J Bone Joint Surg Am. 2025 Jul 25. doi: 10.2106/JBJS.25.00086. Online ahead of print.

ABSTRACT

BACKGROUND: The U.S. Food and Drug Administration has approved a bupivacaine and meloxicam extended-release (ER) intra-articular injection for pain during total knee arthroplasty (TKA). However, the real-world evidence with regard to analgesic efficacy of that medication has been limited. This randomized clinical trial investigated the efficacy of this new medication compared with our standard periarticular injection for postoperative analgesia after primary TKA.

METHODS: Eligible patients undergoing primary, unilateral TKA for osteoarthritis at our academic center were enrolled. Patients were blinded and were randomized 1:1 to the bupivacaine-meloxicam ER (ZYNRELEF) injection group or the standard injection (ropivacaine, ketorolac, epinephrine) control group. A standardized, multimodal analgesic pathway was implemented. Numeric Rating Scale (NRS) pain scores and tallies of opioid consumption were collected. The primary outcome was the area under the curve (AUC) for NRS pain, adjusted for opioid consumption, over 72 hours. The minimal clinically important difference was considered to be 30%. Power analysis determined a minimum of 44 patients per group. The final groups included 53 patients in the experimental group and 48 patients in the control group.

RESULTS: Similar postoperative analgesia was observed, with an AUC for the adjusted NRS pain score up to 72 hours of 331 in the experimental group and 373 in the control group (p = 0.09). The mean maximum NRS pain scores were similar and reflected good, but not complete, analgesia. Scores were 3 to 5 on the day of the surgery, 4 to 6 on postoperative day (POD) 1, 5 to 6 on POD 2, and 4 to 5 on POD 3 (p > 0.05). One patient in the experimental group and 2 patients in the control group had early postoperative complications, none of which was deemed to be related to the analgesic choice.

CONCLUSIONS: This randomized clinical trial demonstrated similar analgesia with a bupivacaine-meloxicam ER solution and a standard periarticular injection up to 72 hours after primary TKA. Cost, reimbursement, and convenience may ultimately prove to be more important than analgesic differences when choosing between these 2 effective options for managing postoperative pain.

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

PMID:40711999 | DOI:10.2106/JBJS.25.00086

Injury. 2025 Jul 8;56(8):112578. doi: 10.1016/j.injury.2025.112578. Online ahead of print.

ABSTRACT

PURPOSE: Acetabular fractures remain one of the most complex injuries in orthopedic trauma surgery. Although the Judet-Letournel classification is widely accepted, it is predominantly descriptive and may offer limited intraoperative guidance. This study aims to present a simplified framework based on functional fracture orientation, distinguishing between column and transverse fracture families. Through this lens, surgical planning, reduction strategy, and fixation method selection can be facilitated.

METHODS: A five-step interpretation model was developed to classify and manage acetabular fractures. The model includes: (1) identification of primary and secondary fracture lines, (2) radiographic analysis from AP and Judet views, (3) axial CT orientation to determine fracture trajectory, (4) identification of the constant fragment, and (5) evaluation of endo-pelvic and exo-pelvic accessibility. Each fracture family was analyzed to correlate fracture morphology with specific reduction maneuvers, clamp positioning, and definitive implant placement.

RESULTS: Column fractures follow a coronal orientation when viewed on an axial CT, while transverse and T-type fractures propagate in a sagittal plane and often involve both columns. T-type fractures present an additional vertical component requiring dual-column reduction. For each fracture pattern, tailored reduction tools and implant configurations are proposed according to anatomical accessibility and biomechanical demands.

CONCLUSION: This structured approach offers a reproducible analytical tool for preoperative planning and intraoperative execution. By simplifying fracture type interpretation and aligning morphology with fixation strategy, it supports accurate surgical decision-making, enhances training for orthopedic trauma surgeons and improves fixation outcomes.

PMID:40706357 | DOI:10.1016/j.injury.2025.112578

SICOT J. 2025;11:42. doi: 10.1051/sicotj/2025038. Epub 2025 Jul 23.

ABSTRACT

PURPOSE: Severe varus knee osteoarthritis (OA) alters weight-bearing mechanics, leading to progressive stress concentration on the posteromedial tibial plateau. In select cases, this results in the development of a Posteromedial Varus Fatigue Fragment (PVFF), a chronic stress-related fracture that remains ununited and influences knee stability, surgical planning, and implant selection. This study aims to evaluate the incidence, radiographic detectability, and intraoperative significance of PVFF in patients undergoing total knee arthroplasty (TKA).

METHODS: A retrospective analysis was conducted of 856 consecutive TKA cases performed by a single surgeon. Preoperative radiographs, intraoperative findings, and surgical modifications were assessed to determine the incidence and implications of PVFF. Correlation with varus severity and absence of ACL was done.

