Managing the patella remains one of the most fiercely debated topics in primary total knee arthroplasty (TKA). While routine patellar resurfacing with a polyethylene button has historically dominated American operating rooms, a massive counter-trend toward leaving the native patella unresurfaced has surged over the past decade, climbing to 10.3% of all cases nationally. This shift is fueled by the emergence of “patella-friendly” femoral components designed with deeper, more anatomical trochlear grooves that dramatically lower patellofemoral contact pressures.

Despite these biomaterial updates, many surgeons hesitate to abandon the polyethylene button due to an entrenched fear of postoperative anterior knee pain and a perceived need for secondary revision surgeries. Historically, pooled literature painted a grim portrait of unresurfaced patellae, citing secondary resurfacing rates up to 8.7%.

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Mechanical alignment (MA) was introduced in 1973 by Michael Freeman, who proposed systematically performing the femoral and tibial bone cuts perpendicular to their mechanical axes. At the time, instrumentation and implants were rudimentary, and this “one size fits all” technique was a promising approach to simplify and standardize the procedure. Total knee arthroplasty (TKA) performed with MA has since been perceived as essential for TKA success and has established an excellent long-term survival rate of 82% at 25 years.

Interestingly, despite decades of implant design modifications and improved surgical precision with sophisticated robotic-assisted tools, patient function and satisfaction have completely plateaued. Data shows that 75% of patients do not experience a natural joint, 50% suffer from residual symptoms, and 25% would outright refuse to undergo the same surgery again. Applying a systematic, unyielding alignment technique to a highly variable human bony anatomy represents a fundamental flaw that leaves significant room for clinical improvement.

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A colleague of mine, a surgeon, told me something recently that I have not been able to shake.

He said he would rather disclose a surgical complication to the hospital’s peer review board than tell his employer he was struggling with depression.

He is right to be afraid. In most states, a physician who seeks mental health care risks having that history surface during medical license renewal, credentialing reviews, or malpractice proceedings.

The system that demands emotional resilience from physicians at every turn has built the conditions that make asking for help professionally dangerous.

I am going to write about the mental health system in this country from two angles simultaneously, because I think that is the only honest way to do it. The first is the failure of that system to serve patients. The second is the failure of that same system to serve the physicians who are supposed to be providing care inside it. These are not separate stories. They are the same story.

Seventeen Years of a Law That Isn’t Enforced

The Mental Health Parity and Addiction Equity Act became federal law in 2008. Its premise was simple: insurers cannot impose more restrictive requirements on mental health coverage than on physical health coverage. Same deductibles. Same prior authorization standards. Same network adequacy. Equal treatment under the law.

The gap between that premise and reality is one of the most documented, least acted-upon failures in American healthcare policy.

The Department of Labor’s enforcement report found violations in approximately 74% of health plans audited between 2022 and 2024. Not a fringe minority of plans. Not isolated bad actors. Nearly three quarters of audited health plans, operating in violation of a law that has been on the books for seventeen years.

The American Psychiatric Association documented what those violations produce: behavioral health services face denial rates 85% higher than comparable medical services. Eighty-five percent higher. On claims that federal law explicitly requires to be treated equivalently.

The federal government acknowledged the ongoing failure directly. When new parity rule amendments were finalized in 2024, the government’s own language stated: “In the almost 16 years since the enactment of MHPAEA, disparities in coverage between mental health and substance use disorder benefits and medical/surgical benefits have persisted and grown.”

Persisted and grown. Not closed. Not addressed. Grown.

Here is why. Denying mental health claims saves insurance companies money, and the penalties for violations are usually much lower than the savings they can recoup. The math is straightforward. Violate the law, deny the claims, collect the savings, pay the occasional fine. Net positive. Repeat annually.

The law exists. The enforcement doesn’t. And the patients waiting for an approved authorization on a psychiatric hospitalization, or a therapist who takes their insurance, or a treatment plan that extends beyond an arbitrary session limit, are paying the price of that calculation.

