Introduction: International medical graduates (IMGs) continue to play an important role in the US health care system, but little is known about their trends of matching into highly competitive residencies such as orthopedic surgery. The purpose of this study was to analyze temporal trends of IMG applicants matching into US orthopedic residency programs between 2008 and 2024 and compare them with US allopathic (MD) and osteopathic (DO) graduates. Methods: Orthopedic residency specific data for years 2008 to 2024 was obtained from the National Resident Match Program and Electronic Residency Application Service. Variables collected included total number of programs, total positions offered, number of applicants (MD, DO, and IMG), positions filled, and fill rate for each group. Trends were examined using simple linear regression modeling. Results: The number of orthopedic residency programs increased from 160 (2008) to 218 (2024), with total positions increasing from 636 (2008) to 916 (2024). The IMG fill rate decreased from 2.99% in 2008 to 0.87% in 2024 (p < 0.01 for linear trend; β −0.069). This corresponds to an absolute number decrease of 19 IMGs in 2008 to 8 in 2024. More specifically, the proportion of US IMGs decreased from 0.94% to 0.66%, and the proportion of non-US IMGs decreased from 2.04% to 0.21%. Over the 17-year study period, a total of 105 US IMGs and 110 non-US IMGs matched into orthopedic surgery. The US MD applicant fill rate decreased significantly from 96.5% to 85.0% (p < 0.001; β −0.944). The DO applicant fill rate increased significantly from 0.31% to 13.97% (p < 0.0001; β 0.990). Conclusion: The declining rate of IMGs matching into orthopedic residency programs in the United States underscores the growing challenges faced by IMGs in accessing training in this competitive specialty. The notable increase in DO graduates securing orthopedic residency positions likely reflects the integration of a unified accreditation system for MD and DO residency programs established in 2020. Level of Evidence: Retrospective Cohort Study; IV

There is still no evidence of which drug has the greatest therapeutic potential for post-traumatic arthrofibrosis. The aim of this study is to systematically review the literature for quality evidence and perform a meta-analysis about the pharmacological therapies of post-traumatic arthrofibrosis in preclinical models. A comprehensive and systematic search strategy was performed in three databases (MEDLINE, EMBASE and Web of Science) retrieving studies on the effectiveness of pharmacological therapies in the management of post-traumatic arthrofibrosis using preclinical models in terms of biomechanical outcomes. Risk of bias assessment was performed using the SYRCLE's risk of bias tool. A meta-analysis using a random-effects model was conducted if a minimum of three studies reported homogeneous outcomes for drugs with the same action mechanism. Forty-six studies were included in the systematic review and evaluated for risk of bias. Drugs from 6 different action mechanisms of 21 studies were included in the meta-analysis. Overall, the methodological quality of the studies was poor. Statistically significant overall effect in favor of reducing contracture was present for anti-histamines (Chi2 p = 0.75, I2 = 0%; SMD (Standardized Mean Difference) = -1.30, 95%CI: -1.64 to -0.95, p < 0.00001) and NSAIDs (Chi2 p = 0.01, I2 = 63%; SMD= -0.93, 95%CI: -1.58 to -0.28, p = 0.005). Anti-histamines, particularly ketotifen, have the strongest evidence of efficacy for prevention of post-traumatic arthrofibrosis. Some studies suggest a potential role for NSAIDs, particularly celecoxib, although heterogeneity among the included studies is significant.

Reverse shoulder arthroplasty (RSA) has become a widely used procedure since its introduction in the 1980s, and is currently used to treat a wider range of conditions than its original indication. The original Grammont-style RSA revolutionized shoulder arthroplasty but had several limitations, including scapular notching and reduced rotational motion. This review discusses the evolution of RSA design, particularly the development of a lateralized center of rotation constructs, which aims to improve all the disadvantages associated with the Grammont-style design and more closely reproduce the native anatomy in order to improve patient outcomes in an expanded context of pathologies.