RESULTS: PVFF was detected intraoperatively in 17 of 856 cases (1.99%), but only 9 (53%) were visible on pre-op imaging." All PVFF cases exhibited varus alignment exceeding 15° and complete ACL deficiency. Intraoperatively, fragment removal resulted in an increased medial flexion gap, impacting gap balancing and necessitating adjustments in implant selection, including the use of tibial stems or augments in select cases.

CONCLUSION: PVFF is an underrecognized structural lesion for precision in severe varus knee OA, affecting tibial fixation, load distribution, and medial knee stability. Its presence requires careful intraoperative assessment, as fragment removal can alter gap balancing. Improved preoperative recognition and surgical planning are essential to optimize TKA outcomes in patients. Further prospective studies and biomechanical analyses are needed to better understand PVFF's long-term clinical implications and refine surgical strategies.

PMID:40700623 | PMC:PMC12286574 | DOI:10.1051/sicotj/2025038

Injury. 2025 Jul 8:112601. doi: 10.1016/j.injury.2025.112601. Online ahead of print.

ABSTRACT

BACKGROUND: Controversies remain about the decision to proceed to aortic occlusion (AO) using either REBOA or resuscitative thoracotomy (RT) in severely injured patients worldwide. Present study aims to identify and evaluate the differences in AO technique use related to patients' conditions.

MATERIAL AND METHODS: This was a comparative study using a multicenter registry of postinjury AO (October 2013-February 2022). AO via REBOA was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Participants were adult trauma patients 16 years or older who experienced AO via REBOA zone 1 vs RT. The primary outcome was to identify the differences between patients treated with RT or REBOA. Ethical committee study approval number (Maryland IRB #HCR-HP-00,055,545-11).

RESULTS: 1937 patients were included. Median age: 34 (25-49), 1599 (82.5 %) were men. Penetrating trauma: 52.4 %. REBOA was adopted in 501 (25.9 %) patients, RT in 1436 (74.1 %). Patients treated with REBOA were older (40vs32 years, p < 0.001), suffered more frequently blunt trauma (76.3 %vs37.7 %, p < 0.001) and had higher ISS (33vs26, p = 0.003). Fewer of them underwent prehospital cardio-pulmonary-resuscitation (23.2 %vs49.8 % p < 0.001); had higher median SBP and HR (83vs0, p < 0.001 and 106vs0, p < 0.001 respectively), serum lactate levels were lower (7.5vs10.3 p < 0.001). SBP≥ 60 mmHg pre-hospital and at-admission (OR 2.27) and GCS>8 at admission (OR 2.24), trauma cases admitted/year (>4000/year, OR 4.41), transfer from another trauma center (OR 1.94) were related to the use of REBOA. Higher Injury severity score (ISS >55, OR 0.66), lower number of trauma treated (<4000/year, OR 0.66) and penetrating trauma (OR 0.24) were related to the use of RT.

CONCLUSION: REBOA was more frequently used for older patients with blunt trauma, higher prehospital systolic blood pressure, and Glasgow Coma Scale scores above 8. RT was more commonly performed in penetrating trauma, lower injury severity scores, and facilities with fewer annual trauma admissions. These findings suggest that patient characteristics and institutional factors significantly differed between patients treated with REBOA or RT, underscoring the need for further research.

PMID:40701854 | DOI:10.1016/j.injury.2025.112601

Injury. 2025 Jul 8;56(8):112602. doi: 10.1016/j.injury.2025.112602. Online ahead of print.

ABSTRACT

BACKGROUND: Cork University Hospital (CUH) is a model 4 tertiary referral centre in the south of Ireland. A robust Orthopaedic - Orthogeriatric co-management service manages close to 500 hip fractures per year. At CUH all adults aged 60 years or older admitted with hip fracture receive comprehensive geriatric assessment (CGA) and documentation of their frailty status.

OBJECTIVE: This study aims to review the clinical epidemiology of hip fractures in a specialist orthopaedic unit in Ireland, while examining the association between CFS and prespecified patient outcomes.

DESIGN & METHODS: Utilising the Irish hip fracture database (IHFD), we collected data between 1st July 2019 to September 30th 2021. Eligible cases were all adults aged 60 years and older admitted to CUH with hip fracture as defined by IHFD. Prespecified outcomes included Length of Stay (LOS), inpatient mortality and new admission to nursing home care and these were analysed in relation to a patients CFS.

RESULTS: 1132 adults met fracture criteria and were included in the study. Increasing frailty, specifically moderate to severe frailty was associated with increased LOS, inpatient mortality and increased likelihood of discharge to nursing home care when compared to those were not frail or who had very mild to moderate frailty.

CONCLUSIONS: People living with very mild to moderate frailty and severe frailty are at significant risk of hip fracture following low volume trauma. With approximately two years of hip fracture data, we found visible, generalizable data demonstrating the association between frailty and clinical outcomes.

PMID:40700919 | DOI:10.1016/j.injury.2025.112602

Injury. 2025 Jul 11;56(8):112599. doi: 10.1016/j.injury.2025.112599. Online ahead of print.

