Injury. 2025 Sep 15:112761. doi: 10.1016/j.injury.2025.112761. Online ahead of print.

ABSTRACT

INTRODUCTION: Blunt Thoracic trauma (BTT) affects over 10 % of trauma patients and may lead to delayed respiratory complications. The STUMBL (STUdy of the Management of BLunt chest wall trauma) score was developed to identify patients at high risk of complications. This study aimed to validate the STUMBL score in a Canadian setting.

METHODS: We conducted a retrospective cohort study of adult patients with isolated BTT presenting to a Canadian emergency department (ED) of a Level-1 trauma center between 2018 and 2020. STUMBL scores were calculated for each patient. The primary outcome was a composite of in-hospital mortality, early pulmonary complications, ICU admission, or prolonged hospital stay (≥7 days). Secondary outcomes were delayed pulmonary complications and unplanned return to the ED. Receiver operating characteristic (ROC) curves were used to evaluate predictive performance, and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed for each score cutoff.

RESULTS: Among 344 included patients (mean age: 57.8 ± 17.0, male sex: 64.2 %), 18.3 % experienced the primary outcome. The STUMBL score showed good discrimination (AUROC 0.87). A cutoff of ≤10 yielded a sensitivity of 90.5 % and NPV of 97.0 %, while a cutoff of ≤15 showed a sensitivity of 66.7 % and NPV of 92.2 % to predict the composite outcome. In patients with a score ≤15, delayed pulmonary complications occurred in <2 %, and unplanned ED visits in <7 %. Conversely, 82.4 % of patients with STUMBL scores ≥21 experienced the composite outcome. This cutoff was associated with a specificity of 97.9 % and PPV of 82.4 %.

CONCLUSIONS: The STUMBL score demonstrated good performance in predicting early adverse outcomes in Canadian patients with isolated BTT. Patients with a STUMBL score ≤15 and no early complications represent a low-risk group that may be safely discharged. Those with scores ≥21 warrant ICU evaluation. Further prospective validation or refinement is recommended before widespread implementation.

PMID:40976766 | DOI:10.1016/j.injury.2025.112761

Injury. 2025 Sep 14;56(11):112762. doi: 10.1016/j.injury.2025.112762. Online ahead of print.

ABSTRACT

OBJECTIVE: To predict the risk of spontaneous tendon rupture (STR) in dialysis patients using a low-variable, clinically implementable model and to perform internal validation.

MATERIALS AND METHODS: In a single-centre case-control study, 102 individuals were analysed (34 STR cases, 68 controls). Pre-specified candidate predictors comprised four clinical variables: frailty (Clinical Frailty Scale, CFS), dialysis vintage, calcium-phosphate (Ca-P) product, and quinolone exposure within the past 6 months. Group comparisons were conducted; multivariable analysis used logistic regression. Discrimination and calibration were assessed with an L2-penalised approach, 5-fold cross-validation, and bootstrap optimism correction; decision curve analysis (DCA) was undertaken.

RESULTS: Compared with controls, cases had higher CFS, longer dialysis vintage, higher Ca-P product and intact parathyroid hormone (iPTH), and lower albumin; C-reactive protein did not differ materially. In the multivariable model, CFS and dialysis vintage were independently and positively associated with STR; Ca-P and quinolone coefficients were positive but did not cross conventional significance thresholds. Discrimination was good: apparent AUC 0.806 and optimism-corrected AUC 0.786; Brier score 0.247. Calibration was visually acceptable, with greater uncertainty at higher predicted probabilities. On DCA, across a 15 %-25 % risk threshold range, the model provided higher net benefit than a treat-none strategy and a net benefit comparable to a treat-all strategy. Among cases, the operative rate was 100 %, complications 11.8 %, recurrence 8.8 %, 12-month mortality 6.3 %, and median length of stay 3.7 days. Rupture sites were quadriceps in 44.1 % and patellar tendon in 32.3 %.

CONCLUSIONS: In dialysis patients, STR risk appears predictably estimable using readily obtainable indicators such as CFS and dialysis vintage. The Ca-P/iPTH axis may contribute directionally to risk, while the effect of quinolone exposure warrants confirmation in larger cohorts. The model has potential to inform clinical decision-making; further calibration refinement and external validation are recommended before routine implementation.

PMID:40976189 | DOI:10.1016/j.injury.2025.112762

Injury. 2025 Sep 4;56(11):112725. doi: 10.1016/j.injury.2025.112725. Online ahead of print.

