Injury. 2025 Nov 19:112899. doi: 10.1016/j.injury.2025.112899. Online ahead of print.

ABSTRACT

BACKGROUND: In recent years, more studies have focused on the outcome parameter (health-related) Quality of Life (QOL) after a severe injury. Psychological complaints are known to be associated with QOL. However, little is known about long-term QOL. Studies in other fields, have shown that, apart from disease, patients' personality may be associated with (long-term) QOL.

AIM: The aim of this study was to evaluate QOL, psychological complaints, and physical limitations about ten years after a severe injury and to compare this with the patients' situation 7 years earlier. Furthermore, the association between long-term QOL and patients' personality was examined.

METHODS: The 156 patients who participated in a study to investigate QOL, psychological problems and physical limitations seven years ago, were reassessed to determine their current situation using the same questionnaires as seven years earlier. In addition, patients' personality was assessed.

RESULTS: The response rate was 58%. Except for the social component, no significant differences in patients' QOL, psychological complaints and physical limitations were found in comparison with seven years earlier. The social domain scores had decreased. Personality was significantly associated with all QOL domains. Psychological complaints were not an important confounder in the association between personality and long-term QOL, but they did in the relationship between personality and physical complaints.

CONCLUSION: The QOL, psychological, and physical situation of severely injured patients ten years after their injury is comparable to their situation three years after their injury. Personality was an important factor, strongly associated with long-term QOL. Therapy focused at extending coping strategies may be helpful for patients at risk for low QOL, since no further spontaneous recovery was observed.

LEVEL OF EVIDENCE: This is a Basic Science paper and, therefore, does not require a level of evidence.

PMID:41298216 | DOI:10.1016/j.injury.2025.112899

Injury. 2025 Nov 19;57(2):112896. doi: 10.1016/j.injury.2025.112896. Online ahead of print.

ABSTRACT

BACKGROUND: The surgical strategy of displaced intra-articular calcaneal fractures (DIACFs) remains technically challenging. While sinus tarsi approach (STA) is widely applied for DIACFs, increasing concerns regarding the wound-related sequelae drive surgeons to target and advance minimally invasive surgery (MIS). This study aims to introduce a tailored distractor-assisted MIS and compares its medium-term outcomes with conventional STA approach reduction and fixation in patients with Sanders Ⅱ and Ⅲ calcaneus fractures.

METHODS: From Jan 2021 to Jun 2023, 133 cases (133 feet) diagnosed as DIACFs are prospectively randomized to receive either the tailored distractor-assisted MIS (MIS-arm) or conventional STA (STA-arm) reduction and fixation in the city trauma center. A 2-year follow-up is scheduled to record surgical outcomes. The medical records and radiological measurements during the follow-up are retrospectively retrieved and compared between the two treatment-arms for curative effect evaluation. At the last follow-up, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hind foot score and Visual Analog Scale (VAS) score are used to evaluate the functional rehabilitation.

RESULTS: The basic demographic characteristics and clinical presentations were comparable among the MIS-arm (67 feet) and the STA-arm (66 feet). Perioperatively, the MIS-arm vs STA-arm showed significant advantages in the interval between injury to operation, the operation time, and the hospital stay (average 1.3 vs 3.8 days, P < .05; 40.1 vs 65.4 min, P < .05; 4.9 vs 8.5 days, P < .05; respectively). Notably, the MIS-arm vs STA-arm was less likely to develop wound infection (0 % vs 6.1 %, P < .05). For postoperative radiological measurements, the MIS-arm achieved significant improvement from pre-operation with regards to calcaneal height, width, Bohler's angle, and Gissane angle (p < 0.05, respectively) as the STA-arm done and there were no differences between those two-arms in any above radiological indices (p > 0.05, respectively). At the last follow-up, the functional outcomes including AOFAS and the VAS were comparable between the two cohorts (81.4 ± 7.6 vs 79.5 ± 8.8, t = -2.20, P > .05; 1.3 ± 1.5 vs 2.30 ± 0.9, t = -4.33, P > .05; respectively). During the 2-year follow-up, no failure of reduction were observed. Further subgroup analysis confirmed no technical preference regarding MIS among Sanders type II and III.

CONCLUSION: The tailored distractor-assisted MIS actually worked out as conventional STA strategy did in radiological and functional outcomes for Sanders Ⅱ and Ⅲ calcaneus fractures. Lower rate of incision-related complications showed advantages of the tailored distractor-assisted MIS over STA. Further cohort study is required to clarify its clinical significance vs other MIS techniques.