ABSTRACT

INTRODUCTION: The optimal postoperative weight-bearing regimen for tibial plateau fractures (TPF) remains a topic of debate. It ranges from non- or touch down- weight bearing between 2-12 weeks. More recent studies suggest that early weight-bearing may not result in any loss of reduction or hardware failure.

OBJECTIVES: To describe orthopedic surgeons' preferences for postoperative regimens and factors that influence their decision making in relation to weight-bearing status after treating TPF.

METHODS: A web-based survey was developed by the authors regarding tibial plateau fractures. Participants were asked different questions about timing of weight bearing after osteosynthesis and factors that influenced the surgeon's decision-making process for 3 unicondylar and 3bicondylar tibial plateau fractures.

RESULTS: A web-based survey was developed and 151 surgeons answered our survey. 82 % were men and 62 % of respondents treated > seven tibial plateau fractures per year. In unicondylar fractures 19 % recommended full weight bearing and 81 % recommended restricted weight-bearing. In bicondylar fractures 89 % recommended restricted weight-bearing and 11 % full weight bearing. Restricted weight bearing was recommended for 2, 4, 6, 8, 10 or 12 weeks depending on the surgeon's preference. 73 % of the surgeons stated that the sense of stability in their own construction affects their postoperative weight-bearing plan and in 45 % the regimen was based on "gut feeling". Responders believed they get a stable osteosyntehsis in only 57 % of their own fixations and 48 % responded that they do not believe patients are following the postoperative weight bearing plan.

CONCLUSION: Our survey study demonstrated variability among orthopedic surgeons regarding postoperative weight-bearing in tibial plateau fractures. Further research is required to understand the stability of tibial plateau fractures and quantify whether we can allow patients to weight bear earlier safely.

PMID:40694897 | DOI:10.1016/j.injury.2025.112599

SICOT J. 2025;11:41. doi: 10.1051/sicotj/2025039. Epub 2025 Jul 21.

ABSTRACT

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) remains a significant concern in orthopedic surgery, particularly in total knee replacement (TKR), where infection can lead to severe complications. In procedures like TKR, where implants act as a foreign body and potential surface for biofilm formation, infections can lead to severe complications, including delayed healing, and implant failure, and often need multiple revision surgeries. Screening for MRSA before surgery has become a standard practice in many hospitals to reduce the risk of infection. This study aims to evaluate the prevalence of MRSA in patients undergoing TKR and analyze demographic characteristics.

METHODS: A retrospective analysis was conducted on patients scheduled for TKR. Demographic data, including age, gender, and other relevant clinical information, were extracted from the patient's medical records. MRSA screening was performed as part of the preoperative protocol, and the results were recorded. Descriptive statistics were used to summarize the data and calculate the prevalence of MRSA.

RESULTS: A total of 938 patients underwent MRSA screening prior to TKR. The mean age was 67.25 years (median: 68; range: 33-87). The majority of patients were female, accounting for 706 (75.0%), while 232 (25.0%) were male. MRSA test results revealed that 938 (99.3%) patients tested negative, whereas 6 (0.7%) tested positive. Among MRSA-positive patients, all were aged 60 years or older, suggesting a potential correlation between advanced age and MRSA positivity.

CONCLUSION: This study found a low MRSA prevalence (0.7%) in TKR patients, with all cases occurring in individuals aged ≥60 years. The findings advocate prioritizing preoperative screening in older patients to optimize resource use in low-prevalence settings and highlight the need to investigate TKR-specific risk factors for tailored infection control strategies.

PMID:40689503 | PMC:PMC12278734 | DOI:10.1051/sicotj/2025039

Injury. 2025 Jul 10;56(8):112600. doi: 10.1016/j.injury.2025.112600. Online ahead of print.

ABSTRACT

BACKGROUND: Missed injuries (MIs) remain a significant and potentially preventable complication in trauma care, often associated with increased morbidity, mortality, prolonged hospitalization, and legal consequences. Despite decades of recognition, MIs continue to challenge trauma teams, particularly in complex, multi-injury scenarios.

OBJECTIVE: This study aims to review the literature and identify the most relevant factors contributing to missed injuries in trauma patients, highlighting opportunities for prevention and clinical improvement.

METHODS: A systematic review was conducted according to PRISMA guidelines using PubMed. Inclusion criteria encompassed studies reporting on trauma patients with MIs, their risk factors, prevalence, and clinical outcomes. Exclusion criteria included non-trauma-focused studies, non-peer-reviewed articles, and case reports. Five key domains were assessed: trauma characteristics, injury-specific factors, diagnostic limitations, patient-related challenges, and human (physician) factors.

