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Article History

Received: 9 October 2025

Accepted: 5 February 2026

First Online: 11 February 2026

Declarations

:

: The study was conducted in accordance with the principles of the Helsinki Declaration. Written informed consent was obtained from all participants. This study was approved by the central (single) human subjects review board from the Medical University of South Carolina.

: Not applicable.

: HK has nothing to disclose. CP received royalties from Total Joint Orthopedics and research support from Zimmer Biomet. CP served as a paid consultant for Simith & Nephew, Total Joint Orthopedics, Zimmer Biomet, 3 M, Haereus, and Immunis. CP holds stock in Joint Development LLC. BM served as a paid consultant on the PEPPER trial, through ownership in STATIX, LLC. VP has nothing to disclose. The PEPPER INVESTIGATORS do have any competing interest.

: James A.Browne,MD 3 , Antonia F.Chen,MD 4 , Eric M.Cohen,MD 5 , Charles M.Davis III,MD.PhD 6 , Navin D.Fernando,MD 7 , Kevin B.Fricka,MD 8 , Richard J.Friedman,MD 9 , Kevin L.Garvin,MD 10 , Richard Iorio,MD 4 , Michael S.Kain,MD 11 , Stephen L.Kates,MD 12 , Brent A.Lanting,MD,MSc 13 , William J.Maloney,MD 15 , Robert M.Molloy,MD 16 , Michael A.Mont,MD 17 , Wayne E.Moschetti,MD,MS 2 , James Nace,DO,MPT 18 , Charles L.Nelson,MD 19 , Kevin I.Perry,MD 20 , James D.Slover,MD 21 , Mark J.Spangehl,MD 22 , Lawrence M.Specht,MD 23 , Scott M.Sporer,MD 24 , Robert S.Sterling,MD 25 , Zeke J.Walton,MD 9 3 University of Virginia, Charlottesville, VA, USA 4 Brigham and Womens Hospital, Boston, MA, USA 5 Brown University/Lifespan Health, Providence, RI, USA 6 Penn State University, State College, PA, USA 7 University of Washington, Seattle, WA, USA 8 Anderson Orthopaedic Clinic, Fairfax, VA, USA 9 Medical University of South Carolina, Charleston, SC, USA 10 University of Nebraska, Lincoln, NE, USA 11 Boston University, Boston, MA, USA 12 Virginia Commonwealth University, Richmond, VA, USA 13 University of Western Ontario, London, ON, Canada 14 West Virginia University, Morgantown, WV, USA 15 Stanford University, Stanford, CA, USA 16 The Cleveland Clinic, Cleveland, OH, USA 17 Northwell Health, New Hyde Park, NY, USA 18 Sinai Hospital, Baltimore, MD, USA 19 University of Pennsylvania, Philadelphia, PA, USA 20 Mayo Clinic, Rochester, MN, USA 21 New York University, New York, NY, USA 22 Mayo Clinic Arizona, Phoenix, AZ, USA 23 Lahey Clinic, Burlington, MA, USA 24 Rush University, Chicago, IL, USA 25 Johns Hopkins University, Baltimore, MD, USA