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Status of state trauma registries 2025: Have we made progress?

Injury -

Injury. 2025 Aug 10:112678. doi: 10.1016/j.injury.2025.112678. Online ahead of print.

ABSTRACT

BACKGROUND: High-quality, granular, accessible, and timely data are essential for evaluating regional trauma ecosystems and implementing programs to improve trauma care. State trauma registries play a crucial role in collecting, disseminating, and sharing data for clinicians, researchers, implementation scientists, and policymakers. This study aimed to assess the status and progress of statewide trauma registries in the United States over the past 20 years.

METHODS: A structured electronic survey was administered to eligible and consenting state trauma registry managers or emergency medical services personnel between July 2024 and November 2024. The survey gathered information on registry infrastructure, data collection and reporting processes, and data quality assurance measures. Findings were compared with those from a similar survey conducted in 2004.

RESULTS: All 50 states and the District of Columbia participated in the survey. Forty-seven states (92 %) reported an active trauma registry, an increase of 15 since 2004. Four states have never had a statewide registry, though two are planning to develop one. Among states with registries, only 18 (38 %) mandate data submission from all hospitals. While many registries have transitioned to web-based systems and updated software over the last two decades, 34 registries (72 %) still rely on manual data abstraction, and 28 (60 %) lack integration with electronic health records. Additionally, only 20 (43 %) state registries contribute data to national collection efforts.

CONCLUSIONS: Although progress has been made in establishing and modernizing state trauma registries since 2004, significant gaps remain, particularly in the absence of comprehensive mandatory reporting, the reliance on manual data entry, and the lack of integration with electronic health records and national databases. Addressing these challenges is essential for reducing the burden on registry teams and providing accurate, actionable, and timely data for improving trauma care.

PMID:40825754 | DOI:10.1016/j.injury.2025.112678

Impact of navigation on functional and radiological outcomes after total knee arthroplasty: a retrospective analysis of one hundred and ninety cases

International Orthopaedics -

Int Orthop. 2025 Aug 18. doi: 10.1007/s00264-025-06638-6. Online ahead of print.

ABSTRACT

BACKGROUND: Computer-assisted navigation in total knee arthroplasty (TKA) was developed to enhance implant positioning accuracy and optimize mechanical alignment. However, its impact on clinical outcomes remains controversial. This study aimed to evaluate the influence of navigation on functional and radiological outcomes, safety, and patient-reported quality of life at mid-term follow-up.

METHODS: We conducted a retrospective single-center study including 190 patients who underwent primary TKA between 2015 and 2018, with a mean follow-up of 5.8 years. Ninety-five patients were operated on using optical computer navigation, while 95 underwent conventional instrumentation (sequential allocation). All surgeries were performed by the same two senior surgeons using mechanical alignment in both groups. Outcomes included the Hospital for Special Surgery (HSS) knee score, EQ-5D, SF-12, patient satisfaction, and radiographic alignment. Both univariate and multivariate analyses were performed using SPSS (v28.0/v29.0).

RESULTS: Patients in the navigated group achieved significantly greater improvement in HSS knee scores (mean increase 41.9 vs. 34.9 points; p = 0.043) and a higher proportion of clinically meaningful functional improvement (> 35-point HSS increase: 63.2% vs. 40.0%; p = 0.019) compared to the conventional group. Postoperative knee flexion was also better in the navigated group (118° vs. 113°; p = 0.048). No significant differences were observed in pain improvement (VAS), EQ-5D quality-of-life gain, or complication rates between groups. Navigation significantly reduced the number of outliers in component alignment (6.3% vs. 13.7% outside ± 3° from neutral), although this did not reach statistical significance (p = 0.068). On multivariate analysis, use of navigation was an independent predictor of superior functional improvement (odds ratio 2.65, 95% CI 1.38-5.12; p = 0.003), whereas other factors (age, sex, body mass index, diabetes, baseline HSS) were not significant.

CONCLUSIONS: Computer-assisted navigation in TKA was associated with greater mid-term functional improvement and improved prosthetic alignment, without increasing operative time or complications. Its implementation may be especially beneficial for enhancing stability and precision in mechanically aligned TKA. These findings should be interpreted with caution due to the retrospective design and mid-term follow-up duration.

LEVEL OF EVIDENCE: Level III (retrospective comparative study).

PMID:40820163 | DOI:10.1007/s00264-025-06638-6

Long-term results of cementless humeral head resurfacing for humeral head osteonecrosis - a monocentric longitudinal observational study

International Orthopaedics -

Int Orthop. 2025 Aug 18. doi: 10.1007/s00264-025-06622-0. Online ahead of print.