RESULTS: High Injury Severity Score (ISS), altered mental status (e.g., low Glasgow Coma Scale), polytrauma, and cognitive biases such as anchoring were consistently associated with higher rates of MIs. Non-spinal orthopedic injuries, abdominal and thoracic lesions, and retroperitoneal or diaphragmatic injuries were among the most frequently missed. Diagnostic limitations included false-negative imaging, misinterpretation of radiological exams, and inadequate protocols in unstable patients. Patient factors-such as obesity, advanced age, alcohol or drug intoxication, and pregnancy-also contributed to delayed diagnosis. Inexperience, fatigue, and poor communication were recurrent human factors linked to diagnostic failures. The implementation of Trauma Tertiary Surveys (TTS) significantly reduced MI incidence and improved detection of occult injuries.

CONCLUSION: Missed injuries are multifactorial events influenced by the complexity of trauma, diagnostic limitations, patient characteristics, and human error. Proactive strategies, including TTS, heightened awareness of injury-specific challenges, improved imaging protocols, and fostering a collaborative trauma culture, are critical to minimizing missed diagnoses and enhancing trauma care quality.

PMID:40690819 | DOI:10.1016/j.injury.2025.112600

J Bone Joint Surg Am. 2025 Jul 21. doi: 10.2106/JBJS.24.01191. Online ahead of print.

ABSTRACT

BACKGROUND: Cement augmentation using vertebroplasty (VP) or kyphoplasty (KP) can be employed to manage vertebral compression fractures (VCFs). Randomized controlled trials (RCTs) have disagreed about the superiority of one technique over the other. Therefore, a meta-analysis of RCTs is warranted.

METHODS: PubMed, Cochrane, Embase, and Google Scholar were searched for articles from database inception to July 15, 2024. The inclusion criteria consisted of English and non-English-language RCTs comparing KP to VP in the management of VCFs. The studied outcomes were the risks of cement leakage and adjacent vertebral fractures (AVFs), operative time, the postoperative local kyphotic angle, and postoperative back pain.

RESULTS: A total of 11 RCTs were included, comprising 1,190 patients, of whom 600 (50.4%) underwent KP and 590 (49.6%) underwent VP. We found no difference in the risk of cement leakage (risk ratio [RR], 1.07; 95% confidence interval [CI], 0.68 to 1.69; p = 0.78) or AVFs (RR, 0.60; 95% CI, 0.29 to 1.23; p = 0.16) between the 2 groups. With the inclusion of additional trials, the KP group had a lower risk of AVFs (RR, 0.58; 95% CI, 0.34 to 0.98; p = 0.04). We found no difference in operative time (mean difference, 4.75 minutes; 95% CI, -7.34 to 16.84; p = 0.44) or postoperative pain (mean difference, -0.48; 95% CI, -1.91 to 0.95; p = 0.51) between the 2 groups. A lower postoperative kyphotic angle was observed in the KP group (standardized mean difference, -2.97; 95% CI, -5.62 to -0.32; p = 0.03).

CONCLUSIONS: This meta-analysis revealed that KP was associated with a better postoperative local kyphotic angle and a lower risk of AVFs, with no difference in postoperative pain or cement leakage, compared with VP.

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

PMID:40690559 | DOI:10.2106/JBJS.24.01191

Int Orthop. 2025 Jul 21. doi: 10.1007/s00264-025-06619-9. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this study was to define the variability of the scapulohumeral position during preoperative Computed Tomography (CT) acquisition and to evaluate its influence on angular lateralization and distalization measurements. We hypothesized that the preoperative resting arm position, in terms of humeral abduction, flexion and internal rotation, would vary significantly between patients and that this variability would influence the lateralization (LSA) and distalization shoulder angle (DSA).

METHODS: We analyzed a prospectively collected database of preoperative de-identified CT scans from a single Total Shoulder Arthroplasty (TSA) planning system (Equinoxe, Exactech GPS, Blue-Ortho), including all cases with scapular and humeral segmentation. Validated three-dimensional (3D) bone models were used to compute and automatically position scapular and humeral landmarks. These included: the superior glenoid tubercle; the most lateral border of the acromion and the most lateral border of the greater tuberosity. The position of the humerus relative to the scapula was automatically calculated, allowing the angles of abduction, flexion and internal rotation of the scapulohumeral joint to be assessed. Additionally, the potential relationship between the body mass index (BMI) and the resting arm position was assessed. Finally, LSA and DSA were calculated. A multiple linear regression analysis was performed to assess the relationship between the humeral position and the LSA and DSA.

