adult fracture, representing 17.5% of all fractures.2-4 Yet, many emergency medicine residents feel unprepared to manage DRFs independently upon graduation.5 The standard management of a fracture in the ED setting consists of identifying any urgent aspects of the fracture, controlling pain, performing a reduction if necessary, and applying a splint.6 Poor reduction or splinting techniques can lead to serious complications, including acute carpal tunnel or compartment syndrome, development of severe burns and rarely, amputation.6-8 Though it is common for emergency medicine (EM) resident trainees working in academic institutions to have regular access to orthopaedic surgery consultation, many will go on to practice in community settings or departments without access to full-time orthopaedic coverage. It is essential for EM residents to be familiar with DRF diagnosis and management, including closed reduction and splinting. We seek to create a toolbox for managing upper extremity fractures, with the overall purpose of improving orthopaedic care in the ED setting.

EDUCATIONAL OBJECTIVES: By the end of this didactic session, learners should be able to: 1) assess DRF displacement on pre-reduction radiography and formulate reduction strategies, 2) perform a closed reduction of a DRF, 3) apply a safe and appropriate plaster splint to patient with a DRF and assess the patient's neurovascular status, 4) assess DRF post-reduction radiography for relative fracture alignment, and 5) understand appropriate follow-up and necessary return precautions.

EDUCATIONAL METHODS: Learners attended a didactic session led by orthopaedic surgery residents which included a faculty-approved lecture on DRFs and hands-on skills workshop on reducing the fractures and effectively applying plaster splints.

RESEARCH METHODS: Prior to the educational session, participants completed a pre-workshop survey assessing current practices and baseline confidence regarding DRF management. Self-confidence levels for each skill were measured using a Likert scale from 0 (least confident) to 100 (most confident). Confidence levels were re-assessed immediately after the didactic session and three months later.

RESULTS: Nineteen emergency medicine (EM) residents (n=12, 63% female) across three class years (n=9, 47% PGY 1; n=6, 32% PGY 2; n=4, 21% PGY 3) completed the pre-workshop survey, and 15 residents participated in the didactic session and completed follow-up surveys. Fourteen (75%) EM residents reported reducing DRFs on their own (without an orthopaedic consult) less than half of the time. After the workshop, confidence levels increased significantly across all seven domains of DRF management, most notably in applying a plaster splint (+31.9 points, p<0.001), teaching DRF splinting techniques (+37.0 points, p<0.001), and managing DRF care in the ED independently (+34.6 points, p<0.001). These improvements persisted three months later.

DISCUSSION: The didactic session and skills workshop on DRF management were effective in improving EM residents' confidence measures in the short term. The session was well-received by the residents, who unanimously expressed interest in collaboration for future orthopaedic workshops. Further work should replicate this study with a larger sample and develop skills assessments to objectively evaluate learners' abilities in the short and long-term.

TOPICS: Distal radius fracture, reduction, splinting, collaboration, orthopaedic surgery, orthopaedics, resident education.

BACKGROUND: Hip fractures are increasing as the U.S. population ages and result in significant morbidity, mortality, and cost. Despite guidelines recommending osteoporosis treatment after hip fracture, few patients receive treatment. To address this unmet need, our large, tertiary care, academic hospital initiated an inpatient osteoporosis treatment program with Zoledronic Acid (ZA) led by a single geriatrician co-managing patients with hip fracture admitted to the orthopedic trauma service. This study describes the program's implementation and preliminary data.

METHODS: A prospective cohort of older adults (>/= 65 years) with surgically repaired hip fractures at a single academic center were included from September 12th, 2022, through May 17th, 2024. The ZA program was initiated by geriatrics in collaboration with other specialties, including nursing and pharmacy. Co-managed hip fracture patients were screened for ZA. Eligibility criteria included creatinine clearance >/= 35 mL/min and Vitamin D level >/= 20 ng/mL. The RE-AIM framework was utilized to evaluate the program's implementation: Reach (number of patients admitted, screened and eligible), effectiveness (eligible patients who received ZA, reasons for ineligibility), adoption (time spent) and implementation (program cost).

RESULTS: During a twenty-month period, 232 hip fracture patients with a mean age of 83.8 years were admitted to co-managed care, of which 74% were female. 148 patients were screened for ZA; 67 (45.3%) were eligible, and 58 (39.2%) received ZA prior to hospital discharge. The most common reasons for ineligibility were low vitamin D (32.1%), inadequate kidney function (21%) and previous or current osteoporosis treatment in the outpatient setting (29.6%). No adverse reactions or delays in discharge were noted among treated patients. On average, 30 min were spent on screening and treatment.

CONCLUSION: A co-managed inpatient ZA program led by a single geriatrician appears to be a feasible strategy to treat osteoporosis among hospitalized patients with hip fracture.

BACKGROUND: Fracture healing is a complex, time-dependent process governed by biological and mechanical factors, including implant properties. While finite element (FE) modeling provides detailed mechanobiological insights into this process, its computational cost remains a major limitation for widespread clinical or research use. In this study, we developed and validated a machine learning (ML) framework as a rapid alternative for a previously validated 21-day mechanoregulation-based FE model of femoral fracture healing in rodents.

