JBJS

Exploring the Endorsement and Implementation of Artificial Intelligence Guidelines in Leading Orthopaedic and Sports Medicine Journals: A Cross-Sectional Study

J Bone Joint Surg Am. 2026 Feb 18;108(4):313-319. doi: 10.2106/JBJS.25.00373. Epub 2025 Nov 26.

ABSTRACT

BACKGROUND: The integration of artificial intelligence (AI) in orthopaedics and sports medicine (OSM) has transformed clinical practice and scientific inquiry. However, the increasing reliance on AI raises critical concerns regarding transparency, ethical considerations, and reproducibility. The aim of this study was to systematically evaluate the editorial policies of leading OSM journals concerning AI usage and the endorsement of AI-specific reporting guidelines (RGs).

METHODS: A cross-sectional review was conducted in accordance with STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines. The top 100 peer-reviewed OSM journals were identified using the 2023 SCImago Journal Rank (SJR). Data extraction included journal characteristics, AI-related policies within Instructions for Authors, and references to AI-specific RGs. Data were collected in a masked, duplicate fashion, with discrepancies resolved through consensus.

RESULTS: Of the 100 journals analyzed, 94% referenced AI in their editorial policies, all of which explicitly prohibited AI authorship and required the disclosure of AI use in manuscript preparation. AI-generated content was permitted in 82% of journals. AI-assisted image generation was permitted by 60% of journals and explicitly prohibited by 34%. Despite these policies, only 1% of journals referenced AI-specific RGs, with the Checklist for Artificial Intelligence in Medical Imaging (CLAIM) being the sole guideline mentioned.

CONCLUSIONS: While most of the OSM journals had established policies on AI usage, there was a notable lack of standardization, particularly with respect to AI-generated images. Additionally, the absence of AI-specific RG endorsements highlights a gap in methodological guidance. Standardizing AI policies and encouraging the adoption of RGs could enhance the transparency, reproducibility, and ethical integrity of AI-driven research in OSM.

PMID:41706011 | DOI:10.2106/JBJS.25.00373

Minimizing Missed Diagnoses of Tibial Plateau Fractures: The Role of AI in Radiographic Evaluation

J Bone Joint Surg Am. 2026 Feb 18;108(4):303-312. doi: 10.2106/JBJS.24.00579. Epub 2025 Nov 26.

ABSTRACT

BACKGROUND: Tibial plateau fractures represent a diverse group of intra-articular injuries that can be difficult to detect and characterize on initial imaging. The aim of the present study was to develop an artificial intelligence (AI) diagnostic tool for identifying tibial plateau fractures on radiographs.

METHODS: In this retrospective study, we analyzed radiographs that had been made from January 2018 to December 2020 for 1,809 patients, with an equal distribution of male and female adults. A total of 3,821 anteroposterior and lateral knee radiographs were evaluated with use of the EfficientNet B3 AI model, with computed tomography (CT) images being used as the ground truth. Evaluation metrics focused on the area under the receiver operating characteristic curve (AUC) and positive predictive values across different subgroups.

RESULTS: Our AI model attained AUCs of 0.98 and 0.97 for detecting tibial plateau fractures in the test and external validation datasets, respectively. Subgroup analysis revealed diverse positive predictive values across different Schatzker types and 3-column classifications.

CONCLUSIONS: Our deep learning model exhibits newfound ability for identifying tibial plateau fractures. However, we encountered several limitations, such as imbalances among the sizes of various subgroups in the dataset and an inability to identify radiographs containing foreign objects or other defects.

LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:41706010 | PMC:PMC12885574 | DOI:10.2106/JBJS.24.00579

Enhancing Patient Comprehension in Orthopaedic Surgery: The EXPLAIN Framework for Surgeon-Patient Communication

J Bone Joint Surg Am. 2026 Feb 12. doi: 10.2106/JBJS.25.01047. Online ahead of print.

