JBJS

Subjective and Functional Dysphagia After Anterior Cervical Spine Surgery: A Prospective Controlled Study

J Bone Joint Surg Am. 2025 Dec 26. doi: 10.2106/JBJS.25.00847. Online ahead of print.

ABSTRACT

BACKGROUND: Dysphagia is a common postoperative complaint following anterior cervical discectomy and fusion (ACDF), with incidence rates ranging from 1.7% to 71%. The variability in incidence rates raises the question of whether dysphagia warrants clinical concern or represents a transient, expected symptom. The aim of this study was to characterize the time course and impact of dysphagia following anterior cervical surgery for degenerative pathology with use of both subjective and objective measures.

METHODS: Patients undergoing either lumbar or cervical spine surgery from 2023 to 2024 were prospectively enrolled. Lumbar cases were limited to 1 to 2-level, decompression-only procedures, whereas cervical cases included up to 3-level ACDF and/or cervical disc replacement (CDR). Dysphagia was assessed using the Eating Assessment Tool (EAT-10) and the Yale Swallow Protocol at 5 time points: preoperatively and on postoperative days (PODs) 0, 3, 7, and 30. Postoperative responses were collected electronically. Retropharyngeal radiographic measurements at C3-C7 were obtained preoperatively, immediately postoperatively, and at the first follow-up. Measurements were taken from the vertebral midbody to the posterior airway space.

RESULTS: A total of 134 patients (67 in the cervical group and 67 in the lumbar group) were included. The groups were demographically similar, although the cervical group had a longer mean operative time (86.7 versus 62.2 minutes; p < 0.001). Dysphagia was more prevalent in the cervical group across all postoperative time points: POD0 (70.1% versus 13.4%), POD3 (64.2% versus 10.4%), POD7 (40.3% versus 6.0%), and POD30 (35.8% versus 4.5%) (all p ≤ 0.001). EAT-10 scores correlated strongly across postoperative time points and modestly with procedure duration. Male sex was associated with lower EAT-10 scores through POD7 (p < 0.001). Intraoperative steroid use trended toward reduced EAT-10 scores but was not significant after correction. Retropharyngeal measurements increased immediately postoperatively (notably at C3, C4, C5, and C7), but swelling resolved by the time of follow-up, except at C3 and C4.

CONCLUSIONS: Dysphagia was frequent after anterior cervical surgery, peaking early and partially resolving by 1 month. These findings support its characterization as a common, self-limited postoperative symptom rather than a true complication in most cases.

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

PMID:41452954 | DOI:10.2106/JBJS.25.00847

The Management of Neurological Injuries Following Total Hip Arthroplasty

J Bone Joint Surg Am. 2025 Dec 26. doi: 10.2106/JBJS.25.00389. Online ahead of print.

ABSTRACT

➢ Neurological injury remains the most common reason for ligation following total hip arthroplasty.➢ The main risk factors for neurological injury following total hip arthroplasty are preexisting spinal pathology, revision surgery, complex hip anatomy, female sex, surgeon inexperience, and excessive limb lengthening.➢ Postoperative pelvic computed tomographic scans may be used to assess component positioning and identify any compressive hematomas. Magnetic resonance imaging with a metal artifact reduction protocol may be used to evaluate architectural changes in the affected nerve.➢ Electromyography and nerve conduction studies may help to assess the level and grade of the nerve injury. These tests are most useful when performed in patients who show no signs of neurological improvement 3 to 6 weeks after surgery.➢ The mainstay of nonoperative management is supportive care with physical therapy, an ankle-foot orthosis, and neuropathic pain treatment.➢ The prognosis for a femoral nerve injury is generally more favorable than that for a sciatic nerve injury following total hip arthroplasty.

PMID:41452940 | DOI:10.2106/JBJS.25.00389

The Prevalence of Subtalar Arthritis Following Pilon Fractures

J Bone Joint Surg Am. 2025 Dec 22. doi: 10.2106/JBJS.25.00233. Online ahead of print.