METHODS: We trained and compared seven ML algorithms (SVR, RF, XGBoost, MLP, CNN, RNN, LSTM) using 648 simulated healing trajectories from a validated FE mechanobiological model, varying implant, loading, and biological parameters. Hyperparameters were optimized via Bayesian search with repeated validation. Generalizability was tested on 100 unseen scenarios (interpolation), and robustness was assessed by reducing training data. Extrapolation tests evaluated predictions beyond the training timeline, and SHAP analysis was used to interpret feature contributions.

RESULTS: The sequence-to-sequence LSTM model consistently outperformed other algorithms, achieving up to 98 % error reduction compared to baseline methods in predicting central, intermediate, and outer callus stiffness, as well as total strain energy. SHAP analysis revealed biologically meaningful patterns: screw number strongly increased central stiffness, while excessive loading negatively impacted outer callus formation, aligning with established mechanobiological principles. The model generalized well to unseen (interpolated) input combinations and maintained strong performance even when trained on as little as 50 % of the data, highlighting its robustness and data efficiency. In time-step forecasting, the model accurately predicted future healing outcomes from partial early-stage data, though predictive accuracy declined with increasing extrapolation distance.

CONCLUSION: This study presents a computationally efficient and explainable ML-enhanced surrogate modeling framework that preserves the mechanistic fidelity of FE-based healing simulations while offering near-instantaneous predictions. This approach lays the groundwork for real-time decision support tools in orthopedic research, implant design, and personalized fracture management by enabling rapid scenario testing, sensitivity analysis, and forecasting.

Quantitative information on the composition of bone, specifically the content of calcium phosphate mineral and organic matrix, is essential for accurate diagnosis of metabolic bone diseases such as osteoporosis, osteomalacia, and renal osteodystrophy, as well as for differentiating among these conditions. Conventional MRI fails to provide this information because these substances are solid and, therefore, yield no signal in conventional MRI scans, which typically employ spin or gradient echoes. In this report, we show how phosphorus and proton solid-state MRI yield the desired compositional information in bone specimens with ZTE and WASPI pulse sequences, respectively, coupled with the use of a two-port double-tuned solenoidal RF coil. Electrical network simulations and construction details of the RF coil are detailed. Electrical performance was simulated using QUCS software to find the circuit component values that minimize reflected power and maximize interport isolation. Phantoms of known composition, as well as ex vivo femurs from normal, low bone density, and vitamin D-deficient rats, were included in the study. A simple correction for B1 inhomogeneity was applied to achieve quantitative accuracy in the image intensity values. Bone matrix and mineral densities derived from MRI strongly correlated (R2 = 0.84) with chemical analysis, demonstrating the ability to measure compositional differences relevant to osteoporosis and osteomalacia.

Musculoskeletal trauma remains a leading cause of disability and death worldwide, disproportionately affecting patients in resource-limited settings. Yet traditional models of orthopedic education often reflect the biases of high-income countries, limiting their applicability to the majority of patients globally. We propose a reimagined framework for global orthopedic education built around 3 core principles. First, educational efforts must center on the needs and experiences of surgeons and patients in resource-limited settings, recognizing these environments as sources of innovation and practical excellence. Second, global orthopedic education must prioritize collaboration and bidirectional learning, fostering mutual exchange rather than 1-way dissemination of knowledge. Third, building durable global networks is essential for supporting clinical excellence, research innovation, and mentorship. Programs that integrate these principles-such as academic exchanges and multilingual virtual education conferences-demonstrate the potential for education to build capacity sustainably, improve clinical outcomes, and foster innovation across diverse contexts. As global orthopedics education evolves, embracing these principles can help dismantle traditional hierarchies, amplify underrepresented voices, and advance musculoskeletal health equity worldwide.

INTRODUCTION: Femoral neck fractures in young adults are rare but carry a high risk of complications, including non-union and implant failure. The femoral neck system™ (FNS) is a newer fixation device designed to enhance mechanical stability while minimizing surgical morbidity. Limited reports exist on its failure modes. The purpose of this case report is to describe a unique failure of the FNS and the challenges encountered during revision surgery.

CASE REPORT: A 21-year-old female sustained a basicervical femoral neck fracture and underwent fixation with the FNS and an additional headless screw at an outside institution. Seven months post-operatively, she developed progressive, atraumatic hip pain and was unable to bear weight. Imaging revealed non-union and implant failure at the aperture where the bolt and antirotation screw exit the plate barrel. Revision surgery included intertrochanteric valgus osteotomy and blade plate fixation. Removal of the broken FNS components was technically demanding and required trephination, leading to further compromise of the femoral head and neck bone stock.

CONCLUSION: This case highlights a rare failure mode of the FNS involving simultaneous failure of the bolt and antirotation screw at the barrel aperture. Surgeons should be aware of this potential complication and the technical challenges it may pose during implant removal and revision surgery. These considerations may influence implant selection and pre-operative planning, particularly in young patients at risk for non-union.