This Week in Orthopedics — Sep 10, 2026

Welcome to This Week in Orthopedics. This week we're covering 10 notable papers spanning consensus guidance in sports medicine, prognostication and risk stratification before elective surgery, and population-level data on implants, disparities and bone health. Let's dive in.

We start with two formal European consensus documents, both published in Knee Surgery Sports Traumatology Arthroscopy, that try to bring order to two of the messiest diagnostic areas in our specialty. The first, led by Kany and colleagues for the European Society of Sports Medicine, Knee Surgery and Arthroscopy together with the European Shoulder Associates, tackles partial-thickness posterosuperior rotator cuff tears [1]. A steering group built 33 questions and, after literature review and independent rating, produced twelve statements with strong agreement — though notably five of them rest on expert opinion alone. The high-grade recommendations are that these tears should be characterised using several classification systems together, by location, depth and tendon involvement, and that acute and chronic tears must be distinguished. They also conclude that articular-sided injuries are more common in overhead and contact athletes, and that calcifying tendinitis is not linked to these tears. Equally important is what they could not settle: the rate and timeframe of tear progression is unpredictable, and no imaging modality reliably characterises these lesions. The companion paper, from Hölmich and colleagues with the European Hip Preservation Associates and the European Sports Medicine Association, addresses hip and groin pain in athletes and physically active adults [2]. Fifty-seven experts from 22 countries agreed on five terminology categories — adductor, iliopsoas, inguinal, pubic and hip joint-related groin pain — and on a core clinical examination that includes gait, Trendelenburg's test, palpation and resisted testing of the relevant muscle groups, hip range of motion and the flexion-adduction-internal-rotation test. Every single statement was graded C, which is the honest headline here. Their practical message is that plain radiographs or ultrasound should be first-line, with magnetic resonance imaging, computed tomography and diagnostic hip injections held in reserve, and that imaging is neither sensitive nor specific enough to be interpreted apart from the history and examination.

The second theme is prognostication — identifying, before you operate, who is likely to fail. In the American Journal of Sports Medicine, Pineda and colleagues analysed 585 primary anterior cruciate ligament reconstructions with hamstring autograft followed for at least six years, asking how posterior tibial slope and age interact [6]. Each additional degree of slope raised the odds of graft rerupture by roughly a quarter, and every additional year of age was protective, but there was no statistical interaction — meaning the relative effect of slope is essentially constant across the age range. What changes dramatically is the absolute risk. For a patient with a slope of 15 degrees, the predicted rerupture probability was about 37 percent at age 18 but under 4 percent at age 45. The predicted risk fell below one in ten at around age 27 for a slope of 12 degrees, and around age 35 for a slope of 15 degrees. The practical translation is that slope-correcting osteotomy discussions belong overwhelmingly with your younger patients; the same radiographic number in a 40-year-old carries very different consequences. Alongside that, also in the American Journal of Sports Medicine, Cameron and colleagues followed 243 hip arthroscopies for femoroacetabular impingement syndrome for a minimum of ten years [8]. Psychiatric comorbidity was documented in about 30 percent of patients, and among those patients failure — revision arthroscopy or conversion to arthroplasty — occurred in 23 percent, compared with 5 percent of patients without a psychiatric diagnosis. Failure-free survivorship was shorter by roughly two years, and anxiety, depression, both together, and the combination of psychiatric diagnosis with psychotropic medication use were each independently associated with failure. Both groups did improve, but patients with psychiatric comorbidity gained less and ended lower. This is observational, so it cannot tell us whether treating the mood disorder changes the surgical outcome — but it does tell us the preoperative conversation should be different.