RESULTS: A total of 21,863 patients were included. Preoperative humeral positioning relative to the scapula showed a mean abduction of 10.3°±12.4 (-14.0°; 36.6°), mean flexion of 3.9°±8.9 (-16.0°; 26.1°) and mean internal rotation of 6.5°±18.9 (-41.4°; 48.9°). The preoperative median of LSA and DSA were 87.4°±14.3° and 43°±12.4, respectively. Among the independent variables, abduction showed the strongest negative correlation with LSA (β = -0.2998, p < 0.0001), followed by flexion (β = -0.04342, p < 0.0001). Internal rotation was positively correlated with LSA (β = 0.1229, p < 0.0001). For DSA, abduction had a weak positive influence (β = 0.04321, p < 0.0001), while flexion (β = -0.04302, p < 0.0001) and internal rotation (β = -0.04654, p < 0.0001) were negatively associated. Notably, a 10° variation in abduction, flexion or internal rotation led to a -3°, -0.4° and + 1.2° change in LSA, respectively, whereas DSA was minimally affected, with variations limited to + 0.4°, -0.4° and - 0.5°, respectively.

CONCLUSION: The resting arm position during preoperative CT scans varies significantly, potentially affecting the preoperative planning of TSA. The main findings of this study suggest that there exists a weak correlation between the initial scapulohumeral position and the LSA/DSA measurements.

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

PMID:40690017 | DOI:10.1007/s00264-025-06619-9

Injury. 2025 Jul 8:112591. doi: 10.1016/j.injury.2025.112591. Online ahead of print.

ABSTRACT

PURPOSE: Post-traumatic stress disorder (PTSD) is a known potential sequel to physical trauma. PTSD in trauma patients has seldom been studied in New Zealand. This study aimed to measure the prevalence and predictors of PTSD among hospitalized trauma patients in Christchurch, New Zealand.

METHODOLOGY: Participants who presented to Christchurch Hospital and were included in the NZ Major Trauma Registry (Injury Severity Score ≥ 12) were recruited. Eligible participants were mailed a questionnaire containing a series of self-reported 5-point rating scales that assess DSM-5 symptoms of PTSD. Baseline characteristics and demographic data were obtained from the NZ Major Trauma Registry. PTSD caseness was determined at a cutoff score >30 and analyses were performed accordingly.

RESULTS: Among 203 patients with major trauma (24 % response rate), 37 (18 %) were classed as having PTSD. Questionnaires were completed at mean 2.75 (standard deviation = 0.67) years since the injury. In univariable analysis, crossing PTSD threshold was positively associated with younger age (p < 0.001); the presence of anxiety (p < 0.001) and depression (p < 0.001); higher Injury Severity Score (p = 0.004); vehicle related injury (p = 0.009); GCS <15 (p < 0.001); having an alcohol related injury (p = 0.025); and all subscales of perceived social support (p < 0.05). In a backwards stepwise multivariable model controlling for age and sex unconditionally, the variables predictive of PTSD were younger age; Glasgow Coma Scale <15; and vehicle-related trauma.

CONCLUSION: High rates of PTSD exist in patients following major trauma in NZ. Patients who are young; and those with initial Glasgow Coma Scale <15; and vehicle-related trauma are at a higher risk of developing PTSD following major trauma.

PMID:40683803 | DOI:10.1016/j.injury.2025.112591

Injury. 2025 Jul 15:112614. doi: 10.1016/j.injury.2025.112614. Online ahead of print.

ABSTRACT

INTRODUCTION: Minimizing crystalloid administration to hemorrhaging trauma patients has been shown to decrease morbidity and mortality. Iatrogenic harm from 'over-resuscitation' may be a concern for trauma patients undergoing prolonged EMS transport. Our primary objective was to quantify the volume of prehospital crystalloid administered to hypotensive trauma patients with at least 30 min of exposure to prehospital care for whom fluid administration was not indicated in the intervention arm of prior randomized trials of fluid restriction. In addition, we aimed to identify factors associated with crystalloid administration and determine if trends in administration were present across the study period.

STUDY DESIGN: The ESO Data Collaborative 2018-2022 annual datasets were used for this study. Trauma patients who received prehospital vascular access, had a minimum systolic blood pressure between 75 and 90 mmHg, a GCS ≥ 14, and were exposed to EMS care for >30 min (on-scene to destination arrival interval) were evaluated for inclusion. The primary outcome for this analysis was the documented volume of crystalloid administration. Logistic regression modeling was used to investigate factors associated with the administration of >500 mL of crystalloid.

RESULTS: After application of exclusion criteria, 26,447 patients treated by 1150 EMS agencies were evaluated. Patients received a median of 200 [10,500] mL of fluid in the prehospital setting, and 95 % of patients received <1010 mL. Overall, 5745 (21.7 %) patients received >500 mL of fluid. Factors associated with administration of >500 mL of fluid included increased 'EMS exposure' time (OR 1.01 [1.01, 1.01] per minute), IV cannula size (22 G OR: 0.5 [0.4, 0.6], 20 G OR: [reference], 18 G OR: 2.1 [2.0, 2.3], 16 G OR: 4.6 [4.1, 5.2]), age (0.996 [0.994, 0.997]) per year, female sex (0.72 [0.68, 0.77]), minimum SBP (0.95 [0.94, 0.96] per mmHg), and penetrating injury, (1.9 [1.7, 2.1]).