Why Your Therapist Doesn’t Take Your Insurance

The parity violation at the coverage level compounds a separate structural failure at the provider level. Even if an insurer technically covers mental health services, finding a provider who accepts that insurance is a different problem entirely.

For similar mental health services, nonpsychiatric medical doctors received anywhere from 13% to 20% higher in-network reimbursement than psychiatrists. That is for the same category of service, covered under the same law, paid at a systematic discount because the service is mental rather than physical.

The downstream consequence is predictable and documented. A master’s-level therapist in New Hampshire could bill $29 per hour under Medicaid when the market rate was $45 per hour. That gap does not produce a shortage of patients willing to be seen. It produces a shortage of therapists willing to accept the reimbursement.

Approximately 47% of the U.S. population, 158 million people, live in a mental health workforce shortage area. The shortage is not primarily a training pipeline problem. It is a reimbursement problem. The system has made providing mental healthcare financially nonviable at the rates it pays, and then expresses bewilderment that patients cannot find providers.

This is the same logic I see in orthopedics, in primary care, and in every specialty where insurers have used reimbursement suppression as a demand-control mechanism. Pay less than it costs to provide the service. Providers exit the network. Access contracts. Patients get denied not by an explicit denial but by a network that does not actually exist at the density the insurance card implies.

The mental health version of this is more acute because the stakes are higher and the alternatives are fewer. A patient who cannot access an orthopedic surgeon has pain and functional limitation. A patient who cannot access a psychiatrist may have neither the insight nor the stability to navigate the insurance bureaucracy, find an out-of-network provider, or sustain the self-advocacy a broken system requires.

The Physicians Nobody Is Treating

I want to say something now that most physicians know and almost none say publicly.

According to Medscape’s 2024 physician survey of over 9,000 physicians, 49% report feeling burned out and 20% report depression. Among those burned out, 62% cited bureaucratic tasks as the primary reason, 41% cited spending too many hours at work, and 40% cited lack of respect from administrators.

Nearly half of physicians are burned out. One in five is depressed. These are not marginal findings from a small sample. This is the clinical workforce that 335 million Americans depend on for their care.

And the system has built a structure that makes it dangerous for those physicians to seek treatment.

An estimated 300 physicians die by suicide each year in the United States, nearly one per day. Physicians have one of the highest suicide rates of any profession. And yet the same licensing and credentialing infrastructure that is supposed to ensure physician fitness creates a direct disincentive to disclose mental health treatment. In most states, licensing renewal asks whether a physician has received mental health care. In most hospital credentialing processes, mental health history is a reviewable factor. The message the system sends is clear: suffer in silence, or risk your career.

The result is predictable. Only 14% of physicians who experienced mental health symptoms sought medical attention for those symptoms. The people trained to recognize and treat illness in others are, by enormous margins, not treating their own.

I have watched this pattern in colleagues I respect. The surgeon who is visibly struggling but will not see anyone because the paperwork trail is too risky. The resident who is not sleeping, not eating, not functioning, and who believes asking for help is a sign of weakness the system will use against them. The attending who self-medicates because the alternative requires documentation they cannot afford.

This is not a resilience failure. It is a structural failure with a body count.

The Two Problems Are the Same Problem

Here is what connects these two failures.

The mental health system fails patients and physicians for the same underlying reason: the financial architecture of American healthcare treats psychological illness as categorically less serious than physical illness, and has built reimbursement, coverage, and credentialing structures that encode that hierarchy into every interaction.

A surgeon with a torn rotator cuff gets it fixed. Their career is not threatened by the disclosure. A surgeon with major depression navigates a gauntlet of professional risk to access care that the law nominally guarantees but the system structurally withholds.

A patient with a broken leg gets authorization for surgery quickly. A patient with a psychiatric crisis waits weeks for an authorization that federal law says must be issued on equal terms with physical health approvals, but that gets denied at 85% higher rates anyway.