ABSTRACT

PURPOSE: Humeral head osteonecrosis (HHN) is a joint-destructive condition, for which cementless humeral head resurfacing (CHHR) offers a bone-preserving treatment option. The aim of this study was to report long-term outcomes and implant survival of CHHR in patients with HHN.

METHODS: Patients with humeral head osteonecrosis treated with cementless humeral head resurfacing (CHHR) between 2004 and 2007 were included. Implant survival was assessed according to Kaplan-Meier analysis. Clinical evaluation included Constant-Murley-Score (CMS), Simple Shoulder Test (SST), Subjective Shoulder Value (SSV) and patient centered outcomes regarding satisfaction and quality of life. Radiographs were evaluated for glenoid erosion, Walch glenoid types as well as signs of implant loosening. Statistical comparison was performed using students t-tests with a significance level set to p < 0.05.

RESULTS: Seventeen shoulders were retrospectively included in the implant survival analysis. Two patients underwent revision surgery. five patients died with the implant and were therefore censored. Cumulative survival rate was 100% after ten years and 93.3% after 15 years. Seven shoulders were available for clinical and radiological evaluation at a mean follow-up of 19 years (range 17-22 years). Age- and sex-adjusted CMS improved from preoperative to the latest follow-up (44.4% vs. 82.9%; p < 0.01). No glenoid erosion of higher degree (Sperling grade > 2) and no signs of implant loosening were observed. All patients had Walch type A glenoids preoperatively.

CONCLUSION: In this small cohort with long-term follow-up of 17-22 years, CHHR showed promising durability and functional outcomes in carefully selected patients.

LEVEL OF EVIDENCE: Level IV Case series with no comparison group.

PMID:40820162 | DOI:10.1007/s00264-025-06622-0

Major trauma in equestrian activities in New South Wales, Australia: An eleven-year review

Injury -

Injury. 2025 Aug 7;56(10):112676. doi: 10.1016/j.injury.2025.112676. Online ahead of print.

ABSTRACT

INTRODUCTION: Equestrian activities are popular in Australia for both work and recreation. However, these activities are associated with high rates of injury [including major trauma] when compared to other physical activities and sports. Research assessing equestrian-related major trauma is limited. This study analyses the characteristics of equestrian-related major trauma in New South Wales, Australia, to guide injury prevention initiatives.

METHODS: A retrospective analysis was conducted using data from the New South Wales Trauma Registry on equestrian-related major trauma cases over an 11-year period from 2012 to 2022. Major trauma was defined as patients with an Injury Severity Score (ISS) greater than 12, as well as those admitted to the Intensive Care Unit or those who died in hospital, regardless of ISS. Incidence rates per 100,000 NSW population were analysed using Poisson regression.

RESULTS: A total of 624 equestrian-related major trauma cases were identified over the study period. The median age was 49 years (IQR 29-60), and the median ISS was 17 (IQR: 13-50). Females comprised 56.74 % of cases, with a significantly higher incidence rate than males (IRR 1.24, 95 % CI: 1.19-1.45, p = 0.007). Older individuals were at greater risk, with the highest incidence in the group aged between 40 to 59 (IRR 2.64, 95 % CI: 2.04-3.42). Most injuries occurred on farms (55.93 %), during leisure riding (28.21%) and were a result of a fall or being thrown from a horse (60.90 %). The most frequently injured anatomical regions included the thorax (25.40 %), spine (20.29 %), and head (18.73 %). Severe-to-critical injuries were proportionally highest in the thorax (65.08 %), head (46.97 %), and lower extremities (43.97 %). The incidence rate of major trauma increased steadily during the study period (IRR 1.027, 95 % CI: 1.002-1.053, p = 0.036).

CONCLUSION: The data presented in this paper provides an overview of the characteristics of equestrian-related major trauma. Salient points are that major equestrian-related trauma predominantly affects females and older individuals, with the thorax, spine, and head the most frequently injured anatomical regions. Farms are identified as the primary location of injuries across all age groups. These findings can guide future injury prevention initiatives.

PMID:40818164 | DOI:10.1016/j.injury.2025.112676

Hemiarthroplasty versus nonoperative treatment of comminuted proximal humeral fractures: results of the ProCon multicenter randomized clinical trial

Injury -

Injury. 2025 Jul 19;56(10):112620. doi: 10.1016/j.injury.2025.112620. Online ahead of print.