ABSTRACT

INTRODUCTION: The reverse oblique fracture patterns accounts for about 5-10 % of all intertrochanteric fractures. This type of fracture is regarded as highly unstable and is still associated with high complication and failure rates. Cut-off values for the use of short or long implants are not yet defined. An easy-to-use and comprehensive classification system is still lacking.

MATERIALS AND METHODS: This study was performed as a single center retrospective data analysis. Between 2008 and 2018, 4003 patients with per/subtrochanteric fractures, were screened. A total of 286 (7 %) patients with a reverse-oblique fracture pattern were included. Fracture patterns were analyzed and classified according to a new classification system with 4 main types (I-IV), which are subdivided in to subtypes a and b. The choice of implants, complication rates, revision surgery and time of surgery were raised. Radiological outcome parameters (TAD, calTAD, Parker's Ratio) and loss of reduction were measured.

RESULTS: The distribution between the various subgroups was IIa and IVa (21 %), IIb (20 %), Ia (12 %), IVb (9 %), IIIa (8 %), Ib (6 %) and IIIb (3 %). A rate of 39 (14 %) complications, which needed revision surgery were recorded. Open reduction significantly increased the complication rate (p= 0.0356) as well as an increase in time of surgery (p = 0.0107). The additional use of cerclage wires had no additional influence. There was a trend to more complications after the use of a long implant in patients with type-a fractures (p= 0.056). Radiological parameters did not have any predictive value. Loss of reduction of the medial or lateral cortex shows a trend to a higher complication rate. After a primary complication, the necessity of repeating revision surgery is likely to happen.

CONCLUSION: The novel classification system depicts all relevant fracture patterns. Open reduction and prolonged time of surgery increase the complication rate. In type-a fractures, the use of short implants is recommended. Additional use of cerclage wires does not have a negative impact on outcome.

PMID:40974891 | DOI:10.1016/j.injury.2025.112725

Injury. 2025 Sep 10;56(11):112745. doi: 10.1016/j.injury.2025.112745. Online ahead of print.

ABSTRACT

BACKGROUND: Finger defect reconstruction requires functional and aesthetic restoration. The great toenail flap demands advanced microsurgical skills. We propose a staged approach: initial pedicled flap coverage, followed by second-stage exchange of the great toenail flap with the finger flap, enhancing donor site repair while reducing complexity and expanding access in resource-limited settings.

METHOD: Sixteen patients (2017-2024) underwent staged reconstruction: primary pedicled flap followed by great toenail flap-finger flap exchange. Outcomes included complications, functional metrics (Semmes-Weinstein monofilament test, Michigan Hand Outcomes Questionnaire [MHQ], static two-point discrimination [2-PD]), and donor foot pain (Visual Analog Scale [VAS]). Healthy sides served as controls.

RESULTS: At mean 12-month follow-up, reconstructed fingers showed mean static 2-PD of 5 mm and Semmes-Weinstein result of 3.67 g; MHQ averaged 89.6. Foot donor sites demonstrated mean 2-PD of 5.5 mm and VAS of 1. Complications included partial flap necrosis (1 case) and significant donor foot pain (1 case). Interphalangeal joint motion, 2-PD, and MHQ scores differed significantly from healthy sides (p < 0.001)..

CONCLUSION: This staged protocol provides a safe, practical solution for finger reconstruction, particularly in settings with limited microsurgical resources. It reduces primary hospital treatment thresholds and addresses suboptimal aesthetic/functional outcomes.

THERAPEUTIC: Level III.

PMID:40972085 | DOI:10.1016/j.injury.2025.112745

Injury. 2025 Sep 10;56(11):112754. doi: 10.1016/j.injury.2025.112754. Online ahead of print.

ABSTRACT

INTRODUCTION: Posterior malleolus fractures are frequently associated with varying degrees of comminution. This comminution often leads to osteochondral fragment loss from the posterior articular surface of the tibial plafond. The purpose of this study is to use finite element modeling to determine whether osteochondral defects at the posterior malleolus fracture interface significantly influence tibiotalar contact stress.

METHODS: 3D models of 10 randomly selected patients were created of the tibia and talus from CT scans. A layer of cartilage was added to simulate contact at the tibiotalar joint. Different circular osteochondral defects were modeled at the fracture interface 3 mm, 5 mm, 10 mm in diameter. Two sizes of fractures were modelled (5 mm and 10 mm), from the posterior-most point on the articular tibial surface. Models with fractures and without osteochondral defects, were tested as controls. Models were loaded in finite element software under single-leg-stance at average body weight. Scenarios were repeated for maximal dorsiflexion and plantarflexion. Differences between the sizes of osteochondral defects across different fracture sizes for each ankle range of motion scenario were determined.

