Guy Awad

Background: The Duruöz Hand Index (DHI) is a validated patient-reported outcome measure assessing hand-related functional disability. No formally translated and validated Arabic version previously existed. This study aimed to translate, culturally adapt, and psychometrically validate the Arabic version (DHI-AR). Methods: A prospective cross-sectional validation study was conducted following established cross-cultural adaptation guidelines, including forward translation, reconciliation, back-translation, expert review, and pilot testing. Adults (≥18 years) with hand or wrist pain or functional limitation were recruited from 2 outpatient clinics. Participants completed the DHI-AR and the validated Arabic Patient-Rated Wrist/Hand Evaluation (PRWHE-AR). A clinically stable subgroup completed the DHI-AR again after 5 to 10 days. Analyses assessed internal consistency, test-retest reliability, measurement error, structural validity, convergent validity, and interpretability. Results: A total of 439 participants were included; 76 completed the retest. Internal consistency was excellent (Cronbach’s α = 0.980). Test-retest reliability was excellent (intraclass correlation coefficient [ICC](2,1) = 0.993; 95% CI, 0.990-0.996). Measurement error was low (SEM = 2.30), with minimal detectable change values of 6.38 points for individuals and 0.73 for groups (0-90 scale). Structural validity supported essential unidimensionality (74.82% variance explained). Convergent validity with the PRWHE-AR was strong (ρ = 0.793-0.868; P < .001). Floor and ceiling effects were less than 15%. Conclusion: The DHI-AR demonstrated strong internal consistency, excellent test-retest reliability, low measurement error, a predominantly unidimensional component structure, and strong convergent validity. Responsiveness, minimal clinically important difference, and measurement invariance require further evaluation.

Stereotactic body radiotherapy (SBRT) and conventional external beam radiotherapy (cEBRT) are widely used treatment options for the management of painful bone metastases. Randomized phase III trials have provided direct comparative evidence for SBRT and cEBRT; however, their results vary according to treatment regimen and clinical endpoint, supporting a broader quantitative synthesis of pain response, local control, retreatment, and safety outcomes. A systematic search was conducted in PubMed, Scopus, the Cochrane Library, and Google Scholar from database inception through January 2026. Comparative clinical studies evaluating SBRT versus cEBRT for bone metastases were included. Outcomes assessed encompassed pain-related measures (change in Visual Analog Scale scores at 3 and 6 months; complete, partial, stable, and progressive pain response), opioid consumption at 3 and 6 months, radiologic local progression or treatment failure at 8 months, re-irradiation at 12 months, skeletal-related events (vertebral and non-vertebral compression fractures), spinal cord compression, treatment-related toxicity, and overall survival at 1 year. Pooled analyses were performed using random-effects models. Early pain reduction at 3 months, partial and stable pain response, and opioid consumption at 3 and 6 months were comparable between SBRT and cEBRT (all p > 0.05). However, SBRT demonstrated superior mid-term outcomes, with a significantly higher complete pain response at 6 months (RR = 1.43; p = 0.001) and a significantly lower rate of progressive pain response at 6 months (RR = 0.61; p = 0.03). SBRT was also associated with markedly improved local disease control, reflected by lower rates of radiologic local progression or treatment failure at 8 months (RR = 0.36; p < 0.001) and a substantially reduced need for re-irradiation at 12 months (RR = 0.13; p < 0.001). Rates of vertebral and non-vertebral compression fractures, spinal cord compression, treatment-related toxicity, and overall survival at 1 year did not differ significantly between treatment modalities. This meta-analysis demonstrates that both SBRT and cEBRT are safe and effective treatment options for patients with painful bone metastases. While early pain palliation and safety outcomes are comparable, SBRT provides superior durability of pain control, reduced pain progression, improved local tumor control, and a markedly lower need for re-irradiation. SBRT may be particularly advantageous for patients with longer expected survival, oligometastatic disease, or lesions at higher risk of progression, whereas cEBRT remains an effective and accessible option for rapid symptom palliation in patients with limited prognosis.