ABSTRACT

➢ Patient comprehension in orthopaedic surgery is frequently limited, with substantial gaps between perceived and actual understanding of conditions, procedures, and recovery timelines.➢ Expectation management is a central communication challenge, as patients often anticipate surgery or outcomes in ways that are unrealistic, directly affecting satisfaction and informed consent.➢ The EXPLAIN framework provides a structured, orthopaedic-specific approach to improve communication through 7 components: Educate, eXample, Purpose, Language/Learn, Analogy/Articulate, Illustrate, and Navigate.➢ Evidence supports the use of strategies such as plain language, teach-back, anatomical models, 3-dimensional aids, and structured navigation programs to improve comprehension, reduce anxiety, and lower readmissions.➢ Implementing EXPLAIN can enhance shared decision-making, reduce communication-related malpractice risk, and improve both patient satisfaction and outcomes.

PMID:41678671 | DOI:10.2106/JBJS.25.01047

Transthyretin Amyloid May Drive Fibrosis and Proliferation of Tenosynovial Fibroblasts in Carpal Tunnel Syndrome

J Bone Joint Surg Am. 2026 Feb 12. doi: 10.2106/JBJS.25.00807. Online ahead of print.

ABSTRACT

BACKGROUND: Transthyretin (TTR) amyloid deposition in the tenosynovium in carpal tunnel syndrome (CTS) is a potential early manifestation of systemic amyloidosis. However, its effects on tenosynovial fibroblasts in CTS remain unclear. We aimed to clarify how wild-type and Val30Met mutant TTR amyloids affect tenosynovial fibroblasts in CTS.

METHODS: Synovial tissue from 20 patients undergoing carpal tunnel release surgery was evaluated for TTR amyloid. Expression of genes related to fibrosis, inflammation, and oxidative stress was compared between TTR-positive and TTR-negative groups. Fibroblasts isolated from TTR-negative patients were treated in vitro with wild-type or Val30Met mutant recombinant TTR. Analyses included quantitative RT-PCR (reverse transcription-polymerase chain reaction), Picrosirius Red staining, MTT assays evaluating cell proliferation, reactive oxygen species (ROS) activity measurements, and senescence-related gene expression.

RESULTS: In TTR-positive tissue, fibrosis-related genes (COL1A1, COL3A1, TGFB1, and ACTA2), the inflammatory mediator NFKB1, and oxidative-stress-related genes (KEAP1, NQO1, and SOD1) were significantly upregulated, whereas SOD2 was downregulated. With in vitro treatment in the TTR-negative group, both wild-type and Val30Met TTR increased COL3A1, IL6, and CXCL8 expression, whereas Val30Met TTR further enhanced IL1B expression. Picrosirius Red staining confirmed increased collagen deposition. MTT assays revealed increased cell viability, indicating enhanced fibroblast proliferation, in both groups. The senescence-related genes CDKN2D and GADD45A were downregulated, suggesting enhanced proliferative activity. ROS activity did not differ significantly between groups.

CONCLUSIONS: TTR amyloid was found to promote expression of fibrosis, inflammation, and oxidative-stress-related genes; inhibit senescence pathways; and enhance collagen deposition and fibroblast proliferation in fibroblasts from patients with CTS.

CLINICAL RELEVANCE: CTS with TTR deposition may reflect more than a localized neuropathy, as TTR potentially plays a pathogenic role in CTS development. This finding provides novel insights into the underlying mechanisms of CTS.

PMID:41678652 | DOI:10.2106/JBJS.25.00807

Predictive Factors for Fast Healing Following Surgery for Knee Osteochondritis Dissecans

J Bone Joint Surg Am. 2026 Feb 12. doi: 10.2106/JBJS.25.01026. Online ahead of print.

ABSTRACT

BACKGROUND: Osteochondritis dissecans (OCD) healing can be unpredictably slow, incomplete, or absent after surgical treatment. This frustrates patients, families, and the medical team. We aimed to develop an algorithm to predict the speed of OCD radiographic ossification based on patient demographic, physical, surgical, and imaging data.

METHODS: We studied a prospective cohort of patients with knee OCD lesions in a multicenter database. We included patients who were diagnosed with knee OCD lesions of the lateral or medial femoral condyle and were treated operatively at a single center. We collected patient information from medical records and imaging studies. Radiographic healing was defined on the basis of the percentage of the original OCD lesion that had a normal bone density (ossification) compared with the surrounding condyle, rated on a continuous scale from 0 to 100. An OCD lesion that achieved ≥90% of the normal surrounding bone density at 6 months following surgery was defined as fast healing. Follow-up was conducted with radiographs only. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were performed.

