JBJS

[18F]-Fluoride PET/CT Analyses of Postoperative Bone Mineralization Adjacent to Acetabular Cups in Total Hip Arthroplasty: A Randomized Clinical Trial

J Bone Joint Surg Am. 2026 Mar 3. doi: 10.2106/JBJS.25.00961. Online ahead of print.

ABSTRACT

BACKGROUND: The longevity of total hip arthroplasty (THA) largely depends on adequate bone formation around the implant. This study used [18F]-fluoride positron emission tomography combined with computed tomography (F-PET/CT) to evaluate skeletal metabolism in the bone surrounding the acetabular cup and to compare the metabolic activity in the periprosthetic regions between cups with 2 different surfaces.

METHODS: Twenty-eight Swedish patients (15 females) with a mean age of 61.3 years were randomly assigned to receive an uncemented cup with either a Trabecular Titanium (TT) surface or a hydroxyapatite (HA) coating. The acetabular bone region surrounding the cup was divided into 9 regions of interest (ROIs). All patients were assessed with use of radiographs and clinical scoring at 36 weeks of follow-up and with use of F-PET/CT at 4, 16, and 36 weeks postoperatively.

RESULTS: F-PET/CT scans demonstrated 17% higher levels of metabolic activity indicating osseointegration in the TT group compared with the HA group at 4 weeks postoperatively. Additionally, both groups had higher standardized uptake values (SUVs) compared with the healthy reference acetabulum groups at 4 and 16 weeks postoperatively.

CONCLUSIONS: A detailed analysis of bone growth on the implant surface revealed that the initial healing phase involves increased mineral accumulation for both TT and HA cups. These findings provide valuable insights into the secondary stabilization of implants, which is critical for prosthesis survival.

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

PMID:41774785 | DOI:10.2106/JBJS.25.00961

A Blinded Analysis of Quality and Fidelity in Orthopaedic Patient Education Materials Simplified by ChatGPT and Humans

J Bone Joint Surg Am. 2026 Feb 26. doi: 10.2106/JBJS.25.00982. Online ahead of print.

ABSTRACT

BACKGROUND: Orthopaedic patient education materials (PEMs) within Epic's Elsevier library often exceed the recommended sixth-grade reading level, with a mean grade of 8.6 in English and 5.8 in Spanish, risking poor patient comprehension and adherence. The present study evaluated whether artificial intelligence (AI)-based text simplification can improve readability while preserving clinical accuracy. The objectives were to use previously established readability data for English and Spanish PEMs as baselines, to assess the impact of human-based and ChatGPT-based simplification on reading grade level, and to compare the fidelity of simplified texts against standard materials.

METHODS: In March 2025, 806 orthopaedic PEM documents were simplified using standardized ChatGPT prompts. Readability was reassessed using validated English and Spanish formulas, and fidelity was evaluated in the 86 PEMs that also had human easy-to-read versions. Two blinded clinicians compared human and ChatGPT-4o outputs with the originals to identify hallucinations, omissions, and inconsistencies according to severity. Following the release of ChatGPT-5, an unblinded post hoc analysis was performed using identical criteria.

RESULTS: ChatGPT-4o-simplified PEMs showed mean reading grade levels of 6.1 in English and 3.5 in Spanish. Compared with human simplifications, ChatGPT-4o showed fewer English omissions, similar Spanish omissions, fewer inconsistencies in both languages, and comparable English hallucinations, but higher Spanish hallucinations. Compared with ChatGPT-4o, ChatGPT-5 preserved English performance and improved Spanish fidelity, reducing hallucinations to human-comparable rates.

CONCLUSIONS: AI-driven simplification can produce orthopaedic PEMs that are easier to read while maintaining acceptable fidelity. The improvements observed with ChatGPT-5 highlight its potential for clinician-supervised use in generating accessible and reliable PEMs.

CLINICAL RELEVANCE: This study is clinically relevant because orthopaedic PEMs are routinely delivered through the Epic electronic health record and directly affect patient understanding, consent, and adherence in both English and Spanish. By evaluating the readability and fidelity of AI-simplified materials across languages, this study informs safe, scalable strategies to improve patient communication in everyday orthopaedic practice.