RESULTS: No significant differences in maximum articular contact stresses were observed between different sized osteochondral defect sizes in the 5 mm fracture size and ankle range of motion scenarios. However, significant differences in maximum articular contact stresses were observed between different sized osteochondral defect sizes with 10 mm fracture sizes. These differences were observed in neutral and dorsiflexion, but not in plantarflexion.

CONCLUSION: Larger posterior malleolus fractures with osteochondral defects, when loaded with the ankle in neutral and dorsiflexion, resulted in larger tibiotalar articular stresses.

PMID:40972084 | DOI:10.1016/j.injury.2025.112754

Injury. 2025 Sep 9;56(11):112756. doi: 10.1016/j.injury.2025.112756. Online ahead of print.

ABSTRACT

The fifth metatarsal is essential for balance control during gait and remains susceptible to proximal fractures such as the Jones fracture due to its limited vascularity, making the choice of fixation method of critical importance. The study was conducted to biomechanically compare conventional fixation techniques and identify the most effective strategy for Jones fracture management, culminating in the design and rigorous evaluation of a novel biodegradable implant. A volumetric model of the fifth metatarsal with fixation constructs was developed using medical imaging and digital design tools, and its mechanical performance was assessed by finite element analysis. The proximal end of the metatarsal bone was immobilized, and a 60 N-according to literature-was applied to the distal end; frictional interaction was incorporated at the fracture interface to simulate realistic mechanical conditions. The mechanical properties of Ti6Al4V and CrNiMo alloys were used for the implant models. The intramedullary screw model registered the lowest stress values for both materials, prompting subsequent material and design modifications. A magnesium-based biodegradable material was adopted, and mechanical analyses were conducted again following the implementation of requisite design refinements. The modified biodegradable implant was verified to provide adequate structural performance, indicating its suitability for Jones fracture fixation.

PMID:40967129 | DOI:10.1016/j.injury.2025.112756

Injury. 2025 Sep 9;56(11):112757. doi: 10.1016/j.injury.2025.112757. Online ahead of print.

ABSTRACT

BACKGROUND: Literature on quality of life and functionality following various types of surgically treated foot injuries is limited, despite the significant impact on patients' daily lives. As a result, managing patient expectations becomes challenging. The current objective is to prospectively evaluate long-term patient-reported and clinical outcomes of surgically treated foot injuries.

METHODS: A multicentre prospective cohort study was conducted. Adult patients undergoing operative treatment for traumatic foot fractures and/or dislocations were eligible for inclusion. Data on patient demographics, treatment, patient-reported outcomes (health-related quality of life assessed using the EuroQol questionnaires, functionality evaluated by the American Orthopaedic Foot and Ankle Society scales, satisfaction, and return to work/sports), complications, and reoperations were collected. Follow-up lasted two years. Statistically significant and clinically relevant changes in outcomes were determined using the Friedman test and minimally important differences.

RESULTS: The follow-up response rate was 92%. Patients showed significant and relevant differences in EuroQol scores during follow-up compared to pre-trauma, not returning to their baseline levels. The EQ-VAS™ showed clinically relevant improvement between 1 and 2 years postoperatively. Patients with forefoot injuries had better EuroQol and sports function scores, but lower satisfaction compared to those with midfoot and hindfoot injuries. The EuroQol pain domain exhibited the largest increase in reported problems, followed by usual activities, mobility, anxiety, and self-care. In the forefoot, midfoot, and hindfoot subgroups, the complication rates were 50%, 19%, and 44% respectively. Most complications were related to posttraumatic arthrosis (26%) and infections (24%). Over half of the patients (52%) underwent implant removal. The majority of reoperations involved secondary arthrodesis (37%) or revision surgery (32%).

DISCUSSION AND CONCLUSION: Strengths of this study include the prospective multicentre setting, the high response and follow-up rates, its epidemiological nature, and the inclusion of various injury types with stratified data presentation. Limitations include recall bias, suboptimal minimal important differences, group heterogeneity, and the use of the suboptimal AOFAS scales. The overview of patient-reported and clinical outcomes for patients treated surgically for acute foot injuries presented in this study show persisting impairment in functionality at the two-year follow-up. The data will help manage patient expectations effectively.

PMID:40967128 | DOI:10.1016/j.injury.2025.112757

Injury. 2025 Sep 9;56(11):112751. doi: 10.1016/j.injury.2025.112751. Online ahead of print.

