Publications

BACKGROUND: Rotator cuff (RC) tears are one of the most common tendinous injuries in the adult population, resulting in pain and loss of function. While many tears are often asymptomatic, many patients will experience tears progression and the development of symptoms. The objective of this study is to determine the location of RC tear initiation and the subsequent biomechanical changes as a function of tear size.

METHODS: 8 fresh-frozen (n = 8) human cadaveric supraspinatus tendons (mean age: 68.6 ± 14.2) were subjected to fatigue loading. Images were taken to capture the location of tear initiation and subsequent progression. Tendon stiffness and nominal strain were measured throughout the tendon's lifecycle to determine changes to the biomechanical properties as a function of tear size.

RESULTS: The location of tear initiation was 15.89 ± 3.33 mm (range: 13.00-22.22 mm) from the anterior edge of the supraspinatus tendon. As tears progressed, tendon stiffness decreased (R2 = 0.68, P < .001) and nominal strain increased (R2 = 0.71, P < .001). Biomechanical changes to the supraspinatus tendon occurred between the following tear sizes: 0-100 mm2 and 100-200 mm2 (P = .001) and between 100-200 mm2 and 400 mm2 or larger (P < .001).

CONCLUSION: In a biomechanical model of RC tears induced by fatigue loading, tear initiation was observed approximately 16 mm posterior to the biceps tendon, positioning it further posterior than previously believed. Alterations to the biomechanical properties occur due to tear progression. However, these changes are most severe and significant when tears progress to >100 mm2 and further progress to >400 mm2. These insights provide a potentially clinically relevant definition of tear progression based on biomechanical changes to the supraspinatus tendon.

INTRODUCTION: Rotator cuff (RC) tears are prevalent degenerative injuries associated with progressive loss of shoulder function. Although MRI is routinely used for diagnosing RC tears, the relationship between imaging biomarkers and tendon mechanical function remains poorly understood. This study investigates whether quantitative MRI (qMRI), particularly T2 relaxation time, reflects structural and mechanical changes in supraspinatus tendons with RC tears.

METHODS: Twenty-four human cadaveric supraspinatus tendons (10 intact, 14 torn) were analyzed. Mechanical testing was performed to assess structural and material properties. T2 mapping using a 9.4T MRI scanner was employed to determine relaxation times. Raman spectroscopy and multiphoton imaging were used to assess biochemical composition and collagen organization.

RESULTS: Torn tendons showed significantly reduced stiffness (p = 0.035) and failure force (p = 0.015) compared to intact tendons. T2 relaxation times were significantly elevated in the torn group (23.7 ± 3.5 ms vs. 20.6 ± 3.3 ms; p = 0.035), with higher heterogeneity and 90th percentile values. T2 metrics correlated strongly with mechanical properties (stiffness: rs = - 0.84, p = 0.002; failure force: rs = - 0.86, p = 0.002) and tear area (rs = - 0.79, p = 0.004). Raman spectroscopy showed reduced proline and hydroxyproline spectral biomarkers in torn tendons (p < 0.02), which correlated with mechanical weakening. Multiphoton imaging revealed significant collagen disorganization and damage in torn tendons.

DISCUSSION: This study demonstrates that T2 relaxation time is a sensitive non-invasive biomarker of tendon mechanical health and collagen structure in RC tears. These findings support the clinical utility of qMRI in assessing tendon pathology and guiding treatment strategies.

Traditional antibiotic therapy has encountered significant challenges for clinical treatment of infections for multiple reasons, including antimicrobial resistance (AMR) and poor efficacy against biofilms, demanding research into alternative therapeutic agents. Because of their unique antimicrobial mechanisms as well as their target specificity, diversity, exponential self-amplification, and anti-biofilm activity, combined with recent advances in genomics and synthetic biology, bacteriophages have attracted increased interest as potential alternatives or therapeutic adjuncts to antibiotics. However, obstacles such as phage-host specificity, bacterial resistance, and the selection of optimal phages, amongst other factors, impede clinical adoption of phage therapy. Here, machine learning (ML) and artificial intelligence (AI) tools have the opportunity to revolutionize phage therapy by enhancing scalability, efficiency and precision of these therapies. This article highlights potential key applications of ML/AI in the study, development and deployment of phage therapy.

