Jan P. Szatkowski

Purpose: The management of midshaft clavicle fractures varies depending on fracture characteristics, patient demographics, and surgeon preferences. However, global differences in practice patterns and surgical decision-making for this injury remain poorly characterized.Methods: An international survey was conducted through Orthobullets between March 2021 and September 2024, targeting practicing orthopedic surgeons. Standardized polls, created collaboratively using the best available evidence and a peer-reviewed, evidence-based item list, were designed to capture global treatment preferences. Analyses were then performed to evaluate variation across subspecialties and practice environments. Multivariable regression was applied to examine associations between subspecialty, practice type, the likelihood of selecting operative management, and the preferred surgical techniques.Results: The study included 2,364 surgeons from 76 countries. Overall, 46% (1,076 of 2,337 respondents) selected operative treatment, with notable regional differences. Surgeons from Asia (odds ratio [OR], 1.650), Africa (OR, 1.988), and Latin America (OR, 1.785) were more likely to choose surgery, whereas those from Oceania (OR, 0.464) were less likely. Trauma specialist were 1.45 times more likely to offer operative management. Regarding immobilization, 73.4% preferred a sling, while 23.4% chose a figure-of-eight brace. Among surgeons opting for surgery, 93% (1,479 of 1,590 respondents) selected open reduction and internal fixation with plates and screws.Conclusions: This study demonstrates a notable trend toward operative management of midshaft clavicle fractures, influenced by subspecialty and practice environment. These findings highlight the evolving landscape of fracture care and emphasize the need for standardized approaches and broader understanding across diverse healthcare systems.

Case: A 44-year-old woman with an infected pilon fracture nonunion developed Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) after prolonged intravenous vancomycin and implantation of a vancomycin/tobramycin-loaded antibiotic cement spacer (ACS). Fevers, rash, and eosinophilia persisted despite stopping systemic vancomycin and starting corticosteroids. ACS explantation led to symptom resolution; however, severe thrombocytopenia developed, requiring therapeutic plasma exchange. A daptomycin-loaded spacer was reimplanted before definitive hindfoot fusion. Conclusion: This case of DRESS in the setting of an ACS highlights management challenges, supports early recognition and spacer removal, proposes a treatment algorithm, and suggests daptomycin as an alternative for local antibiotic delivery.

Background and Objective: The integration of artificial intelligence (AI) into medical education is reshaping traditional learning paradigms. In orthopaedic surgery, AI applications such as virtual reality (VR) and augmented reality (AR) simulations and intelligent tutoring systems are being utilized to enhance training. This review aims to explore the current applications, benefits, challenges, and future directions of AI in orthopaedic education, while also addressing relevant ethical and logistical considerations. Methods: A targeted literature review was conducted using PubMed, prioritizing studies published in 2024 and including relevant articles from 2023. Search terms included “artificial intelligence”, “orthopaedic education”, “surgical simulation”, and related keywords. Studies were selected based on relevance to orthopaedic surgery education, with a particular focus on surgical skill acquisition, diagnostic training, and curriculum development. Both peer-reviewed and selected non-peer-reviewed sources were analyzed to synthesize current trends and emerging practices. Relevant articles were also identified using manual reference searching. Key Content and Findings: The review highlights a positive shift in attitudes toward AI among educators and learners, particularly for its ability to simulate surgical environments safely and personalize learning. Current applications include AI-powered VR/AR platforms for realistic procedural training, intelligent tutoring systems that tailor feedback to individual learning gaps, and tools for enhancing diagnostic reasoning. Despite these advances, challenges remain, including concerns about overreliance on technology, institutional readiness, and the need for adjustments to the curriculum. Conclusions: AI presents a transformative opportunity for orthopaedic education by enabling safer, more personalized, and more efficient learning. While current applications show promising results in improving both knowledge and technical skill, ongoing evaluation, thoughtful integration, and structured implementation are necessary to maximize educational value while addressing limitations and ethical concerns.

Objectives: The aim of this study was to determine the applicability of the Revised Risk Analysis Index (RAI-Rev) in orthopaedic trauma and compare the predictive discrimination for the RAI-Rev and the 5-Item Modified Frailty Index (mFI-5) for 30-day postoperative outcomes. Methods: Design: This is a retrospective cohort study. Setting: The American College of Surgeons National Surgical Quality Improvement database was used. Patient Selection: All patients aged 18 or older who underwent surgical treatment for forearm, humerus, pelvis, acetabulum, femur, tibia, and hindfoot fractures from 2015 to 2020 were included. Outcome: 30-day postoperative mortality, major complications, and wound complications consisting of surgical site infection, and wound dehiscence were measured. Results: A total of 206,352 patients met inclusion criteria. The mean age was 69 years, with 64.2% (n = 132,514) being female. Multivariate regression analysis showed that increasing frailty tiers in both RAI-Rev and mFI-5 were independent predictors of mortality, major complications, readmission, and wound complications. The cohort with the highest degree of frailty in both RAI-Rev and mFI-5 had the greatest risk of poor outcomes. RAI-Rev had significantly superior predictive discriminatory thresholds compared with mFI-5 for predicting 30-day mortality (C-statistic: RAI-Rev [0.84] and mFI-5 [0.67], P < 0.001), major complications (C-statistic: RAI-Rev [0.73] and mFI-5 [0.65], P < 0.001), and readmission (C-statistic: RAI-Rev [0.68] and mFI-5 [0.63], P < 0.001). However, mFI-5 outperformed RAI-Rev when predicting wound complications (C-statistic: RAI-Rev [0.52] and mFI-5 [0.55], P < 0.001). Conclusion: The RAI-Rev tool demonstrated superior predictability of postoperative morbidity, mortality, and readmission rates compared with mFI-5 but was less effective in predicting surgical site complications. These findings demonstrate the utility of RAI-Rev in anticipating postoperative complications in the setting of orthopaedic trauma, where optimizing surgical candidate selection is not always possible. Assessing the predicted morbidity and mortality through RAI-Rev enables surgeons to accurately identify patients at high risk of complications, which can further research investigation to mitigate this risk.

