Injury

Study of the ideal insertion point and angle for the antegrade posterior column screw with the anterior approach in acetabular fracture

Injury. 2025 Jul 3:112575. doi: 10.1016/j.injury.2025.112575. Online ahead of print.

ABSTRACT

BACKGROUND: For acetabular fractures of both columns, the antegrade posterior column screw (APCS) is often inserted via the anterior intrapelvic approach to stabilize both columns. Insertion of the APCS can be technically demanding due to the complex anatomy of the posterior column. Misdirection or mispositioning of the screw during surgery can result in penetrate the hip joint or damage the neurovascular structures. The purpose of this study was to detect the ideal insertion point and angles of the APCS based on anatomical landmarks that can be directly identified intraoperatively.

METHODS: We retrospectively reviewed the pelvic CT of 50 adults who underwent serial slice CT imaging. Three reference plane was determined using image analysis software; (1) iliac plane (IP), which contains the anterior superior iliac spine (ASIS), the anterior margin of sacroiliac joint (AMS), and the posterior margin of pubic symphysis (PMS), (2) pelvic inlet plane (PIP), which contains the AMS of both sides, and the PMS, (3) sagittal midline plane of the pelvis (SMP). The ideal insertion point and angles of the APCS, and its maximum length were measured. The ideal insertion point was measured on the line connecting ASIS and AMS (AA line) at a distance from AMS (APCS horizontal distance) and vertical distance from AA line (APCS vertical distance). The ideal angles were measured between the screw and the PIP and between the screw and the SMP.

RESULTS: The APCS horizontal distance was 27.4 ± 6.4 mm. The APCS vertical distance was 1.6 ± 6.6 mm. The angle between the ideal APCS and yz-plane on the outlet view (α-angle) was 5.8 ± 5.8° The angle between the ideal APCS and y-axis on the xy-plane (β-angle) was 51.6 ± 5.0° The length of the APCS was 125.8 ± 9.5 mm.

CONCLUSION: The ideal insertion point detected as the distance from the AMS on the AA line and the ideal insertion angles relative to the PIP and the SMP may aid in proper insertion of the APCS during surgery.

PMID:40645869 | DOI:10.1016/j.injury.2025.112575

Survival outcomes in periprosthetic proximal femur fractures: examining time to surgery and contributing factors in a German monocentric retrospective cohort study

Injury. 2025 Jun 28;56(8):112540. doi: 10.1016/j.injury.2025.112540. Online ahead of print.

ABSTRACT

INTRODUCTION: Periprosthetic proximal femoral fractures (PPFFs) present significant challenges in orthopaedic and trauma care, particularly in older patients with comorbidities. Although guidelines recommend early surgery for native proximal femoral fractures, the optimal time to surgery (TTS) for PPFFs remains uncertain. This study aimed to assess the impact of TTS on survival in patients with PPFFs and investigate the role of patient-specific factors in survival outcomes.

MATERIALS AND METHODS: This retrospective study included 262 patients who underwent surgical treatment for PPFFs at a German trauma centre between 1995 and 2023. Survival outcomes were assessed using Kaplan-Meier analysis with log-rank tests and multivariate Cox regression analysis.

RESULTS: The mean (standard deviation) age was 82.8 (8.1) years, and 68.7% of patients were female, with a mean TTS of 62.8 (27.7) h. Log-rank tests revealed no significant survival difference between the optimal cut-off TTS ≤ 68 h and > 68 h (p = 0.51). Multivariate Cox regression analysis identified age (hazard ratio [HR] = 1.06, 95% CI [1.04, 1.08]), male sex (HR = 1.43, [1.01, 2.02]), dementia (HR = 2.12, [1.50, 3.00]), heart disease (HR = 1.43, [1.02, 2.00]), diabetes (HR = 1.49, [1.03, 2.16]), and tumour disease (HR = 1.62, [1.05, 2.51]) as risk factors for mortality. Protective factors included higher preoperative haemoglobin levels (HR = 0.83, [0.76, 0.90]), and erythrocyte transfusion was associated with improved survival in patients undergoing revision arthroplasty but not in those treated with open reduction and internal fixation. Chronic obstructive pulmonary disease was associated with a reduced mortality risk (HR = 0.68, [0.50, 0.93]).

CONCLUSIONS: Despite limitations related to the retrospective, single-centre design, the long study period, and incomplete documentation of transfusion timing and volume, our findings suggest that TTS did not significantly affect survival. Patient-specific factors, including age, comorbidities, perioperative complications, preoperative haemoglobin levels, and transfusions, were the primary drivers of survival outcomes.