ABSTRACT

BACKGROUND/AIM: The best treatment of comminuted, proximal humeral fractures in the elderly population is an unresolved clinical problem. This study aimed to compare the outcome of hemiarthroplasty (HA) and nonoperative treatment in the elderly population patients with a comminuted proximal humeral fracture.

METHOD: From October 6, 2009 to April 26, 2017, 57 elderly patients with a comminuted proximal humeral fracture were enrolled in the multicenter randomized controlled trial (RCT). Patients were randomized to HA or nonoperative treatment. Outcome measures were the Constant-Murley score (primary outcome), Disabilities of the Arm, Shoulder, and Hand, pain (Visual Analog Score), quality of life (Short Form-36 and EuroQoL-5D-3 L), complications, revision operation, health care consumption, and costs. Patients were followed for two years.

RESULT: Of the 57 patients included, 30 underwent treatment with HA and 27 were treated nonoperatively. Patients had a median age of 77 years, and 89 % was female. According to the Hertel classification, most fractures were type 7 (47 %) or type 12 (42 %). The median Constant-Murley score increased from 23 (95 % CI 17-29) at six weeks to 48 (95 % CI 41-53) at 24 months in the HA group, and from 24 (95 % CI 17-31) to 59 (95 % CI 52-65) in the nonoperative group. Throughout follow-up, scores were similar in both groups. The DASH score consistently decreased over time in both groups. At 24 months, median DASH scores were 24.0 (95 % CI 17.4-30.8) and 23.4 (95 % CI 16.5-30.4) in the HA and nonoperative group, respectively. Pain levels, SF-36, and EQ-5D were similar in both groups throughout follow-up. Eleven patients, of which seven in the HA group, developed one or more complications, of which six patients required surgical interventions. Total costs were higher for HA, although not statistically significant.

CONCLUSION: Based on results of this RCT, primary hemiarthroplasty cannot be considered superior to nonoperative treatment for comminuted proximal humeral fractures in the elderly population. A trend favoring nonoperative treatment is observed in outcomes and in costs.

PMID:40818163 | DOI:10.1016/j.injury.2025.112620

Antegrade insertion of full-length ramus screws for the treatment of pelvic and/or acetabular fracture

Injury -

Injury. 2025 Aug 8;56(10):112669. doi: 10.1016/j.injury.2025.112669. Online ahead of print.

ABSTRACT

INTRODUCTION: The success rate of antegrade insertion of a full-length ramus osseous fixation pathway (OFP) screw remains unreported. The objective of this study was to assess the safety, feasibility, and effectiveness of a novel antegrade technique for inserting full-length ramus screws, as well as to determine the parameters of the ramus OFP based on screw placement.

PATIENTS AND METHODS: From January 2022 to September 2024, patients with fractures of the superior pubic ramus or the anterior acetabular column treated with a novel technique of an antegrade insertion of a superior ramus OFP screw were recruited into this study. Peri- and postoperative complications were documented. Parameters of the OFP were measured based on the position of the inserted full-length screws on postoperative CT scans.

RESULTS: Thirty-eight fully threaded, large-diameter (7 mm) antegrade full-length screws were successfully inserted in 32 patients with no intraoperative screw insertion failures occurring. The procedure was performed without any noted wound infections or associated neurological, urological, and visceral complications. Postoperative CT images confirmed that all 38 ramus screws were correctly positioned within the bony corridors, with no evidence of screw breaching the hip joint. The OFP measures 118.9 ± 5.6 mm in length, with an angle projection of 38.7 ± 3.8 degrees to the horizontal plane and 15.8 ± 4.9 degrees to the coronal plane. All patients were followed for an average duration of 16.1 months (range, 6.2-31 months). Bone union was achieved in all cases with a union time of 3 months (range, 2.5 to 5 months), and no complications such as loss of reduction, screw loosening, breakage, or bone delayed union were noted.

CONCLUSIONS: Our novel antegrade technique for inserting a full-length large ramus screw has been validated for its safety, feasibility, and effectiveness. The parameters obtained through the insertion of a full-length screw in this study accurately represent those of our new ramus OFP and serve as a guide for the placement of full-length screws.

PMID:40816064 | DOI:10.1016/j.injury.2025.112669

Articular involvement impacts unplanned reoperation rates in floating knee injuries

Injury -

Injury. 2025 Aug 10;56(10):112679. doi: 10.1016/j.injury.2025.112679. Online ahead of print.

ABSTRACT

OBJECTIVES: To compare the rate of unplanned reoperation to address fracture-related complications between extraarticular floating knee fracture patterns and those involving the articular surface of the knee, and to assess the impact of concomitant patella fracture on outcomes.