Purpose: The growing geriatric population has led to a sharp rise in geriatric displaced femoral neck fractures (DFNF). Global reporting is pivotal in deciphering surgeons' decision-making, managing geriatric DFNF. This study aims to further analyze the nuanced utilization preferences and stratifies these across various subspecialities, practice environments, and countries. Methods: A longitudinal survey from 2020 to 2023 was conducted online via Orthobullets Case Studies, a global orthopaedic collaboration platform, to ascertain treatment preferences for geriatric DFNF. Standardized peer-reviewed polls were used to capture surgeon preferences for total hip arthroplasty (THA). A multivariable regression analysis assessed THA utilization odds across practice environments, subspecialities, and geographic factors, followed by a robust analysis to furnish precise estimates of THA preferences to represent the general population. Results: Among the 2606 respondents surveyed, 51.5% expressed a preference for THA. Subspecialty preferences were distributed as follows: Arthroplasty (63.4%), Trauma (53.4%), General orthopaedics (51.4%), and Sports (40.2%). Notably, hospitals exhibited a higher inclination towards THA (53.3%) compared to private practices (41.2%) (i.e. one additional THA for every seven fractures managed in a hospital setting). Regression analyses unveiled a significant 3-fold odds difference in THA rates across diverse practice environments and subspecialties. Academic arthroplasty surgeons displayed a 5.4 times higher inclination for THA (i.e. two additional THAs for every five fractures encountered). Conclusion: Practice environment profoundly influences THA utilization for geriatric DFNF. The study findings underscore the critical need for future trials, advocating for randomized evaluations across subspecialties, geographical regions, and varied practice settings to holistically inform best practices in orthopaedic care. Level of Evidence Level III Surgical Practice Survey (Global Practice Trends).

Introduction: We assessed ChatGPT-4 vision (GPT-4V)'s performance for image interpretation, diagnosis formulation, and patient management capabilities. We aim to shed light on its potential as an educational tool addressing real-life cases for medical students. Methods: Ten of the most popular orthopaedic trauma cases from OrthoBullets were selected. GPT-4V interpreted medical imaging and patient information, providing diagnoses, and guiding responses to OrthoBullets questions. Four fellowship-trained orthopaedic trauma surgeons rated GPT-4V responses using a 5-point Likert scale (strongly disagree to strongly agree). Each of GPT-4V's answers was assessed for alignment with current medical knowledge (accuracy), rationale and whether it is logical (rationale), relevancy to the specific case (relevance), and whether surgeons would trust the answers (trustworthiness). Mean scores from surgeon ratings were calculated. Results: In total, 10 clinical cases, comprising 97 questions, were analyzed (10 imaging, 35 management, and 52 treatment). The surgeons assigned a mean overall rating of 3.46/5.00 to GPT-4V's imaging response (accuracy 3.28, rationale 3.68, relevance 3.75, and trustworthiness 3.15). Management questions received an overall score of 3.76 (accuracy 3.61, rationale 3.84, relevance 4.01, and trustworthiness 3.58), while treatment questions had an average overall score of 4.04 (accuracy 3.99, rationale 4.08, relevance 4.15, and trustworthiness 3.93). Conclusion: This is the first study evaluating GPT-4V's imaging interpretation, personalized management, and treatment approaches as a medical educational tool. Surgeon ratings indicate overall fair agreement in GPT-4V reasoning behind decision-making. GPT-4V performed less favorably in imaging interpretation compared with its management and treatment approach performance. The performance of GPT-4V falls below our fellowship-trained orthopaedic trauma surgeon's standards as a standalone tool for medical education.

Purpose The management of geriatric femoral neck fractures, which includes options like hemiarthroplasty (HA), total hip arthroplasty (THA), and fixation, exhibits regional and healthcare setting variations. However, there is a lack of information on global variations in practice patterns and surgical decision factors for this injury. Methods Survey data were collected from April 2020 to June 2023 via Orthobullets Case Studies, a global clinical case collaboration platform hosted on a prominent orthopedic educational website. Collaboratively developed standardized polls, based on the best available evidence and a comprehensive, peer-reviewed, evidence-based item list, were used to capture surgeons’ treatment preferences worldwide. Subsequent analyses explored preferences within subspecialties and practice settings. Multivariable regression analysis identified associations between subspecialty, practice type, the likelihood of choosing THA, and the preferred femoral fixation method. Results Our study encompassed 2595 respondents from 76 countries. Notably, 51.5% of participants (n = 1328; 51.5%, 95% CI 49.6–53.4%) leaned towards THA and 44.9% for HA, while 3.6% favoured surgical fixation. Respondents affiliated with academic institutions and large non-university-affiliated hospitals were 1.74 times more likely to favour THA, and arthroplasty specialists exhibited a 1.77-fold preference for THA. There was a 19-fold variation for cemented femoral fixation between the United Kingdom (UK) and USA with the UK favouring cemented fixation. Conclusion Our study reveals a significant shift towards THA preference for managing geriatric femoral neck fractures, influenced by subspecialty and practice settings. We also observed a pronounced predominance of cement fixation in specific geographic locations. These findings highlight the evolving fracture management landscape, emphasizing the need for standardization and comprehensive understanding across diverse healthcare settings.