Background: While mechanical alignment total knee arthroplasty (TKA) has long been the conventional surgical technique in patients with advanced osteoarthritis, kinematic alignment TKA has emerged as a promising alternative, designed to restore the knee’s native pre-arthritic anatomy. Since superiority of either technique remains inconclusive, we aimed to compare immediate and short-term postoperative outcomes of kinematic versus mechanical alignment TKA. Methods: This prospective cohort study was conducted at a tertiary care centre between January 2020 and August 2022, enrolling kinematic and mechanical alignment TKA patients. Outcomes were assessed during hospitalization and at 14 days postoperatively. Data collected included patient-reported outcome measures (PROMs), functional performance evaluations, pain scores, discharge disposition and hospital length of stay. Both univariate and multivariate regression analyses were conducted, adjusting for potential confounders. Results: The study included 103 patients, with 77 who underwent kinematic alignment and 26 mechanical alignment TKA. Patients in the kinematic alignment group demonstrated statistically significant better postoperative outcomes compared to those in the mechanical alignment group. Kinematic alignment TKA patients demonstrated superior functional performance on the Timed Up and Go test immediately postoperatively and were more frequently discharged home rather than to a rehabilitation facility. Hospital stay length and short-term PROMs also favoured the Kinematic alignment TKA group, showing statistically significant higher scores in the Oxford Knee Score, short form-12 Mental Component Summary, and the Knee Injury and Osteoarthritis Outcome Score Symptoms subscale. Conclusions: Kinematic alignment TKA offers superior immediate and short-term outcomes compared to mechanical alignment TKA, with benefits in functional recovery, hospitalization duration, and discharge disposition. This evidence supports kinematic alignment TKA as a viable alternative, aiding in patient and surgeon decision-making.

Case: We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes. Conclusion: Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

Dorsal lunate dislocation (DLD) is an exceptionally rare injury, typically resulting from high-energy trauma. Due to the scarcity of reported cases, its exact mechanism of injury is not well understood. This study aimed to present three cases of DLD treated at our institution and to perform a systematic review of the literature to evaluate the mechanisms of injury and treatment approaches for pure DLD. A retrospective review was conducted of three patients with pure DLD treated at a single tertiary care center. Data were collected through medical record analysis and radiographic review. Additionally, a systematic literature review was performed to identify reported cases of DLD. Patient demographics, mechanisms of injury, treatment modalities, and clinical outcomes were analyzed. We identified three cases of DLD, while the systematic review uncovered 17 additional cases. Overall, men represented 95% of cases, with high-energy trauma accounting for 85% of injuries. Forced wrist flexion was the most commonly reported mechanism, occurring in 55% of cases. Radiographic analysis showed concomitant wrist fractures in 55% of cases. Treatment strategies included fixation in 65% of patients, ligament repair in 45%, and lunate resection or proximal row carpectomy in 15%. The median follow-up duration was 12 months, with half of the patients achieving favorable outcomes. Notably, two of the three low-energy injury cases were associated with preexisting arthritis. Pure DLD is an extremely rare clinical entity, possibly resulting from axial loading on a flexed wrist or forced hyperflexion. Characteristic radiographic findings include disruption of Gilula's lines and dorsal displacement of the lunate on lateral radiographs. Optimal management involves initial closed reduction followed by surgical fixation and ligamentous repair when indicated to enhance outcomes and restore wrist function.