PMID:41297369 | DOI:10.1016/j.injury.2025.112896

Injury. 2025 Nov 20;57(2):112901. doi: 10.1016/j.injury.2025.112901. Online ahead of print.

ABSTRACT

BACKGROUND: The use of an electromagnetic motorized intramedullary telescopic nail (MITN) simplifies humeral lengthening in patients with significant shortening.

PATIENTS AND METHODS: We conducted a retrospective single-surgeon series of five adult patients (2017-2022) with humeral length discrepancies treated using an electromagnetic-controlled MITN.

RESULTS: All patients underwent an antegrade approach. In four cases an extended lengthening technique exceeded the 5 cm limit of the 8.5 mm MITN. All patients achieved the planned length, were satisfied with the outcome, and regained their preoperative shoulder range of motion by the end of treatment.

CONCLUSION: Motorized intramedullary humeral lengthening is an effective treatment option for humeral length discrepancies.

PMID:41289967 | DOI:10.1016/j.injury.2025.112901

Injury. 2025 Nov 19:112903. doi: 10.1016/j.injury.2025.112903. Online ahead of print.

ABSTRACT

INTRODUCTION: Urotrauma requiring intervention can be managed by trauma surgery (TS), urologic surgery (US) or interventional radiology (IR). There is no clear consensus on preferable specialty for intervention, and limited data compare outcomes by specialty. This study aims to characterize interventions for urotrauma by specialty and analyze outcomes at our institution.

METHODS: We conducted a retrospective review of patients at our Level I Trauma Center with urotrauma requiring intervention from 2020-2023. We performed a descriptive analysis of demographics, injury type, specialty involved, intervention type, injury severity score (ISS), and post-operative course.

RESULTS: Of 387 patients identified, 23 % (87/387) required intervention with median age 32 (IQR 24-48) years. Kidney injuries were most common (68 %, 59/87), followed by ureteral (13 %, 11/87) and bladder (13 %, 11/87). TS performed most of the interventions (47 %, 41/87), followed by US (41 %, 36/87), and IR (12 %, 10/87). TS performed nephrectomy at a higher rate than US (67 %, 24/36 vs 8 %, 1/13). Of the cohort, 20 % (17/87) were readmitted, with 65 % (11/17) requiring a procedure and 63 % (7/11) of which were related to initial urologic injury. US was not initially consulted in nearly 60 % (4/7) of cases requiring urologic intervention upon readmission. The rate of urologic intervention upon readmission was 38 % (3/8) among patients who had an initial urologic consultation, compared to 100 % (4/4) among those who did not. Median length of stay (LOS) for readmitted patients was 76.7 h among those who received an initial US consultation and 134.1 h among those who did not. Follow-up occurred in 86 % (24/28) and 70 % (27/37) of patients treated by US and TS, respectively.

DISCUSSION: TS conducted most urotrauma interventions, while US managed most non-renal cases. The nephrectomy rate for renal trauma was lower when managed by US, suggesting a more organ-preserving approach. Patients without initial US consultation had a nearly 3-fold higher rate of readmission for urologic intervention, longer readmission hospital LOS, and lower follow-up rates. These clinically meaningful trends suggest that US consultation may improve outcomes by reducing the need for nephrectomy, minimizing reinterventions, reducing hospitalization length, and improving continuity of care. Multidisciplinary collaboration should be pursued in the management of urotrauma.

PMID:41276419 | DOI:10.1016/j.injury.2025.112903

Injury. 2025 Nov 19;56(12):112893. doi: 10.1016/j.injury.2025.112893. Online ahead of print.

ABSTRACT

INTRODUCTION: Digital necrosis (DN) is a critical postoperative complication following finger replantation surgery. This can necessitate additional surgical interventions that can adversely affect the patient's hand functionality, psychological well-being, and financial standing. The timely identification and management of the risk of post-replantation DN are thus crucial for enhancing patient outcomes. The objective of this study was to create and validate an easily understandable machine learning (ML) model for predicting the risk of DN following finger replantation surgery.

PATIENTS AND METHODS: Data from 1579 patients who underwent finger replantation surgery at Suzhou Ruihua Orthopaedic Hospital between September 2018 and September 2023 were collected and divided into training and internal validation sets. Additionally, 293 data points from two other institutions were employed as independent external validation sets. Ten machine-learning methods, including Gradient Boosting Machine (GBM), were utilized for modeling. The performance of the model was assessed using the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). SHapley Additive exPlanation (SHAP) was utilized to provide both global and local interpretations of the final model.

