Injury. 2025 Aug 8:112677. doi: 10.1016/j.injury.2025.112677. Online ahead of print.

ABSTRACT

BACKGROUND: Vestibular dysfunction (resulting in dizziness and imbalance) is common in acute traumatic brain injury (aTBI). The most frequently diagnosed cause of peripheral vestibular dysfunction in aTBI is benign paroxysmal positional vertigo (BPPV). However, post-traumatic BPPV is often undiagnosed and left untreated in these patients.

OBJECTIVES: To investigate clinical risk factors for BPPV in patients experiencing aTBI.

METHODS: Patients were recruited from three Major Trauma Centres in London. Logistic regression was used to derive the adjusted odds ratio (aOR) of diagnosed BPPV for sex, categorised age, severity of traumatic brain injury (TBI), and site of skull fracture.

RESULTS: 166 patients with aTBI were included. Approximately a third (n = 55; 33.1 %) tested positive for BPPV. Compared to patients aged less than or equal to 40 years, those aged 41 to 64 years were more likely to experience BPPV (aOR=3.86; 95 % CI: 1.47 to 10.16; p = 0.006), as were those aged 65 years and above (4.41; 1.52 to 12.81; p = 0.006). Patients that experienced both facial and cranial skull fracture were more likely to experience BPPV than those that didn't have a skull fracture (23.64; 6.36 to 87.89; p < 0.001).

CONCLUSION: The risk of post-traumatic BPPV increased with increasing age, plus in those with combined skull and facial fractures when compared to those without a skull fracture. We advocate routine BPPV screening of those with aTBI, especially in older adults and those with combined facial and skull fractures.

PMID:40885629 | DOI:10.1016/j.injury.2025.112677

Injury. 2025 Aug 25;56(11):112722. doi: 10.1016/j.injury.2025.112722. Online ahead of print.

ABSTRACT

Percutaneous fixation of certain types of acetabular fractures is a valid, minimally invasive, and successful procedure. However, the technique for proper insertion of such screws is sensitive and requires adequate understanding of radiographic images. Furthermore, an optimum entry point and trajectory of the screws should be guaranteed to avoid hip joint penetration and screws misplacement. Various tools and techniques were described; we provide a technical note describing a modification on the tip of the cannulated screwdriver where serrations were added, which helped in better stability over the bone while inserting the guidewires for screws insertion, besides protecting the soft tissue envelope, especially in obese patients. We presented two early cases, one with a pure anterior column fracture and the other with a combined anterior column fracture and disruption of the sacroiliac joint on the same side, where we used the technique we described to ease percutaneous insertion of an anterior column screw for acetabular fracture fixation.

PMID:40885165 | DOI:10.1016/j.injury.2025.112722

Injury. 2025 Aug 25;56(11):112726. doi: 10.1016/j.injury.2025.112726. Online ahead of print.

ABSTRACT

INTRODUCTION: Faster time to operative fixation and mobilization decreases morbidity and mortality for hip fracture patients. Many hospitals are working at or above their capacity and beds in surgical floors for surgical patients may not be available. The purpose of this study was to determine if the floor of admission after a hip fracture impacts time to surgical fixation and time to mobilization after surgery.

METHODS: 781 patients over the age of 50 who underwent hip fracture surgery between January 2011 and January 2021 were included in this analysis. Patient demographics, injury characteristics and floor of admission were collected and analyzed. Time of diagnosis was defined as the time of the initial presenting radiograph, and time of mobilization was defined as the time the patient stood at edge of bed with physical therapy. Floor of admission is determined based on admitting service (medicine, orthopaedics, trauma surgery) as well as bed availability. Floors were considered surgical or non-surgical based on standard patient populations.

RESULTS: Time to surgery from diagnosis was significantly longer on nonsurgical floors (28 vs. 22 hours p = 0.003). Time from surgery to mobilization out of bed was significantly shorter for patients on surgical floors (53 vs. 63 hours, p = 0.01). There was no difference in time to evaluation by physical therapy (p = 0.8). Time from diagnosis to surgery and time from surgery to injury was not different across patient races or language spoken.

CONCLUSIONS: Patients admitted to non-surgical floors had a significantly longer time to surgery as well as longer time to mobilization compared to patients who were admitted to surgical floors. Time to physical therapy evaluation following surgery was the same, suggesting different factors such as medical comorbidities, staff training, and resource availability likely contribute to the significant difference in time to mobilization. Race and language did not play a role in delaying time to the operating room or mobilization with physical therapy.

PMID:40885164 | DOI:10.1016/j.injury.2025.112726

Injury. 2025 Aug 23;56(11):112689. doi: 10.1016/j.injury.2025.112689. Online ahead of print.