ABSTRACT

BACKGROUND: Pilon fractures result in substantial morbidity and are associated with a high rate of ankle arthritis. However, literature is scarce regarding the prevalence of posttraumatic subtalar arthritis. Tibiotalocalcaneal (TTC) arthrodesis, or hindfoot nailing, is increasingly used for comminuted pilon fractures, which often involve the subtalar joint. This study aimed to determine the prevalence and severity of posttraumatic subtalar arthritis, to better understand the implications of this surgical technique in these cases.

METHODS: Patients who sustained a pilon fracture and underwent open reduction and internal fixation were retrospectively identified. The patients were categorized into 4 groups on the basis of the time interval between the date of injury and the latest available radiographs: <12, 12 to 24, 25 to 48, and >forty-eight months. The Kellgren-Lawrence (K-L) and NSS (None, Some, Severe) grading systems were used to evaluate the radiographs. Postoperative computed tomography (CT) scans, when available, were similarly graded using the CT Ankle Osteoarthritis (CTAO) system. Pearson correlation, chi-square, Mann-Whitney U, and Welch t tests were used. P < 0.05 was considered significant.

RESULTS: The study included 473 patients (mean age, 46.15 ± 7.50 years, 293 male and 180 female). The cohort was composed of 80.3% White and 15.8% non-White, with 3.9% missing data.(Patient age at the time of injury (p < 0.001) and at the time of imaging (p < 0.001), smoking status (p = 0.01), steroid use (p = 0.04), Charlson Comorbidity Index (CCI) (p = 0.003), AO/OTA classification (p = 0.03), and time from injury to final imaging (p = 0.004) were significantly correlated with the K-L grade. Group 3 was found to have a higher mean K-L grade than Group 1 (by 0.34, 95% confidence interval [CI]: 0.03 to 0.66; p = 0.04) and Group 2 (by 0.39, 95% CI: 0.05 to 0.73; p = 0.02). Group 4 had a higher K-L grade than Group 1 (by 0.37, 95% CI: 0.08 to 0.66; p = 0.01) and Group 2 (by 0.42, 95% CI: 0.11 to 0.73; p = 0.01). The CTAO score demonstrated meaningful correlation between subtalar arthritis and age at both the time of injury (p = 0.004) and the time of final CT (p = 0.01).

CONCLUSIONS: Multiple patient-based factors including age, smoking status, steroid use, CCI, AO/OTA classification, and the time interval since injury were significantly associated with the development of subtalar arthritis, as assessed using the K-L grade, after pilon fracture. This suggests that acute hindfoot nailing as an index treatment option for pilon fractures may have fewer clinical ramifications than has been anticipated on the basis of its violation of the subtalar joint.

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

PMID:41428802 | DOI:10.2106/JBJS.25.00233

AI-Generated Text in Orthopaedic Articles: A Cross-Sectional Analysis

J Bone Joint Surg Am. 2025 Dec 19. doi: 10.2106/JBJS.25.00971. Online ahead of print.

ABSTRACT

BACKGROUND: Large language models are increasingly being used in scientific writing, but their use in orthopaedic literature remains unclear.

METHODS: We analyzed 196 articles published in March 2025 in 10 leading orthopaedic journals. GPTZero quantified artificial intelligence (AI)-generated text by article section. Composite AI scores were calculated and tested for associations with the h5-index, study design, level of evidence, authorship characteristics, and geographic region with use of nonparametric and both Pearson and Spearman correlation analyses.

RESULTS: AI-generated content was detected in 89.8% of articles. The mean AI score was 18.1% (median, 14.9%). Scores differed by section (p < 0.001) and were the highest in the Results. AI use correlated with the proportion of non-MD authors (ρ = 0.22) and with the total author count (ρ = 0.19), but not with the h5-index. No association with study design or level of evidence was found. Differences by geographic region were modest and not significant after correction.

CONCLUSIONS: AI-generated content appears to be widespread, particularly in Results sections. Its use varies by authorship characteristics and geography but not by study design or journal prestige. Clear disclosure standards are essential to guide responsible AI use in scientific writing.

CLINICAL RELEVANCE: This study is clinically relevant because transparency in scientific writing supports accurate interpretation of the evidence used in patient care. Identifying the prevalence of AI-generated text helps to protect the integrity of the orthopaedic literature.