METHODS: Design: Retrospective study of patients with a floating knee injury treated at a single level 1 trauma center from 2012-2022.

SETTING: Single, urban, level 1 trauma center. Patient selection criteria: Patients ≥18 years old with a floating knee injury treated at a single urban level 1 trauma center from 2012-2022, with at least 3 months of followup. Outcome measures and comparisons: The primary outcome measure was the rate of unplanned reoperation to treat infection, obtain union, or surgically address knee stiffness.

RESULTS: Reoperation to address fracture-related complications was high in both extra and intraarticular floating knee patterns, with a trend toward more surgery to address knee stiffness in those with articular involvement (p = 0.078). Concomitant patella fracture and open fracture were present in 12 and 46 of the 64 patients, respectively; the presence of open fracture was significantly associated with reoperation to address either nonunion or infection (p < 0.001). An associated patella fracture was significantly associated with requiring surgery to address knee stiffness (p = 0.009).

CONCLUSIONS: Floating knee injuries with at least one articular fracture, especially when the patella is involved, had higher rates of surgery for knee stiffness. Intraarticular floating knee injuries are challenging, often requiring reoperation for infection, nonunion, or stiffness. Surgeons should be proactive with early motion protocols, supervised therapy, and tools like continuous passive motion to reduce knee stiffness risk.

LEVEL OF EVIDENCE: III.

PMID:40816063 | DOI:10.1016/j.injury.2025.112679

Outcomes of immediate full weight bearing protocol for incomplete intertrochanteric occult hip fractures

Injury -

Injury. 2025 Aug 5;56(10):112649. doi: 10.1016/j.injury.2025.112649. Online ahead of print.

ABSTRACT

INTRODUCTION: Occult hip fractures are femoral neck fractures diagnosed by MRI or CT scan following negative plain radiographs. Incomplete intertrochanteric occult hip fractures (IIOHFs) do not involve the medial cortex. These fractures can be isolated but can also occur in the presence of greater trochanter (GT) fractures. Many authors recommend further imaging to exclude IIOHFs in cases where a GT fracture is present on plain radiograph, in order to evaluate the intertrochanteric region fracture extension. There is no consensus on the optimal treatment for IIOHFs, with approaches ranging from surgical fixation to full weight bearing. At our institution a protocol of immediate full weight bearing for patients diagnosed with IIOHFs was implemented. This study retrospectively evaluates the outcomes of this treatment protocol.

METHODS: The medical records of patients who underwent MRI for suspected occult hip fractures were retrospectively analyzed. Inclusion criteria included: (1) patients with no findings on plain radiographs who were diagnosed by MRI with intertrochanteric fractures not involving the medial cortex, and (2) patients with isolated GT fractures diagnosed by plain radiographs and fracture extension greater than one-third of the intertrochanteric width seen on MRI. Data regarding initial hospitalization, diagnostic timing and findings, and follow-up outcomes were collected.

RESULTS: Of 196 MRI scans performed during the study period, 45 patients met the inclusion criteria. None of these patients experienced secondary displacement of the fracture despite immediate full weight bearing. The average age was 81.1 years, and 21(10.7%) patients were male. The mean time from admission to MRI was 30 h, and the average length of hospitalization was 6.3 days. The 45 intertrochanteric fractures that were included in this study include nine isolated incomplete intertrochanteric fractures and 36 GT fractures with extension greater than one third of the intertrochanteric width. None of the GT fractures had involvement of the medial cortex.

CONCLUSION: Our findings suggest that immediate full weight bearing is a safe treatment approach for IIOHFs. Operative fixation or immobilization may be unnecessary for these fractures. Our findings also challenge the clinical necessity of routine MRI scans in patients with GT fractures to assess for fracture progression.

PMID:40816062 | DOI:10.1016/j.injury.2025.112649

Laminectomy and laminoplasty hybrid decompression versus laminectomy with lateral mass screw fixation for degenerative cervical myelopathy: a propensity score-matched study

International Orthopaedics -

Int Orthop. 2025 Aug 15. doi: 10.1007/s00264-025-06640-y. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare the clinical and radiological outcomes between posterior laminectomy and laminoplasty hybrid decompression and laminectomy with lateral mass screw fixation in multilevel degenerative cervical myelopathy.

METHODS: A total of 158 patients for multilevel degenerative cervical myelopathy (DCM) undergoing surgical treatment were enrolled in this study from May 2018 to December 2023, including 97 patients who underwent posterior laminectomy and laminoplasty hybrid decompression (PLLDH) and 61 patients treated with posterior lateral mass screw fixation (PLMSF). To minimize potential confounding factors, propensity score matching was employed for inter-group comparison. Neurological function scores and radiographic parameters were systematically compared between the two surgical groups.