Spine gives us three papers this week, and together they say that what you do around the operation may matter as much as which scope you hold. In Spine, Udby and colleagues used the Danish National Spine Registry to study 344 patients undergoing lumbar spinal stenosis surgery, grading preoperative multifidus fatty infiltration with the Goutallier system and measuring psoas muscle index [9]. Psoas size predicted nothing. Multifidus fatty infiltration, by contrast, tracked with worse Oswestry Disability Index scores at two years and less improvement, in a dose-response fashion, and each increasing grade cut the odds of achieving a clinically meaningful improvement by roughly a quarter. That grading takes seconds on an magnetic resonance image you have already ordered. Also in Spine, Liu and colleagues report a randomised trial of 110 patients with Schizas grade C or D single-level stenosis, comparing unilateral biportal endoscopic decompression with single-port endoscopic decompression, all performed by one senior surgeon [5]. At twelve months there was no difference in pain scores, disability, satisfaction, dural sac expansion or facet preservation. The biportal technique had shorter operative times, the single-port approach a shorter hospital stay, and there was one dural tear in the single-port group. In other words, in experienced hands this is a preference-and-workflow decision, not an efficacy one. The third spine paper, from de Reus and colleagues across institutions in the United States and United Kingdom, looked at 796 patients undergoing open surgery for spinal metastasis [7]. About one in six developed an infection within 30 days, and 41 percent of patients received an allogenic red blood cell transfusion — which roughly doubled the odds of infection, persisting through sensitivity analysis, with a dose-dependent relationship and no identifiable safe threshold, not even at a single unit. Higher body mass index, chronic obstructive pulmonary disease, low albumin, fast-growing primaries, three or more metastases, four or more operated levels and preoperative systemic therapy also raised risk. The actionable message is restrictive transfusion, nutritional optimisation, and favouring the less blood-loss-prone operation where oncologically defensible.

Finally, three papers using large-scale or population data. In Acta Orthopaedica, Chabaita and colleagues analysed 48,618 primary total hip arthroplasties for osteoarthritis in the Danish Hip Arthroplasty Register, comparing highly cross-linked with conventional polyethylene, stratified by head size [3]. With 36 millimetre heads, cross-linked polyethylene was associated with about three fewer all-cause revisions per hundred patients at ten years, and lower risk of dislocation and of revision for dislocation and infection. With 32 millimetre heads there was less dislocation and less revision for aseptic loosening. With 28 millimetre heads there was no difference at all. The authors are appropriately cautious given the observational design, but the interaction with head size is the interesting signal. In the BMJ, Lu and colleagues pooled 124 randomised trials and more than 18,000 participants aged 40 and over in a hierarchical network meta-analysis of exercise and bone [4]. Brisk walking or jogging and combined aerobic-resistance training probably improve lumbar spine bone mineral density, with brisk walking or jogging performing best at the femoral neck and total hip. Dose-response was an inverted U — more is not better indefinitely — with clinically meaningful benefit around 600 metabolic equivalent-minutes per week, about two to three hours of brisk walking. In the fracture analysis, mixed aerobic exercise and mind-body exercise reduced fracture odds while other modalities were neutral, though certainty was low throughout. And in Clinical Orthopaedics and Related Research, Richardson and colleagues studied 88 patients with high-grade osteosarcoma and compared measures of social determinants of health [10]. Only the Area Deprivation Index discriminated: patients from high-deprivation areas presented through urgent care or the emergency department about half the time versus roughly a fifth, had symptoms for a median of 13 weeks before diagnosis versus 6, and had five-year overall survival of 37 percent versus 65 percent. Childhood Opportunity Index, census-tract poverty and race or ethnicity showed no such differences.

If you only have time for one paper this week, make it the posterior tibial slope and age analysis in the American Journal of Sports Medicine [6]. It converts a familiar radiographic risk factor into age-specific absolute numbers you can actually quote to a patient deciding about slope-reducing surgery.

Here are the key takeaways from this week in Orthopedics. First, the same tibial slope means very different things at 18 and at 45 — stratify by age, not slope alone. Second, screen for psychiatric comorbidity before hip arthroscopy for impingement, because failure rates at ten years were several times higher. Third, grade multifidus fatty infiltration on the preoperative magnetic resonance image before stenosis surgery; psoas size adds nothing. Fourth, in metastatic spine surgery, treat transfusion as a modifiable infection risk with no safe minimum dose. Fifth, for bone health, advise brisk walking or jogging or combined aerobic-resistance work at roughly two to three hours per week, recognising the evidence certainty is only low to moderate. And sixth, both new consensus documents concede that imaging alone cannot characterise partial cuff tears or groin pain — the examination still drives the diagnosis.

That's your roundup for This Week in Orthopedics. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

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