To evaluate the appropriateness, clinical outcomes, and cost burden of interfacility orthopaedic transfers to a Level III teaching hospital, and to assess adherence to institutional transfer protocols. Retrospective Cohort Study. Level III teaching hospital in the Midwest United States. All patients referred for orthopaedic transfer between March 1, 2023, and May 31, 2024 (N = 267 transfers; 192 accepted, 73 denied). Not applicable. This was an observational study. Transfer appropriateness based on consultation timing, surgical intervention, and alignment with institutional protocols; secondary outcomes included transport distances, financial burden, and rate of secondary transfers. Most (77.6%) transfers were accepted by emergency medicine, with orthopaedic consultation requested in 80.9% of cases, but only 21.4% of these consultations occurred before initiation of the transfer. Approximately 50% of transferred patients required surgery, with an average time to surgery of 57.8 hours after their arrival at our Level III facility. The estimated transportation cost ranged from $502,507 to $573,707, with an additional hospital stay cost of $211,697.41. The total cost of transfers and care ranged from $714,204 to $785,404. A substantial proportion of orthopaedic transfers to this Level III hospital were nonurgent, frequently lacked pretransfer orthopaedic consultation, and resulted in significant financial and resource burden. These findings highlight inefficiencies in current interfacility transfer practices and underscore the need for improved triage, communication, and adherence to existing transfer protocols. Further research is warranted to evaluate structured approaches aimed at improving transfer appropriateness and resource utilization. Level III, Retrospective Comparative Study.

Hip and knee osteoarthritis are highly prevalent conditions associated with pain, disability and increasing demand on orthopaedic services. Best practice guidance emphasises early identification and optimisation of modifiable risk factors to improve outcomes following joint replacement, yet these are often inconsistently addressed in routine musculoskeletal care. This quality improvement project aimed to improve the consistency with which clinicians identified and acted on key modifiable risk factors during orthopaedic interface consultations. The project was conducted in an NHS Orthopaedic Interface Service using the Model for Improvement. A retrospective audit of 291 consultations demonstrated low rates of documented action despite a high prevalence of modifiable risk factors. Four domains were prioritised: excess body weight, smoking, diabetes optimisation and psychosocial factors. A bundle of low-burden interventions was introduced through sequential plan-do-study-act cycles. Prospective monthly sampling of 180 consultations over six months assessed change over time. Across 180 prospective consultations, documented action increased from 30% to 78% among consultations where at least one targeted modifiable factor was present. Improvement was clearest for weight-related advice and signposting. Smoking, diabetes and psychosocial findings were limited by small denominators or variable documentation and were interpreted descriptively. The largest increase was observed following introduction of embedded workflow supports, although attribution to any single component is limited by the sequential QI design. A simple quality improvement bundle was associated with improved documentation of action on modifiable risk factors during routine osteoarthritis consultations, particularly for weight-related advice and signposting. Embedded documentation prompts may support more reliable care processes, but further work is needed to assess sustainability, patient-level outcomes and transferability to other settings.

Timely access for orthopaedic spine consultation remains a challenge due to increasing demand and workforce constraints. Integrating advanced physiotherapy consultation models within orthopaedic services is an emerging strategy to streamline care. While common in New Zealand's tertiary care sector, comparable models in secondary care are lacking. This study evaluated the outcomes of a novel physiotherapist-integrated orthopaedic consultation model in secondary care. A retrospective review of patients seen from March to July 2023 was conducted using a five-step physiotherapist-integrated orthopaedic consultation model to assess management decisions, patient satisfaction, impact on consultation wait times and service capacity, and diagnostic concordance. Among 233 patients (mean age 46.8 years; 53.6% male), 73.4% presented with lower back and associated lower limb symptoms. Most (74.7%) were managed non-operatively, 25.3% underwent surgical workup and 10.7% proceeded to surgery. Patient satisfaction was high (overall mean 91.3%), with highest scores for quality of care (92.3%) and explanation of treatment/expected outcomes (91.7%). While mean consultation wait times were longer than the 2021 pre-model cohort (63 vs 47.4 days), service capacity increased by 32%. Across three magnetic resonance imaging variables, diagnostic concordance was substantial (overall agreement: 78.1%; mean kappa: 0.65 [0.63-0.68]). A physiotherapist-integrated orthopaedic consultation model in secondary care is highly accepted by patients, increases service capacity and broadens multidisciplinary decision-making capacity. While a model as such is theoretically positioned to reduce consultation wait times, this was not observed in the present analysis-reflecting a growing unmet need for orthopaedic consultation in secondary care.