INTRODUCTION: Necrotizing soft-tissue infection (NSTI) is a life- and limb-threatening diagnosis, warranting careful evaluation. However, intra-articular gas and soft-tissue emphysema, which are commonly associated with NSTI, may also be observed after traumatic arthrotomy, joint dislocation, and prior instrumentation.

CASE REPORT: We present a 59-year-old woman in extremis from septic shock with left glenohumeral joint pneumarthrosis and emphysema extending to her posterior scapular musculature. While concerning for NSTI, physical examination was discordant. Review of pre-transfer documentation revealed prior instrumentation with an intraosseous line that pierced the left acromion process and violated the glenohumeral joint space.

CONCLUSION: NSTI is a critical diagnosis, particularly in the sick patient with hemodynamic instability, poor infectious source control, and soft-tissue emphysema. Discordant physical examination should raise suspicion for other etiologies such as traumatic arthrotomy, joint dislocation, or recent instrumentation.

UNLABELLED: Orthopaedic surgery relies on specialized devices to ensure effective management of musculoskeletal conditions, but escalating costs have compromised care. This has prompted patients and providers worldwide to explore alternative approaches such as reuse of devices. The benefits of reuse include economic savings, improvement in the availability of resources, and environmental conservation. There are, however, risks associated with reuse including concerns regarding mechanical integrity and sterilization. The medicolegal landscape surrounding reuse further complicates the establishment of recycling programs. Based on the literature, the reuse of external surgical devices, such as clamps and rods of external fixators, have improved access to musculoskeletal care and reduced health care expenditures without compromising outcomes. As such, these devices can be safely reused on a limited basis and with close monitoring. Although reused implantable devices may maintain some degree of mechanical integrity, the consistency of this stability and the appropriate sterilization of these products are currently unknown. Thus, the safety of implantable devices cannot be guaranteed at this time, and further research is needed. Providers interested in reuse must be aware of their national and local policies. In areas that lack formal legislation on device reuse, countries should focus on establishing national policies and laws that are tailored to their specific central processing capabilities and regulatory capacity. Alternative approaches to reuse that are able to achieve similar benefits without the risk should also be sought to improve access to care.

LEVEL OF EVIDENCE: Level V.

PURPOSE: The role of artificial intelligence (AI) in medicine is rapidly evolving, with potential to improve both the clinician and patient experience. We sought to evaluate whether popular AI text-to-image generators could create anatomically accurate images of common hand surgery procedures. We hypothesized that the AI-generated images would not be adequate as patient education materials.

METHODS: We queried five AI text-to-image generators: Craiyon, DALL-E, DeepSeek, Gemini, Midjourney, and Stable Diffusion. They were given the prompt, "Create an anatomically accurate image with labels of [Condition] surgical approach to be used as a visual aid for patient education," with the following conditions inserted: carpal tunnel syndrome, Dupuytren contracture, trigger finger, thumb carpometacarpal arthritis, and de Quervain tenosynovitis. Images were then graded on legibility, detail and clarity, anatomical realism and accuracy, appropriate surgical site, and lack of fabricated anatomy. Images could score a maximum of 2 points per each criterion, with an assumed Control score of 10 points.

RESULTS: A total of 1,500 images were generated and reviewed. When comparing total scores, all AI generators performed significantly lower than the Control, except for DALL-E's images of Dupuytren contracture. For the image detail and clarity category, DALL-E, DeepSeek, Gemini, and Midjourney all scored similarly to the Control and each other. For the remaining criteria (legibility, anatomic realism, surgical site, fabricated anatomy), each of the AI generators scored significantly lower than the Control generator. In total, 99.8% of images contained at least some degree of fabricated anatomy. DALL-E consistently had the highest scores for each category, while Craiyon had the lowest.

CONCLUSIONS: Although the AI servers successfully produced highly detailed and visually engaging images, they failed to portray accurate anatomy and often included fictitious structures. Further work is needed to train and fine tune AI models to produce accurate and appropriate images.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

INTRODUCTION: Hip fractures are common among older adults; and while urgent fracture fixation is recommended, it is often weighed against preoperative optimization needs. Previous studies have reported conflicting findings on the association between time to surgery and mortality risk. In this study, we investigated the association between surgical timing and mortality. We also explored the relationship between time to surgery and secondary outcomes, including length of stay and hospital readmission.