PMID:41417927 | DOI:10.2106/JBJS.25.00971

Low Cognitive Function and Somatic Psychological Symptoms Are Correlated with Greater Risk of Delirium After Total Knee Arthroplasty: A Prospective Cohort Study

J Bone Joint Surg Am. 2025 Dec 19. doi: 10.2106/JBJS.25.00392. Online ahead of print.

ABSTRACT

BACKGROUND: Postoperative delirium (POD) is a clinically important complication in elderly patients undergoing total knee arthroplasty (TKA) that is associated with prolonged hospitalization, increased morbidity, and higher health-care costs. Although cognitive impairment is a known risk factor for POD, the role of comprehensive cognitive and psychological evaluation remains underexplored in patients undergoing TKA. This study aimed to evaluate the correlation of preoperative cognitive and psychological factors with POD after TKA.

METHODS: This prospective cohort study included 574 patients who were ≥60 years of age and underwent primary TKA at 1 of 2 major tertiary care hospitals. We assessed preoperative cognitive function using the Mini-Mental State Examination (MMSE), the full Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery, the Subjective Memory Complaints Questionnaire (SMCQ), and the Seoul Informant Report Questionnaire for Dementia (SIRQD). Psychological assessments were conducted with the Pittsburgh Sleep Quality Index (PSQI), the Patient Health Questionnaire-15 (PHQ-15), and the Hospital Anxiety and Depression Scale (HADS). POD was evaluated daily from postoperative days 1 to 5 using the 4 A's Test (4AT) and the Confusion Assessment Method (CAM). A multivariable logistic regression analysis was performed to identify independent risk factors for POD.

RESULTS: POD occurred in 24 (4.2%) of 574 patients. Univariate analysis revealed that POD was significantly correlated with lower MMSE (p < 0.001), higher PHQ-15 (p = 0.014), higher PSQI (p = 0.014), and higher Charlson Comorbidity Index (p = 0.010) scores; preoperative use of sedatives (p = 0.044) and antidepressants (p = 0.027); and lower mean noise levels in the patient's hospital room (p = 0.002). In the receiver operating characteristic curve analysis, the optimal cutoff value for predicting POD was an MMSE score of ≤25, with a sensitivity of 74.5% and a specificity of 78.3% (area under the curve, 0.834; p = 0.001). Multivariable logistic regression analysis identified lower MMSE scores (odds ratio [OR], 0.771; p = 0.002) and higher PHQ-15 scores (OR, 1.187; p = 0.028) as significant independent predictors of POD.

CONCLUSIONS: This study comprehensively evaluated preoperative cognitive function and psychological symptoms in patients undergoing TKA. Even subclinical cognitive and somatic symptoms were linked to POD, emphasizing the need for preoperative identification of high-risk patients.

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

PMID:41417917 | DOI:10.2106/JBJS.25.00392

AI-Based Medical Decision Support: Exploring the Data Gap

J Bone Joint Surg Am. 2025 Dec 19. doi: 10.2106/JBJS.25.01387. Online ahead of print.

ABSTRACT

Good judgment remains fundamental to clinical decision-making, and yet it is increasingly augmented by data and artificial intelligence (AI). Although AI holds promise for real-time clinical-decision support, its impact on patient care has been modest. The principal limitation is not algorithmic capability but the quality, structure, and completeness of the data available for training and deployment. Most AI systems rely on electronic medical records (EMRs), which were designed primarily for billing rather than clinical insight. Consequently, important clinical information is fragmented, inconsistently documented, or absent altogether. Natural language processing and large language models (LLMs) improve data extraction, and yet they remain constrained by the underlying data quality and important privacy concerns. A critical gap persists in the acquisition of quantitative physiological data, particularly for the musculoskeletal system, where current practice relies on qualitative or semiquantitative assessments collected at single time points. In contrast, other industries-such as the autonomous vehicle industry-have advanced further by integrating continuous, multimodal sensor data to inform real-time decisions. Emerging multimodal wearable technologies offer a pathway toward similarly rich physiological data sets in medicine. Meaningful progress in AI-enabled health care will require such a transformation in data acquisition, enabling more accurate, continuous, and clinically relevant decision support.