NO ABSTRACT

PMID:40967127 | DOI:10.1016/j.injury.2025.112751

Injury. 2025 Sep 6:112747. doi: 10.1016/j.injury.2025.112747. Online ahead of print.

ABSTRACT

INTRODUCTION: Augmented reality (AR) technology is rapidly evolving and is finding an increasing application in education, including medical training. This feasibility study aimed to explore the usability and didactic potential of AR with the HoloLens2™ for medical students, teaching the primary survey of burn wounds.

METHODS: This feasibility study was conducted using a prospective observational cohort design. Test groups consisted of participants with limited (n = 18), moderate (n = 10), or high (n = 5) experience in burn care, and filled in a questionnaire after training with the HoloLens2™.

RESULTS: Outcomes of the questionnaires show AR to be a promising technology for educating medical students in the primary survey of burn wounds.

DISCUSSION: However promising, there is further need for development in usability and image quality. The ability to simulate realistic scenarios in a safe and scalable environment could pave the way for a new era for medical education, where AR becomes a valuable supplement or even replacement for traditional learning methods.

PMID:40947373 | DOI:10.1016/j.injury.2025.112747

Injury. 2025 Sep 8:112758. doi: 10.1016/j.injury.2025.112758. Online ahead of print.

ABSTRACT

PURPOSE: Ecuador has seen a dramatic increase in violence, with homicides rising from 6.4 per 100,000 inhabitants in 2015 to 47.25 in 2023. In response, the government declared a state of internal armed conflict and a "state of emergency" This study aims to analyze the impact of this political measure on the admission of patients who are victims of violence to a hospital in the coastal region of the country.

METHODS: This is an analytical cross-sectional study conducted over nine months, from October 2023 to July 2024, divided into three-month periods. The independent variable was the period of surgical trauma: pre-exception, during the state of exception, and post-exception. The dependent variable was surgical trauma due to violence. A bivariate analysis was performed and a p-value of <0.05 was considered statistically significant.

RESULTS: The study included 160 cases of surgical trauma. Of the traumas reported during the nine months, 80 % (N=128) were due to violence. 78 % (N=125) of patients underwent surgery for penetrating trauma, with 77 % (96/125) of these due to firearms. The proportion of penetrating injuries due to firearms varied significantly according to period (p = 0.020). During the state of exception it fell to 60 % (21/35) from 79 % (31/39) pre-exception, but rose again in the post-exception period to 86 % (44/51).

CONCLUSION: The strategies implemented did not significantly reduce trauma admissions due to violence at this hospital, underscoring the imperative for additional interventions and a comprehensive understanding of the social determinants underlying this public health issue.

PMID:40946074 | DOI:10.1016/j.injury.2025.112758

Injury. 2025 Sep 8;56(11):112752. doi: 10.1016/j.injury.2025.112752. Online ahead of print.

ABSTRACT

The impact of gun violence on the well-being of children in the United States is a vital public health issue. Gaps remain in characterizing the population health burden, exacerbated by gun violence data limitations and research policy restrictions. This study explores the association between neighborhood-level gun violence and the general health status of children nationwide in the Environmental influences on Child Health Outcomes (ECHO) study. 13,450 children ages 0-17 and parents reported general health status. Gun violence incidents, defined as any death or injury caused by a gun, were extracted from the publicly available Gun Violence Archive by census tract between 2020 and 2023. Census tracts were categorized as low gun violence (< 2 incidents between 2020-2023) and high gun violence (≥ 2 incidents). A generalized estimating equation logistic model with robust variance was used to estimate the association between binary general health status (Good/Fair/Poor vs. Excellent/Very good) and neighborhood-level gun violence events adjusting for individual and census tract-level sociodemographic covariates. 11,329 (84 %) reported Excellent/Very Good general health and 2121 (16 %) reported Good/Fair/Poor general health. The adjusted odds of Excellent/Very Good general health were 20 % lower among children living in census tracts with high gun violence compared to low gun violence (OR 0.804; 95 % CI: 0.721, 0.897). When stratified by age group, the odds of Excellent/Very Good general health among younger children (ages 0 - 7) were 17.3 % lower (OR 0.827; 95 % CI: 0.687, 0.997) and 19.7 % lower among older children (ages 8 - 17) among those living in census tracts with high gun violence compared to those with low gun violence (OR 0.803; 95 % CI: 0.702, 0.919). Among children living in high socioeconomic vulnerability census tracts, the odds of Excellent/Very Good general health were 23 % lower in children living in census tracts with high gun violence compared to those with low gun violence (OR 0.767, 95 % CI 0.669, 0.880). Findings underscore the importance of community violence prevention efforts and the need to strengthen our understanding of community risk factors such as gun violence that hinder optimal child growth and development.