METHODS: We conducted a retrospective cross-sectional study of 967 adults aged ≥ 65 who underwent hip fracture repair between 2018 and 2023. Time to surgery (in days) was the primary exposure. Multivariable Cox proportional hazards models were used to assess associations with 30-day, 90-day, and 365-day mortality. Firth penalized logistic regression was used to examine associations with secondary outcomes, including length of stay >7 days and 30-day readmission.

RESULTS: For 30-day, 90-day, and 365-day mortality, each additional day of delay in surgery was associated with an increased risk of mortality, with adjusted hazard ratios (HR) of 1.15 (95% CI [1.02, 1.30], P = .02), 1.13 (95% CI [1.02, 1.26], P = .02), and 1.09 (95% CI [1.01, 1.19], P = .03), respectively. Similarly, each additional day of delay was associated with an increased risk of a length of stay >7 days and readmission within 30 days of discharge, with adjusted odds ratios (OR) of 2.26 (95% CI [1.89, 2.74]) and 1.16 (95% CI [1.05, 1.29]), respectively.

CONCLUSION: Delaying surgery in older adults increases the risk of mortality, along with a potential elevated risk of prolonged hospital stays and readmission. We recommend that, when safe, surgery should be performed promptly for these patients.

BACKGROUND: Meniscal preservation has been demonstrated to contribute to long-term knee health and has been a successful intervention in isolation and in patients with anterior cruciate ligament reconstruction (ACLR). The long-term results of meniscal repair in the setting of revision ACLR have yet to be documented.

PURPOSE: To report the incidence of meniscal repair failures at the 6-year follow-up in a cohort of patients who underwent concurrent revision ACLR and primary meniscal repair.

STUDY DESIGN: Prospective cohort study; Level of evidence, 2.

METHODS: All revision ACLRs with concomitant primary meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Six-year follow-up was obtained to determine whether any subsequent surgery had occurred since their initial revision ACLR. If so, operative reports were obtained, whenever possible, to verify pathological condition and treatment.

RESULTS: In total, 221 patients from 1234 revision ACLRs underwent concurrent primary meniscal repairs (18% of the cohort). There were 238 repairs performed: 173 medial and 65 lateral. The majority of these repairs (n = 181; 76%) were performed with an all-inside technique. Six-year surgical follow-up was obtained in 77% (171/221) of the cohort, or 189 of 238 (79%) of the repairs (136 medial, 53 lateral). The meniscal repair failure rate, defined as reoperation, was 16% (31/189) at 6 years. Of the 31 failures, 28 were medial (24 all-inside, 4 inside-out; 28/136 = 20.6% failure rate) and 3 were lateral (2 all-inside, 1 inside-out; 3/53 = 5.7% failure rate). Three medial failures were treated in conjunction with a subsequent repeat revision ACLR. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears (20.6% vs 5.7%; P = .01) and had a significantly shorter survival time compared with lateral tears (P = .02). No difference was found between the failure and nonfailure groups when it came to tear type, tear length, repair technique utilized, suture/implant type, or number of sutures used between the 2 groups.

CONCLUSION: Meniscal repair in the revision ACLR setting has a 16% failure rate at 6 years. Failure rates for medial tears (20.6%) were found to be higher than that for lateral tears (5.7%), which aligns with previous studies in both the revision and primary ACLR setting.

CASE: We present a 59-year-old male patient with recurrent right knee extensor mechanism deficiency who underwent reconstruction using a free vascularized tensor fascia lata flap from the ipsilateral thigh with submillimeter perforator-to-perforator anastomosis. Performed in a revisional setting (third surgery) with scarring and prior failure, novel aspects included dual-layer reinforcement and limited-incision harvest with tunneling. At 12 months, he regained full extension and a stable, pain-free gait.

CONCLUSION: This case shows that a free vascularized tensor fascia lata flap with perforator-to-perforator anastomosis is a viable option for extensor mechanism reconstruction in complex, revisional cases.