Paralysis of the serratus anterior (SA) is most frequently caused by dysfunction of the long thoracic nerve (LTN). Although this condition presents with classic physical examination findings, it is occasionally missed. The purpose of this study is to review the etiology, diagnosis, and treatment options for SA palsy. This study summarizes the anatomy of the SA and LTN, most common causes of SA palsy, physical examination findings, utility of diagnostic tests, the natural history of this condition, and all treatment options that can be contemplated. SA palsy should be suspected in patients with weak forward flexion and abnormal prominence of the medial edge of the scapula with weakness in shoulder protraction. The diagnosis can be confirmed with electromyography and nerve conduction studies. Magnetic resonance may show neurogenic fatty infiltration or atrophy. Although most patients benefit from conservative treatment (mostly physical therapy) for the first 12 months, many patients experience persistent weakness with various degrees of severity. For patients with disabling symptoms, nerve release or transfers have been reported to lead to SA reinnervation with functional improvements. However, long-standing palsy is best managed with a split pectoralis major transfer of the sternal head to the inferior pole of the scapula. Scapulothoracic arthrodesis is an uncommon procedure for patients in whom a previous tendon transfer has failed. LTN dysfunction leading to SA palsy can be typically diagnosed with certain physical examination findings and confirmed using electromyogram with nerve conduction studies. Although spontaneous recovery can occur, patients with persistent serratus weakness may be considered for neurolysis, nerve transfer, or tendon transfer. Currently, direct transfer of the sternal head of the pectoralis major to the inferior pole of the scapula is our management of choice for patients with disabling symptoms and no improvement despite a good program of physical therapy.

The Coronal Plane Alignment of the Knee (CPAK) classification system categorizes nine phenotypes based on constitutional limb alignment and joint line obliquity (JLO). Understanding relationships between CPAK phenotypes and tibial slope (TS) could streamline total knee arthroplasty planning. This study investigated the correlations between CPAK classification and medial TS in patients with osteoarthritis. A retrospective analysis of 622 cases in 535 patients with osteoarthritis undergoing primary total knee arthroplasty was conducted. Three-dimensional computed tomography imaging with MyPlanner software determined mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, and medial TS. Statistical analysis included multiple linear regression, Pearson correlation, and one-way analysis of variance (ANOVA) with Tukey post hoc testing. Outliers were removed using interquartile range criteria, resulting in 581 knees for final analysis. Multiple linear regression revealed minimal correlation between coronal alignment and TS (TS = 26.35 − 0.1045 arithmetic hip–knee–ankle [aHKA] − 0.1004 JLO; r 2 = 0.0233). aHKA angle and JLO explained only 2.33% of TS variance. Contour mapping demonstrated no discernible patterns in data distribution. Despite weak correlations, ANOVA identified statistically significant differences between CPAK groups for TS (F = 2.97; p = 0.003). Tukey post hoc analysis revealed significant differences between CPAK group I and groups V and VII, with mean differences ranging 1.39 to 2.06 degrees. No clinically meaningful relationship exists between CPAK classification and TS in osteoarthritic knees. While statistical significance differences were observed between certain CPAK groups, the extremely low correlation coefficient and small effect sizes indicate these differences fall within measurement variability and are substantially smaller than TS variations that influence total knee arthroplasty outcomes. CPAK classification cannot reliably predict sagittal plane morphology, necessitating an independent, comprehensive three-dimensional assessment of coronal and sagittal characteristics during surgical planning. Level III—Retrospective Comparative Study.

Frozen shoulder causes prolonged pain and restricted range of motion (ROM), with many patients requiring surgery when conservative treatment fails. Arthroscopic capsular release (ACR) is a common intervention, but the optimal extent of release-particularly the safety of superior capsule release and risk of iatrogenic rotator cuff tears-remains controversial. The purpose of this systematic review is to evaluate the clinical effects of releasing the superior capsule of the shoulder as part of a full circumferential ACR, specifically evaluating the rate of postoperative rotator cuff tears. A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, EMBASE, and Web of Science were searched. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized controlled trials (RoB 2.0) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tools. Included studies reported on frozen shoulder patients treated with circumferential ACR, with or without superior capsule release. Postoperative outcomes-ROM, functional scores, and complications like cuff tears-were extracted. A minimum follow-up of 1 year was required. Procedures including superior capsule release were classified as full circumferential ACR only when they included a superior capsule release; otherwise, they were considered limited ACR. Forty-five studies with 1,921 patients (mean age 51.8 years, 59.1% female) met the inclusion criteria. Only 2 randomized controlled trials and 8 prospective studies were included, along with 35 retrospective studies, which generally exhibited a low to moderate risk of bias. Twenty-one studies (46.7%) used full circumferential and 24 (53.3%) used limited ACR. ROM and functional scores improved across all groups, with comparable outcomes between techniques. Only 3 postoperative cuff tears (0.16%) were reported-all in the full circumferential ACR group. However, postoperative imaging was reported in only 2 studies. Full circumferential ACR, including superior capsule release, does not present a higher risk of rotator cuff tears, though the low incidence and limited imaging data suggest underreporting.