PMID:40945226 | DOI:10.1016/j.injury.2025.112752

Injury. 2025 Sep 9;56(11):112755. doi: 10.1016/j.injury.2025.112755. Online ahead of print.

ABSTRACT

INTRODUCTION: Obesity is a growing global concern. Bariatric surgery (BS) is the only intervention which leads to significant and long-lasting weight reduction. However, it has been associated with an increased risk of fracture. We aimed to investigate the association between BS and distal radius fractures (DRF).

METHODS: A retrospective cohort study of patients with obesity who underwent BS was conducted. The incidence of DRF and the non-osteoporotic scaphoid fracture in the six-years pre-and post-BS was compared. Sub-analysis for surgical type, weight loss, nutritional supplements, and treatment modality was conducted.

RESULTS: Seventeen-thousand, nine-hundred and four patients, aged 40 (SD 2.7) were included in the study, most of whom were females (71.2%). Most underwent restrictive gastric surgery (82.6%). The incidence of both fractures increased following BS (OR 2.091, 95% CI [1.524,2.896], p<0.001 for DRF and OR 6.013, 95% CI [2.819,14.720], p<0.001 for scaphoid fracturs). Women were affected more. DRFs were less common following restrictive surgery (0.6% versus 1.15% for gastric bypass surgery, OR 0.52 95% CI [0.35,0.79], p.=0.002), and their incidence was not associated with the time elapsed from BS. A greater weight reduction was not related with increased fracture risk, regardless of the fracture type, as was nutritional supplements consumption. DRF surgery rates were not affected by BS.

CONCLUSIONS: BS was found to relate with increased risk for DRFs. The risk was greater for gastric bypass patients and independent of the increasing cohort age, the amount of weight lost, the time elapsed from surgery, and the intake of nutritional supplements.

PMID:40945225 | DOI:10.1016/j.injury.2025.112755

Injury. 2025 Sep 5;56(11):112749. doi: 10.1016/j.injury.2025.112749. Online ahead of print.

ABSTRACT

BACKGROUND: Fracture related infection (FRI) is a serious complication of orthopedic trauma. The DAIR (Debridement, Antibiotics, and Implant Retention) approach has been used as a limb- and implant-sparing strategy in selected early infections, but the factors associated with clinical success and bone healing remain incompletely defined.

OBJECTIVE: To evaluate the effectiveness of DAIR in treating early FRI and to identify clinical, surgical, and microbiological factors associated with infection remission, recurrence and fracture consolidation.

METHODS: This retrospective cohort study included adult patients diagnosed with early FRI and treated with DAIR between 2017 and 2023. Clinical remission was defined as infection resolution without further surgery or suppressive antibiotic therapy at 12-month follow-up. Recurrence was defined as clinical or microbiological evidence of infection reappearance. Fracture consolidation was evaluated radiographically. Univariate analyses were performed using logistic regression, Fischer's exact text, chi-square, and t-test where appropriate.

RESULTS: A total of 59 patients were included. Clinical remission was achieved in 86.4 % of cases, while recurrence occurred in 32.2 %. All patients with recurrence had failed clinical remission (p < 0.001). Remission was significantly lower in patients with prior external fixation (72.7 % vs. 94.6 %; p = 0.031) and lower extremity infections (77.1 % vs. 100 % for pelvis and upper limb; p = 0.002). Fracture consolidation was observed in 86.4 % of patients. Although not statistically significant, trends indicated better consolidation in those with remission (90.2 % vs. 62.5 %) and lower healing in patients with comorbidities, or polymicrobial infections.

CONCLUSIONS: DAIR is effective treatment for early FRI, achieving high clinical remission and consolidation rates. Remission is a strong predictor of both infection control and bone healing. Prior external fixation and lower limb involvement were associated with reduced treatment success.

PMID:40945224 | DOI:10.1016/j.injury.2025.112749

Injury. 2025 Sep 5;56(11):112748. doi: 10.1016/j.injury.2025.112748. Online ahead of print.

ABSTRACT

PURPOSE: This study aims to evaluate the efficacy of nail dynamization in patients with delayed union and nonunion of femur and tibia shaft fractures following intramedullary nailing, and systematically analyze the associated factors to guide surgeons.