RESULTS: Following propensity score matching (PSM), baseline characteristics showed no statistically significant differences between the two surgical groups. The matched cohorts demonstrated that operative duration, intraoperative blood loss, VAS scores, Cobb angle, dural sac cross-sectional area at the narrowest level, and posterior dural displacement had no statistically significant differences(P > 0.05). However, significant inter-group differences were observed in JOA scores (P<0.05), NDI scores (P<0.05), and cervical range of motion (P<0.05) postoperatively.

CONCLUSION: Both PLLDH and PLMSF are effective surgical approaches for treating multilevel DCM, demonstrating satisfactory clinical outcomes. However, PLMSF resulted in greater postoperative loss of cervical mobility compared to PLLDH.

PMID:40815488 | DOI:10.1007/s00264-025-06640-y

Impact of Childhood Obesity on Capital Femoral Epiphysis Morphology: A Large-Scale, Automated 3D-CT Study and Potential Implications for SCFE Pathogenesis

JBJS -

J Bone Joint Surg Am. 2025 Aug 14. doi: 10.2106/JBJS.24.01472. Online ahead of print.

ABSTRACT

BACKGROUND: The precise pathological mechanisms through which obesity increases the risk of slipped capital femoral epiphysis (SCFE) remain unclear. We aimed to investigate the impact of childhood obesity on the morphology of the capital femoral epiphysis in children and adolescents without hip disorders.

METHODS: We performed a retrospective cross-sectional study that included 4,888 children and adolescents 7 to 19 years of age who underwent a hip or pelvic computed tomography (CT) scan, most for abdominal pain, between 2004 and 2022. Automated 3D-CT analysis assessed epiphyseal tubercle height, superior and anterior peripheral cupping, and epiphyseal tilt. Generalized additive models (GAMs) were used to examine the associations between epiphyseal morphology and age, stratified by obesity status, while adjusting for sex.

RESULTS: We observed distinct age-related trajectories of femoral-head morphology related to obesity. Subjects with obesity demonstrated a larger femoral-head diameter from ages 7 to 15 years (obese versus normal-weight differences: 0.3 to 2.3 mm), smaller epiphyseal tubercle height after 9 years of age (normal-weight versus obese differences: 0.4% to 1.3%), and a more posteriorly tilted epiphysis, as assessed by a smaller axial tilt angle (normal-weight versus obese differences: 4° to 1°) from ages 7 to 15 years. In subjects with obesity, the superior epiphyseal cupping was larger before 11 years of age (obese versus normal-weight differences: 1.6% to 0.4%), but after 13 years of age, the superior epiphyseal cupping was smaller (normal-weight versus obese differences: 0.2% to 2%).

CONCLUSIONS: Children with obesity demonstrated a smaller epiphyseal tubercle height, greater posterior epiphyseal tilt, and reduced superior cupping compared with children of normal weight. These anatomical differences may contribute to the increased risk of SCFE in patients with obesity and offer potential imaging markers for earlier identification and risk-stratification.

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

PMID:40811524 | DOI:10.2106/JBJS.24.01472

Conversion of Fused Knees to Total Knee Arthroplasty: The 21 to 31-Year Clinical Results and Patient Satisfaction

JBJS -

J Bone Joint Surg Am. 2025 Aug 14. doi: 10.2106/JBJS.25.00149. Online ahead of print.

ABSTRACT

BACKGROUND: There are limited long-term data on the results of conversion of a surgically or spontaneously fused knee to a total knee arthroplasty (TKA) in the literature. The purpose of this study was to determine the long-term (minimum, 21-year) results of TKA in a fused knee.

METHODS: We reviewed the results of 95 TKAs in the fused knees of 93 patients (mean age, 41.9 ± 9.4 years; range, 23 to 62 years) using a TKA system. The mean follow-up was 25.1 years (range, 21 to 31 years).

RESULTS: The mean Knee Society score was 88 points (range, 56 to 96 points) at the final follow-up. The mean range of motion was 76.4° (range, 0° to 105°). Nine knees (9%) required revision for aseptic loosening of TKA components. One knee (1%) was revised for pyogenic infection, and another knee was revised for recurrent tuberculous infection. Approximately 80% of patients were satisfied with the TKA. Approximately 67% of patients reported that their quality of life improved greatly after TKA. Kaplan-Meier survivorship, with revision for failure as the end point, was 88.4% (95% confidence interval, 83% to 97%) at 25.1 years postoperatively.