Metastatic bone disease (MBD) often necessitates orthopaedic surgical intervention, which occurs through either emergent or elective care pathways. This study compared post-operative outcomes between patients undergoing elective versus emergent surgery for MBD involving the pelvis and appendicular skeleton. We performed a retrospective, multicenter, propensity-matched cohort study of patients who underwent surgery for MBD. Emergent surgery was defined as an unplanned admission followed by unscheduled surgery, while elective surgery referred to cases with an outpatient orthopaedic consultation and scheduled procedure. Primary outcomes were overall survival (OS) from the time of surgery, hospital length of stay (LOS), and 30-day readmission. Following propensity matching, 296 patients were included with 148 in each group. OS was significantly shorter in the emergent group (5.0 months 95%CI: 3.0-6.0 vs. 16.9 months 95%CI: 11.1-21.2) [p < 0.001]. LOS was significantly longer in the emergent group (13 days, 95%CI: 6-28 vs. 6 days, 95%CI: 3-10 days) [p < 0.001]. There was a significantly greater rate of readmission in the emergent group (12.2% 95%CI: 10.3-17.6 vs. 6.1% 95%CI: 3.5-10.2) [p = 0.004]. Elective surgery for MBD was associated with significantly superior clinical outcomes. Interventions that reduce the need for emergent surgery could markedly improve outcomes in this population.

To evaluate whether large language models (LLMs) can reduce consults for proximal humerus fractures that do not meet institutional consult criteria. Design: Retrospective review. Single-center Level 1 trauma center. Adults presenting to the emergency department (ED) with isolated proximal humerus fractures over a two-year period were included. Exclusion criteria were polytrauma, concomitant orthopaedic injuries, pathologic fractures, lack of in-house ED imaging, and fractures missed in the ED. Generative Pre-trained Transformer-4o (GPT-4o) and o4-mini were provided history of present illnesses, physical exams, and X-ray reports and asked whether orthopaedics consultation was indicated based on institutional criteria (open fracture, tenting skin, neurovascular compromise, or humeral head dislocation). A gold standard was determined by two independent authors who retrospectively reviewed each case and reached consensus on consult necessity based on these criteria. LLM alignment with this standard was compared with performance of real-world providers using generalized linear models. Consult wait time and work relative value unit (wRVU) savings were estimated using the cohort's average wait time and Current Procedural Terminology-based wRVUs for a 30-minute low-to-moderate complexity outpatient consult. Three-hundred fifteen patients (99 males and 216 females) were included (average age: 65.1 years, range: 20-100 years). Alignment with consult criteria was 92.4% (95% confidence interval (CI) [88.9%, 94.8%]) for GPT-4o, 94.9% (95% CI [91.9%, 96.9%]) for o4-mini, and 32.7% (95% CI [27.7%, 38.1%]) for ED providers. From a baseline of 240 consults, 327.3 wait hours, and 432 wRVUs, GPT-4o could have saved 179 consults, 295.3 wait hours, and 322.2 wRVUs over two years. o4-mini could have saved 183 consults, 302.0 wait hours, and 329.4 wRVUs. Large language models accurately identified uncomplicated proximal humerus fractures, potentially conserving unnecessary ED orthopaedic consults. III.