CONCLUSION: Overall, crystalloid volumes administered in the prehospital setting were low in this cohort of hypotensive trauma patients exposed to at least 30 min of prehospital care. This may suggest that the practice of fluid restriction for patients who are hypotensive following trauma has permeated into EMS practice nationwide.

PMID:40683802 | DOI:10.1016/j.injury.2025.112614

Injury. 2025 Jul 8;56(8):112594. doi: 10.1016/j.injury.2025.112594. Online ahead of print.

ABSTRACT

BACKGROUND: Fragility fractures of the pelvis (FFP) pose significant challenges in geriatric care, with conservative management strategies remaining inconsistent. This scoping review aimed to map current trends in conservative treatment strategies for FFP and summarize associated clinical outcomes and complications.

METHODS: We examined (1) the types of conservative treatments used, (2) their temporal changes, and (3) their associated clinical outcomes. To visualize temporal trends, Pearson's correlation analysis was used to assess the frequency of reported interventions and outcomes over time.

RESULTS: A total of 75 studies were included. The most frequently reported conservative treatments were pain control (66 studies, 88.0 %), rehabilitation (52 studies, 69.3 %), and full-weight-bearing (22 studies, 29.3 %), all demonstrating significant increasing trends (p < 0.05). Outcomes were categorized into objective measures (e.g., mobility, hospitalization, mortality), subjective measures (e.g., Visual Analog Scale [VAS], functional scores), and complications (e.g., thromboembolic events, general infections). However, no statistically significant associations were found between specific conservative treatments and clinical outcomes.

CONCLUSION: Pain control, rehabilitation, and full-weight-bearing strategies have become increasingly central to conservative FFP management, particularly in osteoporotic populations. Evaluated outcomes included mobility, hospitalization, mortality, patient status, pain control, and complications such as infections and thromboembolic events. These findings underscore the variability in current practices and highlight the need for further research to develop a more structured evidence base for conservative FFP management.

PMID:40683060 | DOI:10.1016/j.injury.2025.112594

Injury. 2025 Jul 9;56(8):112592. doi: 10.1016/j.injury.2025.112592. Online ahead of print.

ABSTRACT

BACKGROUND: Abdominal solid organ (ASO) trauma of the spleen, kidney, and liver is common in children and often accompanies other traumatic injuries, posing significant clinical challenges. Non-operative management (NOM) is preferred according to current guidelines for both low- and high-grade lesions when hemodynamic stability is achievable. Aggressive surgical treatment can lead to chronic organ dysfunction, surgical related complications and long-term sequelae, while NOM failure may result in critical bleeding and multiorgan failure. This systematic review aimed to describe the prevalence of NOM failure in pediatric patients with traumatic ASO injuries and its predictors.

METHODS: A systematic literature search was conducted in PubMed, Scopus, and Cochrane Library from inception to August 2024. Studies were extracted for the prevalence of NOM failure and prespecified predictors. Study quality was assessed using the Joanna Briggs Institute's critical appraisal tool for prevalence reporting. A proportion meta-analysis provided a pooled estimate of NOM failure. Subgroup analysis for specific organs and meta-regressions for candidate predictors was performed. Multimodel inference estimated predictor importance in multivariable modeling.

RESULTS: The search yielded 67 studies evaluating the NOM course of 37,340 children. The pooled prevalence of NOM failure was 0.04 (95 % CI: 0.03-0.06). Multimodel inference showed that NOM failure prevalence increased with higher injury severity score (ISS), AAST grade, and age. The confidence in these results was rated moderate. Complications had a pooled prevalence of 0.09 and missed injuries 0.03.

CONCLUSIONS: NOM failure in pediatric post-traumatic ASO injuries is relatively infrequent, with high organ salvage rates achievable even in high-grade and multisystem trauma. Younger children achieve higher NOM success, suggesting potential for more conservative strategies. Complications requiring non-surgical interventions and missed injuries are not negligible, indicating the need for strict monitoring, in particular if aggressive preservation is the objective.

PMID:40683059 | DOI:10.1016/j.injury.2025.112592

Injury. 2025 Jul 16;56(8):112613. doi: 10.1016/j.injury.2025.112613. Online ahead of print.

ABSTRACT

CASE: Femoral shaft fractures with concomitant vascular injury requiring limb revascularization, although rare, are a limb-threatening condition. Historically, emergent external fixation of the femur fracture followed by vascular repair has been considered the standard of care. We discuss four cases of femoral fracture with an associated vascular injury amenable to nail fixation stabilized by expeditious intramedullary nailing (IMN), followed by limb revascularization. We discuss the timeline and duration of the procedure for this technique.

CONCLUSION: Expeditious femoral IMN prior to limb revascularization has multiple clinical advantages and has become our standard protocol for these injuries.