CONCLUSIONS: Conversion of a fused knee to TKA resulted in good long-term fixation and high satisfaction.

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

PMID:40811520 | DOI:10.2106/JBJS.25.00149

Outcomes of Extra-Articular Subtalar Arthrodesis for Valgus Deformity of the Hindfoot in Patients with Cerebral Palsy: A Radiographic and Pedobarographic Study

JBJS -

J Bone Joint Surg Am. 2025 Aug 14. doi: 10.2106/JBJS.24.01611. Online ahead of print.

ABSTRACT

BACKGROUND: Extra-articular subtalar arthrodesis generally has been recommended for treating severe valgus deformities of the hindfoot in patients with cerebral palsy (CP). However, it is unknown whether restricted subtalar joint motion affects the shape of the foot during continued growth in children. The purpose of the present study was to evaluate the effectiveness and longevity of extra-articular subtalar arthrodesis in ambulatory patients with spastic CP, with a specific focus on its impact on the final foot shape and plantar pressure distribution.

METHODS: The present retrospective study included 99 feet in 60 children with a mean age (and standard deviation) of 7.6 ± 2.1 years at the time of surgery and 16.6 ± 4.7 years at the latest follow-up. Radiographic changes were analyzed both during the early postoperative period and at extended follow-up. At the latest follow-up, the feet were classified into 3 categories (hindfoot valgus, neutral, or varus) on the basis of the valgus/varus index obtained from dynamic pedobarographs.

RESULTS: All radiographic parameters improved at 6 months after surgery. However, at the latest follow-up, all measurements except for the lateral talocalcaneal angle indicated overcorrection of the hindfoot valgus deformity. The overall valgus/varus index decreased from 0.54 ± 0.25 before surgery to -0.29 ± 0.35 at the latest follow-up. Five feet (5.1%) were classified as hindfoot valgus, 41 feet (41.4%) as neutral, and 53 feet (53.5%) as varus. Patients with hindfoot varus were younger at the time of surgery, and a lower anteroposterior talus-first metatarsal angle at 6 months after surgery was found to be the only significant radiographic predictor of the development of hindfoot varus. Revision procedures were performed on 22 feet (41.5%) in the varus group.

CONCLUSIONS: Extra-articular subtalar arthrodesis is associated with a high risk of progressive hindfoot varus deformity in patients with CP. Our findings highlight the need to reevaluate traditional surgical indications for correcting hindfoot valgus deformity, which have largely been based on the severity of the deformity observed on radiographs. Decision-making also should account for growth-related changes associated with restricted subtalar motion and the intraoperative position of the hindfoot and forefoot.

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

PMID:40811496 | DOI:10.2106/JBJS.24.01611

Characteristics and outcomes of interprosthetic versus periprosthetic femur fractures

Injury -

Injury. 2025 Aug 7;56(10):112653. doi: 10.1016/j.injury.2025.112653. Online ahead of print.

ABSTRACT

OBJECTIVES: The purpose of this study was to compare demographics, treatments, and outcomes of interprosthetic (IPFFs) and periprosthetic femur fractures (PPFFs). IPFFs were hypothesized to occur in older patients and have higher rates of reoperation, implant failure, and mortality.

METHODS: This was a retrospective cohort at a Level 1 trauma center analyzing adults with PPFFs/IPFFs from 2012-2024. Patients with < 30 days follow-up were excluded. Patient characteristics, treatments, and complications were compared between IPFFs and PPFFs.

RESULTS: 276 patients with 30 IPFFs and 246 PPFFs were included. IPFFs were older (74y v 69y p=.035), more commonly osteoporotic (33% v 11% p<.001), and more commonly current (17% v 14%) or former smokers (7% v 0% p<.001). IPFFs presented with 29 total hip (THA) and knee (TKA) arthroplasties and one THA and unicompartmental knee arthroplasty. PPFFs presented with 130 fractures around THAs and 116 fractures around TKAs. IPFFs more commonly presented with unstable prostheses (40% v 21% p=.017). Of the seven IPFFs treated with nail-plate hybrid constructs (NPCs), six (86%) were immediately weightbearing as tolerated (WBAT). Of the 23 IPFFs not treated with NPCs, 9 (39%) were immediately WBAT (p=.031). IPFFs had more blood loss (811mL v 513mL p=.016). The mortality rate was 15% in IPFFs and 4% in PPFFs (p=.02). IPFFs had higher rates of implant failure (23% v 7% p=.004) and superficial infection (15% v 4% p=.013). Of the seven IPFFs treated with NPCs, there were no implant failures, while 7/23 (30%) IPFFs treated with other techniques failed (p=.09).