The mental health parity law was the right diagnosis. The enforcement has been, for seventeen years, essentially non-existent.

The 2024 rule amendments have teeth, theoretically. Insurers must now document that they are not applying more restrictive criteria to mental health than to physical health. Audit requirements have expanded. The burden of proof has shifted modestly toward the insurer.

I will believe the law is being enforced when the denial rate gap closes. It has not closed yet.

What I Am Asking For

For policymakers: enforce the law that already exists. The 74% violation rate in audited plans is not a compliance problem requiring new legislation. It is an enforcement problem requiring political will. The fines need to be large enough to change the math. Right now, they are not.

For hospital systems and physician employers: stop making it professionally dangerous for physicians to access mental health care. Licensing questions about mental health treatment history should not be the reason a physician in crisis chooses silence over treatment. The credentialing infrastructure needs to distinguish between untreated mental illness and treated mental illness. One is a clinical risk. The other is evidence that a physician is managing their health responsibly.

For physicians reading this: the colleague who asked for help is not the weak one in the room. The system that made asking dangerous is the problem. Not you.

The same anger I carry for patients who cannot access care they are owed, I carry for the physicians who cannot access care they need.

We built a system that demands everything from the people delivering care and provides almost nothing in return when they are the ones who are struggling.

That is not a healthcare system. That is an extraction model. And it is time to say so plainly.

ALSO… did you know… I have a podcast called Unhinged with Dr. Michael Meneghini.

You can see all current and past episodes here: https://www.buzzsprout.com/2627550

The incidence of femoral component revisions following total hip arthroplasty (THA) continues to rise at an unsustainable rate globally. To achieve a stable and durable femoral reconstruction, revision surgery demands specialized implants that can reliably bypass proximal bone defects left behind by the removal of failed primary components. Compared to the rigid, fully porous-coated cylindrical stems used historically, contemporary modular tapered, fluted titanium (TFT) stems have rapidly emerged as the global gold standard. This reputation is built on their immense surgical versatility, reduced stress shielding, and near-immediate axial and rotational stability.

However, achieving definitive biological osseointegration is completely dependent on early mechanical stability. A lack of structural interlock can cause the femoral component to migrate dynamically, resulting in early component subsidence, leg-length discrepancies, and severe mechanical failure. While predictors of implant migration are well documented in primary settings, there is a profound lack of non-registry data exploring the specific behavioral parameters and risk factors for subsidence within a dedicated cohort of aseptic revision revisions. We set out to investigate the true structural incidence and multivariable predictors of early TFT stem subsidence.

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Unicompartmental knee arthroplasty (UKA) utilization has steadily increased in the United States, riding alongside an explosive parallel surge in the adoption of automated robotic platforms. This technological wave is aggressively pushed by claims that manual unicompartmental knee arthroplasty (MUKA) is plagued by high error rates for implant positioning, structural alignment outliers, and compromised long-term survivorship. Two recent high-profile reports by Kazarian et al shockwaves through the arthroplasty community, demonstrating that manual surgeons failed to meet basic implant positioning targets in a staggering 88.1% of cases, resulting in an unacceptable 14.2% all-cause revision rate.

However, these reports failed to account for a critical clinical variable: the baseline caseload and execution of a dedicated, high-volume partial knee specialist. Because faithful scientific replication is essential for establishing the generalizability of status-quo-defining peer-reviewed literature, we set out to determine if this historical robotic dogma holds true when evaluated against an experienced manual reconstruction surgeon.

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Managing manageable access to high-quality care for revision total joint arthroplasty (rTJA) is absolutely imperative, especially in context-heavy cases like periprosthetic joint infection or aseptic failure causing profound patient pain and disability. As value-based healthcare programs expand, interest in the social determinants of health has risen across specialized orthopedic literature. In a purely equitable healthcare environment, one uninfluenced by structural referral bias- insurance type would share no systematic relationship with hospital travel distance or local surgeon sorting behavior.

