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AvertD is an FDA-approved genetic test that identifies patients who may have an elevated genetic risk for developing opioid use disorder (OUD).

During my (S.P.) first year in residency, I spent a month as the night float intern at Harborview Medical Center, managing an orthopedic service with an inpatient census that frequently reached the hundreds. When I was not responding to floor pages, it was expected that I would spend time in the emergency department (ED) assisting the second-year residents with new consults of varying acuity.

Reverse total shoulder arthroplasty (rTSA) continues to expand in indications, and modern implant designs have reshaped the biomechanical role of the subscapularis. However, whether subscapularis repair is necessary after rTSA remains controversial, in part, because its contribution to stability and motion is not uniform across implant geometries. This narrative review synthesizes contemporary biomechanical and clinical evidence to define how glenoid and humeral design features including center of rotation, degree of lateralization, neck–shaft angle, and humeral onlay/inlay configuration, modify subscapularis function, repair demands, and postoperative outcomes. Across the literature, medialized constructs demonstrate greater dependence on the subscapularis for anterior stability and internal rotation. In these configurations, successful repair may enhance stability and internal rotation, whereas failed healing can magnify functional deficits and compromise outcomes. In contrast, lateralized designs at the glenoid, humerus, or both improve deltoid wrapping and soft tissue tensioning, increase intrinsic constraint, and expand impingement-free range of motion, thereby reducing the functional necessity of subscapularis repair and maintaining low instability rates even when the tendon is not repaired. Dual lateralization may provide the most robust stability and external rotation, but it can increase anterior soft tissue tension, making selective repair and careful intraoperative tension assessment critical. Overall, implant geometry, not repair status alone, most strongly determines the clinical relevance of the subscapularis after rTSA. These findings support a shift from routine repair toward a design-specific, patient-tailored strategy that integrates implant configuration, tendon quality, soft tissue balance, and functional goals to optimize stability, motion, and long-term success.

The recording of the JOEI Zoom "Open Mic" featuring Ron Hilllock, MD, Parminder Kang, MD, & Eric Slotkin, DO.

Dr. Stephen Howell shares his thoughts on this topic.

Periprosthetic joint infection (PJI) remains a challenging complication of total joint arthroplasty, in part because biofilm-associated bacteria demonstrate substantially greater antimicrobial tolerance than planktonic organisms. Although systemic antibiotics are central to PJI treatment, concentrations achieved within the joint may exceed the minimum inhibitory concentration (MIC) yet remain insufficient to reach the minimum biofilm eradication concentration (MBEC). This pharmacokinetic mismatch represents a fundamental limitation of conventional antimicrobial therapy. This narrative review examines biofilm biology, the limitations of MIC-based treatment, and the emerging role of MBEC in understanding biofilm eradication. Current local delivery strategies, including antibiotic-loaded polymethylmethacrylate spacers and beads, intra-wound antibiotic powders, and intraoperative irrigation, are reviewed, with emphasis on their limited ability to sustain biofilm-eradicating concentrations. Intra-articular antibiotic infusion offers a potential strategy to overcome these limitations by delivering sustained, high local antibiotic concentrations while maintaining comparatively modest systemic exposure. Available clinical series report encouraging infection-control rates across DAIR, single-stage revision, and salvage procedures; however, evidence remains largely retrospective and heterogeneous. Further comparative studies are needed to define optimal patient selection, antibiotic regimens, dosing strategies, and the clinical efficacy of intra-articular therapy in PJI.

The recording of the JOEI Zoom "Open Mic" featuring Cory Calendine, MD, Elizabeth Gausen, MD, and David Rodriguez, MD.

GLP-1 receptor agonists like Ozempic and Wegovy are reshaping how healthcare systems approach preoperative optimization. Originally developed for diabetes, these therapies are now widely used for weight reduction. In orthopedics, this shift is transforming patient preparation for major surgeries like Total Knee Arthroplasty (TKA).

This study aimed to evaluate the agreement between ChatGPT 4.0 and a fellowship-trained orthopaedic surgeon in detecting periprosthetic osteolysis on radiographs following anatomic total shoulder arthroplasty (aTSA), using the Gruen and Modified Gruen zone scoring systems. Agreement with a fellowship-trained orthopaedic surgeon was evaluated.