Background: The 2022 American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand (AAOS/ASSH) guideline discourages routine operative fixation of distal radius fractures (DRF) in patients aged 65 years or older. This study examined the impact of this recommendation on operative management patterns in this population. Methods: A retrospective, quasi-experimental before-after study was conducted, including all DRF diagnoses among patients aged 65 years or older at a tertiary medical center during 2012 to 2024. Annual age-standardized and sex-standardized DRF incidence and surgery rates were estimated. Multivariable logistic regression evaluated postguideline versus preguideline odds of surgery and model-based projection compared expected with observed postguideline surgery rates. Results: During the study period, 3,137 DRF cases were diagnosed with stable incidence. Surgery rates significantly increased among patients aged 65 to 69 years from 9% to 16% after guideline publication, whereas rates were unchanged in patients aged 70 years or older. Patients aged 65 to 69 years were nearly twice as likely to undergo operative management in the postguideline versus preguideline period. Model-based projection among patients aged 65 to 69 years predicted a postguideline surgery rate of 11%, whereas the observed rate of 16% represented a 44% relative increase. Conclusions: Despite a guideline discouraging operative management of DRF at ages ≥65 years, surgery rates did not decline, and increased in those aged 65 to 69 years, highlighting the limitations of an age-only treatment threshold. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Hip resurfacing arthroplasty remains an appealing option for young and active patients ¹ , but its use has declined because of technical challenges, risks of femoral neck notching, and adverse reactions associated with metal - on - metal bearings, raising concerns regarding long-term implant survival ² . Accurate preparation of the femoral head and acetabulum is critical for successful outcomes ³ . In the present video article, we describe a reproducible technique utilizing preoperative 3D computed tomography (CT)-based planning and patient-specific 3D-printed jigs to optimize femoral head preparation, in conjunction with a direct anterior approach that preserves tendon attachments and avoids muscle injury. Description: Through a standard anterolateral skin incision and fascial split, the tensor fasciae latae (TFL) is mobilized by blunt finger dissection up to the anterior superior iliac spine while maintaining its fascial origin. The superficial internervous plane is created between the TFL laterally and the sartorius medially. Dissection proceeds in the deep interval between the gluteus medius and rectus femoris, with care to preserve the ascending branches of the lateral circumflex femoral vessels. The approach continues to the hip joint capsule, which is sharply incised to allow femoral head dislocation. Femoral head preparation is guided by patient-specific 3D-printed jigs generated from preoperative CT scans. Each jig provides a reproducible entry point and trajectory for a Steinmann pin, ensuring central alignment and avoiding femoral neck notching. Sequential reaming, chamfer cuts, and trialing are performed. The acetabulum is exposed with 3 retractors (anterior and inferior Hohmann and posterior curved 2-pronged) and progressively reamed without fluoroscopy until congruent hemispherical coverage is achieved. A press-fit cup is implanted without cement, followed by cementation of the femoral component with use of a dry-field technique. Stability and leg length are reassessed, and closure is performed in layers with barbed absorbable sutures and a waterproof dressing. If intraoperative stability or leg length restoration is found to be unsatisfactory, adjustments are made prior to final implantation. This may include repositioning of the acetabular component, upsizing or adjusting the femoral component, or performing additional soft-tissue release to achieve proper balance. Cementation of the definitive implants and closure are only performed once stability and length are confirmed in all functional positions. Alternatives: Conventional resurfacing techniques rely on intraoperative fluoroscopy, mechanical alignment guides, or freehand pin placement for femoral head preparation. Compared with these methods, 3D-printed patient-specific jigs minimize intraoperative fluoroscopy, standardize pin trajectory, and reduce the risk of malalignment and implant mispositioning. Similarly, total hip arthroplasty remains a well-established alternative to hip resurfacing, providing predictable pain relief and functional outcomes, although with greater bone resection and different long-term considerations. Rationale: Patient-specific jigs derived from CT-based planning provide individualized guidance that restores native femoral head-neck orientation in slight valgus, reducing the risk of femoral neck notching and improving component survival. The minimally extensile direct anterior approach minimizes soft-tissue damage while ensuring adequate exposure of both the femoral and acetabular sides. Expected Outcomes: Patients may expect early postoperative weight-bearing, decreased need for analgesia, and comparable