Background: Cervical radiculopathy can be managed surgically with anterior cervical diskectomy and fusion (ACDF) or minimally invasive posterior cervical foraminotomy (MIS-PCF). ACDF is widely used and provides indirect decompression and stabilization, while MIS-PCF preserves motion, avoids fusion-related complications, and may offer advantages in perioperative recovery. The aim of this meta-analysis was to compare surgical, patient-reported, and safety outcomes of MIS-PCF versus ACDF to guide clinical decision making. Methods: A systematic literature search of PubMed, Scopus, Cochrane Library, and Google Scholar was conducted through October 2025 to identify comparative studies of MIS-PCF and ACDF for cervical radiculopathy. Data from 12 studies involving 3,185 patients were pooled. Outcomes included surgical time, length of stay, hospital cost, pain scores (VAS arm and neck), functional scores (NDI and EQ-5D), revision surgery rates, and complication rates. Results: MIS-PCF was associated with significantly shorter surgical time (MD = −14.72 min, P < 0.001), reduced length of stay (MD = −0.99 days, P < 0.001), and lower hospital costs (MD = −$9,131.93, P < 0.001) compared with ACDF. Arm pain outcomes showed no significant differences between groups, either immediately postoperatively ( P = 0.35) or at 1 to 2 years ( P = 0.71). By contrast, MIS-PCF demonstrated significantly greater neck pain reduction immediately after surgery (MD = 0.42, P < 0.001) and at 1 to 2 years (MD = −0.22, P = 0.001). Functional outcomes (NDI and EQ-5D) were comparable between techniques ( P ≥ 0.89). Revision surgery and overall complication rates did not differ significantly ( P = 0.39 and P = 0.51, respectively). Conclusion: Both MIS-PCF and ACDF are effective surgical options for cervical radiculopathy, with comparable reported safety and functional outcomes. MIS-PCF may offer perioperative advantages and better neck pain outcomes, supporting its role as a motion-preserving and cost-efficient alternative to ACDF in appropriately selected patients.

Background Adhesive capsulitis causes shoulder pain and limited motion. Physical therapy (PT) helps but is slow to act. This meta-analysis compares PT alone versus PT plus corticosteroid injections for pain, range of motion (ROM), and function. Methods A systematic literature search was conducted in PubMed, Scopus, Embase, and Google Scholar for articles published up to April 24, 2026. Eligible studies were randomized controlled trials comparing PT alone to PT combined with intra-articular corticosteroid injections in adults with adhesive capsulitis. Five studies met the inclusion criteria, including 198 patients, with a follow-up duration ranging from 6 to 24 weeks. Primary outcomes included changes in SPADI (Shoulder Pain and Disability Index) and VAS (Visual Analogue Scale) scores from baseline to final follow-up, as well as ROM improvements in flexion, abduction, external rotation, and internal rotation. Results Patients receiving combined corticosteroid injection and PT were associated with significantly greater improvements in SPADI scores (MD = 17.52; 95% CI: 5.08 to 29.95; p = 0.006), flexion (MD = 12.99; 95% CI: 5.92 to 20.05; p = 0.0003), abduction (MD = 10.68; 95% CI: 0.53 to 20.84; p = 0.04), and external rotation (MD = 10.35; 95% CI: 6.13 to 14.57; p < 0.0001) compared to PT alone. No significant differences were observed in VAS score reduction (p = 0.41) or internal rotation (p = 0.46). Conclusion The addition of intra-articular corticosteroid injections to PT provides superior short-term improvements in functional outcomes and ROM for patients with adhesive capsulitis. These results support a combined treatment approach during the early phases of the disease.