To evaluate pediatric and adolescent patients with posterior sternoclavicular (SC) joint dislocations, identify the prevalence of missed diagnoses at initial presentation, and determine injury features that may aid in earlier recognition. We retrospectively reviewed patients presenting to our institution with CT-confirmed posterior SC joint dislocations between October 2015 and November 2024. Anterior dislocations, subluxations, and cases without confirmatory imaging were excluded. Demographics, injury characteristics, diagnosis timelines, management, and outcomes were recorded and analyzed using descriptive statistics. Thirty-six patients (median age 14.9 years, IQR 13.8 to 16.6; 91.7% male) sustained posterior SC dislocations. Thirteen (36.1%) were missed at initial presentation, with delays up to 19 days (median 7, IQR 2 to 13). Missed cases occurred in both emergency (10/30, 33.3%) and outpatient (3/6, 50.0%) settings, with similar rates in those with (9/25, 36.0%) and without (4/11, 36.4%) clavicle fractures. Injuries most often resulted from a lateral shoulder blow (28/36, 77.8%), and 83.3% of patients with documented forward flexion had pain-limited motion. Most injuries (86.1%) were sports-related. Nearly all (97.2%) underwent surgical fixation without complications, and 77.4% with follow-up returned to sports. Over one-third of posterior SC joint dislocations were initially missed, with similar rates in patients with and without an associated clavicle fracture. These injuries are most often seen in the emergency department, typically from contact sports and a lateral blow to the shoulder. Given the risk of neurovascular injury, timely diagnosis is critical. Clinicians should maintain a high index of suspicion in patients with anterior chest pain after a lateral shoulder impact and when full forward flexion is pain-limited. Prompt recognition, CT imaging, and early orthopedic consultation are critical to ensure proper management and optimal outcomes.

Is there a correlation between season and weather patterns on trauma admissions?

Abstract Introduction Despite diversity being associated with increased patient-reported outcomes, trauma and orthopaedics (T&amp;O) remains one of the least gender-diverse surgical specialties. Short-format, student-organised interventions have been shown to improve perceptions of T&amp;O but their impact across gender groups is not well studied. We aimed to assess changes in perceptions of T&amp;O by gender, following the implementation of a university-based teaching conference. Methods We organised a day-long conference connecting medical students with orthopaedic trainees and consultants. Identical questionnaires were emailed to delegates one week before and immediately following the event, assessing knowledge, perceived barriers, and motivation to pursue a career in T&amp;O. Numeric rating (0–10) and Likert-scale question responses were analysed with Mann Whitney U tests using STATA BE 18. Qualitative responses were thematically analysed. Results 29 participants (13 female, 16 male) completed both questionnaires. Compared with men, women demonstrated significantly greater improvements in career knowledge (P = 0.013), understanding of application requirements (P = 0.028), and awareness of the role of T&amp;O (P = 0.049) following the conference. Trends were observed for training pathway knowledge and exposure, though not statistically significant. No gender differences were seen across other domains, including motivation or confidence following practical workshops, suggesting broadly similar benefits for both groups tested. Conclusions This study found minimal gender-based disparities in perceptions of T&amp;O following a university-based conference. Whilst both genders benefited, women showed greater gains, a positive finding in the context of persistent underrepresentation of women in T&amp;O that indicates that more targeted events may address barriers.

Abstract Objective to evaluate the progression of large language models (LLMs) and their ability to write clinic letters and management plans for common orthopaedic scenarios. Methods Fifteen clinical scenarios were generated and GPT-4, Chat-GPT and GPT-3 were single prompted to write clinic letters and management plans. Letters were assessed for readability using the Readable Tool. Accuracy of letters and management plans were assessed by six independent blinded orthopaedic consultants. Results Readability was compared using Flesch-Kincade Grade Level (GPT-4:9.11;(SD 0.98);ChatGPT:8.77 (SD 0.918);GPT-3:8.47 (SD 0.982)), Flesch Readability Ease (GPT-4:34.26 (SD 7.91);ChatGPT:58.2 (SD 4.00);GPT-3,59.3 (SD 6.98)). GPT-4, Chat-GPT and GPT-3 produced accurate letters (Mean = 8.75/10 (SD 0.96), 8.7/10 (SD 0.60), 7.3/10 (SD 1.41)) respectively. GPT4 and Chat-GPT had a significantly increased letter accuracy compared to GPT-3 (P = 0.024, P = 0.019). Consultant-rated accuracy comparisons across 4.0, 3.5 and 3.0 revealed that ChatGPT-4 exhibited the highest accuracy for management plans (9.08/10 95%c.i., 8.25–9.9). This represents a statistically significant progression of the ability of a large language model to provide accurate management plans from GPT-3 6.84 (95% c.i., 5.41–8.27), to ChatGPT 7.63 to GPT4 (P &amp;lt; 0.0001). Conclusions This study shows that next generation LLMs are effective for generation of clinic letters which are readable and accurate. Further, LLMs can produce generic management plans that are often accurate, demonstrating their evolving improvement. Given these findings a specific LLM trained on accurate and secure healthcare data could be an excellent streamlining tool for clinicians in high demand areas such as virtual fracture clinics.