Unfortunately, contemporary healthcare economics tell a vastly different story. While elective primary total joint replacements are frequently executed close to a patient’s home, individuals requiring highly complex secondary revision reconstructions routinely experience severe regional access constraints. We set out to rigorously evaluate travel burdens following hip and knee revisions to determine if a patient’s insurance profile directly controls their structural access to localized orthopedic care.

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Cost containment and sweeping resource reductions have become the central, unrelenting focus of health policy and value-based research in total joint arthroplasty (TJA). Under federal frameworks, reimbursement rates are determined tightly by the Centers for Medicare and Medicaid Services (CMS), utilizing current procedural terminology (CPT) codes linked to relative value units (RVUs) to establish formal physician compensation. In theory, the higher the procedural RVU weight, the more complex the surgery and the greater the time and effort required for the totality of patient care.

However, multiple large-scale investigations have repeatedly exposed a severe structural flaw in this paradigm: although aseptic revision total joint arthroplasty (rTJA) carries a larger absolute RVU value than primary procedures, the calculated RVUs earned per minute of actual work time are drastically lower. Revision procedures demand significantly higher baseline intraoperative time, yet federal fee updates fail to reflect this reality.

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Satisfaction following primary total knee arthroplasty (TKA) remains stagnant at approximately 80%, leaving 1 in 5 patients unsatisfied with their procedure. In an attempt to shatter this ceiling, the orthopedic community has aggressively adopted advanced technologies, like robotic assistance, which provide surgeons with enhanced precision for implanting TKA components.

However, there is a glaring blind spot in this technological revolution: while surgical precision has shown improvement, data on the true accuracy of optimal implant alignment are lacking, which are necessary for these advanced technologies to become truly valuable. You can execute a bone cut perfectly with a robot, but if your programmed alignment targets are flawed, your patient outcomes will suffer. We deployed advanced machine learning to finally identify the specific multi-planar alignment zones that actually correlate with achieving minimal clinically important differences (MCIDs) in patient-reported outcome measures (PROMs).

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Technological advances across orthopaedic surgery are rapidly accelerating as teams strive to optimize postoperative patient function and lower historically stubborn dissatisfaction rates. Within adult reconstruction, the utilization of robotic-assisted total knee arthroplasty (rTKA) has intensified, championed for its ability to deliver ultra-precise component positioning, reliable gap symmetry assessment, and minimized soft-tissue trauma.

However, despite these elegant intraoperative parameters, a critical systemic question has been left completely unanswered: how is this technological wave shifting the surgical education of our residents? Operating with digital assistance demands an entirely different framework of conceptual and physical steps compared to standard manual surgery.

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Total knee arthroplasty (TKA) stands undisputed as one of the most effective surgical interventions in all of modern medicine, historically relying on polymethyl methacrylate bone cement as the definitive gold standard for immediate component fixation. However, as the demographics of joint reconstruction continue to shift toward younger, heavier, and substantially more active patients, the structural longevity of the cement mantle has faced intense clinical scrutiny. High joint forces and repetitive torsional stress trigger micro-degradation at the bone-cement interface, culminating in osteolysis and premature mechanical failure.

To bypass this interface degradation, cementless press-fit designs re-emerged. Yet, many high-volume reconstruction specialists remain intensely reluctant to adopt non-cemented pathways due to the catastrophic legacy of mid-1990s designs, which suffered failure rates up to 19% from poor osseointegration, early subsidence, and rapid tibial loosening. We set out to evaluate whether massive modern advancements in basic science, engineering, and highly porous biomaterials have successfully banished those historical design flaws.