Perioperative antibiotic prophylaxis is common practice in joint replacement surgery. Antibiotics can cause dysbiosis to the native microbiome which can negatively affect patient health and may play a role Periprosthetic Joint Infection (PJI). The purpose of this pilot feasibility study was to evaluate if (1) we can measure a change in the microbiome of patients undergoing primary hip and knee replacements who receive routine peri-operative antibiotics and (2) at what time point does a patient’s microbiome return to pre-surgery profiles?

Modern healthcare is characterized by a fundamental structural misalignment: physicians deliver care, yet do not control the financial infrastructure that determines its cost, access, or sustainability. This disconnect is particularly evident in orthopedics, where highly standardized, high-value procedures coexist with wide cost variation and administrative inefficiency. In Mid-Missouri alone, independent physicians collect roughly 29% less from Medicare and close to half the commercial rates that the local university hospital receives for identical orthopedic procedures — while the 2026 CMS fee schedule drops total hip reimbursement from $1,043 to $975.20. This paper introduces the Physicians Nexus — a physician-owned capital platform designed to align care delivery, insurance risk, and financial infrastructure under unified physician governance. At its core is a physician-owned financial institution that aggregates capital across specialties and geographies. Through this platform, physician groups participate in the health cooperative that standardizes benefit design and generates predictable utilization. This alignment enables the formation of a physician-governed captive insurance structure that captures underwriting gains and retains reserves within the system. By internalizing the economic value of care delivery and redeploying it through a coordinated financial structure, the Physicians Nexus shifts physicians from participants in fragmented systems to owners of an integrated platform. This model reduces cost, improves access, and restores physician autonomy while creating a scalable, self-reinforcing system of care and capital formation.

The recording of the JOEI Zoom "Open Mic" featuring Daniel Choi, MD, John Dundon, MD, & Kevin Plancher, MD.

Musculoskeletal (MSK) care sits at the center of the shift toward value-based care. As one of the highest-spend and highest-variation categories in healthcare, MSK represents one of the largest remaining opportunities to meaningfully reduce total cost of care and enhance patient outcomes. Orthopaedic and spine surgeons (specialists) stand at a critical inflection point: They can either lead the redesign of MSK care delivery across the entire patient journey or be relegated to procedural technicians within systems designed by others. Recent federal policy signals, including CMS’ TEAM, ACCESS, and Ambulatory Specialty Care models, make it clear that specialty-driven accountability is no longer optional. These models accelerate the shift from fee-for-service and surgical episode-centric decision-making toward population-level clinical governance and at-risk accountability. This commentary argues that Specialist-Led value-based Care is a sustainable path forward for MSK care. Surgeons possess unique episode-level insight, clinical authority, and the ability to influence both upstream and downstream utilization and long-term patient outcomes. When supported by data transparency, aligned incentives, and infrastructure, MSK surgeons can drive meaningful improvements in quality, access, and affordability. Conversely, failure to lead this value-based care evolution could result in solutions that erode specialist autonomy, fragment care, and diminish the specialist’s unique MSK expertise. The window of opportunity is narrow, but the potential impact is profound: Orthopaedic and spine surgeons are one paradigm shift away from solidifying their leadership role in the future of MSK care delivery.

Three-dimensional (3D) printing has emerged as a powerful tool in joint replacement surgeries, enabling the creation of custom implants that address complex anatomical deformities. In shoulder arthroplasty, particularly in cases involving severe glenoid bone loss or fracture, custom 3D-printed glenoid baseplates offer solutions not possible with standard implants. This review outlines the step-by-step workflow for designing a custom implant, using the case of an 80-year-old patient with advanced glenoid deformity and fracture to illustrate clinical application. The process included high-resolution CT imaging, digital segmentation, and advanced planning for implant design, material selection, and fixation strategy. Postoperatively, the patient demonstrated significant pain reduction, improved range of motion, and radiographic evidence of implant stability and osseointegration. This case highlights the promise of 3D-printing in complex shoulder reconstruction and underscores the importance of continued innovation to expand access, streamline production, and validate long-term outcomes.

Physical therapy is a critical component of postoperative rehabilitation after ACL surgery. However, access to formal physical therapy is not universal, and patients who do not receive adequate rehabilitation may experience worse postoperative outcomes. The primary objective of this study was to evaluate whether the addition of a low-cost, desktop 3D-printed knee extension device and at-home video program led to an increased rate of obtaining full knee extension following anterior cruciate ligament reconstruction in the early postoperative period.