CONCLUSIONS: IPFFs were older, more commonly osteoporotic, more likely to be smokers, and more often had unstable prostheses at presentation than PPFFs. While treatments were similar, the rate of mortality, implant failure and superficial infection was higher in IPFFs. NPCs may allow for earlier weightbearing but their long-term effects regarding outcomes and stability require further investigation in prospective studies.

LEVEL OF EVIDENCE: III.

PMID:40812247 | DOI:10.1016/j.injury.2025.112653

Severity of mountain accidents in Catalonia over the period 2011 to 2021: An ordinal regression analysis

Injury -

Injury. 2025 Aug 8;56(10):112672. doi: 10.1016/j.injury.2025.112672. Online ahead of print.

ABSTRACT

Mountain accidents have increased over the last decade all around the globe mostly due to a raise of mountain activity practitioners. Outcomes of accidents usually imply evacuation, traumatic injuries or even cardiovascular events. Sex, age, activity, altitude, experience, and equipment adequacy relate to accidents as direct causes or moderators of accident severity. This study focuses on the mountain accidents in Catalonia with descriptive and ordinal regression analysis aiming to characterize a victim vulnerability profile, which remains largely unexplored. The current sample includes 3257 mountain rescue operations from the Catalan Fire Department records between 2011 and 2021. Descriptive analysis showed that the most common profile was being hiker (63 %), climber (11.6 %), mountain biker (10.2 %), man (60.3 %), going in group (84.3 %), occurring in weekends (53.7 %), and suffering traumatic events (61.4 %) or needing technical support (20.4 %). Moreover, the main causes of fatality were falls and cardiovascular issues with the latter showing the higher fatality rate (55.5 %). Ordinal regression analysis explained a modest amount of variance (Nagelkerke R2 = 0.12), suggesting that predictors of higher severity were Group, Altitude, Male, Gathering, Mountain Biking and other practices such as Hunting. Recommendation to rescue teams comprise standardizing and potentiate data collection, conducting awareness campaigns targeted mainly to hikers, mountain bikers and elderly men, and to reinforce awareness campaigns and rescue teams during weekends.

PMID:40812246 | DOI:10.1016/j.injury.2025.112672

How mode of evacuation, roadway environment, and traffic conditions relate to injury severity score? Untangling the role of pre-hospital time in road crashes

Injury -

Injury. 2025 Aug 8;56(10):112668. doi: 10.1016/j.injury.2025.112668. Online ahead of print.

ABSTRACT

This study explores the effects of some of the key factors, including emergency response measures, roadway and environment, traffic-related attributes, and crash-specific factors, on the Injury Severity Score (ISS) of Road Traffic Crashes' (RTCs) victims, both directly and through pre-hospital time (PHT), using rigorous path analysis. Data for 298,654 crashes, compiled by the Road Traffic Injury Research and Prevention Center (RTIRPC) in Karachi (Pakistan), were used for analyses. Owing to the corner-solution distribution of the response variables (PHT and ISS), two Tobit regression models are estimated after accounting for missing values through synthetic data generation. Marginal effects from these models are used in the path analysis. The findings suggest that ISS increases by 0.01 units with a unit increase in PHT, highlighting the critical need for rapid evacuation of crash victims to medical facilities. The mode of evacuation emerged as a crucial factor, with ambulances resulting in increased PHT and ISS compared to private or public transport, underscoring the improvement needed in the dedicated ambulance-based emergency response. PHT and ISS were found to be higher in nighttime crashes, necessitating better emergency medical services (EMS) response during the night. Intersection crashes were associated with lower PHT and ISS; whereas, crashes on undivided roads and those involving multiple or large vehicles increased PHT and ISS. The path analysis revealed that the overall effects of some of the key variables on ISS were higher than their direct effects - something that could not be explored without the path analysis. These insights can help policymakers develop strategies to improve emergency response and road safety, ultimately reducing the number of RTC-related injuries and fatalities.

PMID:40812245 | DOI:10.1016/j.injury.2025.112668

Futility indications in resuscitative thoracotomy: A retrospective observational study evaluating practice guidelines

Injury -

Injury. 2025 Aug 6;56(10):112673. doi: 10.1016/j.injury.2025.112673. Online ahead of print.

ABSTRACT

BACKGROUND: Resuscitative thoracotomies (RTs) are controversial interventions that heavily consume resources and can pose risks for the surgical team. Increasingly limited resources and risk to healthcare teams have encouraged the continued refinement of RT guidelines. We evaluated RT futility indicators amid institutional RT practice guideline changes.

