Avanish Yendluri

Study Design: Statistical fragility analysis. Objective: The management of thoracolumbar burst fractures (TLBFs) is challenging, and many surgeons rely on randomized controlled trials (RCTs) to inform decision-making. RCTs often report P- values, which may not fully reflect statistical robustness. This study utilizes fragility statistics to assess the reliability of RCTs evaluating TLBF outcomes. Summary of Background Data: Thoracolumbar burst fracture management remains controversial. Surgeons often rely on RCTs, though P -values alone may not reflect the reliability of the results. Fragility analysis offers deeper insight into the robustness of reported outcomes, yet its use in TLBF research remains limited. Methods: RCTs assessing TLBF management outcomes (2014–2024) were identified through PubMed, Embase, and Medline. Fragility index (FI) and reverse FI (rFI) were calculated as the number of events required to reverse the significance for significant and nonsignificant outcomes, respectively. Fragility quotient (FQ) was derived by dividing FI by the sample size. Subgroup analyses included pain, function, complications, perioperative metrics, and radiographic outcomes. Results: Of the 1073 studies screened, 22 RCTs were included, yielding 179 outcomes (114 continuous and 65 dichotomous). The median FI was 6 [Interquartile Range (IQR) 3–15], indicating that a median of 6 patient reversals changes statistical significance. The median FQ was 0.13 (IQR=0.08–0.24). Subgroup analyses demonstrated median FQs of 6 for pain (IQR=3–12), 6 for function (IQR=3–9), 4 for postoperative complications (IQR=2.75–6), 7 for intraoperative complications (IQR=7–7), 16 for perioperative metrics (IQR=10–20), and 5 for radiographic outcomes (IQR=2–8). Conclusions: Outcomes reported in RCTs evaluating TLBF management are statistically fragile, with an overall fragility quotient of 0.13. The significance of radiographic outcomes can be altered by as few as 6 event reversals. Reporting fragility metrics alongside P- values is recommended to improve the interpretation of RCT results and enable better-informed surgical decisions.

Study Design: Retrospective cohort study.Purpose: This study investigated the impact of cage material on subsidence and segmental lordosis following anterior cervical discectomy and fusion (ACDF), comparing polyetheretherketone (PEEK), titanium, and ceramic synthetic cages, as well as structural allografts.Overview of Literature: Subsidence following ACDF surgery can negatively impact clinical outcomes. Although extensively studied, the relationship between cage type and subsidence remains unclear due to conflicting data and inconsistent control for confounders, underscoring the need for multivariable analysis to determine material-specific effects.Methods: Retrospective study of 120 patients (223 fusion levels) who underwent ACDF between 2016 and 2021. Spacer types included structural allografts, PEEK, titanium, and ceramic cages. Radiographic measurements of subsidence were obtained from immediate (≤8 weeks) and long-term (≥6 months) postoperative lateral cervical radiographs. Multivariable linear regression was used to assess the association between spacer type and subsidence, adjusting for patient demographics, surgical levels, smoking history, and osteopenia.Results: The mean age of patients was 53.6±10.9 years and 41.7% were male; 47.5% had a smoking history and 20.8% had osteopenia. There were 38 one-level (31.7%), 61 two-level (50.8%), and 21 three-level fusions (17.5%). Spacer distribution included 62 structural allografts (51.7%), 27 PEEK (22.5%), 20 titanium (16.7%), and 11 ceramic (9.2%) cages. On multivariable analysis, PEEK cages were associated with significantly less anterior subsidence (β=−0.972, p <0.001) and posterior subsidence (β=−0.666, p=0.001) compared to allografts, and greater preservation of segmental lordosis (β=1.393, p=0.024). No significant differences in subsidence were found between titanium, ceramic, and allograft spacers.Conclusions: PEEK cages showed reduced subsidence and better preservation of cervical lordosis compared to structural allografts, while titanium and ceramic cages did not differ significantly from structural allografts. These results suggest that PEEK cages may help minimize subsidence-related complications and improve outcomes.