PMID:41417882 | DOI:10.2106/JBJS.25.01387

Fluoroscopy-Guided Lateral Tibial Plateau Fracture Fixation with and without Needle Arthroscopy: A Biomechanical and Reduction-Quality Comparison

J Bone Joint Surg Am. 2025 Dec 19. doi: 10.2106/JBJS.25.00793. Online ahead of print.

ABSTRACT

BACKGROUND: Articular depression, especially in central tibial plateau segments, is surgically challenging. According to the 10-segment classification, the anterolateral approach visualizes only 36.6% of the tibial plateau. The aim of this study was to compare biomechanical performance between fluoroscopy-guided fixation techniques with and without needle arthroscopy.

METHODS: This cadaveric study used 16 knee specimens with standardized lateral tibial plateau fractures. Specimens were randomized to fluoroscopy-guided (FG) or fluoroscopy plus needle arthroscopy-guided (FNG) reduction performed via an anterolateral approach. Kirschner wires and proximal tibial plates were used for fixation. The primary outcome was load to failure. Secondary outcomes included stress, strain, stiffness, reduction quality, radiation exposure, and operative time.

RESULTS: Sixteen cadaveric specimens (9 right knees; 12 males) were studied. The FG group had greater mean articular depression (1.77 versus 1.69 mm) and step-off (2.44 versus 2.26 mm) than the FNG group. The FNG group had a higher mean load to failure (1,784 versus 1,063 N), whereas the FG group had greater mean stiffness (170.34 versus 130.82 N/mm) and a longer mean operative time (1,662 versus 1,524 seconds). The FG group also demonstrated higher mean fluoroscopic doses and larger differences in condylar width and the medial tibial plateau angle than the FNG group.

CONCLUSIONS: FNG reduction improved articular congruity and load to failure in lateral tibial plateau fractures without increasing operative time, supporting needle arthroscopy as a valuable adjunct for managing complex articular fractures with less invasive exposure.

CLINICAL RELEVANCE: This study is clinically relevant because it shows that incorporating needle arthroscopy during fixation of lateral tibial plateau fractures can improve reduction quality and stability without prolonging operative time.

PMID:41417880 | DOI:10.2106/JBJS.25.00793

Bezeotermin Alfa (rhBMP-6) Administration in Lumbar Interbody Fusion Surgery Using a Posterior Approach: A Randomized, Double-Blinded, Placebo-Controlled Phase-2 Study

J Bone Joint Surg Am. 2025 Dec 17;107(24):2735-2743. doi: 10.2106/JBJS.25.00424. Epub 2025 Nov 17.

ABSTRACT

BACKGROUND: Novel osteoconductive and osteoinductive therapies for posterior-based lumbar interbody fusion surgery are needed. Bezeotermin alfa (recombinant human bone morphogenetic protein [rhBMP]-6, previously referred to as AGA111) is a potential potent stimulator of bone regeneration. This prospective, multicenter, randomized, double-blinded, placebo-controlled Phase-2 trial evaluated the safety and preliminary efficacy of bezeotermin carried by autologous blood coagulum (ABC) in patients undergoing lumbar interbody fusion surgery between L3 and S1 for degenerative disc disease.

METHODS: Adult patients scheduled for single-level elective lumbar interbody fusion surgery across 6 clinical trial sites in the People's Republic of China were randomized 1:1:1 to placebo, 0.25 mg bezeotermin, or 0.5 mg bezeotermin and followed for 12 months. The primary end point was the incidence of adverse events (AEs). Secondary end points included anti-rhBMP-6 antibodies, the success rate of radiographic fusion, changes in the Oswestry Disability Index (ODI) score, changes in the pain score on a visual analogue scale (VAS), and serum drug concentrations.

RESULTS: Sixty-three patients with a mean age of 59.2 years (52% female, 98.4% Han) were enrolled in the study. Twenty-one, 20, and 22 of the patients were randomized to placebo, 0.25 mg bezeotermin, and 0.5 mg bezeotermin, respectively. All patients reported at least 1 AE during the study, but most AEs were mild to moderate in severity. No drug-related serious AEs were reported in the bezeotermin groups. There was a trend toward a higher rate of successful radiographic fusion and greater improvement of the ODI and VAS scores in the bezeotermin groups than in the placebo group from month 3 to month 12.