AimsThe indications for reverse shoulder arthroplasty (RSA) have expanded beyond the primary design philosophy of an implant used to deal with rotator cuff deficiency. Its application in the cuff intact shoulder is growing in clinical practice. Despite this, there is little understanding of how surgeons decide between implants, specifically RSA and total shoulder arthroplasty (TSA) in this clinical scenario.MethodsTrauma & Orthopaedic Consultants specializing in shoulder surgery were recruited to participate in semistructured interviews by the research team. Using grounded theory methodology, the transcribed interviews were analyzed to generate themes and theories on factors affecting the decision-making between RSA and TSA. Collection and analysis was concluded when data saturation had been reached.ResultsPatients characteristics, specifically ‘physiological age’, a term incorporating age, comorbid status, and preoperative function played a key role in decision-making. Anatomical factors specifically glenoid morphology and retroversion angle significantly contributed to implant choice; however, specific cut-offs for determining implants were not universal. Other themes identified included revision profiles of the implants, functional outcomes, and surgical training and experience.ConclusionThe decision-making between RSA and TSA for osteoarthritis and cuff intact patients is complex and multifactorial. The main factors surgeons consider are physiological age, patient anatomy, and functional outcomes. Within these factors however, there is no uniform agreement on which implant is best for which patients.Cite this article: Bone Jt Open 2026;7(3):433–441.

A treatment journey (TJ) outlines a patient’s needs, actions, and experiences when seeking treatment. In Singapore, the quality of knee osteoarthritis (KOA) care is suboptimal. Mapping the TJ of older KOA patients can identify gaps in care influencing treatment decision, experiences, timeliness, and effectiveness for optimizing care in Singapore. This qualitative study was embedded in a larger qualitative study conducted in an urban, referral-based tertiary hospital in Singapore that evaluated and explored KOA patients’ treatment experiences of a randomized controlled trial. The larger study conveniently sampled 46 patients (22 intervention, 24 control). Semi-structured interviews were conducted in a quiet private hospital room. Framework analysis was used to analyze all 24 control patients’ transcripts. There was sufficient information power to fulfill the study’s objectives. Eighteen participants described relatively linear TJs comprising five sequential stages. Themes and sub-themes related to the stages are discussed. Participants gained awareness as symptoms impacted their daily lives, alongside sense-making processes shaped by beliefs that KOA was an inevitable consequence of ageing. A strong need to cure their condition drove informal knowledge-seeking from social networks. Participants experimented with topical agents, supplements, traditional Chinese medicine, analgesics, and exercise, often delaying formal care until symptoms worsened. Symptomatic exacerbation or persistence triggered treatment-seeking. Many participants felt dissatisfied with and dismissed from receiving limited explanations, passive management, and gatekept from specialist care. Orthopedic consultations gave participants hope in conservative physiotherapy treatment and position surgery as a last resort. Positive treatment experiences and symptom improvement fostered hope, confidence, and treatment engagement. Conversely, dissatisfactory experiences led some participants to disengage from treatment and question its relevance and value. Participants transitioned to self-management. Engagement in exercise and physical activity was motivated by the desire to avoid pain, deterioration, and surgery, and to maintain independence. However, inertia and perceived lack of time emerged as barriers. Six participants experienced complex, non-linear TJs involving multiple and/or repeated healthcare touchpoints that caused confusion and frustration. Improving community knowledge of KOA could meet older KOA patients’ strong need for treatment information, which influences sense-making, self-efficacy, decisions, and eventually treatment length, complexity, effectiveness, and experience. Healthcare providers could provide informative communication and feedback that fulfill their patients’ expectations for both information and care, as well as their need for hope confidence, reassurance, help, and relief. Inertia and a lack of time can be counteracted by providing meaningful, manageable, and adaptable care. Inadequate communication from healthcare providers are pain points in a TJ. Pain history and severity, and degree of physical functioning and KOA knowledge can influence a TJ’s length and complexity. This study, embedded in a larger study that qualitatively evaluated data from a randomized controlled trial (NHG DSRB ref no: 2020/00067) Tan et al. (BMC Musculoskelet Disord. 21(1):684, 2020) that explored the treatment experiences of KOA patients, is not a clinical trial (clinical trial number: not applicable).

