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Introduction No study to date has examined the association between organism profile and ideal interstage duration in patients undergoing two-stage exchange arthroplasty. The purpose of this study was to evaluate the impact of the type of infecting organism on the optimal timing of reimplantation in this patient population. Methods This retrospective study identified 576 patients with chronic periprosthetic joint infection (PJI) of the knee that underwent two-stage exchange arthroplasty with a minimum 1-year follow-up. PJI was defined using the 2013 Musculoskeletal Infection Society (MSIS) criteria. Patients with a time to reimplantation >180 days from resection arthroplasty (n=76) and those that underwent spacer exchange were excluded (n=49). Treatment failure was defined as any reoperation for infection or PJI-related mortality. Receiver operator characteristic (ROC) curve analyses were used to identify whether the optimal interstage duration differed by infecting organism. Multivariate regression analyses were performed to identify risk factors for failure. Results 451 patients with a mean follow-up time of 5.8 ± 3.6 years were included. Of these, 71 (15.7%) patients experienced failure and 380 (84.3%) experienced success. ROC curve analyses demonstrated that the optimal interstage duration was longest for patients infected with “high-virulence” pathogens (129 days), followed by those with MSSA (117 days), culture negative PJI (98 days), and coagulase-negative Staphylococci (86 days). After controlling for co-variates, regression analyses showed that an interstage duration above the identified cutoff for each pathogen group was a predictor of treatment failure (all p<0.05). Conclusion We found that the ideal interstage duration varied considerably by the type of infecting organism in patients undergoing two-stage exchange. Greater awareness of this data may help guide the optimal timing of reimplantation in this patient population.

Introduction The alpha-defensin test has witnessed a surge in popularity following reports of its superior diagnostic capabilities, when compared to more conventional synovial markers. Despite this, no study to date has evaluated the utility of alpha-defensin for the diagnosis of acute periprosthetic joint infection (PJI). The purpose of this multicenter study was to determine whether the alpha-defensin test provided additional clinical benefit, when compared to synovial white blood cell (WBC) count and polymorphonuclear leukocyte percentage (PMN%), in the diagnosis of acute postoperative PJI. Methods This retrospective study identified all patients who underwent arthrocentesis within 90 days of their primary total joint arthroplasty (TJA) at three institutions. PJI was defined as revision TJA for infection within 2-weeks of joint aspiration with >=1 positive intraoperative culture. Patients were considered aseptic if they had no reoperation for >=1-year after arthrocentesis. Receiver operator characteristic (ROC) curves were used to assess the utility of alpha-defensin, WBC count, and PMN% in the diagnosis of acute PJI. Pairwise comparison was performed to compare whether the area under the curve (AUC) was significantly different between the three markers. Results A total of 143 patients were included. Of these, 85 (59.4%) were infected and 58 (40.6%) were aseptic. After plotting ROC curves, WBC count was found to have the highest diagnostic utility (AUC 0.912, sensitivity 80.0%, specificity 91.2%), followed by PMN% (AUC 0.869, sensitivity 70.5%, specificity 93.0%), and alpha-defensin (AUC 0.812, sensitivity 62.4%, specificity 100%). Using pairwise comparison, the AUC for WBC count was found to be significantly higher than that of alpha-defensin (p=0.005). However, there was no difference in the AUC between alpha defensin and PMN% (p=0.154). Conclusion Based on our findings, it appears that alpha-defensin provides little to no additional clinical benefit in the diagnosis of acute PJI, when compared to synovial WBC count and PMN%.