short-term functional outcomes. Patients may expect a more extensile incision, for adequate manipulation and dislocation of the femoral head, compared with the standard Smith-Petersen approach performed for conventional total hip arthroplasty ^3,4 . There is limited visualization of the superolateral aspect of the femur and posterolateral aspect of the acetabulum compared with the posterior approach, which may result in longer operative time because of technical challenges. Possible complications of the procedure are femoral neck fracture, component malpositioning, and lateral femorocutaneous nerve paresthesia ⁴ , which itself is not associated with a limitation in function ^5,6 . In addition, femoral nerve palsy as a result of inaccurate placement of retractors is a dreaded complication. Other potential complications associated with this procedure include metal-on-metal reactions (when applicable), dislocation, procedure failure requiring conversion to total hip arthroplasty, superficial or deep infection, hemorrhage, and other related adverse events. In a recent study conducted at our institution but not yet published, the revision rate was 10% at a median follow-up of 17 months, with the most common reason for revision being postoperative femoral neck fracture. Additional findings included a Forgotten Joint Score of 67% at 1 year postoperatively, closely matching the 68% reported in recent total hip arthroplasty studies ^8,9 . The mean blood loss was 118.75 mL, and the mean length of hospital stay was 2.25 days. Important Tips: The anterior approach requires meticulous dissection and hemostasis. The anterior approach is conducted with minimal exposure, requiring careful manipulation to release the capsule. The use of 3D models is essential for accurate guidewire placement and alignment and for achieving a precise fit of ceramic or metal heads. Finger dissection of the TFL up to the anterior superior iliac spine avoids detachment and preserves muscle integrity. The posterior curved 2-pronged retractor exposes the posterior acetabulum and displaces the femoral head posteriorly, creating a working space and protecting cancellous bone. Ensure meticulous drying of the femoral head before cementation to optimize fixation. During acetabulum reaming, the reamer head can be introduced first, followed by attachment of the handle, in order to maximize clearance in tight spaces. Acronyms and Abbreviations: CT = computed tomography ASIS = anterior superior iliac spine

BACKGROUND Large language models (LLMs) are increasingly used in orthopaedic education, but their performance on the 2025 Israeli Orthopaedic In-Training Examination (OITE) remains poorly defined. OBJECTIVE To compare the performance of two contemporary reasoning-oriented LLMs on the 2025 Israeli OITE and to identify item-level factors associated with correctness. METHODS All 95 multiple-choice questions (MCQs) from the 2025 OITE were analyzed. ChatGPT 5.1 thinking and Gemini Pro 3 thinking each answered all questions once using a standardized prompt. The primary outcome was question-level correctness according to the official answer key. Questions were annotated for question type, question stem word count, image presence, and model-reported certainty. Model-specific factors associated with correctness were assessed using logistic regression, and head-to-head comparisons were performed using the exact McNemar test and paired generalized estimating equations (GEE). RESULTS Both models achieved identical overall accuracy (68/95, 71.6%), with no measurable difference on paired comparison (odds ratio [OR], 1.00; 95% CI, 0.58-1.73; P=1.000). Accuracy was substantially higher on questions without images than on image-containing questions (90.5% vs 56.6%). In model-specific multivariable analyses, image presence was independently associated with lower correctness for both ChatGPT (adjusted OR [aOR], 0.12; 95% CI, 0.04-0.40; P<.001) and Gemini (aOR, 0.08; 95% CI, 0.02-0.28; P<.001). For Gemini, longer question stem word count was independently associated with greater odds of correctness (aOR per 10 words, 1.47; 95% CI, 1.01-2.13; P=.042), and Application questions were associated with lower odds of correctness than Knowledge questions (aOR, 0.26; 95% CI, 0.08-0.85; P=.026). In the primary paired GEE model, no measurable difference in correctness was observed between Gemini and ChatGPT (OR, 1.00; 95% CI, 0.58-1.73; P=1.000), whereas Application questions (OR, 0.34; 95% CI, 0.14-0.84; P=.019) and image-containing questions (OR, 0.09; 95% CI, 0.03-0.24; P<.001) were associated with lower odds of correctness. CONCLUSIONS ChatGPT 5.1 thinking and Gemini Pro 3 thinking demonstrated similar overall performance on the 2025 Israeli OITE, with identical crude accuracy and no measurable difference in paired comparative analyses. Both models were substantially less accurate on image-containing questions, and Application questions were also associated with lower correctness, particularly in Gemini-specific and paired analyses. These findings suggest that current LLMs may have value as adjunctive educational tools in orthopaedic knowledge domains, but they remain insufficiently reliable for unsupervised use, particularly in image-dependent and application-based settings. CLINICALTRIAL not applicable