RESULTS: Nine indices, including the seniority of the doctor and the neutrophil count, were identified as independent predictors of DN. The GBM model showed optimal model with high predictive accuracy for DN risk in both the training set (AUC: 0.995) and the internal validation set (AUC: 0.978), which was confirmed using external validation (AUC: 0.983). The reliability and utility of the GBM model and the web-based computing platform were confirmed by DCA, calibration curve, accuracy, and sensitivity analyses.

CONCLUSION: An interpretable machine-learning model based on complete blood counts and related inflammatory marker levels was constructed and validated to predict the likelihood of developing DN following finger replantation. This model can assist clinicians in the prompt identification of high-risk patients post-replantation, enabling timely intervention.

PMID:41275725 | DOI:10.1016/j.injury.2025.112893

Injury. 2025 Nov 14;56(12):112891. doi: 10.1016/j.injury.2025.112891. Online ahead of print.

ABSTRACT

BACKGROUND: This study aimed to compare the effects of obesity and sex on 90-day medical outcomes and two-year outcomes following open reduction and internal fixation (ORIF) of upper extremity fractures.

METHODS: A retrospective analysis was conducted using a nationwide database to identify patients who underwent ORIF of upper extremity fractures including (shoulder and upper arm, elbow and forearm, wrist and hand) between 2003-2023 and had a minimum of 2 year follow-up. Patients were divided into two cohorts based on their BMI: nonobese (BMI<30) and obese (BMI≥30). Further subanalyses were conducted based on BMI categories. Patients were 1:1 propensity score-matched yielding 27,810 patients per group. Primary outcomes included fracture related outcomes at 2 years postoperatively while secondary outcomes were healthcare utilization and medical outcomes at 90 days postoperatively.

RESULTS: At 90 days, obese patients had higher risks of pulmonary embolism (RR 1.57, p = 0.001), deep vein thrombosis (DVT) (RR 1.32, p = 0.011), hospital readmission (RR 1.13, p = 0.042), and wound complications (RR 1.16, p = 0.005), while stroke incidence was lower (RR 0.68, p = 0.034). At 2 years, obese patients had increased risks of malunion/nonunion repair (RR 1.25, p = 0.002), malunion (RR 1.35, p = 0.009), and nonunion (RR 1.18, p = 0.001).

CONCLUSION: Obesity increases 90 day and 2 year complications following upper extremity ORIF. This highlights the need for tailored perioperative management for obese patients undergoing surgical fixation of upper extremity fractures.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

PMID:41273807 | DOI:10.1016/j.injury.2025.112891

Injury. 2025 Nov 14;56(12):112889. doi: 10.1016/j.injury.2025.112889. Online ahead of print.

ABSTRACT

INTRODUCTION: Non-tobacco nicotine dependence (NTND) has become an increasing alternative to traditional tobacco use. However, limited data exists in NTND patients undergoing operative fixation for unicondylar tibial plateau fractures. The purpose of this study was to investigate differences in perioperative complications and mortality among patients with and without NTND undergoing tibial plateau open reduction internal fixation (ORIF).

METHODS: The TriNetX US Collaborative Network database was queried using ICD-10 and CPT codes to identify patients aged 18 and older undergoing unicondylar tibial plateau ORIF between 2004 and 2024. Patients were divided into two cohorts depending on history of NTND. These cohorts were propensity-matched based on age, gender, race, ethnicity, body mass index, and various medical comorbidities. Rates of complications and mortality were compared between cohorts.

RESULTS: A total of 99,060,931 patients aged 18 and older were identified, of which 13,589 underwent ORIF for unicondylar tibial plateau fractures. Among these, 12,055 (88.7 %) were non-nicotine users and 1534 (11.3 %) were NTND. After 1:1 propensity score matching, each cohort included 1498 patients. Complications including stroke (OR 1.658), pneumonia (OR 2.036), emergency department (ED) visits (OR 1.536), and death (OR 1.883) were significantly higher in NTND patients 90 days postoperatively (p < 0.05). Furthermore, rates of pneumonia (OR 1.733), osteomyelitis (OR 3.456), and ED visits (OR 1.798) were significantly elevated in the NTND cohort compared to their counterparts 1 year postoperatively (p < 0.05).

CONCLUSIONS: NTND patients have higher rates of mortality and numerous postoperative complications including stroke, pneumonia, osteomyelitis, ED visits, and death following tibial plateau ORIF. Overall, this study suggests providers should counsel patients with NTND pre-operatively and consider screening patients prior to operatively managing unicondylar tibial plateau fractures.

LEVEL OF EVIDENCE: Retrospective cohort study; Level of evidence III.

PMID:41270685 | DOI:10.1016/j.injury.2025.112889

Injury. 2025 Nov 13;56(12):112892. doi: 10.1016/j.injury.2025.112892. Online ahead of print.