RESULTS: This study included 79 OCD lesions in 72 individuals. The mean patient age was 13.79 ± 2.71 years (range, 8.56 to 22.98 years), and 45 (62.5%) of the 72 patients were male. A total of 56 patients (77.8%) were White, and 69 patients (95.8%) were of non-Hispanic ethnicity. In all, 23 lesions (29.1%) fit the of fast healing. A multivariable regression analysis revealed that high preoperative bone density within the OCD lesion (p < 0.001) was the only feature that had an association with fast healing. A preoperative lesion density rating of ≥70% predicted fast ossification with a sensitivity of 87% and a specificity of 66.1%.

CONCLUSIONS: A preoperative OCD density rating that was ≥70% of that of the normal surrounding bone was found to be the only independent predictor of fast ossification following surgery.

LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

PMID:41678591 | DOI:10.2106/JBJS.25.01026

Surgical Robotic System for Precision Femoral Fracture Reduction

J Bone Joint Surg Am. 2026 Feb 11. doi: 10.2106/JBJS.25.00874. Online ahead of print.

ABSTRACT

Malalignment after femoral fracture repair remains common, with up to one-third of patients experiencing malrotations. Manual femoral fracture reduction remains physically demanding and fluoroscopy-dependent. Surgeons must apply traction forces to overcome forces generated by the surrounding muscles during the reduction process. Current orthopaedic robots, designed primarily for arthroplasty or spine procedures, generally cannot deliver the high traction or torque required for long-bone manipulation. To address the need for controlled high-force manipulation during femoral fracture reduction and to reduce reliance on fluoroscopy for assessing alignment, we developed a novel surgical robotic system. The system combines a 6-degrees-of-freedom (6-DOF) parallel mechanism with a high load capacity, an optical tracking system that provides continuous pose feedback, and a gauge-based graphical interface that displays translational and angular offsets between bone fragments and the target alignment. The system is intended to provide controlled application of clinically relevant traction and torque during femoral fracture reduction. These capabilities reduce reliance on sustained manual traction and support reduction maneuvers that are more repeatable, potentially improving intraoperative alignment consistency and procedural workflow. Future work will focus on hardware and software updates to improve operating-room integration and to expand the usable workspace. It will evaluate the use of artificial intelligence (AI)-assisted registration and 3D visualization to support alignment assessment and automated alignment workflows.

PMID:41671345 | DOI:10.2106/JBJS.25.00874

Increased Critical Shoulder Angle Impairs Tendon-Bone Healing in a Rat Model of Chronic Rotator Cuff Tears

J Bone Joint Surg Am. 2026 Feb 10. doi: 10.2106/JBJS.25.00970. Online ahead of print.

ABSTRACT

BACKGROUND: The role of an elevated critical shoulder angle (CSA) in rotator cuff healing following rotator cuff repair (RCR) remains a subject of clinical controversy. The present study aimed to investigate the effect of increased CSA on tendon-bone interface healing following RCR.

METHODS: A bilateral chronic rotator cuff tear model was established in 48 Sprague-Dawley rats. Acromion lateralization (Acr) surgery was performed unilaterally to increase CSA. After 4 weeks, bilateral RCR was performed. Micro-computed tomography was utilized to measure CSA. Tendon-bone interface healing was assessed at 3, 6, and 9 weeks post-RCR with use of magnetic resonance imaging (MRI), biomechanical testing, gait analysis, and histological evaluation.

RESULTS: The mean CSA in the Acr group was significantly greater than that in the RCR-only group (37.2° ± 2.6° versus 29.7° ± 3.1°; p < 0.001). At 6 and 9 weeks postoperatively, the Acr group demonstrated significantly poorer outcomes on MRI (i.e., higher signal-to-noise quotient), biomechanical strength (i.e., lower ultimate failure load and stiffness), and gait parameters compared with the RCR-only group (p < 0.05). Histological analysis revealed inferior tendon-bone interface integration in the Acr group (p < 0.01), including reduced fibrocartilage formation, disorganized collagen fibers, and a lower collagen I/III ratio. Immunohistochemistry showed significantly higher Piezo1 expression in the Acr group (p < 0.001), suggesting a mechanobiological response to increased mechanical stress.