ABSTRACT

BACKGROUND: Humeral shaft fractures treated surgically have a 5-10 % risk of nonunion. NSAIDs, including ketorolac, are frequently prescribed postoperatively for pain management, but concerns persist regarding their effects on bone healing. Although prior studies suggest a potential association between ketorolac and nonunion, findings remain inconclusive. This study aims to assess the impact of ketorolac on nonunion risk in adults undergoing surgical treatment for humeral shaft fractures.

METHODS: The TriNetX Research Database was queried using ICD and CPT codes to identify patients who underwent operative fixation of humeral shaft fractures with a minimum of 2 years of follow-up. Exclusion criteria included prior humeral shaft nonunion, pathologic fractures, and age under 18. Patients were divided into two cohorts based on whether they received ketorolac within 1 month postoperatively. Outcomes included nonunion diagnosis, nonunion surgery, opioid utilization, wound complications, superficial infection, deep infection, and hardware infection. Outcomes were analyzed at 30 days, 90 days, 1 year, 2 years, and final follow-up.

RESULTS: There was no significant difference in opioid utilization within 30 days postoperatively (HR 1.051, 95 % CI 0.987-1.118, p = 0.073; prescriptions 3.2 ± 4.9 vs. 3.2 ± 5.0, p = 0.721). However, at 1-year, 2-year, and overall follow-up, patients receiving ketorolac demonstrated a significantly increased risk of nonunion surgery. At final follow-up (2.9 ± 2.8 years vs. 3.4 ± 3.5 years), nonunion incidence was not significantly different (4.7 % vs. 4.2 %, p = 0.317), but ketorolac use was associated with a 45.1 % increased risk of nonunion surgery (95 % CI 1.050-2.006, p = 0.023).

CONCLUSION: Ketorolac use was associated with approximately 40 % increased risk of nonunion surgery without reducing postoperative opioid use. Further research is warranted to evaluate the perioperative administration of ketorolac and other NSAIDs in humeral shaft fractures.

LEVEL OF EVIDENCE: Level III Retrospective Cohort Comparison Using Large Database Prognosis Study.

PMID:40885163 | DOI:10.1016/j.injury.2025.112689

Injury. 2025 Aug 16;56(11):112683. doi: 10.1016/j.injury.2025.112683. Online ahead of print.

ABSTRACT

INTRODUCTION: To minimize the complications associated with proximal humerus open reduction internal fixation (ORIF), various augmentation strategies have been utilized to manage humeral head bone loss. The purpose of the study is to report clinical and patient reported outcomes of calcium sulfate hydroxyapatite bio-composite bone void filler augmentation of proximal humerus ORIF.

METHODS: A prospective cohort of patients who sustained a proximal humerus fracture (PHF) treated with ORIF were collected between 2022-2024. All patients were treated with adjunctive calcium sulfate hydroxyapatite bio-composite bone void filler (CERAMENT BONE VOID FILLER, BONESUPPORT INC, Needham, MA) after reduction and instrumentation. Peri-operative complications were recorded. PROMIS scores of physical function and pain interference were collected. Follow-up radiographs were evaluated for bone void filler resorption/remodeling and union. These patients were 1:1 propensity matched to a retrospective comparative cohort of PHF without augmentation for comparative analysis.

RESULTS: 24 patients were enrolled in the study. 20 patients (83 %) were female. Mean age was 68±11 years and mean BMI was 29±7 kg/m2. Patients had a mean follow up of 424±123 days. All patients had radiographic evidence of bone void filler resorption and remodeling at an average of 130±77 days. Of the 24 patients, 21 had available PROMIS scores. At final follow up, patients reported an average 46.3 ± 9.9 physical function score and 63.8 ± 6.3 pain interference score at an average of 273±191 days post operative. The 24 patients augmented with CBVF were matched to 24 patients with PHF without augmentation. Twenty-two patients in the CBVF group had fracture union compared to twenty in the non-augmented group(92 % vs 83 %, p = 0.38). Additionally, the CBVF group had reduced rates of screw penetration(4 % vs 21 %, p = 0.08), progressive fracture displacement(4 % vs 17 %, p = 0.16), and revision surgery(4 % vs 17 %, p = 0.16). On multivariate analysis, the use of CBVF significantly lowered the odds of developing intra-articular screw penetration(OR = 0.007, p = 0.02) CONCLUSION: This series demonstrates favorable outcomes in proximal humerus ORIF augmented using calcium sulfate hydroxyapatite bio-composite as bone void filler compared to a matched cohort of patients treated without augmentation. There is a low rate of loss of fracture fixation and high union rate with favorable patient reported outcome measures.