Introduction: Knee chondral defects are a common cause of pain and dysfunction. This study assessed the prevalence of spin and methodological quality of systematic reviews and meta-analyses on knee chondral defects in orthopedic literature. Methods: Following PRISMA guidelines, a systematic review was conducted in May 2025 using PubMed, Web of Science, and Embase. Reviews addressing knee chondral defects in orthopedics were included. Abstracts were evaluated for 15 spin types, and methodological quality was rated using AMSTAR 2. Data on PRISMA adherence, publication year, and Level of Evidence were extracted. Associations between study characteristics and spin were analyzed using t tests, ANOVA, Fisher’s exact tests, and Spearman’s rank correlations. Results: Of 238 studies identified, 21 reviews met criteria. Spin was present in 18 (85.7%). The most common types were type 3 (66.7%), type 5 (57.1%), and type 1 (52.4%). Misleading reporting occurred in 85.7%, misleading interpretation in 81.0%, and extrapolation in 52.4%. AMSTAR 2 rated 95.2% as “critically low” and 4.8% as “moderate.” Journal impact factor correlated with spin presence ( P = 0.016) and greater number of spin types ( P = 0.012). Discussion/Conclusion: Most reviews on knee chondral defects contained spin and were of poor quality, underscoring the need for critical appraisal and improved reporting.

Purpose: To systematically review return-to-sport (RTS) patient-reported outcome measure (PROM) usage following autologous chondrocyte implantation (ACI) and matrix-induced autologous chondrocyte implantation (MACI). We hypothesized that RTS reporting would be highly inconsistent, limiting clinical applicability. Methods: A systematic review was conducted using PubMed, Embase, and Scopus (January 1, 2014–December 8, 2024). Eligible studies reported RTS PROMs after ACI/MACI. Extracted data included study design, demographics, name and type of scale used, and assessment modality. Results: Of 807 studies screened, 85 met inclusion criteria. Measures used to report RTS varied widely. The Knee injury and Osteoarthritis Outcome Score–Sport/Rec and the International Knee Documentation Committee Subjective Knee Evaluation Form were the most commonly reported validated PROMs, included in 71.8% and 49.4% of studies, respectively. Only 15.3% of studies reported RTS as a postoperative percentage. Of all, 22.4% of studies used custom, nonvalidated tools. Most studies (49.4%) were prospective, and in-person evaluation was most common (52.8%). Timepoints of RTS measurement were inconsistent. Conclusions: RTS is inconsistently quantified following ACI/MACI, limiting cross-study comparisons and complicating clinical interpretation of outcomes. Standardized use of and expansion of validated PROMs is needed to improve the clinical applicability of data on RTS for ACI/MACI

Context: Lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction have been adopted by some surgeons as augmentations during anterior cruciate ligament reconstruction (ACLR) to improve anterolateral rotatory instability. Objective: The objective of this study was to assess the statistical robustness of outcomes reported in randomized controlled trials (RCTs) assessing the clinical significance of LET and ALL reconstruction in ACLR. Methods: PubMed, Embase, and MEDLINE were systematically searched. RCTs published January 1, 2010 to December 31, 2024 assessing LET and ALL reconstruction during ACLR were included. Fragility index (FI) or reverse FI (rFI) was calculated for each outcome, representing the number of event reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The fragility quotient (FQ) was determined by dividing the FI or rFI by sample size. Level of Evidence: Level 1. Results: Of 112 RCTs screened for inclusion, 17 were included for analysis, resulting in 51 total outcomes. The median FI across the 51 outcomes was 4 [interquartile range (IQR), 2-7] with an associated median FQ of 0.031 (IQR, 0.014-0.049). Statistically significant outcomes were more fragile (median FI, 3.5; median FQ, 0.015) than statistically nonsignificant outcomes (median rFI, 5; median FQ, 0.038). In 60.8% of all outcomes (31 of 51), the number of patients lost to follow-up was greater than the outcome’s respective FI or rFI. In the 7 RCTs assessing LET, the median FQ was 0.015 (IQR, 0.012-0.042) across 23 outcomes. In the 10 RCTs assessing ALL, the median FQ was 0.035 (IQR, 0.019-0.051) across 28 outcomes. Graft failure, pivot shift, and Lachman/anterior laxity were the most common outcome categories reported, with median FQs of 0.017, 0.035, and 0.048, respectively. Conclusion: Outcomes reported in RCTs for LET and ALL reconstruction as augments of ACLR are statistically fragile, emphasizing the need for additional robust and adequately powered RCTs to better understand the impact of anterolateral augmentation on ACLR outcomes.