ABSTRACT

Fat embolism syndrome (FES) is a severe complication of orthopedic trauma and surgery, associated with high mortality. Traditional mechanical obstruction and biochemical lipotoxicity models explain only part of its pathogenesis and cannot account for the sustained progression, multi-organ involvement, and irreversibility of FES. We propose a novel concept of Lipid Pathological Resonance (LPR)-a self-reinforcing loop involving triglyceride (TG) extravasation, hydrolysis into free fatty acids (FFA), hypoxic signaling, and inflammatory amplification. This model integrates lipid metabolic imbalance, immune activation, and structural injury into a unified kinetic framework, clearly distinguishing it from the classical lipotoxicity theory. Drawing upon multi-omics, pathological, and clinical evidence, we highlight the central role of LPR in the pathogenesis of FES and explore potential therapeutic strategies, including lipase modulation, vascular barrier protection, and inflammation control.

PMID:41265295 | DOI:10.1016/j.injury.2025.112892

Injury. 2025 Nov 11;56(12):112887. doi: 10.1016/j.injury.2025.112887. Online ahead of print.

NO ABSTRACT

PMID:41265294 | DOI:10.1016/j.injury.2025.112887

Injury. 2025 Nov 13;56(12):112888. doi: 10.1016/j.injury.2025.112888. Online ahead of print.

ABSTRACT

INTRODUCTION: Malnutrition has emerged as a significant risk factor for postoperative complications in orthopaedic surgery. Despite this, the impact of malnutrition in orthopaedic trauma remains underexplored. This study aims to investigate 90 day and 1 year postoperative outcomes of ankle and pilon fracture open reduction and internal fixation (ORIF) in malnourished patients.

METHODS: Using a national database, adult patients who underwent surgery for ankle or pilon fractures with a minimum of one-year follow-up were identified. Patients were stratified into two cohorts based on the presence of serum markers for malnutrition within the year preceding surgery. Malnutrition was identified by any of the following values: serum or plasma transferrin ≤204 mg/dL, blood leukocytes ≤1.5 × 10³/µL, or albumin ≤3.5 g/dL. A 1:1 propensity score matching was performed with matched controls for relevant risk factors, demographics and comorbidities.

RESULTS: Before matching, 80,761 ankle fracture patients (7,455 malnourished; 73,306 controls) and 14,258 pilon fracture patients (1,648 malnourished; 12,610 controls) were identified. After matching, 14,676 ankle fracture (mean age 58.4 ± 16.9 years) and 3,214 pilon fracture (mean age 50.1 ± 17.2 years) patients were included. In the ankle fracture analysis, malnourished patients had higher rates of wound complications, post-operative infection, anemia, blood transfusions, incision and drainage and implant removal at 90 days post-operatively (p<0.0001). Within one year, malnutrition was significantly associated with increased malunion, non-union, amputation and implant related complications such infections, implant removal and irritation and debridement (p<0.05). Comparisons for pilon fracture patients were the same in addition to higher rates of wound complications (p<0.001) in malnourished patients.

CONCLUSION: Patients with malnutrition undergoing surgical fixation for ankle and pilon fractures experienced significantly higher rates of systemic complications and adverse surgical outcomes including infections, nonunion and all-cause return to the OR for staged removal of hardware, debridements, arthrodesis, and amputation. These findings should direct postoperative risk management and motivate study into interventions aimed at promoting nutrition and preventing complications in this at-risk population.

PMID:41265293 | DOI:10.1016/j.injury.2025.112888

Injury. 2025 Nov 13;56(12):112884. doi: 10.1016/j.injury.2025.112884. Online ahead of print.

ABSTRACT

BACKGROUND: The rise of homelessness in the United States has resulted in an alarming burden of unmet medical need. Homeless patients are at higher risk for orthopedic trauma yet there is limited literature investigating it. This study aims to investigate open reduction and internal fixation outcomes of lower extremity fractures in homeless patients.

METHODS: This retrospective database analysis evaluated homeless patients who underwent open reduction and internal fixation of the lower extremities. Patients were categorized based on the housing status preoperatively, resulting in 3596 homeless and 436,540 housed patients. A 1:1 propensity score matching analysis was performed, adjusting for age, sex, race, ethnicity, body mass index and comorbid conditions (diabetes, hypertension, chronic kidney disease, tobacco use, obesity, heart failure, liver diseases, substance abuse and opioid dependence). Postoperative complications were assessed at 90 days, and both surgical and medical related complications were evaluated at 1 year.