CONCLUSIONS: An increased CSA impaired tendon-bone interface healing following RCR in a rat model. Although these findings were preclinical, they provide experimental evidence that an increased CSA may influence rotator cuff healing, supporting the potential role of CSA modification (e.g., with acromioplasty) in reducing the risk of retear.

CLINICAL RELEVANCE: The present study provides experimental evidence to support the consideration of CSA reduction in selected high-risk patients undergoing RCR to promote rotator cuff healing and potentially reduce retear rates.

PMID:41666274 | DOI:10.2106/JBJS.25.00970

Medial Unicompartmental Versus Total Knee Arthroplasty in the Treatment of Isolated Anteromedial Knee Osteoarthritis: Two-Year Results from a Double-Blinded, Multicenter, Randomized Trial of 350 Patients

J Bone Joint Surg Am. 2026 Feb 9. doi: 10.2106/JBJS.25.00612. Online ahead of print.

ABSTRACT

BACKGROUND: The superiority of medial unicompartmental knee arthroplasty (mUKA) versus total knee arthroplasty (TKA) for isolated anteromedial knee osteoarthritis (AMOA) remains a subject of ongoing debate. We present the 2-year results of a multicenter, randomized trial comparing the patient-reported and clinical outcomes of these 2 implant types in the treatment of AMOA.

METHODS: This double-blinded superiority trial recruited patients with severe AMOA at 10 arthroplasty centers and randomized them to undergo either mUKA or TKA. The primary outcome was the average improvement in the Oxford Knee Score (OKS) over 2 years, analyzed by intention-to-treat. A range of patient-reported outcomes served as secondary outcomes. Death, revision, and other reoperations were analyzed as serious adverse events (SAEs).

RESULTS: Between September 2017 and March 2021, 350 patients were randomized: 177 (79 female, 98 male; mean age, 67.7 ± 7.5 years) to mUKA and 173 (84 female, 89 male; mean age, 66.7 ± 7.8 years) to TKA. The average 2-year OKS improvement differed by 3.5 points (95% CI, 2.3 to 4.7; p < 0.001) in favor of mUKA, although this difference was below the generally accepted minimal clinically important difference (MCID) of 4 to 5 points. Ten of the 12 secondary outcomes favored mUKA, while the remaining 2 were nonsignificant. The differences in the Forgotten Joint Score (FJS) (14.1; 95% CI, 9.5 to 18.6), range of motion during the first 2 years (7.0°; 95% CI, 5.3° to 8.7°) and at 2 years (5.5°; 95% CI, 3.6° to 7.4°), Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms score (10.3; 95% CI, 7.8 to 12.8), and Short Form-36 (SF-36) bodily pain score (7.6; 95% CI, 4.1 to 11.1) all favored mUKA and reached the MCID. Non-revision reoperations were performed in 4 patients (2.3%) after mUKA and in 12 patients (6.9%) after TKA (9 of the 12 underwent manipulation under anesthesia); the difference was 4.7% (95% CI, 0.2% to 9.8%). There were no differences in the rates of revision or death between the groups.

CONCLUSIONS: Averaged over the 2-year follow-up, mUKA demonstrated minor advantages that did not achieve clear clinical superiority on the basis of the OKS difference. However, the FJS, range of motion, KOOS symptoms score, and SF-36 bodily pain score all demonstrated differences in favor of mUKA that were clinically meaningful. The overall findings suggest that mUKA and TKA yield similarly favorable short-term results, with small advantages for mUKA.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PMID:41662451 | DOI:10.2106/JBJS.25.00612

The Association Between Perioperative Denosumab and Local Recurrence After Surgical Management of Giant Cell Tumors: A Meta-Analysis

J Bone Joint Surg Am. 2026 Feb 9. doi: 10.2106/JBJS.25.01058. Online ahead of print.