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Total hip arthroplasty (THA) is widely celebrated as the “operation of the century,” boasting high survival rates and stellar patient satisfaction. Yet, despite decades of innovation, the devastating complication of postoperative dislocation continues to plague the field. Dislocation is reported to occur in up to 10% of primary THAs and remains a leading cause for aseptic revision in the United States.

The posterior surgical approach, favored for its excellent visibility, has historically been scrutinized for higher dislocation rates compared to anterior approaches. However, recent advancements in highly cross-linked polyethylene have fundamentally changed the mechanical equations of THA. These stronger, thinner liners allow surgeons to utilize significantly larger femoral heads, which provide a greater arc of motion before impingement and an increased “jump distance” to resist dislocation. We evaluated dislocation rates following primary THA, as large femoral heads and select dual-mobility bearings were introduced into a contemporary posterior approach practice.

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In the United States, two-stage exchange arthroplasty remains the therapeutic gold standard for treating chronic periprosthetic joint infection (PJI). Despite the historical success of this staged approach, clinical failure remains a persistent challenge, with reinfection incidence climbing up to 10% within the first year and hitting 17% at long-term follow-up. Proceeding to the final stage demands an exceptionally accurate assessment of absolute infection clearance.

Unfortunately, diagnosing persistent or recurrent infection in a patient with an antibiotic spacer is notoriously difficult, as baseline inflammatory responses remain structurally elevated compared to primary joint arthroplasty. To navigate this, historical dogma and international consensus statements have widely popularized a reliance on a downward trend toward normalization in serum markers before clearing a patient for surgery. We set out to investigate whether these popular percentage-change trends hold any statistical validity when compared directly against rigid, absolute numerical thresholds.

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As the volume of primary total knee arthroplasties (TKA) continues to escalate worldwide, containing resource consumption is becoming a critical objective for modern healthcare systems. This is especially true as advanced workflows—including computer navigation, robotics, custom implants, and patient-specific instrumentation—shift from a luxury to a baseline standard of care. To drive their accuracy, these advanced technologies typically mandate preoperative 3D imaging via a computed tomography (CT) scan.

Unfortunately, traditional 3D workflows impose a severe triple-threat: they add substantial operational cost, require additional clinic visits, and expose the patient to unnecessary ion radiation. We evaluated whether a novel machine learning algorithm could bypass these hurdles by converting standard, inexpensive two-dimensional plain radiographs into 3D bone reconstructions of equivalent diagnostic accuracy.

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Femoral neck fractures remain a massive healthcare challenge in the elderly population, serving as a primary driver of major patient morbidity and post-surgical mortality. While treatment ranges from internal fixation to hemiarthroplasty, total hip arthroplasty (THA) has expanded significantly as a premier option to restore high-level function and long-term quality of life. Currently, the American Academy of Orthopaedic Surgeons clinical practice guidelines note moderate evidence favoring cemented femoral stems for hip fractures.

However, nearly all of the historical literature backing that consensus was derived strictly from hemiarthroplasty series. In the United States, an “uncemented paradox” persists: despite registry data warning of complications, the vast majority of trauma THAs are performed using cementless femoral stems. Advocates argue that press-fit implants mitigate the risks of cemented hips, such as extended operative times, increased baseline implant costs, and bone cement implantation syndrome (BCIS). We set out to evaluate whether this massive national shift toward cementless stems is truly safe when performing a full THA for acute hip fractures.

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While patellar resurfacing during total knee arthroplasty (TKA) remains a hotly debated topic, it continues to be the most popular technique utilized across the United States. However, complications related to costly patellar component revisions persist, driving a steady clinical shift toward leaving the patella unresurfaced during primary TKA. This anatomical retention strategy has historically been criticized due to older studies citing an increased risk of secondary reoperations for anterior knee pain.

Crucially, those historical series utilized older-generation femoral components that lacked modern, “patella-friendly” trochlear geometries. Furthermore, much of the anterior knee pain historically blamed on an unresurfaced patella was likely unrecognized flexion instability—a distinct clinical entity with nearly identical presenting symptoms. We set out to evaluate the true effect of selective patellar resurfacing on validated Patient-Reported Outcome Measures (PROMs) using contemporary, state-of-the-art implant designs.