Introduction: Few studies have reported on the clinical care of hostages released from captivity. This study aims to describe the establishment of a clinical protocol for hostages returning from captivity. Methods: This study describes the process of creating procedures for the implementation of the clinical protocol itself. The study was conducted at Shamir Medical Center (SMC) and assessed the outcomes of 24 returning hostages. Data collected included the clinical protocol for receiving the returning hostages and the returning hostages’ demographics and clinical data. Results: All returning hostages were foreign workers, and all but one were from the same nationality. The majority group of 23 returning hostages from the same nationality received testing for Q-fever, Hepatitis B, and HIV. Orthopedic, dermatological, and ear, nose, and throat consultation, chest and limb X-ray, head and abdominal CT scans, and antibiotics were also utilized by the majority. The returning hostage from a different nationality of origin utilized consults with an ENT, hearing test, and tests for Q-fever, urine toxicology, Hepatitis B, and HIV. Among the majority group, the mean percentage loss of body weight was 10%±10%. No correlation was found between age and change in weight (rho = -0.227; p=0.350). In addition, 17.4% tested positive for Q fever, 30.4% tested positive for Hepatitis B, and 13% tested positive for a sexually transmitted disease. They spent a mean of 5±1 days hospitalized. The sole hostage lost 15% of his body weight, tested positive for Q fever, and spent three days hospitalized. Consults with social workers and dietitians, translators, and Covid-19 tests were used by all returning hostages. Conclusion: This novel clinical protocol was successfully utilized in real time and may serve as a framework for the complex and sensitive clinical management of returning hostages, in case of need.

Introduction: On October 7, 2023, Hamas carried out an unprecedented attack on the State of Israel and kidnapped 251 people into captivity in the Gaza Strip. Several months later, as part of a humanitarian exchange deal, 105 hostages were released in five phases and admitted to one of six hospitals throughout the country for treatment. Shamir Medical Center (SMC) was one of these facilities. This study aims to describe the structure, process, and outcomes of establishing a comprehensive, multi-step operational protocol for receiving hostages returning from captivity. Methods: Description of the process of preparing SMC as a receiving center, the establishment of procedures for implementation of the medical protocol, and the assessment of multi-disciplinary team preparedness and implementation, and outcomes in an institutional protocol. Results: Twenty-four returning hostages were received at SMC. Social workers, dietitians, and translators were used by 100% of the majority group of returning hostages from the same country of origin, and the sole individual from the other country of origin utilized a dietitian, social worker, ENT consultations, and a hearing test. Among the majority group, orthopedic and dermatological consultations were utilized by 17.4%, and 13% received an ENT consultation. Of the administered imaging, 13% received a chest X-ray, 8.7% received a limb X-ray, 17.4% received a head CT scan, and 4.3% received an abdominal CT. In addition, 21.7% were provided with antibiotic therapy. Protocol efficacy was measured by assessing the time to various operational aspects of protocol implementation and medical procedures, such as the mean hours to room assignment, primary physician evaluation, and social worker session. No correlation between age and operational variables was found. Conclusion: This novel operational protocol was successfully implemented and may serve as a framework for managing similar unpredictable sensitive events in the case of future need.