RESULTS: At 90 days, homeless patients had significantly higher rates of emergency department (ED) visits (RR 2.47, p < 0.0001), readmissions (RR 2.49, p < 0.0001), opioid dependence (RR 2.48, p = 0.001), substance abuse (RR 2.96, p < 0.0001), surgical site infections (RR 2.54, p < 0.0001), postoperative infections (RR 1.49, p < 0.0001), and blood transfusions (RR 2.12, p < 0.0001) compared to controls. At 1 year, homeless patients continued to demonstrate higher rates of ED visits (RR 2.62, p < 0.0001), admissions (RR 2.35, p < 0.0001), opioid dependence (RR 1.62, p = 0.011), and substance abuse (RR 4.00, p < 0.0001). Implant removal (RR 0.75, p = 0.001) and malunion/nonunion repair (RR 0.63, p = 0.018) were less frequent in homeless patients, while amputation was more common (RR 1.87, p = 0.018).

CONCLUSION: Homeless patients experience significantly higher rates of medical complications, fracture-related complications and increased opioid dependence following surgical fixation of lower extremity fractures. Further investigation into these findings and potential for perioperative medical optimization is indicated.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

PMID:41260189 | DOI:10.1016/j.injury.2025.112884

Injury. 2025 Oct 31;56(12):112871. doi: 10.1016/j.injury.2025.112871. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-reported outcomes following treatment of open lower limb fractures in the elderly are poorly reported. This study aimed to report clinical outcomes from the South Wales orthoplastic service using the Lower Extremity Functional Scale (LEFS).

MATERIALS AND METHODS: A retrospective observational cohort study was performed using LEFS scores for patients aged 65 years and over with open lower limb fractures undergoing either local or free flap reconstruction from June 2020 - June 2023. LEFS scores were collected from paper questionnaires of patients returning to the orthoplastic clinic for follow up. Deep infection, secondary amputation and time to union were recorded. Patients undergoing primary closure alone or reconstruction due to infection were excluded.

RESULT: Fifty-one patients were included, 15 (29 %) male and 36 (71 %) female. The median age was 72. There were 26 (51 %) ankle, 24 (47 %) tibial and 1 (2 %) mid-foot open fractures. Of the 24 open tibial fractures, 17 (71 %) were fixed with nails, 5 (21 %) with plates and screws or a combination of both (2, 8 %). Sixteen (67 %) received local flaps and 9 (38 %) required free flaps. Ankle fractures were fixed with screws, plates or fibula nails. Seven (27 %) required free flaps and 19 (73 %) pedicled flaps. The mid foot fracture received a bridging plate, screws and a free flap. Of these 51, 3 (6 %) died during admission, 3 (6 %) were lost to follow and 1 (2 %) died before the first follow up appointment. Of the remaining 44 patients, the median LEFS score was 35 at a median follow up of 51 weeks indicating moderate functional limitation. The median time to union was 26 weeks. One (2 %) patient developed a deep infection requiring metalwork removal and there were 6 (14 %) non-unions. There were no secondary amputations.

CONCLUSIONS: Open lower limb fractures in the elderly population can present challenges for orthoplastic reconstruction. We have shown successful fix and flap procedures are possible in a cohort traditionally considered to be high risk for surgery. Patients had reasonable functional outcomes at 12 months post-operatively. LEFS scores can provide objective data to evaluate recovery following orthoplastic reconstruction in this cohort.

PMID:41253070 | DOI:10.1016/j.injury.2025.112871

Injury. 2025 Nov 13;56(12):112890. doi: 10.1016/j.injury.2025.112890. Online ahead of print.

ABSTRACT

INTRODUCTION: Despite advancements in surgical technique, patellar fractures remain challenging to manage. Internal fixation of simple transverse patellar fractures is commonly performed using tension band wiring techniques, such as cannulated screw anterior tension band wiring (CATB). However, CATB is associated with high rates of symptomatic hardware, fixation failure, and reoperation. The wagon wheel (WW) construct is a novel transtendinous/transligamentous technique that involves circumferential mini-fragment plating with radially directed screws. A previously published case series demonstrated that the WW construct was associated with decreased rates of reoperation, symptomatic hardware, time to union, and gait aid dependences compared with CATB. However, no biomechanical study has compared these fixation strategies. The goal of this study was to evaluate the biomechanical performance of the WW construct compared to CATB for fixation of simple patella fractures.

MATERIALS AND METHODS: Seven paired fresh-frozen human cadaveric lower extremities (n=14 knees) were utilized. All patellae were fractured using an oscillating saw to simulate two-part simple transverse AO/OTA 34-C1 patella fractures. Matched pairs of knees underwent randomization to the WW and CATB constructs. All surgically fixed specimens underwent cyclic loading testing through 1000 cycles, as well as subsequent load-to-failure testing. Failure was defined as fracture displacement ≥ 2 mm. High-resolution optical motion tracking system recorded fracture displacement in three dimensions throughout testing.