PMID:40683058 | DOI:10.1016/j.injury.2025.112613

Injury. 2025 Jul 11;56(8):112596. doi: 10.1016/j.injury.2025.112596. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma team activation criteria (TTAC) are used within Trauma Activation Systems (TAS) to facilitate the rapid identification of patients with major traumatic injuries requiring a hospital trauma system response, including the attendance of a multidisciplinary trauma team. The value of individual activation criteria available at the time a decision to activate the system response is made is uncertain. We conducted a systematic review to identify TTAC associated with the presence of major traumatic injuries in adult trauma patients.

METHODS: We searched MEDLINE, EMBASE, and CINAHL (01-01-2000 to 5-07-2024) for studies using multivariable methods to evaluate associations between physiological, anatomical and mechanism of injury variables available or obtained at emergency department triage and the presence of major traumatic injuries. Risk of bias was assessed using the QUIPs tool, meta-analysis was conducted using a random effects approach, and certainty of evidence assessed using GRADE.

RESULTS: We included 7 studies from major trauma centres in North America (n = 3), Australia (n = 2), Israel (n = 1) and Italy (n = 1). Studies were predominantly retrospective, evaluated a wide range of activation criteria, and used varying definitions of major trauma. We demonstrated with moderate certainty that low Glasgow Coma Score (OR 9.4 95 %CI 4.6-19.3), systolic hypotension (OR 4.4 95 %CI 2.2-8.8), abnormal vital signs (OR 3.7 95 %CI 2.6-5.3) and multi-region trauma (OR 4.7 95 %CI 3.5-6.5) were associated with the presence of major trauma. The certainty of evidence for the association between mechanism of injury and other physiological criteria and major trauma was low or very low.

CONCLUSION: Low GCS, systolic hypotension, abnormal vital signs at emergency department triage and the presence of multi-region trauma predict the presence of major trauma in adult trauma patients. These criteria could form the foundation of evidence-based TTAC. Remaining TTAC should reflect the trauma population and local major trauma response capabilities, with audit and revision necessary for optimal TTAC.

PMID:40683057 | DOI:10.1016/j.injury.2025.112596

Injury. 2025 Jul 13;56(8):112607. doi: 10.1016/j.injury.2025.112607. Online ahead of print.

ABSTRACT

INTRODUCTION: There is a strong demand for research on the long-term outcomes of tibial plateau fractures (TPFs) in large cohorts. Stringent data protection regulations and high ethical standards are essential for safeguarding participants' rights, but they can increase the logistical complexity of conducting multicentre studies. This study aims to evaluate clinical outcome data collected over more than a decade through a collaborative data network in surgically treated TPFs.

PATIENTS AND METHODS: This retrospective cohort study was conducted at two level-I trauma centers and included 364 adult patients with operatively TPFs, classified according to the Schatzker system. Eligible patients were treated between January 2010 and September 2022, were ≥18 years of age at the time of injury, resided in Germany, and had a minimum follow-up of 1.25 years with completed patient-reported outcome measures. Patients with cognitive or physical impairments preventing survey participation were excluded. Data collection occurred between September 2022 and January 2023. Outcome measures included the International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the Lysholm Score. Multiple linear regression was used to assess associations between outcome scores, follow-up duration, and Schatzker classification.

RESULTS: Longer follow-up times were associated with significantly higher scores for IKDC (p < 0.05), KOOS Pain (p < 0.05), Activities of Daily Living (ADL) (p < 0.05), Sports (p < 0.05), and Quality of Life (QoL) (p < 0.00001). Complex fractures (Schatzker IV-VI) were consistently linked to worse outcomes, particularly in the KOOS Sports (p < 0.001) and Quality of Life (p < 0.00001) subscores. Adjusted R-squared values ranged from 2 % to 10 %, with the highest values observed in KOOS QoL scores.

CONCLUSIONS: Patient-reported outcomes (PROMs) were found to be positively associated with longer follow-up durations, up to 12 years postoperatively emphasizing the need for prolonged aftercare in TPFs. Complex fractures, in particular, might benefit from tailored, long-term follow-up. Given the severity of TPFs, it is crucial to manage patient expectations and address psychosocial factors to optimize the outcome. Collaborative data networks, like the one used here, hold promise for expanding research and improving treatment strategies across multiple centers.

PMID:40683056 | DOI:10.1016/j.injury.2025.112607

Injury. 2025 Jul 12;56(8):112606. doi: 10.1016/j.injury.2025.112606. Online ahead of print.

ABSTRACT

BACKGROUND: Indirect calorimetry (IC) is the gold standard method for measuring resting energy expenditure (REE). Although clinical guidelines recommend nutrition be delivered based on measured REE, easily applied predictive equations are most commonly used in practice, with potential for over-and under-estimation of energy needs. We aimed to 1) determine the feasibility and acceptability of using IC to measure REE and 2) compare measured to estimated REE in self-ventilating patients with a traumatic injury.