PMID:40644865 | DOI:10.1016/j.injury.2025.112540

Early surgical intervention in combat-related peripheral nerve injuries: Lessons from a consecutive cohort from the 2023-2024 Israel-Hamas war

Injury. 2025 Jul 1;56(8):112573. doi: 10.1016/j.injury.2025.112573. Online ahead of print.

ABSTRACT

PURPOSE: Combat-related peripheral nerve injuries (CRPNIs) are frequently associated with significant long-term disability. While conventional practice often favors delayed exploration to avoid unnecessary interventions, emerging evidence supports early intervention.

METHODS: We retrospectively reviewed 184 patients (265 CRPNIs) treated during the first ten months of the 2023-2024 Israel-Hamas war. Collected data included demographics, injury details, surgical timing, intraoperative findings, procedures performed, and postoperative complications. Surgical Explorations were considered positive if partial/complete nerve transection or nerve compression (e.g., by shrapnel or bone fragment) were found.

RESULTS: Of 184 patients, 136 (74%) underwent nerve exploration at a median of 8 days post-injury, with positive findings in 72% of these cases. Definitive nerve procedures (DNP), such as direct repair or graft reconstruction, were performed in 48% of explored cases, yielding a 5% perioperative complication rate. Early DNP recipients had significantly fewer secondary nerve procedures than those managed nonoperatively (19% vs. 38%, p=0.01).

CONCLUSIONS: Early surgical exploration in CRPNIs demonstrated a high rate of actionable findings and reduced the subsequent need for surgical interventions, supporting a more aggressive initial approach. Further studies are warranted to determine long-term functional outcomes.

PMID:40644864 | DOI:10.1016/j.injury.2025.112573

Only fair accuracy of the radiographic classification of adult proximal humeral fractures in the Swedish Fracture Register: a cohort analysis

Injury. 2025 Jun 30;56(8):112558. doi: 10.1016/j.injury.2025.112558. Online ahead of print.

ABSTRACT

INTRODUCTION: Quality registers are used for quality assessment, cost analyses, and research regarding outcomes of surgical and non-operative treatments. As the Swedish Fracture Register (SFR) expands, and is used as a platform for randomized trials, assuring reliability and accuracy of the data is essential.

AIM: This study aimed to investigate the accuracy of the radiographic classification data for proximal humerus fractures recorded in the SFR.

METHOD: All radiographic images of 171 patients with a proximal humerus fracture registered in the SFR between 2019 and 03-01 and 2019-08-31 at 3 hospitals were included. The radiographs were independently assessed at 2 occasions >3 weeks apart by 1 surgeon at each center and IRR was calculated to validate the modification of the AO/OTA classification used in the register. A "gold standard" classification for each patients' images was then established with a consensus discussion involving 4 shoulder surgeons. The gold standard classification was compared with the classification registered in the SFR.

RESULTS: Intra-rater reliability was moderate (kappa 0.549-0.596) with percent agreement (PA) 61-66 %. Inter-rater reliability was also moderate (kappa 0.508-0.557) with PA 58-62 %. Accuracy of the SFR recordings compared with gold standard was fair with kappa 0.36 (95 % CI 0.297-0.425) and PA 44 %.

CONCLUSION: For registers to be of use the accuracy of data is essential as well as coverage, completeness, validity and reliability. The modified AO/OTA classification for proximal humerus fractures used in the SFR had moderate reliability but registered data only fair accuracy compared with a gold standard. This questions its value as a base for scientific research and clinical decisions.

PMID:40639131 | DOI:10.1016/j.injury.2025.112558

Long-term opioid use in operatively managed orthopaedic patients with fracture-related infections: A data linkage study

Injury. 2025 Jun 27;56(8):112566. doi: 10.1016/j.injury.2025.112566. Online ahead of print.

ABSTRACT

BACKGROUND: Fracture-related infection (FRI) is a devastating complication of musculoskeletal trauma. Pain and poor functional outcomes are common, however there is limited insight to the long-term opiate use in this cohort. This study aims to 1) compare the rate of chronic opiate use between trauma patients with and without FRI, and 2) identify risk factors for chronic opiate use among patients with FRI.

METHODS: A cohort of adult injured patients hospitalized in Queensland, Australia between 2014 and 2015 undergoing operative fracture management was extracted from the Community Opioid Dispensing after Injury (CODI) study. This included person-linked hospitalization clinical data, community opioid dispensing and mortality. Data were extracted from 3-months prior to the index-hospitalization to 2-years after discharge. Community opioid dispensing was compared for patients with and without FRI. Increased risk of chronic opiate therapy (COT) (≥90 days cumulatively) was examined using multivariable logistic regression, odds ratios (OR) and 95 % Confidence Intervals (95 % CI).