PMID:40885162 | DOI:10.1016/j.injury.2025.112683

Injury. 2025 Aug 25;56(11):112724. doi: 10.1016/j.injury.2025.112724. Online ahead of print.

ABSTRACT

INTRODUCTION: Acetabular fractures typically involve disruption of cortical columns or walls and are well-classified by Judet, Letournel, and AO/OTA systems. However, some injuries involve pure osteochondral impaction of the articular surface without cortical involvement, making them difficult to detect and unclassified by current systems. This study identifies and evaluates a rare, previously undescribed acetabular injury pattern-posterior dome osteochondral impaction without cortical fracture.

AIM: To characterize this unique injury pattern and assess clinical and radiological outcomes following two surgical techniques aimed at anatomical restoration.

METHODS: A retrospective review was conducted on eight patients (six males, two females; mean age 34 years) treated at a tertiary referral center between 2008 and 2023. Inclusion criteria included isolated posterior dome osteochondral impaction confirmed by computed tomography, absence of cortical disruption, and minimum six months follow-up. Patients underwent surgical management via either posterior wall osteotomy or a cortical window technique, with subchondral support provided by autologous bone graft or rafting screws. Functional outcomes were measured using the Modified Merle d'Aubigné and Postel score. Radiological results were assessed according to Matta criteria.

RESULTS: All injuries followed high-energy trauma, predominantly motor vehicle collisions. Posterior wall osteotomy was performed in five patients: cortical window technique in three. Anatomical reduction was achieved and confirmed radiologically in all cases. At a mean follow-up of 12 months, no evidence of secondary collapse, hardware failure, or early osteoarthritis was noted. Functional outcomes were excellent in five patients and good in three (mean Merle d'Aubigné score 16.4).

CONCLUSION: Isolated osteochondral impaction of the posterior acetabular dome without cortical fracture is a distinct injury not encompassed by current classification systems. Surgical intervention using posterior wall osteotomy or cortical window elevation facilitates anatomical reduction and yields excellent mid-term outcomes. Recognition of this lesion and its inclusion in future acetabular fracture classifications are essential for accurate diagnosis and optimal treatment.

PMID:40885161 | DOI:10.1016/j.injury.2025.112724

Injury. 2025 Aug 26;56(11):112723. doi: 10.1016/j.injury.2025.112723. Online ahead of print.

ABSTRACT

BACKGROUND: Lateral compression type 1 (LC1) pelvic fractures are common injuries with ongoing debate regarding the cost-effectiveness of operative versus non-operative treatment. The goal of this study is to evaluate the cost-effectiveness of operative versus non-operative management for lateral compression type 1 (LC1) pelvic fractures, using pain (Brief Pain Inventory, BPI) and functional recovery (Majeed Pelvic Score, MPS) as outcome measures across early follow-up intervals.

METHODS: A decision tree model was developed to analyze the costs and outcomes of operative and non-operative management for LC1 fractures. Costs were derived from Medicare reimbursement rates, and probabilities were informed by clinical data and expert opinion. BPI and MPS scores were used as proxies for utility, with incremental cost-effectiveness ratios (ICERs) calculated at 2, 6, and 12-week follow-ups. An ICER exceeding the willingness-to-pay (WTP) threshold of $50,000 indicated that non-operative management was the more cost-effective option. Sensitivity analyses explored the utility improvements required for operative treatment to meet the WTP threshold of $50,000 per meaningful change in BPI or MPS.

RESULTS: Operative management was cost-effective for early pain relief, with an ICER of $33,466.08 per meaningful change in BPI at 2 weeks. However, it exceeded the WTP threshold at 6 weeks ($68,632.04) and only approached cost-effectiveness again at 12 weeks ($50,828.58). Using MPS, operative management was found to be cost-effective at 12 weeks ($44,992.90), but not at 2 or 6 weeks. Sensitivity analyses demonstrated that small utility gains could make operative management cost-effective at intermediate follow-up intervals.

CONCLUSION: Operative management of LC1 fractures may offer early cost-effective pain relief and possible delayed cost-effective functional recovery, particularly by 12 weeks. These findings may support surgical intervention for patients prioritizing rapid recovery by 12 weeks, but careful patient selection remains critical.

LEVEL OF EVIDENCE: Level 3.

PMID:40885160 | DOI:10.1016/j.injury.2025.112723

Int Orthop. 2025 Aug 30. doi: 10.1007/s00264-025-06644-8. Online ahead of print.