METHODS: A comprehensive search of PubMed, EMBASE, and Cochrane Library databases was conducted to identify relevant studies. We screened the literature based on the eligibility criteria, extracted relevant data, and assessed the quality of the included studies. A single-arm meta-analysis using a random-effects model was conducted to estimate overall union rates, while meta-regression and subgroup analyses explored sources of heterogeneity and contributing factors. Sensitivity analyses were used to assess result stability.

RESULTS: 11 studies consisting of 318 patients met the inclusion criteria. The pooled union rate after nail dynamization was 77.2 % with significant heterogeneity. Meta-regression identified the time of dynamization, the method of dynamization, and Fracture Healing Index (FHI) as critical factors affecting union rates. Subgroup analysis revealed that dynamization within 6 months, preserving the dynamic locking screw, and an FHI >1.17 were significantly associated with higher union rates.

CONCLUSION: Nail dynamization is an effective treatment for delayed union and nonunion of femur and tibia shaft fractures following intramedullary nailing. Early dynamization (within 6 months), preserving the dynamic locking screw, and ensuring an FHI >1.17 are crucial strategies for maximizing union rates.

PMID:40929874 | DOI:10.1016/j.injury.2025.112748

Injury. 2025 Aug 29:112721. doi: 10.1016/j.injury.2025.112721. Online ahead of print.

ABSTRACT

BACKGROUND: Hemorrhage remains the principal cause of death on the battlefield. It is suggested that Tranexamic acid (TXA) can improve survival of severely-bleeding casualties. The intravenous approach is not always available in the pre-hospital setting. It was shown that for every 15 min delay, the efficiency of TXA decreases by 10 %. This study was designed to assess the pharmacokinetic, pharmacodynamic, and pre-clinical efficacy of a TXA autoinjector in uncontrolled hemorrhage in swine.

METHODS: Non-compressible hemorrhage was induced by laparoscopic partial liver resection. TXA was administered intramuscularly by autoinjector (n = 25) or intravenously (control, n = 5). Blood levels of TXA and dynamics of clot formation were determined. Euthanasia was performed ninety minutes after injury followed by a laparotomy for the measurement of free blood and clots in the abdomen.

RESULTS: The TXA levels in the autoinjector group exceeded the effective therapeutic threshold within <5 min and remained above the 10 mg/L threshold throughout the experiment. Intra-abdominal blood volumes, hemodynamic parameters, and indices of clot formation were similar between autoinjector-delivered and intravenouslyadministered groups.

CONCLUSIONS: Autoinjector-based TXA provides sustained, anti-fibrinolytic levels within 2-5 min of administration in a swine model of uncontrolled hemorrhage emphasizing its important.

PMID:40915868 | DOI:10.1016/j.injury.2025.112721

Injury. 2025 Sep 2;56(11):112746. doi: 10.1016/j.injury.2025.112746. Online ahead of print.

ABSTRACT

INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for Type 2 diabetes and obesity due to their cardiometabolic benefits. However, their effects on fracture healing remain controversial. This study investigates perioperative GLP-1 RA use and outcomes following surgical treatment of lower extremity (LE) fractures.

METHODS: A retrospective analysis utilizing a large multicenter database compared patients on GLP-1 RAs within one year prior to and after lower extremity index surgery (+GLP) with those not on GLP-1 RAs (-GLP). Propensity score matching was performed on 275,970 included patients, matching 1:1 on age, sex, tobacco use, diabetes mellitus, primary hypertension, hyperlipidemia, chronic ischemic heart disease, chronic lower respiratory disease, and body mass index (BMI), resulting in 6125 "best-matched" patients per group. This was conducted utilizing multivariate logistic regression with a 0.1 caliper. Outcomes were assessed at 1 month, 3 months, and 1 year.

RESULTS: At 1-year follow-up, GLP-1 RA users demonstrated a significantly higher rate of nonunion compared to matched controls (5.4% vs 4.4%, Risk Ratio 1.2, 95% CI 1.0-1.4, P < 0.05) when assessing patients who also continued GLP-1 RAs postoperatively. There were no significant differences in wound dehiscence, deep or superficial surgical site infections, or hematoma. Importantly, the +GLP group experienced significantly lower rates of cardiac arrest (0.8% vs 1.6%, RR 0.5, 95% CI 0.3-0.7, P < 0.01) and all-cause mortality (4.4% vs 8.0%, RR 0.5, 95% CI 0.4-0.6, P < 0.01).

