Samuel K. Simister

Background: Low- and middle-income countries (LMICs) are disproportionately affected by trauma, resulting in >5 million deaths annually. An essential treatment for musculoskeletal trauma is external fixation. However, in LMICs, current external fixator assemblies are unaffordable, costing patients upward of $5,000 (USD), leaving LMICs to rely on donations that fail to meet the needs of the patient population. Methods: New, affordable external fixator (AEFIX) clamps (SONA Global), designed for use in LMIC settings, were compared with Hoffmann 3 (Stryker Medical) clamps to examine their mechanical efficacy compared with commercially available, industry-standard clamps in the U.S. market. In axial and torsional loading scenarios, mechanical testing was performed at the component level and construct level (uniplanar external fixation of a tibial diaphyseal fracture). Results: The AEFIX constructs showed no differences in axial or torsional stiffness compared with Stryker constructs. AEFIX constructs yielded at 434.5 N compared with Stryker constructs at 533.6 N (p = 0.04); however, the pins failed before clamp failure could occur in all AEFIX and Stryker constructs. Under cyclic loading at 100 and 300 N, no differences were observed in construct stiffness or interfragmentary gap change. At 500 N of cyclic loading, the AEFIX and Stryker constructs resulted in median gap changes of −4.3 and −1.1 mm, respectively (p < 0.001), with no difference in % change in construct stiffness (p = 0.281). Conclusions: AEFIX clamps were comparable to industry-standard Stryker Hoffman 3 clamps in terms of mechanical properties and effectiveness, suggesting that the AEFIX clamps may provide safe external fracture fixation in the non-weight-bearing patient. Clinical Relevance: As a safe and affordable solution, AEFIX clamps provide a foundation for enhancing essential trauma surgery capacity in resource-constrained settings around the globe.

Aims: Complex elbow fracture-dislocations often result in suboptimal outcomes and necessitate a thorough understanding of injury patterns to guide effective management and reduce adverse sequelae. The Wrightington Classification System (WCS) offers a comprehensive approach and considers both bony and soft-tissue disruption, providing clearer guidance for treatment. This is the first external study to assess the reliability of the WCS for elbow fracture-dislocations.Methods: A blinded study of patients with elbow fracture-dislocations at a single institution between December 2014 and December 2022 was conducted. Five assessors with a range of experience, including orthopaedic surgeons and radiologists, independently classified injuries using the WCS across three image methods: plain radiograph, 2D CT, and 2D and 3D CT reconstruction images, on two occasions with an eight-week interval. Interobserver and intraobserver reliability were evaluated using kappa statistics and the Landis and Koch criteria.Results: A total of 73 patients were included in the study. Interobserver reliability was moderate, with mean kappa values of 0.518 (95% CI 0.499 to 0.537), 0.557 (95% CI 0.537 to 0.577), and 0.582 (95% CI 0.562 to 0.601), for radiographs, 2D CT, and 2D and 3D CT reconstructions, respectively. Intraobserver agreement was substantial (mean kappa 0.695 (SE 0.067), 0.729 (SE 0.071), and 0.777 (SE 0.070) for radiographs, 2D CT, and 3D CT reconstructions, respectively).Conclusion: The WCS is a reliable and valuable tool for characterizing elbow fracture-dislocations and guiding surgical interventions. This study found moderate reliability in using the WCS, with higher reliability with combined 2D and 3D CT imaging. Further refinement within the WCS in differentiating between coronoid avulsions, basal, anteromedial, and/or anterolateral facet injuries may help improve reliability and reproducibility.Cite this article: Bone Joint J 2025;107-B(2):188–192.

Introduction: The introduction of generative artificial intelligence (AI) may have a profound effect on residency applications. In this study, we explore the abilities of AI-generated letters of recommendation (LORs) by evaluating the accuracy of orthopaedic surgery residency selection committee members to identify LORs written by human or AI authors. Methods: In a multicenter, single-blind trial, a total of 45 LORs (15 human, 15 ChatGPT, and 15 Google BARD) were curated. In a random fashion, seven faculty reviewers from four residency programs were asked to grade each of the 45 LORs based on the 11 characteristics outlined in the American Orthopaedic Associations standardized LOR, as well as a 1 to 10 scale on how they would rank the applicant, their desire of having the applicant in the program, and if they thought the letter was generated by a human or AI author. Analysis included descriptives, ordinal regression, and a receiver operator characteristic curve to compare accuracy based on the number of letters reviewed. Results: Faculty reviewers correctly identified 40% (42/105) of human-generated and 63% (132/210) of AI-generated letters ( P < 0.001), which did not increase over time (AUC 0.451, P = 0.102). When analyzed by perceived author, letters marked as human generated had significantly higher means for all variables ( P = 0.01). BARD did markedly better than human authors in accuracy (3.25 [1.79 to 5.92], P < 0.001), adaptability (1.29 [1.02 to 1.65], P = 0.034), and perceived commitment (1.56 [0.99 to 2.47], P < 0.055). Additional analysis controlling for reviewer background showed no differences in outcomes based on experience or familiarity with the AI programs. Conclusion: Faculty members were unsuccessful in determining the difference between human-generated and AI-generated LORs 50% of the time, which suggests that AI can generate LORs similarly to human authors. This highlights the importance for selection committees to reconsider the role and influence of LORs on residency applications.