Purpose To evaluate the clinical outcomes of patients with increased posterior tibial slope (PTS ≥12°) undergoing primary anterior cruciate ligament reconstruction (ACLR) with concomitant lateral extra‐articular tenodesis (LET) and to determine whether the addition of LET mitigates the elevated risk of graft failure associated with increased tibial slope. Methods This single‐center retrospective cohort study included patients ≥16 years who underwent primary ACLR with LET between 2013 and 2022 with a minimum 2‐year follow‐up. Patients were stratified by PTS ≥12° versus <12° and required preoperative lateral radiographs for slope measurement and high‐risk features (pivot shift ≥2, Beighton ≥4, or return to pivoting sports). Outcomes included graft failure, residual pivot shift, complications, and patient‐reported outcomes (International Knee Documentation Committee and Lysholm). Achievement of minimal clinically important difference was assessed. Multivariable logistic regression and Cox proportional hazards analysis were performed to identify independent predictors of graft failure. Results A total of 289 patients (mean follow‐up, 38 months) were included: 45 with PTS ≥12° (13.0° ± 1.2°) and 244 with PTS <12° (8.1° ± 1.5°). Graft failure occurred in 24% versus 18%, respectively ( P = .411). On multivariable Cox proportional hazards analysis, no independent predictor of graft failure was identified, including PTS (hazard ratio, 1.07 per degree; 95% confidence interval, 0.95‐1.19; P = .260). Complications and contralateral anterior cruciate ligament injury rates were similar between groups. On sex‐disaggregated analysis, similar patterns were observed in both male and female cohorts, with no significant between‐group differences in graft failure, retear, or complication rates by tibial slope. Patient‐reported outcomes were comparable at all time points. At final follow‐up, minimal clinically important difference achievement for International Knee Documentation Committee and Lysholm was 98% and 100%, respectively, with no between‐group differences. Conclusions In high‐risk patients with a PTS of ≥12°, primary ACLR with LET led to similar clinical results as patients with a PTS of 12 or less. A PTS of ≥12° may be considered an indication for the addition of an LET during primary ACLR. Level of Evidence Level III, retrospective comparative case series.

Background: Tobacco use is a known risk factor for poor healing after rotator cuff repair (RCR), but the effects of nontobacco nicotine products remain unclear. Purpose: To compare postoperative complications among nontobacco nicotine users, tobacco users, and nonusers undergoing RCR. Study Design: Cohort study; Level of evidence, 3. Methods: Using the PearlDiver database, the authors identified patients who underwent arthroscopic RCR with ≥2 years of follow-up. Three 1:1 propensity-matched comparisons were conducted: nontobacco nicotine users versus nonusers (n = 4844), tobacco users versus nonusers (n = 19,182), and nontobacco nicotine users vs tobacco users (n = 4882). Outcomes included 90-day complications and 2-year revision surgeries. Results: Nontobacco nicotine users had mildly higher rates of lysis of adhesions than controls (0.7% vs 0.4%; OR, 1.95; P = .033) but no other significant differences. Tobacco users showed increased rates of acute kidney injury (AKI), pneumonia, infections, emergency department (ED) visits, readmissions, and revision surgery compared to controls. Compared to tobacco users, nontobacco nicotine users had moderately strong lower risks of pneumonia (0.6% vs 1.2%; OR, 0.46), ED visits (8.8% vs 13.6%; OR, 0.62), and readmissions (0.8% vs 1.5%; OR, 0.54) (all P < .01). Conclusion: While nontobacco nicotine use was associated with a modestly increased risk of lysis of adhesions after RCR, it did not significantly elevate the risk of major medical complications, infections, or revision surgery when compared to nonnicotine users. In contrast, tobacco users demonstrated consistently worse postoperative outcomes across multiple domains, including higher rates of AKI, pneumonia, surgical site infection, ED visits, readmissions, and revision procedures. Notably, when compared directly to tobacco users, nontobacco nicotine users had significantly lower rates of pneumonia, ED utilization, and readmissions. These findings suggest that although nontobacco nicotine products may not be entirely benign, their perioperative risk profile appears to be less severe than that of traditional tobacco use.

Background Long-term corticosteroid (LTC) use is a known risk factor for adverse outcomes after various surgical procedures. However, the impact of LTC use on surgical complications after TSA remains underexplored. This study aims to assess the influence of LTC use on 90-day and 5-year complications following TSA. Methods A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary TSA with a minimum 5-year follow-up were included. LTC users were propensity-matched 1:10 with controls based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and long-term complications within 5 years were compared between groups. Multivariable logistic regressions were used to compare complications controlling for demographic variables and comorbidities. Results In a matched cohort of 556 LTC users to 4942 controls, corticosteroid users exhibited a 2.91-fold higher risk of pneumonia (95% CI: 1.69–4.80, p < 0.001) and a 2.19-fold higher risk of venous thromboembolism (VTE) (95% CI: 1.30–3.51, p = 0.001) within 90 days following TSA. No significant differences in 5-year surgical outcomes were observed. Discussion LTC users are at a heightened risk for 90-day medical complications, including pneumonia and VTE following TSA. However, their 5-year risk of surgical complications was comparable to patients without LTC use.

