Carolina Stocchi

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.

Introduction: Recently, the role of a patient's primary spoken language (PSL) has emerged as a potential contributor to perioperative outcomes. This study aimed to identify the association between a patient's PSL and hip fracture perioperative outcomes, including hospital length of stay (LOS), in-hospital mortality, nonhome discharge, 30-day emergency department visits, 90-day readmissions, and 90-day complications. Methods: An institutional review board–approved retrospective cohort study was performed using institutional data. Two cohorts were created for patients who underwent either open reduction and internal fixation (ORIF) or arthroplasty (total or hemiarthroplasty) for a hip fracture in 2016 to 2023 in a multihospital academic health system. Within each cohort, patients with non-English and English PSL were matched 1:3 based on age, sex, insurance, American Society of Anesthesiologists Classification, dementia, and obesity. Generalized linear models measured associations between PSL and outcomes, adjusting for Charlson Comorbidity Index; adjusted odds ratios are reported for binary outcomes and adjusted mean differences are reported for continuous outcomes. Results: The matched cohorts included 729 patients undergoing ORIF and 473 undergoing arthroplasty. In multivariable analyses in the ORIF cohort, non-English PSL (versus English) was associated with a markedly longer LOS by an average of 0.95 days (95% confidence interval [CI], 0.28 to 1.62, P = 0.01) and decreased likelihood of discharge to a nonhome setting (odds ratio = 0.62, 95% confidence interval, 0.39 to 0.98, P = 0.04). For arthroplasty, non-English PSL (versus English) was markedly associated with shorter LOS by an average of 1.04 days (95% CI, −1.99 to −0.09, P = 0.03). No notable associations were identified between PSL and the other outcomes. Conclusion: These findings suggest language-based differences in perioperative outcomes for surgical management of hip fracture. Further research is needed to identify the mechanisms of these associations and evaluate the clinical significance on long-term outcomes.

Case: We describe a case of a 28-year-old woman who presented with a left closed, displaced distal tibia and fibula fracture and underwent closed reduction with retrograde intramedullary osteosynthesis. Conclusion: This case report highlights that retrograde tibial nailing is technically possible and produced good results. Currently, it requires off label use of a nail designed for antegrade insertion using custom insertion and bending techniques. Retrograde tibial nailing is a reasonable alternative when a standard antegrade technique may not be possible or desirable. If further cases of this technique yield similarly good outcomes, it may be valuable to create a commercially available retrograde tibial implant.

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.

Case: Here, we describe a case of a 49-year-old female patient with a history of hypertension and polysubstance use disorder presenting with a distal tibial metaphyseal malunion treated with a clamshell osteotomy. Her follow-up was 2.5 years long. Conclusion: Malunions in the tibial diaphysis and distal metaphysis can cause significantly increased joint reaction forces and altered gait mechanics leading to cosmetic dissatisfaction and decreased quality of life for these patients. Correction of these deformities can improve patient satisfaction and quality of life, along with decrease the risk of early arthritis. The clamshell osteotomy, although initially described to treat diaphyseal long bone malunions, can safely be performed for treatment of complex periarticular metaphyseal malunions.