Int Orthop. 2025 Jun 20. doi: 10.1007/s00264-025-06571-8. Online ahead of print.

ABSTRACT

PURPOSES: To compare radiological and clinical outcomes of TiRobot-assisted versus traditional freehand percutaneous anterior column screw fixation for transverse with or without posterior wall fractures of acetabulum based on the Kocher‑Langenbeck (K‑L) approach.

METHODS: Patients suffering transverse with or without posterior wall fractures of acetabulum that were fixed by TiRobot-assisted or traditional freehand percutaneous anterior column screw fixation via the K-L approach were divided into two groups:group A (TiRobot-assisted fixation) and group B (traditional freehand fixation). Surgical time, blood loss, postoperative complications, follow-up length, hospital stay and fracture healing time were recorded. Fracture reduction quality was estimated via criteria described by Matta.Fracture healing was evaluated on the pelvic radiographs at each follow-up. Functional outcomes were examined using the Postel Merle D'Aubigné score system at the final follow-up.

RESULTS: A total of 29 patients who met the inclusion and exclusion criteria were evaluated for eligibility in this study, with 16 patients assigned to group A and 13 to group B.The mean intraoperative blood loss was 581.3 ± 242.8 ml in group A and 761.5 ± 193.8 ml in group B(P < 0.05). The average intraoperative fluoroscopy in group A was 8.3 ± 1.5 times, while that in group B was 12.7 ± 2.0 times(P < 0.001). The mean number of needle adjustments was 0.6 ± 0.6 in group A and 2.0 ± 0.7 in group B(P < 0.001). No signifcant differences in surgical time of the anterior column screw fixation,hospital stay,reduction quality, fracture healing time, complications and functional outcomes were noted between the two groups. It is worth noting that, in TiRobotic-assistance early-stage group the mean surgical time of anterior fracture fixation was 29.3 ± 2.5 min, while it was 19.3 ± 2.2 and 26.7 ± 4.2 min in Tirobotic-assistance late-stage group and freehand group respectively, with a statistically significant inter-group difference (P < 0.001).

CONCLUSIONS: The K‑L approach combined with TiRobot‑aided anterior column screw fixation is a safe and effective option for transverse with or without posterior wall fractures of acetabulum. Compared with traditional freehand percutaneous anterior column screw fixation, TiRobot‑aided screw fixation has obvious advantages on blood loss, invasiveness, screw placement accuracy, patient and physician radiation exposure. Tirobot‑aided screw fixation involves a learning curve. During the initial phase, the surgical time is prolonged due to unfamiliarity with the technology; however, as proficiency improves, the surgical time is significantly reduced compared to traditional freehand technique. The K‑L approach combined with traditional freehand percutaneous anterior column screw fixation can also be a reliable alternative for transverse with or without posterior wall fractures of acetabulum, with the similar reduction quality, complications and functional outcomes.

PMID:40540034 | DOI:10.1007/s00264-025-06571-8

Injury. 2025 Jun 11:112523. doi: 10.1016/j.injury.2025.112523. Online ahead of print.

ABSTRACT

INTRODUCTION: Traumatic brain injury (TBI) is a major contributor to emergency department (ED) visits worldwide, with older adults being particularly susceptible due to fall-related injuries. The widespread use of anticoagulants, including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), raises concerns about the risk of delayed intracranial haemorrhage (dICH), even in cases where the initial head computed tomography (CT) scan shows no abnormalities. The optimal strategies for managing and monitoring these patients remain a subject of ongoing debate.

MATERIALS AND METHODS: We conducted a monocentric retrospective observational study at Santa Croce e Carle Hospital, Cuneo, Italy, from January 2019 to August 2024. We included patients aged ≥18 years, on chronic anticoagulant therapy, presenting with mild TBI (GCS ≥13) and a negative initial CT scan. All patients underwent a second CT after 24 h of observation, regardless of clinical changes. The primary outcome was the incidence of dICH. Secondary outcomes included neurosurgical interventions and 30-day mortality.

RESULTS: The study included 596 patients (median age 83 years; 46.5 % male). Most patients were on DOACs (74.5 %), and falls were the most common trauma mechanism (90.4 %). dICH was diagnosed in 2 % of patients (n = 12), with subarachnoid haemorrhage and subdural hematoma being the most frequent findings (5 patients each). None of the dICH cases required neurosurgical intervention or resulted in mortality at 30 days. Patients with dICH were more likely to have a GCS <15 upon arrival (16.7 % vs. 3.9 %; p = 0.17) and experienced high-energy trauma mechanism, (16.7 % vs. 1.7 %; p = 0.044); among patients with dICH, 41.7 % were on VKA therapy, compared to 25.2 % of patients without dICH (p = 0,33). Complications during hospitalization, primarily nosocomial infections and delirium, occurred in 66 % of patients hospitalized for dICH.

CONCLUSION: Our findings confirm that dICH after TBI in anticoagulated patients with a negative initial CT is rare and typically benign. Routine prolonged observation and repeat CTs may not be necessary for all patients, particularly those without high-risk factors; individualized management based on clinical risk factors could minimize unnecessary hospitalizations, reduce complications, and optimize healthcare resources.