ABSTRACT

PURPOSE: Fracture models in animals are essential to analyze bone healing in musculoskeletal research fields. Especially in small animals, fractures are difficult to simulate and stabilize. Therefore, a fracture model is desirable with a short operation time, high safety of the model without stabilization failure and low costs. Aim of this study is the evaluation of a new open tibial shaft model in mice for musculoskeletal research.

METHODS: In 12 eight week-old wild type mice, an open tibial shaft fracture was simulated and stabilized with a retrograde over the fracture inserted intramedullary pin. X-rays confirmed the correct fracture localization and stabilization. After eight weeks of follow-up, the mice were euthanized. Fracture healing and biomechanical stability were analyzed in a micro-CT scan and in torsional load-to-failure tests.

RESULTS: The whole operations lasted in mean eight min and 50 s. All mice recovered very quickly after the operative intervention and started using the operated leg again on the first postoperative day onwards if not earlier. No infections or failure of the stabilization occurred. All fractures healed completely within 8 weeks and substantial callus formation was confirmed in the micro-CT analysis. Biomechanically, higher torsional moment and stiffness were found for the operated tibia compared to the non-operated tibia in the same mouse.

CONCLUSION: The presented tibial fracture model with open osteotomy and retrograde pin insertion revealed minimal operative intervention and anesthesia, quick recovery and fracture healing with big callus formation. It is an easy to address fracture model for musculoskeletal research.

PMID:40884561 | DOI:10.1007/s00264-025-06644-8

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01630. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious complication associated with notable loss of function, impaired quality of life, and excess short-term mortality. In this study, we aimed to report the impact of PJI on long-term mortality and its associated risk factors.

METHODS: Using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), we used Kaplan-Meier estimates of survivorship and standardized mortality ratios (SMRs) based on Australian period life tables to describe mortality rates following revision for PJI, aseptic revisions (excluding those for fracture), and unrevised primary TKA. Additionally, hazard ratios (HRs) were calculated with multivariable proportional hazard models to assess the impact of the risk factors of age, gender, comorbidities, and minor versus major revisions.

RESULTS: Among 867,113 TKA procedures overall, there were 8,642 first revisions for PJI and 25,328 aseptic first revisions. At 5, 10, and 15 years, 16.1%, 34.4%, and 53.4% of patients with revision for PJI had died. When compared with a matched population, the SMR for revision for PJI was 1.33 (95% confidence interval [CI]: 1.28 to 1.39); for aseptic revision, 0.84 (95% CI: 0.82 to 0.87); and for unrevised primary TKA, 0.79 (95% CI: 0.78 to 0.79). Increasing age and higher American Society of Anesthesiologists (ASA) scores were significant mortality risk factors. Major revisions for PJI were not associated with a greater mortality risk compared with minor revisions for PJI.

CONCLUSIONS: Patients with revision for PJI had a 33% greater-than-expected mortality. There was a high mortality in the early postoperative period, and the excess mortality risk persisted beyond 15 years. Increasing age and higher ASA scores were associated with increased mortality.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40880507 | DOI:10.2106/JBJS.24.01630

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01466. Online ahead of print.

ABSTRACT

BACKGROUND: There is no foundational classification that 3-dimensionally characterizes arthritic anatomy to preoperatively plan and postoperatively evaluate total knee arthroplasty (TKA). With the advent of computed tomography (CT) as a preoperative planning tool, the purpose of this study was to morphologically classify pre-TKA anatomy across coronal, axial, and sagittal planes to identify outlier phenotypes and establish a foundation for future philosophical, technical, and technological strategies.

METHODS: A cross-sectional analysis was conducted using 1,352 pre-TKA lower-extremity CT scans collected from a database at a single multicenter referral center. A validated deep learning and computer vision program acquired 27 lower-extremity measurements for each CT scan. An unsupervised spectral clustering algorithm morphometrically classified the cohort. The optimal number of clusters was determined through elbow-plot and eigen-gap analyses. Visualization was conducted through t-stochastic neighbor embedding, and each cluster was characterized. The analysis was repeated to assess how it was affected by severe deformity by removing impacted parameters and reassessing cluster separation.

RESULTS: Spectral clustering revealed 4 distinct pre-TKA anatomic morphologies (18.5% Type 1, 39.6% Type 2, 7.5% Type 3, 34.5% Type 4). Types 1 and 3 embodied clear outliers. Key parameters distinguishing the 4 morphologies were hip rotation, medial posterior tibial slope, hip-knee-ankle angle, tibiofemoral angle, medial proximal tibial angle, and lateral distal femoral angle. After removing variables impacted by severe deformity, the secondary analysis again demonstrated 4 distinct clusters with the same distinguishing variables.

