Kyle Nuland, MD

@alisongrimaldi Great points! Generally series of releases involve 1) Superolateral capsule 2) Conjoined 3) Piriformis 4) Externus in that order. Try to do as little release as possible. Most cases able to “flip” the piriformis over the tip of the troch without release. Externus almost never

🦴 Anterior hip replacement ≠ completely “muscle-sparing.” Deep hip rotators (obturator internus & externus, gemelli, sometimes piriformis) are often affected. ✅ Know what’s involved to guide rehab. Read more: dralisongrimaldi.com/blog/deep-exte… #HipReplacement #HipRehab #Physio

@BrandonLuuMD Seems pretty efficient!

The ideal day in medicine without specialists: 9am: perform an EBUS 10am: knee replacement 12pm: admit a patient with acute hyponatremia 1pm: cardiac cath on a STEMI → triple vessel disease → convert to CABG 3pm: read a blood film for schistocytes 5pm: deliver a baby

@DrJesseMorse If his MRI looked like that he wouldn’t be getting arthroscopic surgery for the meniscus

Maxx Crosby: “a significant meniscus tear and the related stress injury to the bone and cartilage in his knee” his surgeon Dr. Neal EtAttrache told ESPN this morning Injury to cartilage = arthritis + Stress fracture / reaction + Meniscal tear The location of these is likely unclear, either medial or lateral, but they are likely ‘on top’ of each other. MRI probably looks something like ⬇️

@orthobullets @FL_Ortho @traumaticum @itius @DrFraneNicholas @schulte_ss @jointdocShields @yoon_rs @IMNailR @bonesmith_ @drsebheaven @sportsdoc2016 At two weeks post-op I’d have a very low threshold to revise that stem to a diaphyseal component. Probably can get by with just cables at that point.

*This is a multi-part case covering the complications of interprosthetic femur fractures. The initial operations were not performed by Dr. Palumbo. Here are postop images of yesterday's case presented by Dr. Brian Palumbo and Florida Orthopaedic Institute @FL_Ortho. INTERPROSTHETIC PROXIMAL FEMUR FX IN 55F PROCEDURE: ORIF OF PROXIMAL INTERPROSTHETIC FEMUR FRACTURE This case will be debated at the Tampa Revision Arthroplasty Course in Tampa, Florida, March 27-28, 2026. Here is the link to the clinical presentation and the pre-op imaging: x.com/orthobullets/s… Do you agree with the treatment? Why or why not? #orthotwitter Vote on this case for CME: orthobullets.tiny.us/mpz5hnbf

@pgholam But there is a fracture 🤣

The mocking and belittling of orthopedic surgeons by internists is uncalled for and sophomoric. Ortho is the most competitive speciality. Period. The true value of an orthopedic surgeon is best revealed when you or family need one. #livertwitter #medtwitter

@KoneruMd I admittedly have major concerns with the above conclusions. The “RCT” from the Russian Military Medical Bulletin gives no P values, has significant dropout from the control arm, uses 2 views to diagnose KG grades, doesn’t explain their MRI rational. Do you happen to have a PDF

@KoneruMd I’m interested in any minimally invasive treatment for OA and our current tools are admittedly lacking. So in your opinion should I be offering LDRT to all patients with KG2/3? How about 4? In your opinion do these studies justify that recommendation?

We have never run a sham-controlled RCT for total knee replacement. Not once. The most commonly performed orthopedic procedure in the United States, 700,000+ per year, has never been tested against placebo. And yet when low-dose radiotherapy (LDRT) for knee OA is presented, the first objection is always: "Where's the sham-controlled data?" That double standard is worth naming out loud. Here is what LDRT actually has: → 2 positive sham controlled trials (Korean and Iranian) → A 292-patient prospective RCT (Russian) with 11 year follow-up → 4.5x difference in pain scores at 36 months across every domain (pain, stiffness, function, quality of life) → Plain-film radiography and MRI at 10 years showing a statistically significant reduction in marked progression → A 50-year European safety record with no meaningful toxicity Here is what the treatments currently in OA guidelines have: → NSAIDs: known cardiovascular, renal, and GI harm at chronic doses → Glucosamine/chondroitin: failed large RCTs. Still in some guidelines. → Corticosteroid injections: emerging evidence of accelerated cartilage loss with repeat use → TKA: no sham trial. Ever. If LDRT was a pill, it would be in every guideline. The evidence bar being applied to LDRT is not being applied to anything else in this space. The critics aren't wrong that we need a multicenter sham-controlled trial. We do. That's the ask. But the argument that the current evidence is insufficient to justify treatment while we continue recommending interventions with weaker or more harmful evidence bases is not scientific rigor. It is asymmetric scrutiny. The field has been waiting decades for a non-surgical, disease-modifying treatment for OA. The data suggests we may have had it all along. That conversation is overdue.