PMID:40537351 | DOI:10.1016/j.injury.2025.112523

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01225. Online ahead of print.

ABSTRACT

BACKGROUND: Implant-associated infections (IAIs) require aggressive debridement to eliminate microbial bioburden. The use of irrigants may improve microbial killing during debridement. This study compared the efficacy of surgical irrigants in vitro against Staphylococcus aureus alone and in combination with Candida albicans, in both planktonic and biofilm states.

METHODS: Full-strength Dakin's solution, 0.35% povidone-iodine (PI), 10% PI, 3% hydrogen peroxide (HP), a 1:1 combination of 10% PI and 3% HP (PI + HP), Irrisept, XPERIENCE, Bactisure, and normal saline solution were tested. For planktonic testing, 1 × 106 colony-forming units (CFUs) of S. aureus and C. albicans were utilized, and biofilms were grown in these conditions on 0.8 × 10-mm titanium alloy Kirschner wires for 48 hours. Killing assays were performed using 5-minute dwell times. Success was defined by complete eradication of planktonic or biofilm CFUs.

RESULTS: PI + HP and Bactisure were the only irrigants to eradicate S. aureus in both planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states.

CONCLUSIONS: PI + HP and Bactisure were superior irrigants against S. aureus, eliminating it in planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states. In vivo studies are needed to evaluate the clinical effectiveness.

CLINICAL RELEVANCE: Surgical irrigants have variable efficacy in eradicating microbes depending on their state of existence (planktonic versus biofilm). In this study, the most effective eradication of polymicrobial S. aureus + C. albicans bioburden was a 1:1 combination of 10% PI and 3% HP, which is of nominal cost.

PMID:40536949 | DOI:10.2106/JBJS.24.01225

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01485. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-level value analysis (PLVA) has been applied to several orthopaedic procedures but has not yet been utilized to assess the value of total knee arthroplasty (TKA). The purpose of this study was to evaluate the 1-year episode of care for TKA with use of PLVA to identify characteristics that influence value at both the patient and surgeon level.

METHODS: The institutional patient-reported outcome (PRO) database was queried for all patients who underwent TKA from 2020 to 2022. Patients were excluded on the basis of an index revision procedure, a pathology other than primary osteoarthritis, unicompartmental knee arthroplasty, robotic-assisted TKA, incomplete baseline or 1-year PROs, concomitant procedures (i.e., bilateral TKA or hardware removal), complications requiring readmission or reoperation, TKA without patellar resurfacing, the use of constrained implants, incomplete cost information, or other hip or knee arthroplasty procedure during the 1-year episode of care. PROs of interest included preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) scores. Episode-of-care costs were calculated using time-driven activity-based costing. The 1-year value quotient (VKOOS) was calculated for each patient as the ratio of the 1-year change in KOOS-JR score to the total episode-of-care cost.

RESULTS: A total of 684 patients (62% female; mean age, 68 ± 8 years) met the inclusion criteria. The mean KOOS-JR score significantly increased from baseline (53 ± 11) to 1 year (79 ± 14; p < 0.001), with a mean improvement of 26 ± 16. The mean total episode-of-care cost was $9,563 ± $2,370. There was no significant correlation between episode-of-care costs and the change in KOOS-JR score (r = 0.02; p = 0.581). Surgery performed at an ambulatory surgery center (p < 0.001) and as an outpatient procedure (p = 0.036) were predictive of lower costs. Patient-specific instrumentation (p < 0.001) and a tibial stem extension (p < 0.001) were predictive of higher costs. Older age (p = 0.023) and male sex (p = 0.007) were predictive of less improvement in KOOS-JR scores from baseline to 1 year.

CONCLUSIONS: Our study identified patient and surgical characteristics that drive costs and PROs in TKA. PLVA can be used to identify "bright spots" in orthopaedic procedures to optimize care delivery.

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

PMID:40536933 | DOI:10.2106/JBJS.24.01485

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01484. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-education materials (PEMs) are essential to improve health literacy, engagement, and treatment adherence, yet many exceed the recommended readability levels. Therefore, individuals with limited health literacy are at a disadvantage. This study evaluated the readability of spine-related PEMs from the American Academy of Orthopaedic Surgeons (AAOS), the North American Spine Society (NASS), and the American Association of Neurological Surgeons (AANS), and examined the potential of artificial intelligence (AI) in optimizing PEMs for improved patient comprehension.

METHODS: A total of 146 spine-related PEMs from the AAOS, NASS, and AANS websites were analyzed. Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG) Index scores, as well as other metrics, including language complexity and use of the passive voice. ChatGPT-4o was used to revise the PEMs to a sixth-grade reading level, and post-revision readability was assessed. Test-retest reliability was evaluated, and paired t tests were used to compare the readability scores of the original and AI-modified PEMs.