BackgroundKnee joint pathologies are a common cause of orthopedic consultation, with many requiring imaging. Magnetic resonance imaging (MRI) is considered the non-invasive imaging reference standard with superior soft tissue resolution. However, it is expensive and time-consuming. High-resolution ultrasonography (HRUS), on the other hand, provides high soft tissue resolution for superficial structures, is cheaper, and is readily available with dynamic capabilities.MethodsThis prospective study was carried out on 50 patients referred from orthopedics to the radiology department of Government Medical College and Hospital, Jammu, with a request for MRI of the symptomatic knee joint. All patients underwent USG first, followed by MRI with standard knee protocol on a 1.5 T Siemens MRI (Munich, Germany). MRI was used as the reference standard. Ultrasonography (USG) findings were compared with MRI findings, and diagnostic indices, including sensitivity, specificity, accuracy, positive predictive value, and negative predictive value, were calculated.ResultsThe anterior cruciate ligament and the medial meniscus were the most commonly damaged structures. HRUS showed low sensitivity (46.1% and 40%, respectively) but high specificity (95.8% and 97.5%, respectively) for medial and lateral meniscus injuries. Diagnostic performance of USG was excellent for superficial structures, including collateral ligaments, tendons, synovitis, collections, and popliteal cysts, with specificity approaching 100%. Joint effusion detection showed 94.7% sensitivity and 100% specificity. However, the cruciate ligaments were poorly visualized on USG.ConclusionAlthough MRI remains the gold standard for thorough evaluation of knee pathologies, USG has shown strong specificity and good diagnostic performance for superficial soft tissue structures. Therefore, USG may serve as a valuable screening tool, particularly in resource-limited settings.

Intoeing is a common reason for pediatric orthopedic consultations. Families increasingly use YouTube for medical information, but the reliability and quality of this content are unclear, and no previous study has evaluated videos on intoeing. This study assessed the reliability, educational quality, and popularity of YouTube videos on intoeing using validated scoring systems and a novel disease-specific tool. YouTube was searched using the terms 'intoeing', 'pigeon toe', and 'toeing in'. After applying inclusion and exclusion criteria, 48 videos were analyzed. Video characteristics were recorded, and reliability and quality were evaluated using the Journal of the American Medical Association score, Global Quality Score, DISCERN instrument, and the Intoeing Specific Score (ISS) developed for this study. Popularity was measured using the Video Power Index. Interobserver and intraobserver reliability were calculated, and statistical analyses examined associations between scores, video sources, and content. Overall quality was low: 76.4% of videos scored less than or equal to 2 on the Journal of the American Medical Association score, and 54% were rated poor or very poor by DISCERN. According to the ISS, 43.8% were very poor. Academic and physician-generated videos had higher educational quality but lower popularity than nonprofessional sources. Videos from YouTube-verified uploaders scored significantly higher in all quality measures, yet popularity did not correlate with educational quality. YouTube videos on intoeing are generally low quality, revealing a gap between popularity and reliability. Although academic and physician-generated content is more accurate, it is less represented among popular videos. The ISS showed strong reliability and may be useful for future evaluations of disease-specific online content.

Osteoarthritis (OA) of the first metatarsophalangeal (MTP) joint is accompanied by pain and stiffness and associated with reduced health-related quality of life. Although prevalence of radiographic 1st MTP joint OA is high, the incidence of clinical 1st MTP joint OA is unknown. Therefore, we aimed to determine the incidence and management of general practice (GP) consultations for symptomatic 1st MTP joint OA. A retrospective cohort study was conducted using electronic health records of GPs. An algorithm was defined to identify 1st MTP joint OA patients based on free text and codified data between 2013 and 2022. First MTP joint OA incidence rate, comorbidities and management strategies were assessed. The overall 1st MTP joint OA incidence was 0.74/1000 person-years in patients ≥35 years. The most initiated management by GPs was explanation/reassurance (360/672 (53.6 %)), followed by referral to podiatry (171/672 (25.4 %)) and orthopedic surgeon consultation (162/672 (24.1 %)). Of the 823 patients consulting their GP with foot/toe problems in the year before diagnosis, 491 (47.1 %) were referred to radiology, and 271 (26 %) for orthopedic surgeon consultation. The incidence of 1st MTP joint OA has been estimated for the first time in general practice. Most patients are diagnosed after referral to radiology or orthopedic surgeon consultation. From diagnosis, half of 1st MTP joint OA patients are referred, mostly for orthopedic surgeon consultation and podiatry. As evidence for these diagnostic and management strategies is lacking, research into their effectiveness for 1st MTP joint OA in general practice is needed.