CONCLUSIONS: CT-based phenotyping established a 3D classification of arthritic knee anatomy into 4 foundational morphologies, of which Types 1 and 3 represent outliers present in 26% of knees undergoing TKA. Unlike prior classifications emphasizing native coronal plane anatomy, 3D phenotyping of knees undergoing TKA enables recognition of outlier cases and a foundation for longitudinal evaluation in a morphologically diverse and growing surgical population. Longitudinal studies that control for implant selection, alignment technique, and applied technology are required to evaluate the impact of this classification in enabling rapid recovery and mitigating dissatisfaction after TKA.

LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

PMID:40880455 | DOI:10.2106/JBJS.24.01466

Int Orthop. 2025 Aug 30. doi: 10.1007/s00264-025-06642-w. Online ahead of print.

ABSTRACT

INTRODUCTION: Shoulder dislocations occur in approximately 45% of all joint types, and anterior shoulder dislocations account for more than 90% of cases. The purpose of this study was to assess the functional outcomes of an open Latarjet operation for patients with recurrent anterior shoulder dislocations.

METHODS: A prospective hospital-based study was conducted at the Orthopaedic Department of Al Thawra Modern General Hospital, Sana'a City, between 2015 and 2022. Consecutive patients who experienced recurrent anterior shoulder instability underwent the open Latarjet procedure. Preoperative and postoperative clinical, radiographic, and functional outcomes according to the Rowe score were assessed during the study period.

RESULTS: Twenty patients, with a mean age of 20.9 ± 2.9 years, were included in this study. The most common age group at surgery was ≤ 20 years (70%). The median number of recurrent dislocations before surgery was 25. 40% of the patients presented more than two years after the first dislocation, with a mean duration of 2.5 ± one year. Postoperatively, haematoma, infection, neurovascular injury, graft malposition, graft nonunion and osteoarthritis were not observed in any patient. However, one patient (5%) had a stress fracture in the coracoid graft. All patients showed improvement in the preoperative mean Rowe score of 6.5 ± 4.6 to the postoperative mean Rowe score of 91 ± 7% (an excellent grade) at the last follow-up.

CONCLUSION: The open Latarjet procedure had excellent outcomes with a very low rate of complications in this study. We recommend the open Latarjet procedure for the management of recurrent anterior shoulder dislocation in patients with significant glenoid bone defects, especially in developing countries with limited resources, such as Yemen.

PMID:40883518 | DOI:10.1007/s00264-025-06642-w

Int Orthop. 2025 Aug 29. doi: 10.1007/s00264-025-06646-6. Online ahead of print.

ABSTRACT

PURPOSE: Posterior femoro-acetabular impingement in patients with increased femoral version can result in significant hip pain, chondro-labral injury, and limited range of motion. Femoral rotational osteotomy may address these issues by correcting excessive femoral anteversion.

METHODS: This retro-spective case series included 25 adolescents (mean age 14.8 years) with symptomatic increased femoral version (> 35°) treated between 2015 and 2022. Inclusion required hip pain, limited range of motion, and increased femoral version confirmed on computed tomography. Patients underwent femoral external rotational osteotomy targeting a post-operative femoral version of ~ 15°. Outcomes assessed included femoral version, hip range of motion, and Harris Hip Score pre-operatively, at six months, and at two years post-operatively.

RESULTS: Mean femoral version improved significantly from 39° ± 3° pre-operatively to 19° ± 7° post-operatively (P < 0.001). Internal rotation decreased from 54° ± 9° to 32° ± 8°, while external rotation increased from 38° ± 4° to 44° ± 5° (P < 0.001). Mean Harris Hip Score improved from 62.5 ± 10.3 to 86.1 ± 6.4 at 6 months, with sustained results at two year follow-up. Radiographic union was achieved in all patients, and no major complications were observed.

CONCLUSION: Femoral rotational osteotomy is a safe and effective treatment for posterior hip impingement in young patients with excessive femoral version.

PMID:40879765 | DOI:10.1007/s00264-025-06646-6

Injury. 2025 Aug 25;56(11):112693. doi: 10.1016/j.injury.2025.112693. Online ahead of print.

ABSTRACT

INTRODUCTION: Although ketorolac's association with poor bone healing remains debated, no study has examined the impact of ketorolac administration in adults with proximal humerus fractures (PHFs) after open reduction and internal fixation (ORIF), limiting surgeon decision-making. Therefore, the primary aim of this study was to examine the association between short-term ketorolac administration within the first three days after ORIF for PHF and the incidence and risk of nonunion or malunion through one year.