RESULTS: The original PEMs had a mean FKGL of 10.2 ± 2.6, which significantly exceeded both the recommended sixth-grade reading level and the average U.S. eighth-grade reading level (p < 0.05). ChatGPT-4o generated articles with a significantly reduced mean FKGL of 6.6 ± 1.3 (p < 0.05). ChatGPT-4o also improved other readability metrics, including the SMOG Index score, language complexity, and use of the passive voice, while maintaining accuracy and adequate detail. Excellent test-retest reliability was observed across all of the metrics (intraclass correlation coefficient [ICC] range, 0.91 to 0.98).

CONCLUSIONS: Spine-related PEMs from the AAOS, the NASS, and the AANS remain excessively complex, despite minor improvements to readability over the years. ChatGPT-4o demonstrated the potential to enhance PEM readability while maintaining content quality. Future efforts should integrate AI tools with visual aids and user-friendly platforms to create inclusive and comprehensible PEMs to address diverse patient needs and improve health-care delivery.

PMID:40536932 | DOI:10.2106/JBJS.24.01484

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01483. Online ahead of print.

ABSTRACT

BACKGROUND: Computer navigation and patient-specific instrumentation in unicompartmental knee replacement (UKR) improve the precision of implant positioning, but there is limited information regarding their impact on implant survival and patient-reported outcomes. We aimed to compare postoperative implant survival, Oxford Knee Score (OKS) values, health-related quality of life (measured using the EuroQol-5 Dimension 3-level version [EQ-5D-3L]), and intraoperative complications between UKRs performed using computer navigation or patient-specific instrumentation versus conventional instrumentation.

METHODS: Using National Joint Registry data, an observational study of patients who underwent primary UKR for osteoarthritis between 2003 and 2020 was performed. The primary analyses focused on all-cause revision, and the secondary analyses focused on differences in the OKS and EQ-5D-3L at 6 to 12 months postoperatively. To account for several covariates, weights based on propensity scores were generated. Cox proportional hazards models and generalized linear models were used to assess for differences in revision risk, and OKS and EQ-5D-3L change scores, respectively, between patient groups. Sensitivity analyses accounting for body mass index were performed. Effective sample sizes (ESSs) were computed, representing the statistical power comparable with that of an unweighted sample.

RESULTS: Compared with conventional instrumentation, the hazard ratio (HR) for all-cause revision was 1.126 (95% confidence interval [CI], 0.909 to 1.395; p = 0.277; ESS, 4,273) with computer navigation and 0.805 (95% CI, 0.442 to 1.467; p = 0.478; ESS, 1,199) with patient-specific instrumentation. No difference was found in the change in OKS between the groups (-1.287; 95% CI, -2.851 to 0.278; p = 0.107; ESS, 470), although improvement in the EQ-5D-3L scores was relatively lower for computer-navigated UKR compared with conventional instrumentation (-0.049, 95% CI, -0.093 to -0.005; p = 0.028; ESS, 455). However, sensitivity analyses demonstrated that computer navigation was associated with an increased risk of all-cause revision (HR, 1.446; 95% CI, 1.102 to 1.898; p = 0.008; ESS, 3,011) and relatively smaller improvements in the OKS (-2.845; 95% CI, -5.006 to -0.684; p = 0.010; ESS, 272) and EQ-5D-3L scores (-0.087; 95% CI, -0.145 to -0.030; p = 0.003; ESS, 286). There were no differences in intraoperative complications (p = 0.073).

CONCLUSIONS: This study found no clinically meaningful differences in patient-reported outcomes following computer-navigated UKR. Although likely underpowered, the primary analyses showed no difference in implant survival. While a sensitivity analysis suggested that computer navigation could worsen implant survival, this analysis had a smaller sample size. These findings highlight potential signals that warrant further investigation.

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

PMID:40536918 | DOI:10.2106/JBJS.24.01483

Int Orthop. 2025 Jun 19. doi: 10.1007/s00264-025-06582-5. Online ahead of print.

NO ABSTRACT

PMID:40536561 | DOI:10.1007/s00264-025-06582-5

Injury. 2025 Jun 5;56(8):112471. doi: 10.1016/j.injury.2025.112471. Online ahead of print.

ABSTRACT

INTRODUCTION: Tibial shaft fractures are common injuries seen particularly because of high velocity trauma. Considerable debate exists between the suprapatellar and infrapatellar approach for nailing of tibial shaft fractures. The aim of this study was to compare the clinical, radiological and functional outcomes and intra-operative fluoroscopy time, total blood loss and operative time between supra-patellar and infra-patellar insertion techniques in the treatment of extra-articular tibial shaft fractures.

METHODS: Sixty patients aged between 18-45 years who presented to our Level I trauma-centre with AO/OTA type 42 fractures were randomized into Suprapatellar (SP) and Infrapatellar (IP) groups. Operative time, intra-operative blood loss and radiation exposure was recorded. Severity of knee pain by VAS score and knee range of motion were documented at 2 weeks, 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months follow-up. Functional outcomes were measured using Knee Society Score, Lysholm Knee Score and KOOS-PF score and radiological union assessed with radiograph done at 6 weeks, 3 months, 6 months, 12 months, 18 months and 24 months post-operatively.

