Jie J. Yao

Cases: Three patients (61-81 years) experienced abrupt shoulder pain and functional decline more than 5 months after reverse total shoulder arthroplasty (RTSA) using a monoblock central-screw baseplate in graft-reconstructed glenoids. Imaging revealed central screw breakage with variable baseplate displacement. Two underwent successful revision with restoration of stable fixation; in the third, revision was deferred for medical comorbidities. Conclusion: Central screw breakage is an important marker of glenoid fixation failure after RTSA. These cases suggest an association with graft-dependent baseplate fixation, limited native bone support, and consequently late fatigue failure. Prompt diagnosis and timely management are essential.

Background: Advantages of preoperative planning computed tomography (CT) scans for shoulder arthroplasty (SA) are known; however, risks of ionizing radiation exposure remain unknown. We retrospectively reviewed institutional trends in utilization and estimated radiation risk of preoperative planning CT scans obtained for SA. Methods: From 2016 to 2024, the annual percent incidence of SA patients that received a preoperative planning CT was determined. The National Academy of Sciences Biological Effects of Ionizing Radiation VII report on lifetime attributable risk (LAR) cancer incidences and received radiation dose were utilized to estimate patient-level LAR projections for 100 patients stratified by sex, age, and cancer type. Results: From 2016 to 2024, utilization of preoperative planning CT increased linearly (R ² = 0.78) from 53% to 66% of all SA patients. For all solid cancers, LAR (per 100,000 people) decreased as patient age increased, ranging from 73.1 to 9.6 for females and 40.7 to 31.4 for males (from the 50–59-year-old group to the 80–89 group). In the 60–69-year-old and 70–79-year-old groups, estimated thyroid and lung LARs were significantly higher in women. Discussion: Utilization of preoperative shoulder CT scans is increasing. Preoperative shoulder CT may be associated with a small but quantifiable projected cancer risk most pronounced in younger women.

Background: The use of large language models (LLMs) is increasingly common. However, LLMs may exhibit sycophancy, echoing users’ beliefs while avoiding contradiction. In the present study, we describe sycophancy in general-purpose LLMs when applied to orthopaedic contexts. Methods: We investigated sycophancy in 2 general-purpose LLMs. We evaluated performance on 3 tasks: (1) accuracy on benchmark answering: LLMs were tested on validated benchmark orthopaedic questions, with correct and incorrect cues, and the change in accuracy and sycophancy error rate were determined; (2) user belief agreement: LLMs were provided with ambiguous statements and a user belief, and LLM agreement, contradiction, and uncertainty were described; and (3) false information detection: false information was placed within a task prompt to measure noncontradiction and propagation rates. Results: Baseline factual accuracy on benchmark questioning was 78%, decreasing with correct hints (71%) (p = 0.49). With incorrect hints, LLM accuracy declined significantly (48%) (p < 0.001), with a sycophancy error rate of 52%. Presented with user beliefs about an indefinite, controversial statement, models echoed user beliefs in 56%, expressed uncertainty in 12%, and contradicted users in 32% of statements. In noncontradiction tasks, models perpetuated incorrect attributions 99% of the time yet reliably corrected statistical distortions 97% of the time. Conclusions: Although popular general-purpose LLMs have useful orthopaedic applications, they exhibit sycophancy, with a tendency toward agreement and without recognition of ambiguity. This is a key weakness to be addressed. Findings should be interpreted cautiously given the variability in model design, prompting, and models evaluated. Clinical Relevance: The tendency of general-purpose LLMs to agree without recognizing clinical ambiguity may limit their reliability in orthopaedic applications.

» Isolated greater tuberosity (GT) fractures account for approximately 20% of all proximal humerus fractures. » Displaced GT fractures can compromise the rotator cuff biomechanics and behave as rotator cuff deficient shoulders, leading to weakness (external rotation and scaption strength), loss of range of motion (elevation, abduction, external rotation), and subacromial impingement. » Most nondisplaced to minimally displaced fractures (<5 mm) can be treated nonsurgically with good outcomes. Secondary displacement of GT fractures is low, but the presence of associated shoulder instability predisposes patients to a higher risk, and thus, these patients should be monitored closely. » Displaced fractures benefit from surgical treatment. A tension band construct or buttressing mechanism is required to neutralize the deforming force of the posterior and superior rotator cuff on fracture fixation. » There is no consensus on the surgical approach (arthroscopic vs. open) and type of fixation (plate, screws alone, suture anchor repair, or hybrid fixation) for the surgical treatment of these fractures. Each fixation option has its own unique profile of advantages and risks, emphasizing the importance of individualized management. » Small (<1 cm) avulsion or depressed type fractures are amenable to arthroscopic treatment with suture anchor repair, with or without screw fixation, resulting in good outcomes. » Open repair is more common in split type fracture patterns or fractures with a large fracture fragment. There is no consensus on the surgical approach (deltopectoral vs. anterolateral or lateral deltoid approach) for open repair.