Developmental dysplasia of the hip (DDH) requires timely, guideline-concordant decisions to prevent long-term morbidity. ChatGPT-5.0 may support clinicians-especially where pediatric orthopedic expertise is limited, but their reliability across typical and discordant presentations is uncertain. This scenario-based validation study evaluated the accuracy of ChatGPT-5.0's management recommendations for DDH using 30 structured clinical cases and compared these outputs against AAOS (2022) and AAP (2016) guidelines. Scenario-based validation using 30 unique cases: 20 concordant (aligned clinical and imaging findings) spanning Graf and acetabular index-based ages, and 10 mismatch scenarios with correct examinations but intentionally erroneous radiology. The primary outcome was guideline-concordant accuracy, categorized as correct, partially correct, undertreatment, overtreatment, or incorrect. Secondary outcomes included the effect of error-aware prompts and multilingual consistency. In concordant scenarios, guided ChatGPT achieved 100% correct, while non-logged-in ChatGPT achieved 95% with one overtreatment. In mismatch scenarios, guided ChatGPT frequently tends toward overtreatment and failing to recommend repeat ultrasound or urgent pediatric orthopedic consultation. Non-logged-in ChatGPT performed better in mismatch cases but similarly under-emphasized remeasurement/consultation. Error-aware prompts did not materially alter recommendations in either environment. Swahili queries produced outputs clinically identical to English responses. ChatGPT-5.0 provides reliable, guideline-concordant guidance for DDH when clinical and radiologic data are concordant, supporting potential use as a decision aid in settings without immediate pediatric orthopedic access. Safe clinical implementation requires human oversight and integration of guideline-based safety checks to prevent mismanagement in ambiguous cases.

The pathways for patient referral for specialist musculoskeletal care is fragmented and poorly integrated with other healthcare services. These systems lead to delays in diagnosis, treatment, access to specialist care, and increased healthcare costs. A rural tertiary sport medicine clinic initiated a self-referral Acute Injury Clinic (AIC) to address these issues. The primary purpose was to determine the utilization and access of the AIC. The secondary purpose was to determine the type and incidence of injuries, and the time to tertiary or definitive care. The AIC model utilised a team approach by a physiotherapist and sport medicine physician to assess and diagnose acute injuries that occurred within 10 days. Orthopaedic surgery consultations were completed on the same day or via internal referral processes when indicated. Electronic medical records were reviewed for all AIC assessments completed between December 2022 and October 2024. Demographic data (age, sex) and confirmation of acute injury within the last 10 days were recorded to determine utilization and access. To determine type and incidence of injury and time to tertiary and definitive care, the injury site, diagnosis, activity at the time of injury, time from injury to AIC assessment, and time from AIC assessment to orthopaedic consult and surgery were recorded. Overall, 945 patients were assessed at AIC. Five hundred and one (53.0%) identified as male and 444 (47.0%) identified as female. Patients ranged in age from 7 to 97, with a mean age of 37.7 (SD=17.9). Preliminary analysis of the March – October 2023 (n=262) consultations indicated that 222 (84.7%) injuries were acute. The mean time from injury to AIC assessment was 9.6 days (SD=9.2). Two hundred and thirty-one patients (88.2%) received a definitive diagnosis, with 31 (11.8%) requiring further investigation. The most common activity at the time of injury was a snow sport (skiing/snowboarding) (n=76, 29.0%), followed by slips and falls (n=19, 7.3%), biking (n=17, 6.5%), hiking (n=15, 5.7%), soccer (n=13, 5.0%), and running (n=12, 4.6%). The most common site of injury was the knee (n=147, 56.1%), followed by the shoulder (n=50,19.1%), ankle (n=22, 8.4%), Achilles (n=7, 2.7%), wrist (n=5, 1.9%) and elbow (n=5, 1.9%). Further analysing the 147 knee injuries, the most common diagnosis was anterior cruciate ligament injury (n=55, 37.4%). Thirty-four (61.8%) of these injuries required surgery with a mean time of 98.9 days (range=0–398) and 218 days (range=20–575) from AIC assessment to consent for ACL surgery, and to surgery respectively. Further analysis of the initial 2-years of AIC consultations will be conducted, including comparing AIC and usual care for access and care costs for injuries and surgeries. Preliminary results indicate a successful implementation of a self-referral acute injury clinic, with 88% of consultations resulting in a diagnosis within 10 days of injury. Less than 12% of AIC patients required further investigations. Time to orthopaedic surgery consultation and surgery was reduced compared with provincial care reporting.