RESULTS: Thirty patients each underwent nailing by suprapatellar and infrapatellar approach. A statistically significant difference favouring the suprapatellar group was noted in the operative time (p-value 0.003) and mean intra-operative blood loss (p-value 0.027). There was no difference between the two groups in terms of knee pain or knee range of motion and the mean functional scores.

CONCLUSION: Suprapatellar nailing of tibial shaft fractures may help to reduce operative time and intra-operative blood loss with similar intra-operative radiation exposure, clinical and functional outcomes compared to infrapatellar nailing.

PMID:40532333 | DOI:10.1016/j.injury.2025.112471

Injury. 2025 May 28;56(8):112456. doi: 10.1016/j.injury.2025.112456. Online ahead of print.

ABSTRACT

BACKGROUND: Preoperative planning is a helpful tool for orthopaedic trauma cases, but clinical experience dictates that its use remains inconsistent. The primary aim of this cross-sectional survey study was to investigate practices and applications of preoperative planning for orthopaedic trauma cases and to identify factors influencing its use.

METHODS: A cross-sectional 26-item survey was distributed to members of the Orthopaedic Trauma Association and The Netherlands Orthopaedic Trauma Association between April 2024 and August 2024. Four key areas of interest were assessed: (1) general preoperative planning practices; (2) features of the preoperative plan; (3) use of preoperative planning for resident training; and (4) factors influencing the decision to make a preoperative plan. General preoperative planning practices were compared between attendings and residents or fellows.

RESULTS: Two-hundred-eleven orthopaedic surgeons, fellows, or residents completed the survey (84 % male, 74 % attending, 55 % of attendings trauma-fellowship-trained). Overall, 84 % of respondents considered preoperative planning very or extremely important. Formal preoperative planning was performed on average for 50 % of cases. Residents or fellows planned significantly more often than attendings (76 % vs. 30 %, p < 0.001) and used digital templating more often (59 % vs. 38 %, p= 0.006). The most common features of the plan were tactical, including positioning of implants and specific steps of approach and reduction. Residents reported that preoperative plans were discussed preoperatively in 75 % of cases and postoperatively evaluated in 40 %. Case complexity was the most influential factor in deciding to plan.

CONCLUSION: Respondents considered preoperative planning to be very or extremely important for orthopaedic trauma cases but made a formal preoperative plan on average in only half of cases. Residents or fellows made a preoperative plan twice as often. Complexity of the case was the most important factor in deciding to make a preoperative plan. Benefits of preoperative planning such as improving resident teaching and learning, efficiency, and teamwork should be considered more often in the decision to make a preoperative plan.

PMID:40532332 | DOI:10.1016/j.injury.2025.112456

Injury. 2025 Jun 8;56(8):112465. doi: 10.1016/j.injury.2025.112465. Online ahead of print.

ABSTRACT

BACKGROUND/PURPOSE: Forearm lacerations are frequently associated with involvement of tendon, nerve, and vessel injuries. An accurate diagnosis and timely intervention are critical to avoid any functional impairment, but clinical examination alone may not always be reliable, particularly in combined injuries or uncooperative patients. High-resolution ultrasound (USG) is a useful tool for the rapid assessment of these injuries. This study aims to evaluate the effectiveness of pre-operative USG in diagnosing tendon, nerve, and vascular injuries in acute trauma cases, using surgical exploration as the gold standard.

METHODS: This prospective observational study was conducted at the Department of Plastic Surgery of a tertiary care Trauma centre, between April 2022 and July 2024. Thirty-eight patients with forearm lacerations were included. All patients underwent clinical examination followed by USG (3-15 MHz) for injury assessment. The cases were examined by the operating surgeon. USG findings were compared with intraoperative findings to assess the diagnostic accuracy.

RESULTS: USG demonstrated diagnostic accuracy of 99.62 % in tendon injuries, with a high sensitivity (98.61 %) and specificity (100 %). It identified nerve injuries with a accuracy of 96.49 %, and interpreting arterial injuries was more challenging, with an accuracy of 90.7 %. The outcome of evaluation with high resolution USG with clinical examination was better than that of isolated clinical examination for tendon and neurovascular injuries. The mean time for an USG diagnosis in forearm laceration was 9.53 min.

CONCLUSION: High-resolution ultrasound is an effective, non-invasive tool for a quick assessment of forearm lacerations. It offers a high sensitivity and specificity for tendon and nerve injuries, aiding in targeted surgical interventions. While it is less sensitive for vascular injuries, it remains valuable for surgical planning in combined injuries. This study supports its integration into routine trauma care to improve diagnostic accuracy and better outcomes.

LEVEL OF EVIDENCE: Level IIIA, Prospective observational study.

PMID:40532331 | DOI:10.1016/j.injury.2025.112465

J Bone Joint Surg Am. 2025 Jun 18. doi: 10.2106/JBJS.24.01601. Online ahead of print.

ABSTRACT

BACKGROUND: Accurate and timely differential diagnosis of hip prosthesis failures remains a major clinical challenge. Radiographic examination remains the most cost-effective and common first-line imaging modality for hip prostheses, and integrating deep learning has the potential to improve its diagnostic accuracy and efficiency.