METHODS: Thoracotomies conducted at our Level 1 Trauma Center from January 2017 to July 2023 were reviewed and classified as either RT or non-resuscitative (non-RT). Injury characteristics, patient demographics, procedure details, and mortality outcomes were collected through chart review.

RESULTS: Of 78 thoracotomies, 56 (71.8 %) were RTs, predominantly on patients with penetrating injuries (55.4 %), specifically gunshot wounds (46.4 %). Most RTs (87.5 %) complied with Eastern Association for the Surgery of Trauma guidelines. The procedure mortality rate was 4.6 % for non-RT and 67.9 % for RT, and hospital mortality was 13.6 % for non-RT and 89.3 % for RT. Thus, 10.7 % of RT patients survived to discharge, including 5 (16.2 %) with penetrating injuries and 1 (4.0 %) with blunt injuries. Ten (17.8 %) RT patients arrived with fixed and dilated pupils, 11 (19.6 %) arrived with no signs of life, and 4 (10.7 %) received pre-hospital CPR, all of whom did not survive to discharge. Changes in institutional practice guidelines decreased the frequency of total thoracotomies, but not RT numbers.

DISCUSSION: RT utilization and mortality rates remained consistent after implementing stricter institutional guideline policies. Improving odds of survival may require further refinement to RT practice guidelines regarding patient selection criteria. We recommend adding witnessed cardiac arrest and prioritizing pupillary response to RT futility guidelines regardless of injury pattern.

PMID:40812244 | DOI:10.1016/j.injury.2025.112673

Will Investigators Enroll Particular Subjects in a Randomized Controlled Trial?: A Mixed-Methods Study to Gauge Investigator Equipoise in a Trial of Surgery Versus Nonoperative Therapy in Subjects with Meniscal Tear and Persistent Pain Following...

JBJS -

J Bone Joint Surg Am. 2025 Jul 18. doi: 10.2106/JBJS.24.01575. Online ahead of print.

ABSTRACT

BACKGROUND: Clinician equipoise-indifference between treatment arms-provides an ethical foundation for clinician participation in randomized controlled trials (RCTs). In preparation for an RCT comparing arthroscopic partial meniscectomy versus enhanced nonoperative therapy for patients with a meniscal tear and knee osteoarthritis (OA) who remain symptomatic after a course of physical therapy, we conducted a mixed-methods study to assess equipoise among potential enrolling clinicians.

METHODS: Fifteen clinicians with experience managing meniscal tears assessed 29 vignettes of hypothetical patients who met trial eligibility criteria. We randomly varied 13 vignette features (e.g., age, sex, radiographic severity, tear morphology). Clinicians expressed their willingness to enroll each hypothetical patient. After polling, we recorded and transcribed a moderated discussion to document clinician thought processes. We performed a quantitative analysis to identify clinical features associated with the likelihood of enrollment and an exploratory thematic analysis of the transcribed discussion to explicate the quantitative findings.

RESULTS: The 15 orthopaedic surgeons and physician assistants assessed 29 vignettes describing hypothetical patients. Eight votes were missing, leaving 427 vignettes, of which the clinicians were willing to enroll 302 (71%) (range, 24% to 100%) in the trial. Three clinicians were willing to enroll <50% of vignettes. Clinicians were willing to enroll just 39% of vignettes with bucket-handle tears. In logistic regression analyses, a bucket-handle tear (adjusted odds ratio [aOR], 0.12; 95% confidence interval [CI], 0.04 to 0.37) and Kellgren-Lawrence 3 radiographs (aOR, 0.54; 95% CI, 0.36 to 0.82) were independently associated with clinician unwillingness to randomize. The qualitative analysis confirmed that clinicians believed that bucket-handle tears should be managed operatively, whereas combinations of greater age, severe OA, inability to walk 200 yards, and higher body mass index (BMI) pushed clinicians toward nonoperative therapy.

CONCLUSIONS: This methodology can be used to identify clinicians who should be engaged in discussions and interventions to support equipoise. It can also inform development of exclusion criteria (e.g., exclude bucket-handle tears) to increase the proportion of eligible subjects referred for enrollment.

CLINICAL RELEVANCE: Orthopedic surgeons play crucial roles in randomized controlled trials, the foundation of clinical practice guidelines, by enrolling patients from their practices. This article examines clinician equipoise, a key determinant of the willingness of clinicians to enroll eligible patients in trials.

PMID:40802780 | DOI:10.2106/JBJS.24.01575

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