Abstract Background Little research exists regarding geographic comparisons within the United States for Medicaid reimbursement. We compared Medicaid reimbursement for a broad range of orthopedic surgery codes from each state on a geographic and state level. Methods We obtained Medicaid reimbursement rates in each state for 211 orthopedic procedure codes along with corresponding work Relative Value Units (wRVUs). Rates were divided by wRVUs to control for differences between procedures and subspecialties. States were designated as either West, Midwest, South, or Northeast. Kruskal-Wallis tests with Dunn’s post-hoc analyses ascertained differences between regions and each orthopedic subspecialty by state. Coefficient of variation (CoV) values were calculated to measure the amount of variability in rates. A Kruskall-Wallis with Dunn’s post-hoc test assessed differences in quartiles for reimbursement compared to a square miles per orthopedic surgeon ratio. Results The West region reimbursed the highest at $72.92/wRVU and the Northeast reimbursed the lowest at $51.78. Hand surgery was the highest reimbursing subspecialty ($94.58/wRVU) and Oncology the lowest ($62.89/wRVU). The CoV ranged from 0.15–0.77 by state and 0.27–0.50 by subspecialty. A linear regression model between wRVU-adjusted Medicaid reimbursement and square miles per surgeon yielded an R2 value of 0.453. States with the most land area relative to orthopedic surgeons reimbursed significantly higher. Conclusion The West geographic region is associated with the highest Medicaid reimbursement for orthopedic procedures, and the Northeast the lowest. Wide variability was seen in rates, both between states and within states. Large, sparsely-populated states may increase Medicaid reimbursement as a tactic to attract physicians. Level of Evidence: IV; Economic Analysis

Purpose To assess the ability of artificial intelligence (AI) to identify common sports‐related pathologies using radiologic imaging and to compare ChatGPT 4.0 with 2 competitors, Grok 2 and Claude 3.5 Sonnet. Methods ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet were used. Five common orthopaedic sports pathologies were chosen: anterior cruciate ligament tears, posterior cruciate ligament tears, meniscal tears, chondral pathologies, and rotator cuff tears. Fifty images representing each pathology were collected from a radiologic imaging database when possible, which included radiographic images, computed tomography, and magnetic resonance imaging. Normal images were collected that corresponded to each diagnostic category. Receiver operator characteristic curves and area under the curve values were calculated to assess the accuracy of each AI platform. Results ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet accurately identified the pathology in 23.6%, 15.7%, and 17.1% of diseased images, respectively. ChatGPT and Grok were most accurate at identifying meniscus pathologies (ChatGPT: 48%, Grok: 42%), whereas Claude Sonnet was most accurate at identifying anterior cruciate ligament pathologies (30%). The area under the curve for ChatGPT, Grok, and Claude Sonnet was 0.21, 0.16, and 0.15, respectively (ChatGPT 4.0 vs Grok 2, P = .30; ChatGPT 4.0 vs Claude 3.5 Sonnet, P = .24; Grok 2 vs Claude 3.5 Sonnet, P > .99). There were no differences in performance between the 3 platforms overall or within any of the diagnostic categories. Conclusions ChatGPT 4.0, Grok 2, and Claude 3.5 Sonnet correctly identified the pathology in less than 25% of images of common sports‐related pathologies and showed area under the curve values well below 0.5, indicating poor accuracy. Based on these findings, we do not recommend the current use of these generative AI models for image‐based diagnosis in orthopaedics. Clinical Relevance As the use of AI becomes more popular within the general public, it becomes increasingly important to make aware the capabilities and limitations of popular AI platforms in regard to their current image‐based diagnostic capabilities.

Background: To our knowledge, there are no studies assessing associations between patients on preoperative estrogen replacement therapy (ERT) undergoing distal radius open reduction and internal fixation (DRORIF) and postoperative outcomes. Thus, the purpose of this study was to compare surgical and medical complications in patients on ERT undergoing DR-ORIF with a matched control cohort. Materials and Methods: The PearlDiver Mariner database was searched for female patients who took ERT within 3 months of the index procedure. Patients were matched 1:4 with non-ERT controls using propensity score matching. Complications were assessed at 90 days, 2 years, and 5 years. Statistical analyses were conducted using odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was determined at a P value of <.05. Results: The ERT cohort consisted of 1,815 ERT users, and the control cohort consisted of 7,247 patients. At 2 years, the ERT cohort was associated with a slightly greater incidence of malunion/nonunion (OR, 1.57; 95% CI, 1.13–2.18) but with no increased risk of revision surgery (OR, 1.10; 95% CI, 0.50–2.10). Similarly, at 5 years, the ERT cohort was associated with a slightly higher likelihood of a malunion/nonunion diagnosis (OR, 1.69; 95% CI, 1.24–2.30). Conclusion: The current study suggests that patients on preoperative ERT had a slightly increased risk of malunion/nonunion at 2 years and 5 years after DR-ORIF. We did not find associations between increases in the risk of any other major or minor complications and the cohort of patients on preoperative ERT within 5 years postoperatively.