CONCLUSIONS: Perioperative GLP-1 RA use was associated with a higher risk of nonunion following lower extremity fracture surgery, though without increased wound complication rates. Importantly, GLP-1 RA use was linked to reduced cardiac arrest and mortality within one year. These findings suggest that while the increased rate of nonunion is statistically significant, its clinically significance is limited. Thus, the mortality reduction may be more clinically meaningful for patient counseling and perioperative management. Further study is required to clarify the balance between systemic benefits and surgical outcomes of GLP-1 RAs in orthopedic trauma.

PMID:40915058 | DOI:10.1016/j.injury.2025.112746

Injury. 2025 Aug 28;56(11):112718. doi: 10.1016/j.injury.2025.112718. Online ahead of print.

ABSTRACT

BACKGROUND: Critical size bone defects represent a clinical challenge, associated with considerable morbidity, and frequently trigger the requirement of secondary procedure. To fill osseous gaps, multiple steps are required, such as proliferation and differentiation on the cellular level and the building of extracellular matrix. In addition, the osteogenic potential of cell-derived extracellular matrices (CD-ECM) is known to enhance bone healing. We therefore examined the osteogenic potential of fibroblast-derived ECM (Fibro-ECM) and assessed the influence of Dextran-sulfate (Dx-S) addition regarding the production of extracellular matrix (ECM).

METHODS: ECMs were generated by culturing human dermal fibroblasts, adipose-derived stromal cells (ASCs), and osteoblasts derived from ASCs (Osteo-ECM) for four days, with or without Dx-S supplementation. After decellularization, skeletal stem cells (SSCs) isolated from femoral head aspirations were seeded onto the ECMs and differentiated under osteogenic conditions for 17 days. Osteogenesis was assessed by Alizarin Red S staining for calcium deposition and RT-qPCR analysis of osteogenic marker genes.

RESULTS: SSCs cultured on Fibro-ECM exhibited enhanced osteogenesis compared to Osteo-ECM and ASC-derived ECM, as evidenced by increased calcium deposition. Notably, Dx-S supplementation further improved the osteoinductive capacity of Fibro-ECM, leading to an upregulation of osteocalcin (OCN) and bone morphogenetic protein 2 (BMP2). In contrast, Dx-S had no significant effect on Osteo-ECM.

CONCLUSION: The addition of Dx-S in autologous fibroblast-derived ECM induces an improvement in osteoinductivity. Addition of Dx-S may therefore be a useful adjunct in the in vitro bone generation models. Whether these results may represent a piece in the puzzle for difficult healing situations in patients with nonunions and bone defects should be subject to further study.

PMID:40915057 | DOI:10.1016/j.injury.2025.112718

Injury. 2025 Aug 26;56(11):112720. doi: 10.1016/j.injury.2025.112720. Online ahead of print.

ABSTRACT

BACKGROUND: Lateral-sided tibial plateau fractures are most common and can range from minor to very extensive injuries of the lateral plateau. The impact of fracture location and extent on functional outcomes remains unclear. This study aimed to investigate this relationship.

METHODS: A retrospective cross-sectional study was performed in 529 patients treated for a lateral tibial plateau fracture within 6 hospitals between 2003-2018. Patients were approached by posted mail and completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire after a median follow-up of six years (IQR: 4-9 years). Fractures were classified according to the Krause 'Ten segment method'. The seven most prevalent fracture patterns were identified and compared using descriptive statistics. Multivariate regression analysis, adjusted for age, sex, Schatzker classification, treatment, and residual incongruity, was performed to assess the association between fracture location, number of affected segments, and patient-reported outcome.

RESULTS: The most frequent lateral tibial plateau fracture patterns were: pattern 1 - two posterior segments (KOOS = 82, IQR:66-93); pattern 2 - four lateral segments (KOOS = 74, IQR:53-94); pattern 3 - two anterolateral and one posterior segment (KOOS = 82, IQR:62-93); pattern 4 - anterolateral involvement (KOOS = 87, IQR:59-97); pattern 5 - involvement of the entire lateral plateau (KOOS = 60, IQR:40-71); pattern 6 - two posterior and one anterolateral segment (KOOS = 81, IQR:67-93); and pattern 7 - isolated lateral involvement (KOOS = 60, IQR:46-84). Patterns 5 and 7 showed the lowest KOOS scores (p = 0.008). Overall KOOS declined by 2.59 points per additional segment involved (p = 0.010), with similar trends observed in the ADL, sport, and QoL subscales (p < 0.05).

CONCLUSION: Surgeons should be aware during management of lateral tibial plateau fractures that all regions of the plateau-anterior, medial, lateral, and posterior-are crucial in preserving function. Fractures involving the entire lateral plateau (pattern 5) and isolated lateral segments (pattern 7) result in worse functional outcomes, likely due to the severity of the injury and associated soft tissue involvement, especially in the meniscal area. Greater fracture extent, as indicated by increased segment involvement, correlates with worse patient-reported outcomes.