METHODS: In a single-centre prospective observational study, REE was measured using IC via a canopy hood in patients admitted to a trauma ward with ≥7day hospital stay. Feasibility was set at >50 % of IC measurements being valid (≥5 min with a respiratory quotient between 0.67 - 1.3, and ≤10 % variation in VO2 and VCO2). Following the measurement, patients and staff completed an acceptability survey. Measured REE (kcal) was compared to estimated REE (kcal) using predictive equations (Schofield, 25kcal/kg and 30kcal/kg), with ±10 % difference considered clinically significant.

RESULTS: Of 30 IC measurements, 25 (83 %) were valid. Measurements were not completed or valid in 5 (17 %) participants due to discomfort (n = 1), pain (n = 1), difficult bedspace (n = 1) and high CO2 variability (n = 2). Of those that completed the survey, 83 % of participants (n = 24) reported that the test was comfortable, and all staff (n = 11) agreed IC was acceptable to incorporate into usual care. Measured REE was within ±10 % of estimated REE with the Schofield equation, 25 kcal/kg and 30 kcal/kg in 44 %, 28 %, and 60 % cases, respectively.

CONCLUSION: Measured REE using IC is feasible and acceptable following traumatic injury. Estimated REE using predictive equations were not commonly within 10 % of measured REE, which may lead to under or over-feeding of patients following traumatic injury. Further research is warranted to evaluate whether IC-guided energy delivery improves patient outcomes.

PMID:40683055 | DOI:10.1016/j.injury.2025.112606

Injury. 2025 Jul 1;56(8):112570. doi: 10.1016/j.injury.2025.112570. Online ahead of print.

ABSTRACT

Artificial intelligence (AI) has emerged as a transformative technology in healthcare, with significant applications in orthopedic trauma. This comprehensive review analyzes 217 studies published between 2015 and 2025 to evaluate the current state, applications, and future directions of AI in orthopedic trauma. The field has experienced exponential growth, with 52.5 % of all studies published in 2024 alone. Deep learning approaches (43.3 %) and traditional machine learning methods (39.2 %) dominated the research landscape. Fracture detection (24.4 %) and classification (12.0 %) were the most common applications, followed by prediction (21.2 %) and segmentation (8.3 %). Hip/femur (19.4 %), spine (18.9 %), and wrist fractures (12.0 %) represented the most frequently studied anatomical sites. AI systems frequently matched or exceeded specialist performance in detection and classification tasks, with sensitivities and specificities above 90 % commonly reported. Predictive models for complications and mortality consistently outperformed traditional scoring systems, with improvements in AUC typically between 0.10-0.15. However, only 14.5 % of studies underwent external validation, and just 3.2 % reported prospective clinical validation. Despite remarkable progress in developing accurate AI systems for orthopedic trauma, significant challenges remain in clinical integration, data standardization, and validation across diverse populations. Future development should focus on multimodal approaches integrating diverse data sources, transparent algorithms providing rationales for predictions, and rigorous clinical validation. Point-of-care applications and integration with emerging technologies offer promising directions for clinical impact. As these challenges are addressed, AI has the potential to significantly enhance orthopedic trauma care by improving diagnostic accuracy, optimizing treatment selection, and identifying high-risk patients for targeted interventions.

PMID:40683054 | DOI:10.1016/j.injury.2025.112570

Int Orthop. 2025 Jul 19. doi: 10.1007/s00264-025-06604-2. Online ahead of print.

ABSTRACT

PURPOSE: The Both Column Screw (BCS) fixation technique is a recently introduced, innovative method for the treatment of acetabular posterior column fractures. This study aims to biomechanically compare the BCS technique with conventional posterior column lag screw fixation methods using finite element analysis.

METHODS: Five different internal fixation models were simulated using five distinct screw fixation techniques: antegrade posterior column screw (APCS), retrograde posterior column screw (RPCS), magic screw (MS), anterior BCS (aBCS), and posterior BCS (pBCS). The modeling process included meshing, assignment of material properties, and definition of boundary conditions. Each model was subjected to three different loading conditions: level walking, stairs up, and stairs down. The biomechanical performance of each fixation technique was evaluated based on five parameters: maximum stress in the screw, maximum stress in the bone, total deformation, gap in fracture surfaces, and sliding distance in the fracture surface.

RESULTS: Finite element analysis demonstrated biomechanical differences among the five fixation techniques. The APCS model consistently showed the highest stress values and deformation across all loading conditions, whereas the MS, aBCS, and pBCS models exhibited lower deformation and stress parameters. Among these, pBCS generally displayed the most favorable performance in terms of stress reduction and fracture stability. Overall, the BCS configurations (aBCS and pBCS) showed improved biomechanical behavior compared to conventional fixation methods.

CONCLUSION: The BCS fixation technique, due to its superior biomechanical properties, may serve as a valuable addition to current methods for acetabular posterior column fractures. It broadens surgical options and may support clinical decision-making for orthopaedic surgeons.

PMID:40682622 | DOI:10.1007/s00264-025-06604-2