Injury. 2025 Aug 26;56(11):112723. doi: 10.1016/j.injury.2025.112723. Online ahead of print.

ABSTRACT

BACKGROUND: Lateral compression type 1 (LC1) pelvic fractures are common injuries with ongoing debate regarding the cost-effectiveness of operative versus non-operative treatment. The goal of this study is to evaluate the cost-effectiveness of operative versus non-operative management for lateral compression type 1 (LC1) pelvic fractures, using pain (Brief Pain Inventory, BPI) and functional recovery (Majeed Pelvic Score, MPS) as outcome measures across early follow-up intervals.

METHODS: A decision tree model was developed to analyze the costs and outcomes of operative and non-operative management for LC1 fractures. Costs were derived from Medicare reimbursement rates, and probabilities were informed by clinical data and expert opinion. BPI and MPS scores were used as proxies for utility, with incremental cost-effectiveness ratios (ICERs) calculated at 2, 6, and 12-week follow-ups. An ICER exceeding the willingness-to-pay (WTP) threshold of $50,000 indicated that non-operative management was the more cost-effective option. Sensitivity analyses explored the utility improvements required for operative treatment to meet the WTP threshold of $50,000 per meaningful change in BPI or MPS.

RESULTS: Operative management was cost-effective for early pain relief, with an ICER of $33,466.08 per meaningful change in BPI at 2 weeks. However, it exceeded the WTP threshold at 6 weeks ($68,632.04) and only approached cost-effectiveness again at 12 weeks ($50,828.58). Using MPS, operative management was found to be cost-effective at 12 weeks ($44,992.90), but not at 2 or 6 weeks. Sensitivity analyses demonstrated that small utility gains could make operative management cost-effective at intermediate follow-up intervals.

CONCLUSION: Operative management of LC1 fractures may offer early cost-effective pain relief and possible delayed cost-effective functional recovery, particularly by 12 weeks. These findings may support surgical intervention for patients prioritizing rapid recovery by 12 weeks, but careful patient selection remains critical.

LEVEL OF EVIDENCE: Level 3.

PMID:40885160 | DOI:10.1016/j.injury.2025.112723

Int Orthop. 2025 Aug 30. doi: 10.1007/s00264-025-06644-8. Online ahead of print.

ABSTRACT

PURPOSE: Fracture models in animals are essential to analyze bone healing in musculoskeletal research fields. Especially in small animals, fractures are difficult to simulate and stabilize. Therefore, a fracture model is desirable with a short operation time, high safety of the model without stabilization failure and low costs. Aim of this study is the evaluation of a new open tibial shaft model in mice for musculoskeletal research.

METHODS: In 12 eight week-old wild type mice, an open tibial shaft fracture was simulated and stabilized with a retrograde over the fracture inserted intramedullary pin. X-rays confirmed the correct fracture localization and stabilization. After eight weeks of follow-up, the mice were euthanized. Fracture healing and biomechanical stability were analyzed in a micro-CT scan and in torsional load-to-failure tests.

RESULTS: The whole operations lasted in mean eight min and 50 s. All mice recovered very quickly after the operative intervention and started using the operated leg again on the first postoperative day onwards if not earlier. No infections or failure of the stabilization occurred. All fractures healed completely within 8 weeks and substantial callus formation was confirmed in the micro-CT analysis. Biomechanically, higher torsional moment and stiffness were found for the operated tibia compared to the non-operated tibia in the same mouse.

CONCLUSION: The presented tibial fracture model with open osteotomy and retrograde pin insertion revealed minimal operative intervention and anesthesia, quick recovery and fracture healing with big callus formation. It is an easy to address fracture model for musculoskeletal research.

PMID:40884561 | DOI:10.1007/s00264-025-06644-8

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01630. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious complication associated with notable loss of function, impaired quality of life, and excess short-term mortality. In this study, we aimed to report the impact of PJI on long-term mortality and its associated risk factors.

METHODS: Using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), we used Kaplan-Meier estimates of survivorship and standardized mortality ratios (SMRs) based on Australian period life tables to describe mortality rates following revision for PJI, aseptic revisions (excluding those for fracture), and unrevised primary TKA. Additionally, hazard ratios (HRs) were calculated with multivariable proportional hazard models to assess the impact of the risk factors of age, gender, comorbidities, and minor versus major revisions.

RESULTS: Among 867,113 TKA procedures overall, there were 8,642 first revisions for PJI and 25,328 aseptic first revisions. At 5, 10, and 15 years, 16.1%, 34.4%, and 53.4% of patients with revision for PJI had died. When compared with a matched population, the SMR for revision for PJI was 1.33 (95% confidence interval [CI]: 1.28 to 1.39); for aseptic revision, 0.84 (95% CI: 0.82 to 0.87); and for unrevised primary TKA, 0.79 (95% CI: 0.78 to 0.79). Increasing age and higher American Society of Anesthesiologists (ASA) scores were significant mortality risk factors. Major revisions for PJI were not associated with a greater mortality risk compared with minor revisions for PJI.

CONCLUSIONS: Patients with revision for PJI had a 33% greater-than-expected mortality. There was a high mortality in the early postoperative period, and the excess mortality risk persisted beyond 15 years. Increasing age and higher ASA scores were associated with increased mortality.

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

PMID:40880507 | DOI:10.2106/JBJS.24.01630

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01466. Online ahead of print.