Background: The Pennsylvania Shoulder Score is a common patient-reported measure of shoulder pain, function, and satisfaction. Cross-cultural adaptation is essential for non-English-speaking populations. Methods: This prospective cross-sectional validation of the Arabic Pennsylvania Shoulder Score (PSS-AR) followed translation and cultural adaptation steps. Adults ≥18 years with shoulder pain/dysfunction were recruited from two outpatient clinics. Participants completed the PSS-AR (Pain 0–30; Satisfaction 0–10; Function 0–60; Total = sum, higher = better) and Arabic Simple Shoulder Test (SST-AR; 0–100). Readability was assessed using Automatic Arabic Readability Index (AARI). Stable participants repeated PSS-AR after 5–10 days. Results: 219 patients participated; 102 stable individuals completed retesting. AARI showed readability levels of grade 5.24 for PSS-AR and 2.92 for SST-AR, below the recommended sixth-grade threshold. Function showed excellent internal consistency (Cronbach's α=0.96). Exploratory factor analysis supported essential mono-dimensionality: Factor 1 explained 54.90% of variance (factor 2 + 5.19%; cumulative 60.09%) with loadings 0.47–0.85. Convergent validity with SST-AR was strong (Spearman ρ: Total 0.792, function 0.788, pain 0.538; all p < 0.0001). Test–retest reliability was excellent: ICC(2,1) = 0.95 (95% confidence interval 0.93–0.97). Mean change was minimal (Δ=−0.47 ± 9.36) without systematic shift (F = 0.09, p = 0.76). SEM was 4.98; MDC individual=13.80 and MDC_group=1.37. Conclusion: The PSS-AR is reliable, valid, and culturally appropriate for Arabic-speaking patients.

Background Bearing surface selection is a key determinant of long-term performance in total hip arthroplasty (THA), yet comparative evidence across modern ceramic and polyethylene-based couples remains inconsistent. This meta-analysis provides a comprehensive comparative evaluation of ceramic-on-ceramic (CoC) bearings versus metal-on-polyethylene (MoP), metal-on–highly cross-linked polyethylene (MoHXLPE), ceramic-on-polyethylene (CoP), and ceramic-on–highly cross-linked polyethylene (CoHXLPE). Methods A systematic search of four databases identified randomized controlled trials and comparative observational studies evaluating CoC bearings against alternative articulations in primary THA. Thirty-three studies were included (over 120,000 THAs). Outcomes included implant survivorship, revision, dislocation, wear, osteolysis, functional scores, radiographic findings, and postoperative complications. Pooled analyses were performed using fixed-effect or random-effects models according to heterogeneity. Results Across all comparisons, revision rates, aseptic loosening, and periprosthetic fracture were similar between CoC and polyethylene-based bearings; periprosthetic joint infection was also comparable (all p > 0.05), except that a lower pooled PJI rate was observed with CoC versus MoHXLPE (RR 0.42, p < 0.00001). CoC demonstrated reduced prosthetic hip dislocation compared with MoP (RR 0.39, p = 0.05) and MoHXLPE (RR 0.77, p = 0.004), and lower osteolysis relative to MoP (RR 0.26, p = 0.02) and MoHXLPE (RR 0.48, p = 0.004). Squeaking was consistently more frequent with CoC, particularly versus MoP (RR 2.14, p = 0.002), CoP (RR 8.60, p = 0.04), and CoHXLPE (RR 5.98, p = 0.0007). Functional outcomes were broadly equivalent, although in the CoC vs MoHXLPE subgroup CoC showed modestly better Harris Hip Score (MD 1.78, p = 0.0009) and lower WOMAC scores (MD –6.16, p = 0.005). Kaplan–Meier survivorship was excellent in the CoC vs MoP and CoC vs MoHXLPE comparisons, with a small but consistent numerical advantage favoring CoC, frequently remaining above 95% at long-term follow-up. Conclusion Modern bearing surfaces provide generally comparable safety and survivorship in THA. CoC bearings offer specific benefits, including reduced dislocation risk and lower osteolysis, balanced against a higher incidence of squeaking. These findings support individualized bearing selection based on patient age, activity level, and tolerance for ceramic-specific complications.