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Periprosthetic joint infection (PJI) remains one of the most common causes of early revision total joint arthroplasty (TJA), representing 14.8% of total hip arthroplasty (THA) and 25.5% of total knee arthroplasty (TKA) revisions performed in the United States. Revision takes a great toll on patients, surgeons, healthcare professionals, hospitals, and the healthcare system, carrying an in-hospital mortality rate higher than that of coronary or carotid procedures.

While the American Academy of Orthopaedic Surgeons and international consensus groups outline clear diagnostic guidelines, no single test or scoring method has been shown to be 100% sensitive and specific in diagnosing PJI. Furthermore, while novel biomarkers like alpha-defensin, calprotectin, and adenosine offer potential for increased detection, they are costly and remain unavailable in many standard hospital laboratories.

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Operative time is related to complications in total joint replacement, including total hip arthroplasty (THA). Longer operating times for the direct anterior (DA) approach THA have been documented, and some have linked operative duration to complications.

We set out to compare procedure and anesthesia duration in DA and posterior approach primary THAs performed in hospitals and ambulatory surgery centers (ASCs), and their relationship to nontraumatic all-cause, surgical, and medical readmissions within 90 days of discharge for the index procedures.

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Periprosthetic joint infection (PJI) is the most devastating complication following primary total knee arthroplasty (TKA). The therapeutic ‘gold-standard’ for treating chronic PJI is the two-stage revision, which yields durable infection eradication. Two-stage revision involves implant removal, insertion of an antibiotic-loaded cement spacer, and eventual reimplantation with a new prosthesis.

However, deciding whether to resurface the patella during reimplantation remains debated. Proponents of resurfacing cite historical norms, reduced anterior knee pain, and potential cost savings. Opponents point to the risks of catastrophic extensor mechanism complications and argue that leaving the patella unresurfaced yields equivalent patient-reported outcome measures (PROMs). We set out to evaluate whether patellar resurfacing during reimplantation confers a functional benefit or increases implant survivorship after two-stage treatment for PJI.

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Total hip arthroplasty (THA) has been referred to as one of the most successful procedures in all of medicine due to its ability to restore a patient’s quality of life and functional status. Orthopedic surgeons routinely use multimodal analgesia to manage the postoperative pain associated with THA. Although oral and intravenous medications are commonly used in a multimodal analgesic protocol, the injection of local anesthetic as a regional nerve block or periarticular local anesthetic infiltration (PAI) is meant to reduce the transmission of pain signals associated with neuropathic pain.

A variety of regional nerve blocks have been described around the hip joint to provide analgesia after THA, with fascia iliaca, lumbar plexus, and quadratus lumborum blocks among the most commonly used. Utilization of regional nerve blocks for THA must balance the risks of motor blockade while considering the individual risk associated with each type of regional nerve block.

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Total knee arthroplasty (TKA) is among the most common orthopedic procedures performed in the United States, which improves a patient’s quality of life and functional status. Despite the long-term clinical success of the procedure, more than 80% of TKA patients experience moderate to severe pain during the postoperative period, making TKA among the most painful orthopedic procedures. Multimodal analgesia protocols have been widely adopted by orthopedic surgeons and anesthesiologists to provide better postoperative pain control and reduce the side effects of opioid medications.

Regional nerve blocks and peri-articular local anesthetic infiltration (PAI) provide analgesia through the administration of local anesthetics to reduce the transmission of neuropathic pain signals. When regional nerve blocks were introduced to improve pain management after TKA, it was more common to use a combined femoral and sciatic nerve block. Although the combination of femoral and sciatic nerve blocks resulted in total analgesia of the lower extremity, it was accompanied by significant motor blockade.

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