RESULTS: There were 19,218 operatively managed orthopaedic trauma patients, of which 394 (2.1 %) were complicated with FRI. Opioids were dispensed post injury for 9399 patients. Patients with FRI were more likely to be prescribed opioids (68 %) than patients without FRI (48.5 %, p < 0.001). COT was associated with FRI, with 29.0 % of infected patients being dispensed opiates >90 days (23.8 % no FRI group, p < 0.001). The median duration of opiate therapy among patients with FRI who were dispensed opiates was 60 days [IQR 15-237] (versus 23 days [IQR 15-84] for no FRI, p < 0.001) and the median end dose was 14 mg oral morphine equivalent for both groups [FRI IQR 10-30; No FRI IQR 10-28]. Among patients with FRI, pre-injury opiates, high injury severity, length of stay >21 days and >2 revision surgeries were associated with COT.

CONCLUSION: Infection following trauma surgery is associated with long term opiate use. Risk factors identified for with COT include pre-injury opiate use, high injury severity, increased length of stay and multiple revision surgeries. These insights should be utilised to guide opiate stewardship programs, advocate for improved prevention and treatment strategies for FRI and optimise physical and mental rehabilitation.

PMID:40639130 | DOI:10.1016/j.injury.2025.112566

Ultrasound-guided erector spinae plane block for traumatic rib fractures: A feasible method of analgesia for the nonspecialized emergency physician

Injury. 2025 Jul 1:112569. doi: 10.1016/j.injury.2025.112569. Online ahead of print.

ABSTRACT

INTRODUCTION: Rib fractures are associated with substantial morbidity and mortality. Ultrasound-guided erector spinae plane block (ESPB) is increasingly used to manage pain in patients with rib fractures. However, ESPBs are often performed by proceduralists with extensive experience in regional anesthesia. The purpose of this study was to determine whether nonspecialized physicians could effectively perform ESPBs in patients with rib fracture pain in the emergency department.

METHODS: In a prospective convenience sample of 19 patients who came to the emergency department with rib fractures, ESPBs were performed by resident physicians under the supervision of experienced attending physicians. Pain scores, opioid use in morphine milligram equivalents (MME) per day, forced vital capacity, and maximum inspiratory pressure (MIP) were compared before and at several time points after ESPB.

RESULTS: Pain scores were higher before ESPB (median [IQR], 7.0 [6.0-8.0]) than at any time point after the procedure (P = .018). Median (IQR) opioid usage before ESPB was 57.6 (43.5-92.6) MME/d, which was significantly reduced at 24 h after ESPB (median [IQR], 51.5 [29.5-82.9] MME/d; P = .020) and during the remainder of the patients' stay (median [IQR], 33.8 [9.6-50.7] MME/d; P = .003). Further analyses showed that MIP before ESPB (median [IQR], 27.5 [6.3-32.5] cm H2O) was significantly lower than that at 0 to 6 h (median [IQR], 40.0 [35.0-60.0] cm H2O; P = .040), 12 to 18 h (median [IQR], 49.0 [30.0-60.0] cm H2O; P = .039), and 18 to 24 h (median [IQR], 60.0 [35.0-60.0] cm H2O; P = .028) after ESPB. No complications, 30-day readmissions, adverse events, or deaths occurred.

CONCLUSION: When adequately educated and supervised by experienced physicians, nonspecialized proceduralists can safely perform the ESPB procedure in the emergency department to provide effective analgesia to patients with rib fractures. ESPBs significantly decreased pain scores, reduced opioid usage, and improved respiratory mechanics.

PMID:40628600 | DOI:10.1016/j.injury.2025.112569

Understanding governance for a national hip fracture clinical audit: a scoping review

Injury. 2025 Jul 2;56(8):112572. doi: 10.1016/j.injury.2025.112572. Online ahead of print.

ABSTRACT

BACKGROUND: There is a plethora of literature regarding hip fracture care, including care standards, use of registry/clinical audit data for improvement, benchmarking and outcomes. There is, however, very little published information describing how to establish and govern a national hip fracture audit. To explore the availability of information about hip fracture national clinical audit (NCA) development and governance, a scoping review was conducted.

METHODS: Electronic searches of MEDLINE (Ovid), Embase (Elsevier) and CINAHL (EBSCOHost) were conducted for articles describing national hip fracture clinical audits, published in English between 1988 and 2024. Factors for establishing the governance of a national hip fracture clinical audit were extracted and reported. Findings were shared with knowledge users from the Global Fragility Fracture Network (FFN) Hip Fracture Audit Special Interest Group and the Irish Hip Fracture Database Governance Committee to ascertain their completeness and validity. Descriptive analysis was used to summarise findings.