METHODS: A deep learning-based clinical classification system (Hip-Net) was developed to classify multiple causes of total hip arthroplasty failure, including periprosthetic joint infection (PJI), aseptic loosening, dislocation, periprosthetic fracture, and polyethylene wear. Hip-Net employed a dual-channel ensemble of 4 deep learning models trained on 2,908 routine dual-view (anteroposterior and lateral) radiographs for 1,454 patients (Asian) across 3 medical centers. An interpretive subnetwork generated spatially resolved disease probability maps. Discrimination performance and interpretability were tested in external and prospective cohorts, respectively. The correlation between model-generated individual PJI risk and inflammatory biomarkers was assessed.

RESULTS: Hip-Net demonstrated strong generalizability across different settings, effectively distinguishing between 5 common types of hip prosthesis failures with an accuracy of 0.904 (95% confidence interval [CI], 0.894 to 0.914) and an area under the receiver operating characteristic curve (AUC) of 0.937 (95% CI, 0.925 to 0.948) in the external cohort. The spatially resolved disease-probability maps for PJI closely aligned with intraoperative and pathological findings. The model-generated individual PJI risk scores exhibited a positive correlation with the C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR).

CONCLUSIONS: Hip-Net provided a clinically applicable strategy for accurately classifying and characterizing multiple etiologies of hip prosthesis failure. Such an approach is highly beneficial for providing interpretable, pathology-aligned probability maps that enhance the understanding of PJI. Its integration into clinical workflows may streamline decision-making and improve patient outcomes.

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

PMID:40531980 | DOI:10.2106/JBJS.24.01601

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):51-59. doi: 10.2106/JBJS.24.01223.

ABSTRACT

BACKGROUND: Initial surgical management of Gustilo-Anderson type-I to IIIA open fractures varies from surgical fixation of the fracture with immediate closure of the traumatic wound to various combinations of staged fracture and wound management. The decision to choose staged management has historically been based on wound contamination and the severity of the open fracture. The purpose of this study was to compare the rates of surgical site infection (SSI), wound complication, nonunion, and 1-year reoperation between patients with type-I to IIIA open fractures who underwent fix-and-close treatment and those who underwent planned, staged treatment.

METHODS: This is a secondary analysis of participants who were enrolled in the Aqueous-PREP and PREPARE-Open studies, excluding those with type-IIIB and IIIC open fractures. Participants were divided into fix-and-close or planned, staged groups and were matched using propensity scores that were computed with multiple variables, including patient and injury characteristics. Associations between treatment type and outcomes were analyzed.

RESULTS: A total of 3,170 participants (staged, 872: 70% White, 20% Black, and 10% other or unknown race; fix-and-close, 2,298: 62% White, 21% Black, and 17% other) with Gustilo-Anderson type-I to IIIA open fractures were identified. Eight hundred and thirty-six participants who underwent planned, staged treatment were propensity score-matched to 836 participants who underwent fix-and-close treatment. Staged treatment was significantly associated with increased odds of deep SSI within 90 days (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.15 to 3.47]; p = 0.01) and reoperation specifically for infection within 1 year (OR, 1.47 [95% CI, 1.06 to 2.04]; p = 0.02) but was not associated with increased odds of wound dehiscence (OR, 0.85 [95% CI, 0.49 to 1.49]; p = 0.57), wound necrosis or failure of the wound to heal (OR, 1.37 [95% CI, 0.83 to 2.25]; p = 0.21), reoperation requiring any free or local flap coverage (OR, 0.96 [95% CI, 0.55 to 1.68]; p = 0.89), or reoperation for delayed union or nonunion (OR, 1.30 [95% CI, 0.92 to 1.83]; p = 0.14).

CONCLUSIONS: Fix-and-close treatment of open fractures of type IIIA and lower was associated with decreased odds of deep SSI within 90 days and reoperation for infection within 1 year without an increased risk of wound complications or nonunion and may be considered even in fractures with embedded contamination provided that adequate debridement is performed.

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

PMID:40531233 | DOI:10.2106/JBJS.24.01223

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):60-70. doi: 10.2106/JBJS.24.01184.

ABSTRACT

BACKGROUND: Food deserts-communities with limited access to healthy food-have been linked with poor surgical outcomes; however, their impact on orthopaedic trauma outcomes remains unknown. The aims of this study were to determine the prevalence of food desert residency among orthopaedic trauma patients and to investigate the impact of food desert residency on the rate of unplanned reoperation with use of a large, high-quality, prospectively collected dataset with adjudicated outcomes. We hypothesized that orthopaedic trauma patients would reside in food deserts at a higher rate than the general U.S. population and that living in a food desert would be independently associated with an increased rate of unplanned reoperation.

METHODS: We included all patients from the Aqueous-PREP and PREPARE trials who had documented ZIP codes. The primary outcome was unplanned reoperation within 1 year, and the secondary outcomes included the reasons for reoperation. Residing in a food desert was the independent variable and was defined by the United States Department of Agriculture (USDA). Census tracts were converted to ZIP codes in order to assign food access for an individual's residence with use of the USDA Food Access Research Atlas.