RESULTS: The WW construct demonstrated less mean fracture displacement on the first flexion cycle (WW: 0.09 vs. CATB: 0.32 mm; p=0.11) and after 1000 cycles of flexion (WW: 0.31 vs. CATB: 1.0 mm; p=0.017), equating to 69% less mean fracture displacement than CATB. The mean force required to cause construct failure was more than double for knees fixed with the WW construct compared with CATB (900 vs. 434 N; p=0.025) DISCUSSION: In the first human cadaveric biomechanical study to compare the novel WW construct to CATB, the WW construct demonstrated superior fixation stability and 69% less fracture displacement after 1000 cycles of flexion. The findings of this study provide biomechanical validation for previously reported clinical advantages of the peripheral plate-based WW construct, compared to CATB, demonstrating that the WW may offer superior fracture fixation stability through cyclic loading.

PMID:41253069 | DOI:10.1016/j.injury.2025.112890

Injury. 2025 Nov 10;56(12):112881. doi: 10.1016/j.injury.2025.112881. Online ahead of print.

ABSTRACT

The study aims to define a management protocol to outline a variety of clinical presentations associated with residuum pain after osseointegration. This is expected to assist clinicians in diagnosing and treating adverse events. In the present cohort study, a total of 406 patients with 429 (262 transfemoral and 167 transtibial) osseointegration cases were evaluated over the period spanning from November 2010 to November 2023 at Macquarie University and Norwest Private Hospital. International patients were excluded from the study due to the lack of detailed imaging and regular follow-up care. The average follow-up since surgery was found to be 6.1 ± 2.49 years. The stump pain management protocol was developed by retrospective analysis. Residuum pain is driven by mechanical, neuropathic, and infectious processes. Stump infections were categorized according to the OGAAP classification. Mechanical pain caused by aseptic or septic loosening was classified into grading systems to segregate the management. After clinical and radiological localization of neuroma, 94/262 ( 35.8%) transfemoral cases underwent 129 nerve-related procedures (117 TMR +12 RPNI). Out of 167 transtibial cases, 65 nerve interface procedures (61 TMR+4 RPNI) were performed in 42 (28.1%) cases on single or multiple nerves. Stump refashioning procedures were carried out in 115 cases (85/262 (32.4%) transfemoral; 30/167 (17.9%) in transtibial) who had pain due to recurrent soft tissue infections and overhanging soft tissues. The analysis of the average time between refashioning surgery and index surgery revealed a mean interval of 2.86 ±1.98 years. The use of bone-anchored prostheses, whilst safe and highly successful, necessitates a long-term commitment, with a potential need for ongoing management of adverse events. Based on radiographic and clinical data, the resultant categorization corresponds with related soft-tissue or bony pathology, which allows the surgeon to decide on the best course of management.

PMID:41242204 | DOI:10.1016/j.injury.2025.112881

Injury. 2025 Oct 20;56(12):112830. doi: 10.1016/j.injury.2025.112830. Online ahead of print.

ABSTRACT

IMPORTANCE: Methoxyflurane, an inhalational analgesic, has proven safety and efficacy in clinical trials and clinical practice. This double-blind, well-controlled study aimed to establish the benefit-risk of methoxyflurane in a paediatric population.

OBJECTIVE: To evaluate the safety and efficacy of methoxyflurane in children with minor trauma and acute pain presenting to emergency departments (ED).

DESIGN: Randomised, double-blind, multicentre, placebo-controlled study (MAGPIE).

SETTING: Conducted at 11 EDs in the UK and Ireland.

PARTICIPANTS: Participants aged from 6-<18 years of age with minor trauma and pain scores of 60-80 mm on a visual analogue scale (VAS), or 6-8 on a Wong Baker Pain Scale, were recruited.

INTERVENTIONS: Methoxyflurane 3 mL or placebo (normal saline, 5 mL) via a Penthrox® inhaler device, with a second inhaler upon request.

MAIN OUTCOME(S) AND MEASURE(S): Primary: change in VAS pain intensity from baseline to 15-minutes in participants aged 9-<18 years (secondary: included the total Intent-To-Treat (ITT) population, aged 6-<18 years).