OBJECTIVES: The purpose of this study was to evaluate the biomechanical stability of a modified triangular osteosynthesis construct with S1 pedicle screws compared with other described lumbopelvic fixation constructs in a U-type sacral fracture model. METHODS: U-type sacral fractures were created in validated fourth-generation spinopelvic models. Four different constructs were cyclically loaded with displacement measured in all planes: (1) bilateral L5 pedicle screws with rods attached to iliac bolts, (2) bilateral L5 and S1 pedicle screws with rods attached to iliac bolts, (3) bilateral L5 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw, and (4) bilateral L5 and S1 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw. RESULTS: The bilateral L5 and S1 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw construct had significantly decreased horizontal, vertical, and angular displacement compared with all other constructs. CONCLUSIONS: From a biomechanical perspective, a modified triangular osteosynthesis construct with S1 pedicle screws improves stability in fixation of U-type sacral fractures.

Background Patients with secondary metastatic involvement of the musculoskeletal system due to primary cancers are a rapidly growing population with significant risks for health-related end-of-life morbidities. In particular, bone metastases or metastatic bone disease (MBD) imparts significant adversity to remaining quality of life. No rigorous review of clinical trials on the use of supportive care interventions for MBD has been conducted. The objective of this review was to examine the characteristics of supportive care interventions for MBD and critically appraise study designs, key findings, and quality of evidence of the research. Methods We searched for published clinical trials, systematic reviews and meta-analyses in PubMED, CINAHL and Google Scholar for articles published between September 2017 and September 2022. Some examples of Medical Subject Headings terms were: ‘secondary neoplasm’, ‘metastatic bone disease’, ‘palliative care’ and ‘supportive care intervention’. Quality of published evidence was evaluated based on treatment types and study design. Results After reviewing 572 publications, 13 articles were included in the final review and evaluation including seven clinical trials, two trial protocols and four systematic reviews. Feasible interventions included enhanced palliative care consultation, palliative radiotherapy and alternative medicines. Interventions addressed primary endpoints of fatigue (N=4, 31%), pain (N=3, 23%) or cancer-related symptoms (N=3, 23%) with patient-reported outcome instruments. No interventions reported on fracture complications or endpoints, specifically. The quality of most studies was moderate to strong. Conclusion Supportive care interventions for MBD are feasible and the impact is measurable via patient-reported outcome measures. While the evidence for interventions was moderate to strong, there are very few specific controlled trials for skeletal-related events and impacts of social determinants of health. Further clinical trials are needed to define supportive care interventions for MBD that demonstrate reduced risk of fracture and that mitigate the reduced quality of life when negative musculoskeletal outcomes arise.

In this special edition update on soft tissue sarcomas (STS), we cover classifications, emerging technologies, prognostic tools, radiation schemas, and treatment disparities in extremity and truncal STS. We discuss the importance of enhancing local control and reducing complications, including the role of innovative imaging, surgical guidance, and hypofractionated radiation. We review advancements in systemic and immunotherapeutic treatments and introduce disparities seen in this vulnerable population that must be considered to improve overall patient care.

Background: Since 2015, the American College of Radiology (ACR) has recommended staging for lung metastasis via chest computed tomography (CT) without contrast for extremity sarcoma staging and surveillance. The purpose of this study was to determine our institutional compliance with this recommendation.Methods: This was a retrospective chart review of patients diagnosed with sarcoma in the extremities who received CT imaging of the chest for pulmonary staging and surveillance at our institution from 2005 to 2023. A total of 1916 CT studies were included for analysis. We scrutinized ordering patterns before and after 2015 based on the ACR‐published metastasis staging and screening guidelines. An institutional and patient cost analysis was performed between CT modalities.Results: The prevalence of CT scans ordered and performed with contrast was greater than those without contrast both prior and post‐ACR 2015 guidelines. Furthermore, 79.2% of patient's final surveillance CTs after 2015 were performed with contrast. A cost analysis was performed and demonstrated an additional $297 704 in patient and institutional costs.Conclusions: At our institution, upon review of CT chest imaging for pulmonary staging and surveillance in patients with extremity sarcoma the use of contrast has been routinely utilized despite a lack of evidence for its necessity and contrary to ACR guidelines.

Case: A 16-year-old male patient presented with isolated bilateral sacroiliac (SI) joint dislocation. In this report, we discuss the presentation and focus on strategies for operative reduction and fixation for this rare injury. Conclusion: In conclusion, we present a case of a bilateral ligamentous SI joint dislocation in an adolescent. The patient was reduced in the supine position with a sacral bump and bilateral traction with direct and indirect reduction aids inserted through a lateral window. Bilateral SI screws stabilized the pelvis, facilitating uncomplicated healing.