PMID:40913857 | DOI:10.1016/j.injury.2025.112720

Injury. 2025 Aug 25;56(11):112728. doi: 10.1016/j.injury.2025.112728. Online ahead of print.

ABSTRACT

OBJECTIVE: This study aimed to comprehensively describe the clinical characteristics of rib fractures in patients with traumatic thoracic vertebral fractures (TVFs), and to develop machine learning (ML) models for predicting the risk of rib fractures.

METHODS: We retrospectively reviewed patients diagnosed with TVFs at a single hospital between January 2007 and November 2024, enrolling 1420 patients and 20 variables. Chest CT scans were used to confirm the presence of rib fractures and to examine their distribution characteristics. Several ML models, including Support Vector Machine (SVM), XGBoost, Logistic Regression (LR), Decision Tree (DT), Random Forest (RF), Gradient Boosting Decision Tree (GBDT), Naive Bayes (NB), Neural Network (NN), and Ensemble Learning (EL), were applied. Model performance was evaluated using indicators such as area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), F1 score, density, discrimination slope, and a scoring system. Additionally, the prediction performance of the ML models was compared with that of three experienced clinicians.

RESULTS: Rib fractures were identified in 222 patients (15.6 %), with a total of 1035 rib fractures recorded. Only 22.5 % were single rib fractures, and the distribution of unilateral and bilateral fractures was comparable (54.5 % vs. 45.5 %). Multivariate logistic regression revealed four significant predictors of rib fractures: gender (P = 0.004), cardiovascular disease (P = 0.003), trauma mechanism (P < 0.001), and the number of thoracic fractures (P < 0.001). Among all models, the EL model demonstrated the best predictive performance, achieving an accuracy of 0.920, F1 score of 0.767, sensitivity of 0.683, specificity of 0.977, PPV of 0.875, NPV of 0.928, and the highest overall score (48). Notably, its performance surpassed that of all three clinicians.

CONCLUSIONS: Rib fractures are relatively common in patients with TVFs and may be underdiagnosed, especially in the absence of clear symptoms. The EL model developed in this study offers strong predictive capability and may serve as a valuable clinical decision-support tool to identify high-risk patients and reduce the likelihood of missed diagnoses.

PMID:40913856 | DOI:10.1016/j.injury.2025.112728

Injury. 2025 Aug 23;56(11):112692. doi: 10.1016/j.injury.2025.112692. Online ahead of print.

ABSTRACT

INTRODUCTION: Mass casualty incidents (MCIs) involving extensive ballistic and explosive injuries place considerable pressure on healthcare resources. This study aimed to evaluate the rehabilitation resources required for individuals who sustained blast and ballistic injuries during an MCI.

METHODS: A retrospective review was conducted using Electronic Medical Records (EMRs) of patients admitted to Sheba Medical Center (SMC), Israel, following an MCI on 7 October 2023. Patients diagnosed with gunshot wounds (GSW), or blast injuries (BI) were included. Data were collected over an almost 7-month period, focusing on injury patterns, rehabilitation department admissions, total hospital length of stay, and associated budgetary requirements.

RESULTS: A total of 419 patients received rehabilitation at SMC: 205 with BI, 175 with GSW, 10 with both, and 9 with unknown injury causes. Two patients were under 18; the majority (76 %) of adults were aged 18-29. Military personnel comprised 90 % of the cohort, with 95 % male. Paediatric rehabilitation admitted the two minors, while adult patients were distributed across respiratory (n = 7), neurological (n = 32), head trauma (n = 44), and orthopaedic (n = 68) rehabilitation units. Additionally, 266 patients were treated in three newly established rehabilitation wards. BI patients experienced more complex, multi-trauma injuries, including traumatic brain injuries (11 %) and spinal cord injuries (11 %), underwent more surgical procedures, and had longer hospital stays. Consequently, the average rehabilitation cost per BI patient exceeded that of GSW patients.

CONCLUSION: Through strategic planning and multidisciplinary collaboration, SMC effectively managed a high volume of MCI-related injuries. BIs required significantly more rehabilitation resources than GSWs. These findings underscore the importance of preparedness, resource allocation, and interdepartmental coordination in managing rehabilitation during MCIs. SMC's experience offers valuable insights for global healthcare systems facing similar high-demand emergency scenarios.

PMID:40912126 | DOI:10.1016/j.injury.2025.112692