RESULTS: Thirteen articles were eligible for inclusion, representing 60 % of the known established hip fracture NCAs. From these, 11 components for the governance of hip fracture NCAs were identified, however the level of detail varied across the included articles. At least one of these components appeared in 83 % of the included articles, suggesting substantial consistency across hip fracture NCAs. Notably, five articles provided descriptions of all 11 components.

CONCLUSIONS: Overall, there was congruency in the approach taken to establish the governance of hip fracture NCAs and therefore the components identified could be used to support existing and emerging hip fracture NCAs in their development and sustainability.

PMID:40627997 | DOI:10.1016/j.injury.2025.112572

CT-derived bone density as an adjunct predictor of sacral fracture complexity in older adults

Injury. 2025 Jun 30;56(8):112576. doi: 10.1016/j.injury.2025.112576. Online ahead of print.

ABSTRACT

BACKGROUND: Bone mineral density (BMD) is a known risk factor for fragility fractures, yet its relationship with specific sacral fracture morphologies, particularly H-type fractures, is not well understood.

OBJECTIVES: To evaluate whether CT-derived Hounsfield Units (HU) correlate with the complexity of sacral fractures, focusing on H-type fracture patterns.

METHODS: A retrospective study was conducted involving 164 elderly patients (≥60 years) with sacral fractures. HU values were measured at the L5 vertebral body using CT imaging. Fractures were classified by Fragility Fractures of the Pelvis (FFP) classification and Denis zones. Logistic regression models were developed to identify predictors of H-type fractures. Model performance was evaluated using accuracy, AUC, precision, and recall.

RESULTS: Among 164 patients, 59 (36 %) had H-type fractures. FFP classifications were distributed as follows: FFP II (n = 68), FFP III (n = 18), and FFP IV (n = 78). HU did not significantly differ across FFP categories. A weak but significant negative correlation was observed between HU and age (r = -0.22, p = 0.0039). In multivariate logistic regression, FFP classification (OR = 10.03, p < 0.001), Denis zone involvement (OR = 8.58, p < 0.001), and HU (OR = 1.14, p = 0.63) were evaluated for their predictive value. The model achieved 92 % accuracy (AUC = 0.93).

CONCLUSION: HU alone is not a strong standalone predictor of H-type sacral fractures but improves multivariate model performance when combined with anatomical and clinical variables. HU's inverse relationship with age supports its utility as a surrogate marker for bone quality, especially when DXA is unavailable.

PMID:40618422 | DOI:10.1016/j.injury.2025.112576

Hip fracture outcomes, risk prediction, and hospital comparisons: a population-based study in Ontario Canada

Injury. 2025 Jul 2;56(8):112577. doi: 10.1016/j.injury.2025.112577. Online ahead of print.

ABSTRACT

INTRODUCTION: Hip fracture repair is one of the most common urgent procedures performed in hospitals. Having a high burden of mortality, hip fracture repair is frequently targeted for health system quality improvement and hospital performance monitoring. In the present study, we measure hospital variability and explore factors associated with 90-day mortality and the time from emergency department (ED) visit until surgery.

METHODS: Patients were 50-105 years of age at the time of their hip fracture surgery between fiscal years 2015/16 and 2023/24 in Ontario Canada. Hospital variation was measured using random intercept models, risk-adjusted mortality rates, and funnel plots. Risk-adjusted mortality was computed as observed/expected (O/E) ratios multiplied by the population mortality rate. Expected mortality was estimated using logistic regression or CatBoost machine learning methods adjusted for age, sex, comorbidity, and other measures of healthcare utilization. Funnel plots were presented using crude and risk-adjusted mortality by hospital volume. Bootstrap sampling was used to compute 95 % confidence intervals.

RESULTS: A total 12,607 deaths (12.1 %) occurred within 90 days of hip fracture repair (N = 103,887), 4488 (36 %) of which occurred in hospital. Hospitals only accounted for 0.6 % of the total variation in 90-day mortality. Other predictors of mortality included older age, male, higher comorbidity score, facility transfer, pre-operative anemia, home care, residence in long-term care, no prior receipt of anti-osteoarthritic medication, and no previous bone-mineral density scan (p < 0.0001 for all). Hospitals accounted for 9.2 % of the variability in the odds of receiving surgery within 48 h of ED visit. There was no clear cut-point of the time from ED arrival until surgery on the risk of 90-day mortality. There was no ecological association between hospital performance on timeliness (receipt of surgery within 48 h) and performance on 90-day mortality.

CONCLUSION: There was little hospital variation in 90-day mortality. Using three different approaches, there were a few hospitals that consistently stood out as performing better/worse than expected. There was more substantial variation in the time until treatment across hospitals, but the relationship between the time until surgery and 90-day mortality was tenuous.

PMID:40618421 | DOI:10.1016/j.injury.2025.112577

Pages