RESULTS: 4513 patients screened, 249 participants randomised (127 methoxyflurane, 122 placebo), 192 treated (92 methoxyflurane, 100 placebo). Mean (standard deviation (SD)) age 11.1 (2.45) years; 108/192 (56 %) were male. At 15-minutes, the mean change from baseline in VAS was -20.0 mm (methoxyflurane) and -13.2 mm (placebo); least squares (LS) mean difference in 9-<18-year old's -6.8 mm [95 % CI -12.5 to -1.2 mm], p = 0.018, which was similar to the total ITT population. Fewer methoxyflurane participants required rescue medication (9.8 % vs 30.0 %). There were statistically significant odds of better global medication performance assessments for the methoxyflurane group compared to the placebo group, based on physician (OR 5.29, 95 % CI 3.02 to 9.45, p < 0.001) and research nurse assessments (OR 5.78, 95 % CI 3.32 to 10.27, p < 0.001). Adverse events were more common with methoxyflurane (64 %) vs. placebo (55 %). Common treatment emergent adverse events (TEAEs) included dizziness (methoxyflurane 41 %, placebo 12 %) and euphoric mood (methoxyflurane 12 %, placebo 0 %). Discontinuations due to TEAEs occurred in 8 methoxyflurane and 1 placebo participant. There were no serious adverse events related to methoxyflurane.

CONCLUSIONS AND RELEVANCE: In this pivotal placebo-controlled trial, methoxyflurane was efficacious for treatment of acute trauma-related pain in paediatrics, with a safety profile consistent with adults.

TRIAL REGISTRATION: NCT03215056.

PMID:41242203 | DOI:10.1016/j.injury.2025.112830

Injury. 2025 Nov 8;56(12):112883. doi: 10.1016/j.injury.2025.112883. Online ahead of print.

ABSTRACT

BACKGROUND: Post-traumatic hypothermia is a prevalent complication in trauma care, affecting up to 66 % of multiple trauma patients upon emergency admission and doubling trauma-related mortality. While risk prediction models for post-traumatic hypothermia have been developed, guidelines and evidence specific to their clinical utility-especially in pre-hospital and low- to middle-income country (LMIC) settings-remain scarce. This systematic review evaluates existing post-traumatic hypothermia risk prediction models, their performance characteristics, and applicability in diverse clinical contexts.

METHODS: Databases including China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, China Biomedical Literature Database, PubMed, Web of Science, and Cochrane Library were searched from the time of database establishment to July 2025. Two researchers independently screened the literature, extracted relevant data, and conducted quality assessments. The included studies were analyzed to comprehensively evaluate the predictive models for post-traumatic hypothermia risk.

RESULTS: A total of 9 studies were included, comprising 9 predictive models for the risk of post-traumatic hypothermia, with a total sample size of 91 to 732 cases and 24 to 117 outcome events. The area under the receiver operating characteristic curve (AUC) for the predictive models ranged from 0.704 to 0.990, with specificity ranging from 50.6 % to 95.2 %. and sensitivity ranging from 70.9 % to 92.8 %. The most frequently identified predictive factors in the models were trauma severity, wet clothing, lack of warming measures, fluid resuscitation, and environmental temperature at the time of injury. The included risk prediction models demonstrated overall good applicability, but they had a high risk of bias, which was associated with limitations in sample selection, indicator selection and measurement, study design flaws, and inadequate model validation.

CONCLUSION: Although the predictive model for post-traumatic hypothermia risk demonstrates certain advantages in overall applicability and can provide reference for clinical prediction of post-traumatic hypothermia risk, it has a high risk of bias. Future studies should be conducted in a multicenter, large-sample setting to strengthen external validation of the model and test its performance in different clinical environments to ensure its stability and accuracy.

PMID:41240776 | DOI:10.1016/j.injury.2025.112883

Injury. 2025 Nov 8;56(12):112886. doi: 10.1016/j.injury.2025.112886. Online ahead of print.

ABSTRACT

INTRODUCTION: Tibial plateau fractures are some of the most commonly treated injuries around the knee and loss of range of motion has a significant effect on post-operative outcomes, very few studies have demonstrated the impact of flexion contractures. The purpose of this study was to determine the effect that development of a knee flexion contracture has on outcomes following operative repair of tibial plateau fractures.

METHODS: Patients operatively treated for tibial plateau fractures (Schatzker II, IV, V, and VI) between 2005-2024 at a multi-center academic urban hospital system were included in this retrospective comparative study. Patients were grouped into 3 cohorts: 1. Full extension (FE), 2. 5-10 degrees of flexion contracture (Mild, ME) and 3. Greater than 10 degrees of flexion (Severe, SE) contracture at 6 months post-operatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Statistical analysis was used to evaluate outcomes including patient reported pain levels, Short Musculoskeletal Function Assessment (SMFA) scores, complication rates and reoperation rates.

