Orthogate Landmark Trials: Practice-Defining Musculoskeletal Evidence (November 2026)

Critical appraisals of practice-changing clinical trials and high-level evidence syntheses across flagship orthopaedic journals, structured using the SBAR framework for immediate surgical and clinical application.

Featured Landmark Studies This Edition (November 2026)
Level I RCT

1. Supervised physiotherapeutic scoliosis-specific exercises provide limited additional benefit at 24 months in braced adolescents with idiopathic scoliosis: a randomized trial.

Authors: Zhang X, Liang M, Huang Y, Lin B, Lin Y et al. | Journal: The Bone & Joint Journal (Nov 2026) | View Source / DOI

Situation

Physiotherapeutic scoliosis-specific exercises (PSSE) are frequently prescribed as an adjunct to bracing in adolescent idiopathic scoliosis (AIS), yet rigorous randomized evidence establishing their long-term clinical and radiological value remains limited.

Background

This randomized trial evaluated whether supervised Schroth-based PSSE (physiotherapist-led sessions combined with daily home exercises) provides clinically important radiological and patient-reported benefits compared with self-directed general exercise in braced patients with AIS (major Cobb angle 25° to 45°; Risser grade 0 to 2) recruited at a tertiary scoliosis centre between December 2018 and December 2022.

Assessment & Findings

  • Co-Primary Endpoints & Thresholds: Co-primary outcomes were change in major Cobb angle and change in health-related quality of life measured via the Chinese Brace Questionnaire-34 at 24 months, with a 5° between-group difference prespecified as the minimal clinically important difference (MCID).
  • Radiological Change at 24 Months: Supervised PSSE achieved a statistically greater reduction in major Cobb angle compared with self-directed exercise at 24 months (adjusted between-group difference -3.23°, 95% CI -3.51 to -2.96; p < 0.001), but this difference remained below the prespecified 5° MCID threshold.
  • Categorical Curve Status & Quality of Life: When 24-month radiological outcomes were categorized using the 5° threshold as improved (> 5° decrease), stable (-5° to +5°), or worsened (> 5° increase), adjusted ordinal logistic regression showed comparable distributions between groups in both intention-to-treat analysis (adjusted OR 1.08, 95% CI 0.58 to 2.03; p = 0.805) and per-protocol analysis (OR 1.48, 95% CI 0.75 to 2.92; p = 0.263), with no clinically meaningful difference in quality of life.

Recommendation & Practice Takeaway

Clinical Pearl: In braced adolescents with AIS (major Cobb angle 25° to 45°, Risser grade 0 to 2), adding supervised Schroth-based PSSE yields a statistically significant but clinically modest Cobb angle difference (-3.23°) at 24 months that does not cross the 5° MCID or improve categorical curve stability or brace-related quality of life compared with self-directed general exercise.

Level I RCT

2. A Prospective Comparative Study of UBE-ULBD Versus Endo-ULBD for Lumbar Spinal Stenosis.

Authors: Liu W, Du Y, Wang Y, Li P, Kao Y et al. | Journal: Spine (Nov 2026) | View Source / DOI

Situation

Unilateral biportal endoscopic unilateral laminotomy for bilateral decompression (UBE-ULBD) is an established minimally invasive option for degenerative lumbar spinal stenosis (LSS), but direct randomized comparisons against single-port endoscopic unilateral laminectomy for bilateral decompression (Endo-ULBD) remain limited.

Background

This prospective randomized controlled trial directly compared the clinical and radiologic outcomes of UBE-ULBD versus Endo-ULBD in 110 patients with single-level Schizas grade C/D LSS randomized equally (55 per group) and operated on by the same senior surgeon with a 12-month follow-up.