RESULTS: Of the 2,607 patients included, 1,453 (55.7%) lived in a ZIP code containing a food desert compared with 49% of the U.S. population. Patients residing in a food desert were 42% female, 26.6% non-White, and 64% employed prior to injury, whereas patients not residing in a food desert were 41% female, 15% non-White, and 63% employed prior to injury, all of which was collected via patient self-report. Multivariable analysis demonstrated that living in a food desert was independently associated with 40% higher odds of unplanned reoperation (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.06 to 1.85; p = 0.019). This was driven by reoperation for delayed union or nonunion (OR, 1.75; 95% CI, 1.19 to 2.57; p = 0.004) and reoperation for a wound-healing complication (OR, 1.60; 95% CI, 1.01 to 2.54; p = 0.044).

CONCLUSIONS: This study found a strong association between residing in a ZIP code containing a food desert and an increased rate of unplanned reoperation, which was primarily driven by delayed union or nonunion and wound-healing complications. Addressing nutritional deficiencies in this population may help to effectively triage the use of health-care resources. Further research should focus on clarifying specific deficiencies and assessing the effectiveness of targeted interventions.

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

PMID:40531219 | DOI:10.2106/JBJS.24.01184

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):43-50. doi: 10.2106/JBJS.24.01250.

ABSTRACT

BACKGROUND: External fixation is often used in the management of open lower-extremity fractures. The objectives of this study were to identify hospital characteristics that are associated with greater use of temporary external fixation and to determine if external fixation reduces the odds of surgical site infection (SSI) and unplanned reoperation among patients with open lower-extremity fractures.

METHODS: This is a secondary analysis of the Aqueous-PREP and PREPARE-Open trials involving open lower-extremity fractures. Wilcoxon rank-sum and Fisher exact tests were used to assess if temporary external fixation use varied between hospital clusters. Mixed-effects logistic regression models controlling for hospital cluster and participant characteristics estimated the associations between temporary external fixation and SSI or unplanned reoperation.

RESULTS: There were 2,438 patients with an open lower-extremity fracture identified, with 568 (23.3%) undergoing temporary external fixation. There were 34 participating hospitals with a median external fixation rate of 21.5%. Hospitals with higher temporary external fixation use had a higher number of surgeons treating patients with fracture (p = 0.02). There was no difference in SSI at 90 days (odds ratio [OR], 1.16 [95% confidence interval (CI), 0.82 to 1.66]; p = 0.40) or 1 year (OR, 1.30 [95% CI, 0.97 to 1.75]; p = 0.08) between patients who did and did not undergo temporary external fixation. Patients who underwent temporary external fixation were more likely to have unplanned reoperations within 1 year (OR, 1.40 [95% CI, 0.96 to 1.79]; p = 0.05).

CONCLUSIONS: More temporary external fixation for open lower-extremity fractures was performed at hospitals with more surgeons treating fractures. There was no difference in SSI at 90 days or 1 year between patients who did and did not undergo temporary external fixation. Temporary external fixation tended to be used in more critically ill patients and patients with more severe fractures but was not associated with increased unplanned reoperations at 90 days or at 1 year.

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

PMID:40531191 | DOI:10.2106/JBJS.24.01250

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):71-79. doi: 10.2106/JBJS.24.01249.

ABSTRACT

BACKGROUND: The purpose of this study was to describe the culture and speciation results of patients with surgical site infection (SSI) from the PREPARE and Aqueous-PREP studies from the PREP-IT Investigators.

METHODS: Patients with suspected SSI underwent collection of deep or organ tissue samples for culture. The culture positivity rate was estimated as a percentage along with the exact binomial 95% confidence interval (CI). Microbial species were reported as percentages. Comparisons between open and closed fractures were conducted with the Z-test for proportions. Significance was set at p < 0.05.

RESULTS: Among the 2 primary studies, a total of 484 cases (defined as an anatomic fracture area; some patients had multiple fractures, which were each defined as a case if they developed an infection) had culture samples taken from deep or organ tissue. The culture positivity rate was 96.7% (95% CI, 94.7% to 98.0% [468 of 484 cases]). There were no significant differences (p = 0.507) in culture positivity between open fractures (97.2% [95% CI, 94.5% to 98.6%]; 273 of 281 cases) and closed fractures (96.1% [95% CI, 92.4% to 98.0%]; 195 of 203 cases). There was information on microbial species in 84.4% (395) of 468 cases. For patients with positive cultures, 43.3% (171 of 395 cases) were polymicrobial infections. Open fractures (47.8% [111 of 232 cases]), compared with closed fractures (36.8% [60 of 163 cases]), were more likely to be polymicrobial (p = 0.029). Staphylococcus aureus microbes (methicillin-sensitive S. aureus, methicillin-resistant S. aureus, and coagulase-negative S. aureus) accounted for 43.3% (462 of 1,066) of all positive cultures. The median time to infection was 58.5 days (95% CI, 49.0 to 67.0 days). The median time to infection was not significantly different in cases of open fractures (61.0 days [95% CI, 51.0 to 71.0 days]) compared with closed fractures (54.0 days [95% CI, 43.0 to 67.0 days]) (hazard ratio [HR], 0.92 [95% CI, 0.72 to 1.12]). SSIs associated with gram-negative bacteria had a shorter median time to infection at 46.0 days (95% CI, 36.0 to 58.0 days) compared with SSIs not associated with gram-negative bacteria at 70.0 days (95% CI, 56.0 to 88.0 days) (HR, 1.79 [95% CI, 1.55 to 2.03]). There was also a shorter median time to infection for patients with polymicrobial infections (47.0 days [95% CI, 38.8 to 52.1 days]) compared with patients with monomicrobial infections (78.6 days [95% CI, 57.2 to 86.8 days]) (HR, 1.26 [95% CI, 1.03 to 1.49]).