METHODS: A pre-registered retrospective propensity-matched cohort study was performed using a large United States health records-based database (TriNetX, LLC). Patients included adults (≥18 years old) who underwent first-time proximal humerus ORIF and received either acute (≤3 days) postoperative ketorolac (ketorolac cohort) or acetaminophen (control cohort). The primary outcome was the risk ratio (RR) of nonunion through one year. Secondary outcomes explored the incidence and risk of reoperation by surgery type, other relevant postoperative adverse events (such as malunion), and RR and mean count of postoperative oral opioid prescription. Over fifteen risk factors associated with bone union were used for propensity matching.

RESULTS: There were 2143 patients per cohort (n = 4286 total) with a mean age of 55 years. Comparing the ketorolac cohort to the control cohort, there was a statistically significant increase in risk of nonunion (p = 0.040; RR: 1.46 [1.02, 2.10]; 3.3% versus 2.2%; 70 patients versus 48 patients). Individual outcomes demonstrated no statistically significant difference in risk of malunion (p = 0.288; RR: 1.28; 1.9% versus 1.5%), revision ORIF (p = 0.493), total shoulder arthroplasty (p = 0.354), or acute kidney injury (p = 0.423). There was a statistically significant decrease in risk (p = 0.015) and mean count (p = 0.033) of oral opioid prescription.

CONCLUSION: Acute postoperative ketorolac after ORIF for PHF is associated with a modest increase in risk of nonunion and reduction in opioid prescriptions, with no significant differences in malunion, reoperation, or acute kidney injury. These findings support the need for individualized decision-making to weigh risks and benefits in postoperative pain management, with future research needed on dosages.

PMID:40876112 | DOI:10.1016/j.injury.2025.112693

Injury. 2025 Aug 19;56(11):112685. doi: 10.1016/j.injury.2025.112685. Online ahead of print.

ABSTRACT

BACKGROUND: To prepare junior surgeons for possible increased trauma call burden and improve young surgeons' workplace marketability, there has been an increase in fellowship programs offering combined arthroplasty and trauma curriculums. The purpose of this study was to determine the relative importance of factors considered by applicants applying to combined programs. This information will serve program directors, who can improve applicant recruitment, along with improving the experiences of fellows.

METHODS: Survey respondents were asked to rate 23 fellowship program factors on a 1-to-5 Likert scale with 1 being "not important at all" and 5 being "critical". Respondents were also asked to list their top 5 factors in order of decreasing importance with 1 being the most important. A two-sample t-test was used to analyze subgroups. Statistical significance defined as P-value < 0.05.

RESULTS: Surveys were sent to 192 applicants, and 75 responses were received with a 39.1 % response rate. The overall highest rated factors were operative experience (mean 4.87; SD 0.34), revision total joint experience (mean 4.61; SD 0.61), periprosthetic fracture experience (mean 4.52; SD 0.60), and primary total joint experience (mean 4.17; SD 0.86). A subgroup analysis was performed by creating three groups: surgical experience, program details and history, and financial factors. Surgical experience group was ranked highest (mean 3.81; SD 1.72). Programs details and history (mean 3.12; SD 1.05) and financial factors (mean 2.35; SD 1.08) rated significantly lower than surgical experience (P-value < 0.01).

CONCLUSIONS: Applicants of combined arthroplasty and trauma fellowships value similar characteristics in a program as those applying to either arthroplasty or trauma alone. Combined fellowship programs should update their websites as applicants frequently use online sources to educate themselves on existing programs.

PMID:40876111 | DOI:10.1016/j.injury.2025.112685

Injury. 2025 Aug 24;56(11):112719. doi: 10.1016/j.injury.2025.112719. Online ahead of print.

ABSTRACT

BACKGROUND: Indications for stabilization of the medial collateral ligament (MCL) after repair of the lateral ulnar collateral ligament (LUCL) remain controversial. Here, we propose a standardized fluoroscopic sequence to reveal residual medial elbow instability to facilitate intraoperative decision-making.

METHODS: Eight matched cadaveric upper extremity pairs (N = 16) were mounted to simulate intraoperative positioning. Fluoroscopic images were acquired using the following: full extension, 45-degree flexion, 90-degree flexion, and full flexion with the forearm in neutral/pronation/supination. These were acquired at "baseline" and following destabilization of the LUCL/MCL. The proposed fluoroscopic sequence was then repeated following surgical fixation of the LUCL ("post-LUCL repair") followed by MCL repair ("post-LUCL & MCL repair). Blinded images were fitted using a best-fit circle to compute ulnohumeral distance (UHD, millimeters) and determine residual lateral (supination) and medial (pronation) instability defined by the presence of a drop sign (UHD>4 mm). Radiocapitellar ratio (RCR) was computed to determine radiocapitellar instability (RCR>10 %). Blinded images were also qualitatively evaluated against the contralateral baseline to simulate intraoperative assessment.