OBJECTIVES: To evaluate and compare the ability of three popular open-source artificial intelligence platforms to diagnose common trauma-related fractures using radiologic imaging. METHODS: Design: Retrospective diagnostic performance comparison study. Setting: Publicly accessible online radiologic imaging databases. Patient Selection Criteria: Five common orthopedic trauma fractures were assessed: ankle, tibial plateau, intertrochanteric, femoral neck, and humerus. Radiographs and computed tomography (CT) images were collected. Images were randomly selected from confirmed diagnoses on Radiopaedia.org. Outcome Measures and Comparisons: ChatGPT 5, Grok 3, and Claude 4.5 Sonnet were queried with each image. Diagnostic accuracy, sensitivity, specificity, positive and negative predictive values, and performance by modality (X-ray vs. CT) were assessed. The reference standard was the expert-verified diagnosis provided by Radiopaedia.org, limited to cases labeled with a “diagnosis certain” tag. RESULTS: Each model was provided with 30 radiographs and 20 CT images whenever possible. ChatGPT 5, Grok 3, and Claude 4.5 Sonnet accurately diagnosed diseased images in 26.8%, 18.8%, and 22.4% of cases, respectively. By fracture type, ChatGPT 5 demonstrated the highest correct classification rates for ankle (10%), femoral neck (38%), humerus (40%), and tibial plateau (44%) fractures. Grok 3 demonstrated the highest correct classification rate for intertrochanteric fractures (6%). Overall sensitivities were 0.267, 0.187, and 0.223 for ChatGPT 5, Grok 3, and Claude 4.5 Sonnet, respectively. ChatGPT 5 and Grok 3 outperformed Claude 4.5 Sonnet (both P < 0.001). No modality-based performance differences were observed for any model. CONCLUSIONS: Among the publicly available large language models evaluated for radiologic interpretation of orthopedic trauma imaging, ChatGPT 5 demonstrated the highest overall diagnostic accuracy, followed by Claude 4.5 Sonnet and Grok 3. Despite relative variation between the models, overall diagnostic accuracy for fracture detection was low across all platforms (<27%). In their baseline forms, these publicly accessible large language models are not recommended for radiologic imaging interpretation. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abstract Despite the reported benefits of testosterone replacement therapy (TRT), prior studies have shown that TRT is correlated with increased incidence of adverse outcomes after orthopedic procedures. There is a paucity of literature assessing the outcomes of patients on preoperative TRT undergoing distal radius open reduction and internal fixation (DR-ORIF). Our purpose was to evaluate rates of surgical and medical complications in patients on TRT undergoing DR-ORIF with a matched control cohort. The PearlDiver database was queried for patients who used TRT within 3 months prior to the index procedure. Patients were matched 1:4 with nonuser controls using propensity score matching. Matching was conducted based on age, Elixhauser Comorbidity Index, hypogonadism, osteoporosis, and other comorbidities. Complications were assessed at 90 days and 2 years. Statistical analyses were conducted using chi-square tests. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for each complication. Statistical significance was determined at a p-value of < 0.05. The matched group included 657 TRT users and 2,236 controls. There were significant differences in depression (control: 40.6% vs. TRT: 45.7%, p = 0.02) and rates of hypogonadism (control: 74.1% vs. TRT: 77.9%, p = 0.05) between the groups. No other statistically significant demographic or characteristic differences were noted. TRT use was not associated with increased surgical or medical complication rates at 90 days postoperatively. At 2 years, TRT use was associated with a greater incidence of revision (OR: 2.80, 95% CI: 1.34–5.85) and nonunion (OR: 2.76, 95% CI: 1.59–4.81). There were no other associations noted at 2 years. Preoperative TRT was associated with an increased risk of revision surgery and nonunion at 2 years postoperatively. No other significant associations in the risk of major or minor complications were observed. Level III