RESULTS: The cohort consisted of 3 groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average knee flexion contracture for the mild cohort was 5 degrees and the average knee flexion contracture for the severe cohort was 12.7 degrees. Patients who experienced flexion contracture had poorer SMFA scores at 6 months, and those in the severe cohort had the poorest SMFA scores (112.6) when compared to those with full extension at 6 months (77.7) (p<0.001). Flexion contractures were associated with higher rates of fracture related infection (FRI) (p =0.002). Patients with flexion contracture also had a higher rate of subsequent re-operation, with 36.7% of the ME undergoing re-operation and 40% of SE undergoing re-operation.

CONCLUSIONS: Patients who developed a flexion contracture following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long term follow up compared to those who achieved full knee extension.

PMID:41240775 | DOI:10.1016/j.injury.2025.112886

Injury. 2025 Oct 31:112865. doi: 10.1016/j.injury.2025.112865. Online ahead of print.

NO ABSTRACT

PMID:41238443 | DOI:10.1016/j.injury.2025.112865

Injury. 2025 Nov 1;56(12):112855. doi: 10.1016/j.injury.2025.112855. Online ahead of print.

ABSTRACT

BACKGROUND: Neurovascular complications after tibial plateau fractures are rarely reported, despite their clinical relevance. While Schatzker type IV fractures have traditionally been considered the most at risk, supporting evidence is limited. This is the first large-scale study systematically evaluating neurovascular injuries in tibial plateau fractures. The aim was to determine the incidence of arterial and neurological injuries and to identify fracture patterns most frequently associated with these complications.

METHODS: We conducted a retrospective review of patients who underwent open reduction and internal fixation for tibial plateau fractures at a level I trauma center between January 2015 and December 2023. Eligible patients had complete records, radiographs, CT angiography, and ≥12 months follow-up. Fractures were classified using both Schatzker and AO/OTA systems. Arterial injury was defined as a CT angiography confirmed lesion requiring surgical repair, and neurological injury as a motor or sensory deficit documented clinically or by electromyography within 1 month.

RESULTS: A total of 320 patients were included (mean age 44.3 years; 71.3 % male). Vascular injury occurred in 2 cases (0.62 %), both high-energy open fractures classified as Schatzker VI and AO/OTA C3. Five additional patients (1.56 %) had arterial occlusions without rupture or clinical ischemia, all of which resolved without surgery. Neurological injury was observed in 13 patients (4.06 %), 84.6 % related to high-energy trauma. Ten cases corresponded to Schatzker VI, predominantly AO/OTA C3 (n = 8). No neurovascular complications occurred in Schatzker IV fractures. Proximal fibular fracture was present in 61.5 % of neurological cases with a OR of 4.46 (CI 1.41-14.03, p = 0.010).

CONCLUSIONS: Neurovascular complications in tibial plateau fractures are uncommon (<5 %) but are associated with high-energy, open, and complex patterns, particularly Schatzker VI and AO/OTA C3. Contrary to traditional belief, Schatzker IV fractures were not associated with neurovascular compromise. Proximal fibular fracture may serve as a clinical marker for neurological risk. CT angiography should not be performed routinely, but is especially recommended in open and high-energy fractures. Further prospective studies are needed to validate these associations and optimize imaging strategies.

PMID:41237662 | DOI:10.1016/j.injury.2025.112855

Injury. 2025 Nov 13;56(12):112831. doi: 10.1016/j.injury.2025.112831. Online ahead of print.

ABSTRACT

This study aimed to analyse the load-deformation behaviour of pelves treated with external fixation following AO61C1.3a pelvic injury. Designing a biomechanical setup , the load-bearing capacity of pelves was assessed across varying pin configurations (two, three, or four external fixator pins). Mechanical parameters such as stiffness, peak-to-peak, valley-to-valley, fracture line, total displacement, deformation, and maximum load were derived to quantify pelvis stability. The 3-pin configuration demonstrated superior stability with significantly smaller pubis and sacral fracture displacements under all loading conditions (p<0.001), and was the only configuration below the clinical failure threshold. Notably, this configuration minimised fracture movement despite global outcome parameters showing no significant differences between the groups. These findings highlight the importance of fracture-specific stability over global stiffness in ensuring effective fixation. The results indicate that optimal biomechanical resistance to C1.3a pelvic instability is achieved through a combination of two pins on the injured side and a single pin on the stable hemipelvis using contemporary pin devices. This study offers the biomechanical basis required to facilitate the design and execution of clinical trials addressing pelvic ring injuries.

PMID:41237661 | DOI:10.1016/j.injury.2025.112831