CONCLUSIONS: In patients with SSI, tissue samples yielded high rates of microbial culture results. There was a higher proportion of gram-negative organisms in open fractures. Gram-negative infections were also associated with earlier time to infection. Clinicians should not hesitate to take deep-tissue culture samples in patients with suspected SSI and should be prepared to encounter polymicrobial infections.

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

PMID:40531188 | DOI:10.2106/JBJS.24.01249

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):36-42. doi: 10.2106/JBJS.24.01224.

ABSTRACT

BACKGROUND: A preoperative chlorhexidine gluconate (CHG) bath is used to reduce the risk of surgical site infection (SSI) in elective surgery, but its efficacy in the trauma setting is unknown. We compared the incidence of SSI between patients who did versus did not receive a CHG bath before operative fixation of extremity and/or pelvic fractures.

METHODS: We conducted a secondary analysis of the PREP-IT cluster-randomized crossover trials that enrolled patients undergoing operative treatment for open or closed extremity or pelvic fractures. Preoperative CHG bathing (yes or no) was recorded for each patient per study protocol. The association between CHG bathing and SSI within 90 days after definitive fracture surgery was assessed. We performed multivariable regression to adjust for prognostic variables. We also conducted a separate instrumental variable analysis to compare SSI rates between study sites that used CHG bathing for >90% of participants and those that used CHG bathing for <1% of participants.

RESULTS: Of the 10,103 participants (mean age, 51 ± 20 years; 47% female; 77% White; 17% Black; 4% Asian; 7% Hispanic) included in the analysis, 2,674 (26%) had a documented preoperative CHG bath and 7,429 (74%) did not. CHG bathing was not associated with a significant reduction in the odds of 90-day SSI in the multivariable (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.86 to 1.32; p = 0.56) or instrumental variable (OR, 0.88; 95% CI, 0.62 to 1.25; p = 0.48) analyses.

CONCLUSIONS: Among adult patients who underwent extremity or pelvic fracture surgery, preoperative CHG bathing was not associated with a significant reduction in SSI.

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

PMID:40531185 | DOI:10.2106/JBJS.24.01224

J Bone Joint Surg Am. 2025 Jun 18;107(12):1403-1404. doi: 10.2106/JBJS.25.00202.

NO ABSTRACT

PMID:40531184 | DOI:10.2106/JBJS.25.00202

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):28-35. doi: 10.2106/JBJS.24.01178.

ABSTRACT

BACKGROUND: We evaluated antimicrobial resistance (AMR) patterns following local antibiotic use in a large cohort of patients with fractures from the PREP-IT (A Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma) study. We hypothesized that, among patients with extremity fractures who developed fracture-related infection (FRI), there would be no difference in AMR rates between those who had or had not received local antibiotic therapy with surgical fixation.

METHODS: This was a secondary analysis of all patients in the PREP-IT trial who developed FRI. Patient demographics, injury and fracture characteristics, and the primary outcome of the presence of an antimicrobial-resistant FRI were evaluated on the basis of whether the patient had or had not received local antibiotics in the operating room prior to, or at, definitive fixation.

RESULTS: A total of 555 FRIs in 546 patients (mean age, 50 years; 39% female; and 82% White) were included. A total of 268 fractures (264 patients) received local antibiotics. The Injury Severity Score and the proportion of open fractures were higher among patients and fractures that received local antibiotics, respectively. There were more Gustilo-Anderson type-IIIB or IIIC fractures in the local antibiotic group, but the rate did not differ significantly from that in the group with no local antibiotics (20% versus 14%; p = 0.14). Other baseline and fracture characteristics were similar between the groups, with the exception of age (lower in the group with local antibiotics). When examining FRIs with gram-positive organisms, we found that 3 (1.7%) of the FRIs in fractures that had been treated with local vancomycin had organisms resistant to vancomycin compared with 2 (0.9%) of the FRIs in fractures for which local vancomycin had not been used (p = 0.67). When examining FRIs with gram-negative organisms, the number of FRIs with aminoglycoside-resistant organisms was 8 (11.6%) among fractures that received local aminoglycosides and 10 (6.2%) among fractures that did not receive local aminoglycosides (p = 0.26).