RESULTS: Apparent instability in supination status-post destabilization resolved following LUCL repair with evident residual medial-sided instability showed in pronation, which resolved after MCL fixation. Evaluation of the drop sign at 45 and 90 degrees of flexion showed comparable quantitative sensitivity at 97 % and 98 %, unlike in full extension or full flexion (sensitivity <35 %). Quantitative sensitivity was 88 % for RCR in mid-flexion. Qualitative evaluation for the drop sign and RCR resulted in sensitivity of 93 and 75 %, respectively.

CONCLUSIONS: The proposed fluoroscopic sequence provides reliable intraoperative assessment to evaluate for residual medial-sided instability in the setting of multi-ligamentous elbow injuries. After repair of the LUCL, medial residual instability due to MCL rupture is best revealed with the presence of a drop sign in full pronation and midflexion.

LEVEL OF EVIDENCE: IV.

PMID:40876110 | DOI:10.1016/j.injury.2025.112719

Injury. 2025 Aug 16;56(11):112682. doi: 10.1016/j.injury.2025.112682. Online ahead of print.

ABSTRACT

BACKGROUND: The classic surgical technique of the 15-mm incision minimally invasive approach is not suitable for AO 23-B3 distal radius fractures (abbreviated B3). We have modified this technique for B3. This study aimed to investigate the efficacy of the modified 15-mm incision minimally invasive approach with the conventional ORIF approach in the treatment of B3.

METHODS: This retrospective study included 62 patients with B3 who underwent surgical treatment from January 2020 to May 2024, including 31 patients undergoing the modified 15-mm incision minimally invasive approach (M group) and 31 patients undergoing the conventional ORIF approach (C group). The two groups had similar baseline characteristics (P > 0.05). The perioperative data, follow-up data, and imaging results of the two groups were compared. At the last follow-up, the limb function was assessed using the PRWE and DASH scores.

RESULTS: In the C group, 1 patient experienced infection and 1 patient experienced complex regional pain syndrome, whereas in the M group, there were no such patients. In the M group, the incision length, intraoperative bleeding, hospital stay, hospitalization expenses, swelling, and VAS on postoperative days 2 and 7, flexion-extension, ulnar-radial deviation and pronation-supination at postoperative 3 months, and pronation-supination ROM in 12-24 months of follow-up were superior, but the surgical and fluoroscopy time was longer compared to the C group (P < 0.05). There was no difference between the two groups in terms of fracture reduction, fracture healing time, full weight-bearing time, complications, and flexion-extension ROM, PRWE and DASH in the last follow-up (P > 0.05).

CONCLUSION: Both methods were effective for treating B3. The M group was superior in terms of aesthetic appeal of the incision, surgical trauma and associated risks, hospital stay, early recovery, and final rotational function, which are consistent with the principles of MIPO and rapid recovery, but requires longer surgical and fluoroscopy time.

PMID:40876109 | DOI:10.1016/j.injury.2025.112682

J Bone Joint Surg Am. 2025 Aug 28. doi: 10.2106/JBJS.24.00733. Online ahead of print.

ABSTRACT

➢ The use of multirod constructs (≥3 rods) in complex spine surgery has increased as its utility has been recognized over the past decade.➢ There are multiple different rod configurations that may be utilized on the basis of the desired supplemental rod function, with each type having its own advantages and clinical indications.➢ Literature has continued to demonstrate a reduced incidence of pseudarthrosis, rod fracture, and reoperation when comparing multirod constructs with traditional dual-rod constructs.➢ The use of consistent nomenclature when describing multirod constructs will allow for more productive clinical and biomechanical research.

PMID:40875787 | DOI:10.2106/JBJS.24.00733

Injury. 2025 Aug 8;56(10):112659. doi: 10.1016/j.injury.2025.112659. Online ahead of print.

ABSTRACT

Train-related injuries represent a significant yet underreported public health challenge in developing countries, particularly in sub-Saharan Africa, where contemporary data are scarce. This study characterizes the epidemiology, clinical presentation, and outcomes of train-related trauma at a South African Level I trauma center, with a focus on identifying predictors of severe outcomes and informing context-specific interventions for this high-risk population.

METHOD: A retrospective analysis was conducted on 63 patients presenting to Groote Schuur Hospital between April 2008 and June 2013. Data collected included demographics, injury mechanisms, clinical findings, and outcomes. Multivariable logistic regression was performed to evaluate the association between key severity markers (GCS ≤8, hypotension, mangled extremities) and ICU admission.