Infection remains one of the most catastrophic complications following orthopaedic surgery. Despite substantial advances in molecular diagnostics, biomarker assays, and consensus definitions, accurately diagnosing orthopaedic infection continues to challenge even the most experienced clinicians. There are differences in the diagnosis and treatment of infections that are related to different anatomic regions. The difficulty arises from the inherent biological diversity of infecting organisms and surgical locations, variable host responses, and the absence of a true diagnostic “gold standard.” This article summarizes the current diagnostic challenges and emerging solutions, drawing on recent high-impact evidence and consensus frameworks.

Background: Few studies have directly compared limitations in activities of daily living (ADLs) between reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (aTSA). This study evaluates ADL function at mid-term follow-up in patients with revision-free RSA and aTSA. Methods: This retrospective cohort study included 250 patients who underwent primary aTSA (n = 177) or RSA (n = 73) with a minimum follow-up of 7 years (mean 10 ± 2 years). Patients who had revision surgery were excluded. Multivariable ordinal logistic regression analysis was used to assess the odds of RSA patients reporting better ADL function compared to aTSA patients. Results: Postoperatively, a greater proportion of aTSA patients reported normal ADLs compared to RSA patients. On multivariable analysis, controlling for baseline differences, RSA patients reported lower ADL function for personal hygiene/toilet needs (Odds ratio [OR] 0.21 [95% CI: 0.07–0.65]; p = 0.006), washing/combing hair (OR 0.36 [0.13–1.02]; p = 0.049), putting on a button-up shirt (OR 0.08 [0.02–0.25]; p < 0.001), and putting on pants (OR 0.12 [0.03–0.39]; p < 0.001). Discussion: After adjusting for differences in baseline factors, RSA patients reported greater difficulty with specific ADL tasks—including toileting, personal hygiene, grooming, and dressing—compared to aTSA patients. Level of Evidence: Level III; Retrospective cohort study.

Purpose Patella fractures are common and may result in significant morbidity. Open patellar fractures are less common, and there are few investigations into their outcomes and complications. This study aimed to determine acute outcomes after operative treatment of open versus closed patella fractures. Methods This study was a retrospective cohort study from a single academic Level One tertiary trauma center. Patients who underwent open reduction internal fixation of open and closed patella fractures with a minimum of 6 months of follow-up from 2013 to 2018 were included. Those who underwent patellectomy or nonoperative treatment were excluded. The main outcome measures assessed for reoperation rates and clinical complications. Results Forty-six patella fractures treated with operative fixation were included. Of them, 25 were open and 21 were closed fractures. The reoperation rate was significantly higher in the open group compared to the closed group, 43% versus 8%, respectively. Knee manipulation for was also significantly more common in the open group at 24% compared to zero in the closed group. On multivariate analysis, compared to closed injuries, open patella fractures were associated with all-cause reoperation (odds ratio 5.2, 95% confidence interval 1.2–34.5, p = 0.048). Patients in the open group also had significantly increased rates of a high-energy mechanism of injury. Nonunion, malunion, and surgical site infection were not statistically different between the groups. Conclusion Reoperation rates are significantly higher in open patella fractures compared to closed fractures. The increased reoperation rate was mainly driven by the need for manipulation under anesthesia.

Purpose Cutibacterium is commonly isolated from deep tissue samples taken at the time of revision shoulder arthroplasty, but the significance of these positive cultures is debated, and the impact of increasing bacterial loads on clinical outcomes is unclear. The objectives of this study were to (1) identify factors independently associated with high bacterial loads, and (2) compare patient-reported outcomes (PROs) and revision rates in patients found to have high Cutibacterium loads. Materials and methods Male patients undergoing single stage exchange with a minimum 2-year follow-up were included. Culture data were semi-quantitatively scored with the total Cutibacterium score (TShCuS). Two groups were compared: patients with a High Cutibacterium Load (HCL) group and those with Low Cutibacterium Load (LCL) group. PROs and revision rates were compared, and a multivariable analysis was conducted. Results Of 68 male patients that underwent revision shoulder arthroplasty, 29 (42.6%) met the inclusion criteria for the HCL group, while 27 patients (39.7%) were in the LCL group. Mean follow-up was 4.7 ± 3 years. Patients with intraoperative humeral loosening had an 18.4 times increased risk of having high Cutibacterium loads (95% CI 2.1-154.4, p < 0.001). There were no significant differences in PROs or re-revision rates between the HCL and LCL groups. Conclusions Intraoperative humeral loosening was independently associated with high Cutibacterium loads found at the time of revision shoulder arthroplasty. Male patients with high bacterial loads treated with complete single stage exchange and antibiotics had patient-reported outcomes similar to those of patients with minimal to no load. Level of evidence III

➤ Large language models are a subset of artificial intelligence. Large language models are powerful tools that excel in natural language text processing and generation. ➤ There are many potential clinical, research, and educational applications of large language models in orthopaedics, but the development of these applications needs to be focused on patient safety and the maintenance of high standards. ➤ There are numerous methodological, ethical, and regulatory concerns with regard to the use of large language models. Orthopaedic surgeons need to be aware of the controversies and advocate for an alignment of these models with patient and caregiver priorities.