PMID:41747019 | DOI:10.2106/JBJS.25.00982

Mild Lateral Femoral Condyle Cartilage Damage Does Not Affect the Outcomes of Medial Unicompartmental Knee Arthroplasty: A Mean 6-Year Follow-up Study

J Bone Joint Surg Am. 2026 Feb 26. doi: 10.2106/JBJS.25.01031. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this study was to ascertain whether mild cartilage damage of the lateral condyle of the femur influences the mid-term clinical outcomes of medial unicompartmental knee arthroplasty (mUKA) and exacerbates the progression of osteoarthritis in the lateral compartment.

METHODS: Patients with normal cartilage or mild cartilage damage of the lateral femoral condyle (Outerbridge grade, ≤II) who underwent mUKA between March 2016 and December 2020 were retrospectively divided into 4 groups: a normal cartilage group and a cartilage damage group that was subdivided on the basis of the damage location (weight-bearing area, posterior weight-bearing area, and medial side of the lateral condyle). Patients with postoperative overcorrection of limb alignment or preoperative lateral meniscal extrusion were excluded. Outcomes that were compared among the groups included the hip-knee-ankle angle (HKA), lateral compartment Kellgren-Lawrence (K-L) grade, Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Kujala score, patient satisfaction, and complications.

RESULTS: The study included 203 knees in 177 patients (136 female patients; 177 East Asian; mean age, 68.3 ± 7.1 years) with a mean follow-up of 70.8 months (range, 48 to 106 months). The postoperative OKS, FJS, and Kujala score showed no significant differences among the groups. Mid-term full-length standing radiographs of the lower limbs were obtained for 99 of the 203 knees, with a mean follow-up of 54.1 months (range, 49 to 104 months). Of the 99 knees, 26 (26.3%) showed an increase of 1 K-L grade in the lateral compartment and 73 (73.7%) remained unchanged. Three knees (1.5%) from the normal group experienced complications, including 1 periprosthetic fracture, 1 bearing dislocation, and 1 bearing rotation, but none required conversion to TKA.

CONCLUSIONS: In patients in whom postoperative alignment is not overcorrected and preoperative lateral meniscal function is intact, mild cartilage damage (Outerbridge grade I or II) of the lateral femoral condyle does not impact the mid-term clinical outcomes of mUKA and does not exacerbate the progression of osteoarthritis in the lateral compartment.

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

PMID:41747016 | DOI:10.2106/JBJS.25.01031

Measuring Value in Orthopaedics: The U.S. and U.K. Perspectives

J Bone Joint Surg Am. 2026 Feb 25. doi: 10.2106/JBJS.25.01106. Online ahead of print.

ABSTRACT

➢ Despite substantial health-care spending, both the U.S. and U.K. lack standardized, operational definitions of value in specialty care, limiting their ability to optimize patient-centric health outcomes and appropriate selection and utilization of resources.➢ First-generation value-based specialty care models in the U.S., like the Bundled Payments for Care Improvement Initiative and Comprehensive Care for Joint Replacement, have achieved modest savings by focusing on post-acute care and procedural efficiency, without negatively impacting quality metrics. Similarly, the Getting It Right First Time initiative in the U.K. aimed to bring about higher-quality care in hospitals, at lower cost, by reducing unwanted variations in services and practices. However, there remains no true understanding of impact on value, of efficacy based on measurement of patient-centric health outcomes that matter to patients, or of whether interventions were appropriately selected in the first place.➢ A standardized value metric, specifically the incremental cost-effectiveness ratio (ICER), is critical to measuring quality in specialty care, enabling health-care systems to compare treatment options on the basis of both cost and patient-centric outcomes.➢ The ICER integrates quality-adjusted life years, cost data, and the duration of effectiveness, providing a framework for shared decision-making, care variation reduction, and more strategic site-of-service decisions.➢ Health-care systems and policymakers should adopt ICER-based frameworks to transition from volume-based incentives to value-based models that support innovation, accountability, and whole-person musculoskeletal specialty care.

PMID:41739900 | DOI:10.2106/JBJS.25.01106

Cost-Effectiveness of Surgery Versus Functional Bracing for Humeral Shaft Fractures in Adults: A Prespecified Economic Evaluation of the Finnish Shaft of the Humerus (FISH) Trial

J Bone Joint Surg Am. 2026 Feb 24. doi: 10.2106/JBJS.25.00867. Online ahead of print.

ABSTRACT

BACKGROUND: Humeral shaft fractures commonly affect working-age adults and can lead to prolonged work absence and substantial economic burden. Although surgical fixation and functional bracing offer comparable functional outcomes, their relative cost-effectiveness remains unclear.