To determine whether use of a mini C-arm increased emergency department (ED) efficiency and decreased patient radiation exposure and the frequency of repeat closed reductions, as compared with traditional postreduction radiographs in patients with isolated distal radius and ankle fracture. Retrospective chart review. Academic Level 1 Trauma Center. Adult patients with an isolated distal radius (OTA/AO 2R3A2), bimalleolar or trimalleolar ankle (OTA/AO 44B1) fractures requiring closed reduction by the orthopaedic surgery team in an academic level 1 trauma center ED from 2013 to 2023 were included. Patients with pathologic fractures were excluded. Closed reductions in which mini C-arm imaging was used were compared with those that used traditional postreduction radiographs. Total radiation exposure to the patient during the encounter (mGy), closed reduction radiation exposure (mGy), the number of repeated reductions in the ED requiring an additional analgesic/anesthetic event and splint application, orthopaedic consult time, doctor visit to discharge time, and time under sedation (conscious or unconscious) were compared between the mini C-arm group and the traditional postreduction radiographs group. A total of 199 subjects met inclusion criteria (81 ankle fractures and 118 distal radius fractures). For the mini C-arm group, the mean age was 59 years (range 25-93) and 58% of the patients were female (n = 14). For the traditional postreduction radiographs group, the mean age was 58 years (range 21-90) and 55% of the patients were female (n = 96). Use of a mini C-arm (16 ankle fractures and 8 distal radius fractures) versus traditional postreduction radiographs (65 ankle fractures and 110 distal radius fractures) resulted in significantly lower total radiation exposure, 0.9 mGy versus 0.4 mGy ( P < 0.001), and closed reduction radiation exposure, 0.5 versus 0.1 mGy ( P < 0.001); fewer repeated reductions, 65 versus 0 repeated reductions ( P < 0.001); and shorter time from doctor visit to discharge, 6.2 versus 3.8 hours ( P < 0.001), orthopaedic consult time, 4.0 versus 1.7 hours ( P < 0.001), and time under sedation, 37 versus 26 minutes ( P = 0.046). This study found that the use of a mini C-arm compared with traditional postreduction radiographs for distal radius and ankle fracture closed reductions improved ED efficiency and decreased patient radiation exposure and repeated closed reductions. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

IntroductionCalcium pyrophosphate dihydrate (CPPD) deposition in the joints is an inflammatory arthropathy known as pseudogout (PG). Rare cases of pseudogout associated with bisphosphonate therapy have been reported in the literature. Here, we present a patient with primary hyperparathyroidism (PHP) who developed pseudogout in the elbow joint following bisphosphonate use.Clinical CaseA 65-year-old female patient was evaluated due to hypercalcemia and diagnosed with primary hyperparathyroidism. No pathological focus was detected in ultrasonography and scintigraphy. Because of persistently high calcium levels and osteoporosis on bone densitometry, intravenous zoledronic acid (ZA) was administered. Three days after ZA treatment, the patient developed nausea and diffuse body pain. Laboratory evaluation revealed elevated creatinine levels, and she was admitted to the hospital with a preliminary diagnosis of acute kidney injury (AKI). On the third day of hospitalization, she developed pain, swelling, limited motion, and increased temperature in the right elbow. Since septic arthritis could not be excluded after orthopedic consultation, joint irrigation was performed. However, her complaints persisted, and joint culture revealed no bacterial growth. The patient was then evaluated by rheumatology, and pseudogout was considered. Systemic steroid therapy was initiated, leading to significant improvement in her symptoms.ConclusionAlthough bisphosphonates such as zoledronic acid (ZA) have an important role in the treatment of osteoporosis, potential complications should be kept in mind. In this case, the patient’s PHP, age, significant hypercalcemia at admission, and the rapid decrease in calcium levels after ZA treatment were predisposing factors for a PG attack. Pseudogout following ZA treatment is a rare complication reported in the literature.Table 1:Laboratory Parameters Before ZA, During AKI, and After Treatment