CONCLUSIONS: This prospective, randomized, double-blinded, placebo-controlled trial demonstrated that bezeotermin/ABC was safe and well tolerated during posterior-based single-level lumbar interbody fusion. The preliminary efficacy of bezeotermin in accelerating spinal fusion and improving clinical outcomes supports its further clinical development.

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

PMID:41405575 | DOI:10.2106/JBJS.25.00424

Medical Malpractice Litigation in Orthopaedic Surgery in the United States: Risk Factors, Outcomes, and Strategies for Navigating Lawsuits, Prevention, and Reform

J Bone Joint Surg Am. 2025 Dec 17;107(24):2726-2734. doi: 10.2106/JBJS.25.00394. Epub 2025 Nov 18.

ABSTRACT

➢ Medical malpractice litigation in orthopaedic surgery remains a major challenge, as the field consistently ranks among the most frequently litigated specialties. Malpractice claims in orthopaedics often involve surgical errors, misdiagnoses, delayed treatment, and inadequate postoperative care, with substantial financial and emotional consequences for health-care providers.➢ Malpractice risk varies by orthopaedic subspecialty, with adult reconstruction and spine surgeons facing the highest litigation rates, often due to nerve injuries, delayed or missed diagnoses, or postoperative complications. Although defense verdicts are the most common outcome, substantial settlements and plaintiff verdicts occur in cases involving irreversible damages, inadequate informed consent, or technical errors.➢ Proactive risk management and legal preparedness can help to mitigate liability and protect physicians. Preventative strategies include clear, supportive communication to build patient trust, comprehensive documentation ensuring adherence to evidence-based guidelines, and diagnostic accuracy through use of objective tools.

PMID:41405574 | DOI:10.2106/JBJS.25.00394

Trauma and Orthopaedic Surgery: The Spanish Model

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.25.01408. Online ahead of print.

ABSTRACT

➢ The Spanish National Health System delivers equitable, high-quality musculoskeletal care through a nationwide network that connects community-based primary care with tertiary trauma and orthopaedic referral centers.➢ The highly competitive and standardized residency program in trauma and orthopaedic surgery in Spain ensures uniform training quality, the possibility for subspecialization, and well-grounded clinical and surgical competency across all regions.➢ Orthopaedic research in Spain has expanded considerably. It is supported by national and regional networks, an increasing participation in multicenter international trials and cross-border collaboration, and a growing academic output of global relevance.➢ The integration of women in Spanish orthopaedics has been increasing, such that the proportion of female orthopaedic residents in Spain was well above that of many other countries in 2022.➢ Spain combines a broadly extended hospital network with a dynamic academic ecosystem, positioning the country as a leading European hub for trauma and orthopaedic innovation, research, and education.

PMID:41401252 | DOI:10.2106/JBJS.25.01408

Obstacles to Spine Surgery in Limited-Resource Environments

J Bone Joint Surg Am. 2025 Dec 15. doi: 10.2106/JBJS.25.01208. Online ahead of print.

ABSTRACT

Spine surgery in limited-resource environments is challenging due to the complexity of the procedures, which can involve often-costly implants and imaging or navigation tools that may not be available in all regions and markets. Orthopaedic and neurological surgery residents in low to middle-income countries (LMICs) are faced with limited case exposure, faculty shortages, and a lack of simulation tools, resulting in incomplete spine surgery training. International fellowships, telesurgery integration, and global collaboration can help to address these gaps. The high costs of implants, restricted use of intraoperative neuromonitoring, and limited access to advanced technologies such as robotics and endoscopy may hinder optimal surgical care. These challenges could be mediated by the implementation of cost-effective practices, the establishment of clinical guidelines, and the publication of cost-effectiveness data. LMIC contributions to spine research are limited due to a lack of funding, poor research infrastructure, and publication bias. Building research capacity through mentorship, international partnerships, and regional academic platforms is needed to advance global spine care.

PMID:41397046 | DOI:10.2106/JBJS.25.01208

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