ABSTRACT

BACKGROUND: Several studies have assessed the impact of perioperative denosumab on local recurrence (LR) after surgical management of giant cell tumor (GCT), with conflicting results. This meta-analysis evaluates the association between LR in patients undergoing surgical management of GCT and perioperative denosumab, accounting for the type of surgery, number of denosumab doses, and timing of denosumab administration.

METHODS: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar were searched until December 5, 2024. The extracted outcomes consisted of LR and denosumab-related complications.

RESULTS: Sixteen studies from 15 cohorts were included in the meta-analysis. The number of patients totaled 1,551: 310 (20%) in the denosumab group (mean age, 32 years; mean follow-up, 40 months) and 1,241 (80%) in the control group (mean age, 32 years; mean follow-up, 62 months). Patients in the denosumab group had a significantly higher rate of LR compared with patients in the control group (odds ratio = 1.82; p = 0.03), and this remained true even when looking at studies using curettage as the only surgical management (odds ratio = 2.75; p < 0.001). In a subgroup analysis by the timing of denosumab administration, a significantly higher rate of LR was only found among patients receiving denosumab both preoperatively and postoperatively (odds ratio for recurrence relative to control = 5.57; p < 0.001). Overall, the reported incidence of denosumab-related complications was 6.5%.

CONCLUSIONS: In this meta-analysis, patients receiving denosumab only preoperatively did not have a significantly increased rate of LR compared with controls. Increased recurrence was observed primarily in patients being treated with both preoperative and postoperative denosumab.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:41662446 | DOI:10.2106/JBJS.25.01058

Compensatory Load Sharing by Residual Rotator Cuff Subregions Preserves Glenohumeral Mechanics in Partial and Massive Tears

J Bone Joint Surg Am. 2026 Feb 4. doi: 10.2106/JBJS.25.01073. Online ahead of print.

ABSTRACT

BACKGROUND: Rotator cuff (RC) tears are common shoulder injuries that cause pain, dysfunction, and abnormal humeral head translation. Balanced force couples in the transverse and coronal planes help to maintain normal glenohumeral mechanics. Although clinical and biomechanical studies have suggested that compensatory activation of residual RC muscles preserves function, the contribution of individual RC subregions to glenohumeral contact mechanics and humeral head translations across progressively increasing tear sizes remains unclear.

METHODS: Eight fresh-frozen male cadaveric shoulders (mean age, 56 years; 6 Caucasian; 2 Black) were dissected to isolate RC muscle subregions, and 4 progressive RC tear models were created: Tear I (supraspinatus [SSP] + superior region of the infraspinatus [ISP]), Tear II (SSP + complete ISP), Tear III (SSP + ISP + superior one-third of the subscapularis [SSC]), and Tear IV (SSP + ISP + superior one-third of the SSC + coracohumeral ligament). Each model underwent 3 loading conditions: loaded (as in the intact state), unloaded (i.e., unloading of the torn regions), and compensatory (i.e., increased loading of the remaining subregions). Humeral head translations and glenohumeral contact force, area, and pressure were measured at 10° of abduction with neutral rotation.

RESULTS: Unloaded conditions significantly increased superior and posterior humeral head translations and reduced contact force and area in most models, particularly in Tears III and IV. Compensatory loading by residual RC subregions reduced superior translation by 34% to 44% and posterior translation by 60% to 68%, restoring the humeral head center to within 0.1 to 1.7 mm of its position in the intact condition. Contact forces and areas partially recovered under compensatory loading; however, contact pressure remained elevated in the largest tear model.

CONCLUSIONS: Residual RC subregions can partially restore humeral head centering and glenohumeral contact mechanics in progressive RC tears. However, compensation is limited in advanced tear states, highlighting the potential need for surgical intervention to restore force-couple integrity in the transverse plane.

CLINICAL RELEVANCE: These findings support targeted strengthening of the posterior cuff in patients with partial or early-stage massive RC tears to help maintain joint congruency, minimize abnormal glenohumeral contact mechanics and humeral head translation, and potentially delay the progression to cuff tear arthropathy. Surgical repair, particularly of the SSC, may be required in advanced tears to fully restore force coupling and load distribution.

PMID:41637491 | DOI:10.2106/JBJS.25.01073

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