RESULTS: The cohort was predominantly male (96.8 %) with a median age of 26 years (IQR: 22-33). Injuries clustered during winter months (April-October), with 62 % occurring between 4:00 PM and midnight. The most common mechanisms were boarding or alighting from moving trains (46.2 %) and interpersonal assault (33.3 %). Lacerations were the most frequent soft tissue injury (69.8 %), while lower (25.4 %) and upper limb (22.2 %) fractures were the predominant orthopedic injuries. The amputation rate was 20.6 %, strongly associated with mangled extremities. Median hospital stay was 6 days (IQR: 1-17), extending significantly for patients with spinal trauma. Severe traumatic brain injury (GCS ≤8) was independently associated with ICU admission (adjusted OR 15.0; 95 % CI: 2.7-82.4; p < 0.001). Mangled extremities and hypotension were not significantly associated with ICU requirement.

CONCLUSION: Young male commuters are more likely to sustain severe, preventable train-related injuries. Significant musculoskeletal trauma, head, and spinal injuries increased hospital stay, underscoring the need for comprehensive assessment to reduce morbidity and improve outcomes. Our findings support protocolized neurosurgical and orthopaedic triage and targeted prevention strategies in resource-limited settings.

PMID:40865178 | DOI:10.1016/j.injury.2025.112659

SICOT J. 2025;11:50. doi: 10.1051/sicotj/2025031. Epub 2025 Aug 26.

ABSTRACT

BACKGROUND: Proximal femoral megaprosthetic reconstruction is a well-established solution for extensive bone loss in the hip region. Despite its utility in limb salvage, it carries notable complication rates, reported between 30% and 40%, along with increased morbidity and mortality. This study evaluated implant and patient survival, failure modes, and associated risk factors.

METHODS: We retrospectively reviewed 165 patients who underwent proximal femoral megaprosthetic reconstruction between 2003 and 2023. Indications included primary bone tumors (n = 67), metastatic bone disease (n = 60), and non-oncologic conditions (n = 38). A total of 57 METS (Stanmore) and 108 MUTARS (Implantcast) implants were used. Median follow-up was 5 years (range: 0.25-17 years).

RESULTS: Mean implant survival was 5.13 years (range: 0.2-17 years), with an overall complication rate of 30.9%. The most common failure modes were type 1 (11.5%) and type 4 (13.3%) per Henderson classification. Five-year implant survival ranged from 60% to 70% across indications. Independent risk factors for type 4 failure included prolonged hospitalization (OR = 1.07, p = 0.020) and longer operative time (OR = 1.01, p = 0.023). Silver-coated implants showed a trend toward reduced infection (OR = 0.18, p = 0.29), though not statistically significant. METS implants were associated with lower type 1 failure risk (OR = 0.09, p = 0.020), with a soft-tissue failure rate of 3.5% versus 15.7% for MUTARS.

CONCLUSION: Proximal femoral megaprostheses remain effective for limb salvage but are linked to a substantial complication burden. Recognition of modifiable and patient-specific risk factors may improve surgical outcomes and reduce failure rates.

PMID:40857599 | PMC:PMC12380411 | DOI:10.1051/sicotj/2025031

SICOT J. 2025;11:49. doi: 10.1051/sicotj/2025043. Epub 2025 Aug 26.

ABSTRACT

INTRODUCTION: Complications arising from the patellofemoral joint (PFJ) represent the third most common cause for revision in total knee arthroplasty (TKA). Previous in vitro biomechanical studies have altered the native attachments of muscles controlling the PFJ. The purpose of this study was to design an in vitro biomechanical setup that would allow testing of both native and arthroplasty knee joints, specifically the PFJ, without disturbing the native attachments of the quadriceps and hamstrings muscles.

METHODS: After finalising a prototype, a pelvis-to-toe human cadaver specimen was tested. The simVITRO platform was used to simulate movement and control force trajectories. A motion capture system was used to capture the motion of the bones and to measure knee flexion angle and patellar movement with respect to the femur. The forces applied in the PFJ were measured using a custom patella sensor.

RESULTS: Displacement of the reflective cluster attached to the femur was measured during compression loading at different flexion angles, passive flexion and stairs descent trajectory. The femur showed less than 1 mm and 3 mm displacement with respect to the femur clamp in passive flexion and stairs descent. The most translation of 8.37 mm (<2% average femur length) was observed at 90° flexion which occurred at 483 N simulated compression force.

CONCLUSION: This novel design provides a methodology for studying the biomechanics of the PFJ in vitro that preserves the soft tissues influencing the behaviour of the joint. This setup provides a biomechanics model that can be utilised to better understand and study the PFJ in vitro.

PMID:40857598 | PMC:PMC12380413 | DOI:10.1051/sicotj/2025043