METHODS: We conducted a prespecified economic evaluation alongside a multicenter, superiority, randomized clinical trial at 2 Finnish university hospitals between 2012 and 2018. Eighty-two adults (mean age, 48.9 years; 38 women) with displaced, closed humeral shaft fractures were randomly assigned to surgical fixation (n = 38) or functional bracing (n = 44) and followed for 2 years. The primary outcome was the incremental net monetary benefit (INMB) based on quality-adjusted life years (QALYs) measured with the 15-dimensional (15D) instrument, analyzed from both societal and health-care perspectives.

RESULTS: From a societal perspective, surgical treatment was both more effective and less costly than bracing. The mean total cost per patient was €23,680 for surgery and €30,389 for bracing, yielding an INMB of €9,423 (95% confidence interval [CI], €4,139 to €14,609). Cost-effectiveness acceptability curves showed that surgery was highly likely to be cost-effective across all willingness-to-pay thresholds up to €120,000 per QALY. The cumulative QALYs from 6 weeks to 2 years post-injury were 1.776 (95% CI, 1.725 to 1.827) for surgery and 1.705 (95% CI, 1.641 to 1.769) for bracing, corresponding to a QALY difference of 0.071 (95% CI, 0.012 to 0.130) in favor of surgery. From the health-care perspective, functional bracing was less costly (€4,904 versus €10,967) and therefore more cost-effective, with an INMB of -€4,087 (95% CI, -€5,215 to -€3,054). When considering only direct medical costs, surgery was unlikely to be cost-effective at thresholds below €80,000 per QALY, reaching a 75% probability of cost-effectiveness only at €120,000 per QALY.

CONCLUSIONS: Surgery is cost-effective when societal costs are considered. Functional bracing remains a reasonable option, particularly for patients less affected by time away from work. Shared decision-making should incorporate both economic and individual patient factors.

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

PMID:41734249 | DOI:10.2106/JBJS.25.00867

Radiographic Measurement of Psoas Muscle Width: A Simple and Reliable Screening Tool for Sarcopenia

J Bone Joint Surg Am. 2026 Feb 23. doi: 10.2106/JBJS.25.01094. Online ahead of print.

ABSTRACT

BACKGROUND: Sarcopenia, characterized by the progressive loss of skeletal muscle mass and strength, is associated with adverse outcomes, including increased postoperative complications in patients with orthopaedic conditions. Although computed tomography (CT) and magnetic resonance imaging (MRI) remain the gold-standard modalities for assessing sarcopenia, their cost, radiation exposure, and limited availability restrict widespread screening. This study investigated the potential of lumbar spine radiographs as a practical alternative for sarcopenia screening.

METHODS: We retrospectively reviewed data of patients who underwent surgery for degenerative lumbar spine diseases at our hospital's Department of Orthopedic Surgery between June 2013 and April 2024 and had both preoperative standing lumbar spine radiographs and supine CT scans. Demographic variables (age and sex) were collected. The psoas muscle width at the caudal end plate of L3 was measured on anteroposterior lumbar spine radiographs and was compared with CT-based cross-sectional psoas muscle area. Sarcopenia was defined on the basis of previously established psoas muscle index thresholds. Interobserver reliability was assessed with the intraclass correlation coefficient (ICC), and correlation analyses, multivariable regression, and receiver operating characteristic (ROC) curve analyses were performed.

RESULTS: There were 305 patients (177 male patients [58.0%], with a median age of 71.7 years; and 128 female patients [42.0%], with a median age of 69.8 years; all ethnic Japanese) included in the analysis. Of these 305 patients, 114 (37.4%) were classified as having sarcopenia (78 male patients and 36 female patients). Radiographic psoas muscle width demonstrated excellent interobserver reliability (ICC, 0.94) and strongly correlated with the CT-measured psoas muscle area (male patients, r = 0.71; female patients, r = 0.64; both p < 0.001). Multivariable analysis identified the psoas width as a significant predictor of the psoas muscle area. ROC curve analysis revealed that optimal cutoff values for sarcopenia screening were 118.8 mm (area under the curve [AUC], 0.847) for male patients and 99.9 mm (AUC, 0.777) for female patients.

CONCLUSIONS: Radiographic psoas muscle width measurement is a simple and reliable method for sarcopenia screening that may facilitate early sarcopenia identification, enabling timely interventions and improving surgical outcome predictions. Lumbar spine radiographs hold potential as a novel screening tool for sarcopenia beyond their conventional diagnostic role.

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

PMID:41730017 | DOI:10.2106/JBJS.25.01094

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

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