@ProFootballDoc I’m not sure I’d say ex fix with fasciotomies and highly comminuted metaphyseal diaphyseal tibia requiring two approaches and three plates is “expect a good outcome”

Looks horrific but actually best possible news!🙏 Expect a good outcome! 🎉 Given the spanning fixator across knee, could have been worse.👏 Severely comminuted shaft & intra-articular fracture🦴 Triple plating and screws for tibia 😱 No need to fix fibula fracture as will heal👍

@txsportsdoc @Disasterplasty @jointdocShields It will be well fixed. Pencil tip burr around the proximal section then Watson extractor probably will work. Osteotomy backup. Modularity strikes again!

@Disasterplasty Oh man. I hope that stem pulls right out🙏 or likely ETO incoming. How are others dealing with this? @jointdocShields

Thank you Cpt Obvious. Radiologist, “you’re welcome”.

@DrJesseMorse “Appears that the fibula is intact” Jesus

Lindsey Vonn shares her actual X-rays post 6+ surgeries!!! Looks like a severe proximal tibia fracture. Tibial plateau fracture + Metaphyseal/Tibial Shaft fracture Appears that fibula is intact. Unclear if the femur was involved. Based on initial photos, I wouldn’t be surprised if there was an open wound and possible fasciotomy due to compartment syndrome. LONG rehab journey ahead but nothing she hasn’t done probably 5 times already. Mind you eventually she will (likely) have to have her ACL reconstructed. Good luck girl!

Doctors and pharmacists often hesitate to recommend a daily intake of over 5000 IU of Vitamin D, not because it's unsafe, but because they're concerned about losing customers. They'd rather keep you sick than promote a simple, cheap, and effective solution.

@pratikorho THA for me

Neck of femur fracture in 55 year old gentleman, Pauwel type 2 Mild Comminuted ! Did DHS with CC Screw. #medtwitter #medx #orthotwitter #orthox #fracture

@NFL_DovKleiman Toradol is actually pretty quick to hit and a potent anti inflammatory…not sure anything in this is correct

Wow: 49ers HC Kyle Shanahan revealed that Seahawks QB Sam Darnold was on TORADOL an extremely powerful painkiller in order to play through his oblique injury. “It takes a while for the Toradol to kick in, so we knew Sam would be fine once kickoff came.” 😳😳😳

@BarryOnHere 🤦

The problem is, many people think Brady has 7 rings b/c he was just that much better than every other QB ever. But he wasn't, he was just that much luckier. Tuck Rule, now it's 6 rings Dee Ford, now it's 5 rings Seattle runs the ball, now it's 4 rings Atlanta runs the ball, now it's 3 rings Oops, I destroyed Brady's GOAT case by changing just 4 plays. If he was really that dominant, it shouldn't be that easy.

@DrTEHughes @DrJN_SportsMed I think the main caveat to this is that studies on wear rates are variable and not overly representative of the 40year old marathoner. It makes sense that more cycles may lead to higher wear rates but we need more data. doi.org/10.1016/j.arth…

@DrTEHughes @DrJN_SportsMed I would definitely discuss ceramic on ceramic for this age bracket. First generations had problems with squeaking and fracture. Newer models seem to be better, but these risks often worry people. HXPLE wear rates ~.02mm/year so with a 5-6mm thick poly it should last for life!

Consent✅ Lots to think about here Male, 40s- super fit - skiing, running, weights Always had stiff hips and tight 'hip flexors' 👀 hmmmm Recalls aggressive breaststroke kick right side (ie minimal trauma) - sudden catching pain right groin Remained intrusive with mechanical symptoms - pain at rest, sitting, rolling over, deep squat Exam - both hips reduced ROM especially into FADDIR -right particularly irritable Video - AP Xray pelvis - bilateral dysplasia R > L, plus cam bumps.... a hip pain 'perfect storm' POCUS - extensive R sided delamination labral tear (use passive hip rotation to manipulate & 'milk' effusion fluid into tear to highlight it) MRI images (surrogate markers of dysplasia) 1. 'Saturn Sign' (I made this up) - anterior to posterior labral tear 2. Cystic change in ligaments teres 3. Hypertrophic cystic labral changes It's not just women that have dysplastic hips This needs experienced surgical input rather than 'kicking the can down the road'

@txsportsdoc Almost 100% spinal with chloroprocaine for rapid off, much less problems with delayed mobilization and constraints on PT staying late.

To my total joint colleagues, are you still using mostly spinals instead of general? When/why do you choose one over another? With the trend towards outpatient joints, I have seen many with longer lasting spinals, longer to ambulate,urinary retention,longer discharge times and spinal headaches. @jointdocShields @kimtuckinAZ @rkh_md @generalorthomd @DrAntoniaChen @EdinburghKnee @VaHipandKneedoc @drsebheaven @CenterRotation

@ArthroToday @DrCafferky @FaresAniMD Almost all joints getting perioperative IV Dex 10mg in my practice. Makes scientific sense that even earlier Dex may be of benefit, but probably not practical in today’s world?

Dexa now or dexa later? Does timing of IV dexamethasone make a difference in pain and outcomes? @DrCafferky @FaresAniMD @KyleNuland arthroplastytoday.org/article/S2352-…