Assessment & Findings

  • Perioperative Metrics: UBE-ULBD demonstrated a significantly shorter operative time (P < 0.01), attributed to dual-portal ergonomics and high-speed drill utilization (whereas a trephine was used exclusively in Endo-ULBD). Conversely, Endo-ULBD was associated with a shorter postoperative hospital stay (P < 0.01).
  • Clinical & Functional Outcomes at 12 Months: Both cohorts achieved significant clinical improvement from baseline (P < 0.05) with no significant intergroup differences in visual analog scale (VAS), Oswestry Disability Index (ODI), or modified Macnab satisfaction rates at 12-month follow-up in either intention-to-treat (90.9% in UBE-ULBD vs 89.1% in Endo-ULBD, P = 0.92) or per-protocol analyses (98.0% in UBE-ULBD vs 94.0% in Endo-ULBD, P = 0.92).
  • Radiologic Decompression & Safety: Postoperative dural sac cross-sectional area (DSCSA) expansion and facet joint preservation rates were comparable between groups (P > 0.05). One dural tear was recorded in the Endo-ULBD cohort.

Recommendation & Practice Takeaway

Clinical Pearl: Both UBE-ULBD and Endo-ULBD provide safe, effective, and equivalent 12-month clinical and radiologic decompression for single-level Schizas grade C/D lumbar spinal stenosis. Surgeons may select between biportal and single-port endoscopic platforms based on institutional equipment and ergonomic preference, recognizing the trade-off between shorter operative duration with UBE-ULBD and shorter hospital stay with Endo-ULBD.

Level II

3. Platelet-Rich Plasma Provides Small but Superior Short-term Pain Relief and Functional Improvement Compared With Hyaluronic Acid for the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-analysis.

Authors: Zhong C, Wang K, Hu X, Yuan L, Wang W | Journal: Arthroscopy (Nov 2026) | View Source / DOI

Situation

Intra-articular platelet-rich plasma (PRP) and hyaluronic acid (HA) are widely used nonoperative injectables for knee osteoarthritis, but comparative efficacy across time points and the impact of PRP preparation variables remain debated.

Background

Conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO, this Level II systematic review and meta-analysis searched PubMed, Embase, and the Cochrane Library through August 2025, pooling 21 randomized controlled trials (1790 patients) evaluated with Cochrane RoB 1.0 to compare intra-articular PRP and HA and assess preparation and application factors.

Assessment & Findings

  • Pain & Osteoarthritis Index Trajectory: Visual analog scale (VAS) pain scores showed no significant advantage for PRP over HA at 3 and 6 months, but PRP significantly reduced pain compared with HA at 12 months (standardized mean difference 0.76, P = 0.016). Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) improvements significantly favored PRP across all evaluated time points (P ≤ 0.001).
  • Knee-Specific Scores: No statistically significant differences were observed between PRP and HA in Knee Injury and Osteoarthritis Outcome Score (KOOS) or International Knee Documentation Committee (IKDC) outcomes up to 12 months.
  • Preparation & Dosing Modifiers: Subgroup analyses indicated that high-concentration, leukocyte-rich, and activated PRP formulations were associated with superior outcomes at 12-month follow-up, whereas injection frequency showed no consistent effect. Metaregression confirmed platelet concentration as a positive predictor of treatment efficacy at 12 months, though substantial heterogeneity and risk of bias were noted across included trials.

Recommendation & Practice Takeaway

Clinical Pearl: Across 21 randomized trials (1790 patients), intra-articular PRP provides small but statistically significant improvements in WOMAC function across follow-up intervals and VAS pain relief at 12 months compared with HA, without significant differences in KOOS or IKDC scores. When counseling patients on biologic injections for knee osteoarthritis, clinicians should note that higher platelet concentration, leukocyte-rich preparation, and exogenous activation correlate with stronger 12-month efficacy, while interpreting effect sizes cautiously given inter-study heterogeneity.

Orthogate Landmark Trials is curated and synthesized by ORION (Orthopaedic Research, Intelligence & Operations Navigator) for orthopaedic surgeons, fellows, and residents. Evidence synthesized under the clinical direction of Christian Veillette, MD, MSc, FRCSC.