CONCLUSIONS: Among extremity fractures that developed FRI, we were unable to detect differences in the rates of AMR between fractures treated with or without local antibiotic prophylactic strategies in our analysis of a randomized trial of various skin preparation solutions for extremity trauma surgery. These findings provide cautious reassurance regarding the safety of local antibiotics but underscore the need for further prospective analysis.

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

PMID:40531179 | DOI:10.2106/JBJS.24.01178

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):19-27. doi: 10.2106/JBJS.24.01123.

ABSTRACT

BACKGROUND: The ideal antibiotic prophylaxis for open fractures is unknown. We evaluated outcomes following different antibiotic prophylaxis regimens for open fractures.

METHODS: This is a secondary analysis of data from PREP-IT. Prophylactic antibiotics were defined as any intravenous antibiotic given on the day of admission. The outcomes were surgical site infection (SSI) within 90 days and reoperation within 1 year. Logistic regression and an instrumental variable analysis that leveraged site-level variation accounted for confounding. Subgroup variation was evaluated by stratifying by Gustilo-Anderson classification (Types I and II versus III).

RESULTS: Of the 3,331 included participants, the mean age was 45 ± 18 years, 63% were male, 73% were White, 21% were Black, 2% were Asian, and 10% were Hispanic. Cefazolin monotherapy (58% of patients), ceftriaxone monotherapy (10%), and cefazolin plus gentamicin (6%) were the most common regimens. In the instrumental variable analysis, the odds of infection did not significantly differ with ceftriaxone use (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.70 to 2.20; p = 0.45) or cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.04; p = 0.20) compared with cefazolin monotherapy. There were no significant differences between the regimens with respect to infection when stratified by Gustilo-Anderson type. However, we did observe a nearly 3-fold increase in the odds of infection with ceftriaxone use compared with cefazolin monotherapy (OR, 2.73; 95% CI, 0.96 to 7.79; p = 0.06) in Type-I and II fractures, and a 75% decrease in the odds of infection with cefazolin plus gentamicin use (OR, 0.25; 95% CI, 0.03 to 2.02; p = 0.19) compared with cefazolin monotherapy in Type-III fractures.

CONCLUSIONS: Among patients with open fractures, antibiotic prophylaxis with ceftriaxone monotherapy did not provide significant benefits compared with cefazolin monotherapy in preventing infection in Type-I and II fractures. The findings suggest that cefazolin plus gentamicin might reduce the odds of infection in Type-III fractures compared with cefazolin monotherapy, but this difference was not statistically significant.

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

PMID:40531169 | DOI:10.2106/JBJS.24.01123

J Bone Joint Surg Am. 2025 Jun 18;107(Suppl 1):12-18. doi: 10.2106/JBJS.24.01182.

ABSTRACT

BACKGROUND: The purpose of this study was to compare the simplified modification of the Orthopaedic Trauma Association-Open Fracture Classification (OTA-OFC3) with the original OTA-OFC and Gustilo-Anderson classification systems in predicting surgical site infection and unplanned reoperation.

METHODS: This was a retrospective cohort study conducted using the PREP-IT (A Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma) trial data of patients with open fractures. The OTA-OFC and Gustilo-Anderson classifications for each included fracture were determined by the treating surgeon at the initial irrigation and debridement. The OTA-OFC3 classification was determined on the basis of the highest severity level in any OTA-OFC domain. The study outcomes included surgical site infection and unplanned reoperations within 1 year of injury. Prognostic performance was measured by the area under the receiver operating characteristic curve (AUC), and AUCs were compared between classifications with z-tests.

RESULTS: This cohort study included 3,338 patients with 3,627 open fractures. Surgical site infections occurred for 11% of the open fractures, and unplanned reoperations occurred for 15%. The prognostic performance of the new OTA-OFC3 score (AUC, 0.61; 95% confidence interval [CI], 0.58 to 0.64) did not differ significantly from that of the Gustilo-Anderson classification (AUC, 0.63; p = 0.40) or the 5 OTA-OFC domains (AUC, 0.64; p = 0.32) in predicting surgical site infection. The prognostic performance of the OTA-OFC3 system (AUC, 0.62; 95% CI, 0.59 to 0.64) was similar to that of the Gustilo-Anderson classification (AUC, 0.63; p = 0.34) but was significantly worse than that of the 5 OTA-OFC domains (AUC, 0.69; p < 0.001) in predicting unplanned reoperations.

CONCLUSIONS: Simplifying the OTA-OFC to the new OTA-OFC3 significantly decreased its ability to predict unplanned reoperations and did not improve the ability to predict surgical site infection. These findings indicate that this newly proposed classification system, although clinically simpler, omits important prognostic information captured in the original OTA-OFC. Despite this limitation, the OTA-OFC3 demonstrated prognostic performance similar to that of the commonly used Gustilo-Anderson classification, and it may provide a clinically convenient way to communicate critical OTA-OFC information when all OTA-OFC domains are being assessed for research or quality-improvement purposes.

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

PMID:40531166 | DOI:10.2106/JBJS.24.01182