Bone metastases from breast cancer cause skeletal-related events (SREs), including pain, fractures, and the need for radiation or surgery. Denosumab and bisphosphonates (BP) reduce these complications, but their relative efficacy and safety remain unclear. PubMed, Scopus, Cochrane Library, and Google Scholar were searched through October 2025. Five publications (four unique studies: three randomized trials and one retrospective cohort) were included. Sensitivity analyses were limited to randomized trials when feasible. Outcomes included SRE incidence and skeletal endpoints, plus renal, metabolic, hematologic, musculoskeletal, gastrointestinal, infectious adverse events, osteonecrosis of the jaw (ONJ), and serious, grade ≥ 3, and treatment-related events. Denosumab reduced SREs compared to BP (RR 0.77, p < 0.001). It lowered arthralgia (RR 0.62; p = 0.01), myalgia (RR 0.31; p = 0.005), and bone pain (RR 0.77; p = 0.001), with similar back and extremity pain. Renal adverse events (RR 0.55; p = 0.0002), non-serious events (RR 0.98; p = 0.008), and pyrexia (RR 0.33; p = 0.04) were reduced. Other outcomes, including uNTx, ONJ, serious and grade ≥ 3 events, thrombocytopenia, infectious, gastrointestinal, and respiratory events, were comparable. Results were consistent in randomized-only analyses. In breast cancer patients with bone metastases, denosumab may benefit those at higher risk of renal toxicity or skeletal complications, while treatment decisions should remain individualized. www.crd.york.ac.uk/PROSPERO identifier is CRD420251231881.

Background: Avascular necrosis (AVN) of the humeral head can progress to joint collapse and marked functional limitation, often requiring surgical treatment. Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are the main surgical treatment options, but their comparative clinical value remains a topic of debate. In particular, uncertainty persists regarding how functional benefit, complication risk, and implant durability should be balanced in contemporary practice. In this meta-analysis, we compared functional outcomes, complication rates, and revision risk between TSA and HA in patients with humeral head AVN.Methods: We performed a systematic search of PubMed, Scopus, Cochrane Library, Embase, and Google Scholar from database inception through November 2025. Nine comparative studies were included. Pooled mean difference (MD) and risk ratio (RR) were calculated using fixed- or random-effects models.Results: HA was associated with significantly higher patient-reported function as measured by American Shoulder and Elbow Surgeons (ASES) scores compared with TSA (MD, 17.12; P<0.00001), whereas TSA resulted in greater external rotation (MD, –10.23°; P=0.02). HA was also associated with a significantly lower overall complication rate compared with TSA (RR, 0.33; P0.05).Conclusions: In humeral head AVN, HA yields higher ASES scores and fewer complications, whereas TSA results in greater external rotation. Pain and revision rates are comparable, supporting the choice of individualized procedure selection based on glenoid status and patient goals.Level of evidence: III.

Background: Glenoid fixation strongly influences longevity and outcomes in anatomic total shoulder arthroplasty. Keeled and pegged designs are common, but comparative evidence for function, range of motion, and survivorship is inconsistent.Methods: A systematic search of PubMed, Scopus, the Cochrane Library, and Google Scholar was conducted from database inception through December 2025. Thirteen comparative studies (n=3,219) met the inclusion criteria. Evaluated outcomes included patient-reported outcome measures (American Shoulder and Elbow Surgeons [ASES], Constant-Murley score, Simple Shoulder Test [SST], visual analog scale [VAS] pain scores), shoulder range of motion (flexion, external rotation, internal rotation), and implant-related outcomes, including failure and revision. Follow-up ranged from short to long-term (up to 26 years).Results: Across pooled analyses, no significant differences were observed between pegged and keeled glenoid components in ASES (P=0.69), Constant-Murley (P=0.61), SST (P=0.74), or VAS pain scores (P=0.88). Postoperative flexion (P=0.61) and external rotation (P=0.35) were comparable between groups. Pegged glenoid components demonstrated a statistically significant but small improvement in internal rotation (mean difference, 1.60°; 95% CI, 0.54°–2.66°; P=0.003). Revision rates were significantly lower with pegged glenoid components compared with keeled designs (risk ratio, 0.49; 95% CI, 0.28–0.86; P=0.01), while overall failure rates did not differ significantly between groups (P=0.07).Conclusions: Both designs yield similar pain relief, functional gains, and shoulder motion across most patient-reported outcome measures. Pegged components show lower revision risk and slightly better internal rotation, although survivorship findings are primarily supported by observational evidence. Selection should be individualized to anatomy, bone quality, and surgical factors, not expectations of superior overall function.Level of evidence: II.