ABSTRACT

BACKGROUND: There is no foundational classification that 3-dimensionally characterizes arthritic anatomy to preoperatively plan and postoperatively evaluate total knee arthroplasty (TKA). With the advent of computed tomography (CT) as a preoperative planning tool, the purpose of this study was to morphologically classify pre-TKA anatomy across coronal, axial, and sagittal planes to identify outlier phenotypes and establish a foundation for future philosophical, technical, and technological strategies.

METHODS: A cross-sectional analysis was conducted using 1,352 pre-TKA lower-extremity CT scans collected from a database at a single multicenter referral center. A validated deep learning and computer vision program acquired 27 lower-extremity measurements for each CT scan. An unsupervised spectral clustering algorithm morphometrically classified the cohort. The optimal number of clusters was determined through elbow-plot and eigen-gap analyses. Visualization was conducted through t-stochastic neighbor embedding, and each cluster was characterized. The analysis was repeated to assess how it was affected by severe deformity by removing impacted parameters and reassessing cluster separation.

RESULTS: Spectral clustering revealed 4 distinct pre-TKA anatomic morphologies (18.5% Type 1, 39.6% Type 2, 7.5% Type 3, 34.5% Type 4). Types 1 and 3 embodied clear outliers. Key parameters distinguishing the 4 morphologies were hip rotation, medial posterior tibial slope, hip-knee-ankle angle, tibiofemoral angle, medial proximal tibial angle, and lateral distal femoral angle. After removing variables impacted by severe deformity, the secondary analysis again demonstrated 4 distinct clusters with the same distinguishing variables.

CONCLUSIONS: CT-based phenotyping established a 3D classification of arthritic knee anatomy into 4 foundational morphologies, of which Types 1 and 3 represent outliers present in 26% of knees undergoing TKA. Unlike prior classifications emphasizing native coronal plane anatomy, 3D phenotyping of knees undergoing TKA enables recognition of outlier cases and a foundation for longitudinal evaluation in a morphologically diverse and growing surgical population. Longitudinal studies that control for implant selection, alignment technique, and applied technology are required to evaluate the impact of this classification in enabling rapid recovery and mitigating dissatisfaction after TKA.

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

PMID:40880455 | DOI:10.2106/JBJS.24.01466

Int Orthop. 2025 Aug 30. doi: 10.1007/s00264-025-06642-w. Online ahead of print.

ABSTRACT

INTRODUCTION: Shoulder dislocations occur in approximately 45% of all joint types, and anterior shoulder dislocations account for more than 90% of cases. The purpose of this study was to assess the functional outcomes of an open Latarjet operation for patients with recurrent anterior shoulder dislocations.

METHODS: A prospective hospital-based study was conducted at the Orthopaedic Department of Al Thawra Modern General Hospital, Sana'a City, between 2015 and 2022. Consecutive patients who experienced recurrent anterior shoulder instability underwent the open Latarjet procedure. Preoperative and postoperative clinical, radiographic, and functional outcomes according to the Rowe score were assessed during the study period.

RESULTS: Twenty patients, with a mean age of 20.9 ± 2.9 years, were included in this study. The most common age group at surgery was ≤ 20 years (70%). The median number of recurrent dislocations before surgery was 25. 40% of the patients presented more than two years after the first dislocation, with a mean duration of 2.5 ± one year. Postoperatively, haematoma, infection, neurovascular injury, graft malposition, graft nonunion and osteoarthritis were not observed in any patient. However, one patient (5%) had a stress fracture in the coracoid graft. All patients showed improvement in the preoperative mean Rowe score of 6.5 ± 4.6 to the postoperative mean Rowe score of 91 ± 7% (an excellent grade) at the last follow-up.

CONCLUSION: The open Latarjet procedure had excellent outcomes with a very low rate of complications in this study. We recommend the open Latarjet procedure for the management of recurrent anterior shoulder dislocation in patients with significant glenoid bone defects, especially in developing countries with limited resources, such as Yemen.

PMID:40883518 | DOI:10.1007/s00264-025-06642-w

Int Orthop. 2025 Aug 29. doi: 10.1007/s00264-025-06646-6. Online ahead of print.

ABSTRACT

PURPOSE: Posterior femoro-acetabular impingement in patients with increased femoral version can result in significant hip pain, chondro-labral injury, and limited range of motion. Femoral rotational osteotomy may address these issues by correcting excessive femoral anteversion.

METHODS: This retro-spective case series included 25 adolescents (mean age 14.8 years) with symptomatic increased femoral version (> 35°) treated between 2015 and 2022. Inclusion required hip pain, limited range of motion, and increased femoral version confirmed on computed tomography. Patients underwent femoral external rotational osteotomy targeting a post-operative femoral version of ~ 15°. Outcomes assessed included femoral version, hip range of motion, and Harris Hip Score pre-operatively, at six months, and at two years post-operatively.

RESULTS: Mean femoral version improved significantly from 39° ± 3° pre-operatively to 19° ± 7° post-operatively (P < 0.001). Internal rotation decreased from 54° ± 9° to 32° ± 8°, while external rotation increased from 38° ± 4° to 44° ± 5° (P < 0.001). Mean Harris Hip Score improved from 62.5 ± 10.3 to 86.1 ± 6.4 at 6 months, with sustained results at two year follow-up. Radiographic union was achieved in all patients, and no major complications were observed.

CONCLUSION: Femoral rotational osteotomy is a safe and effective treatment for posterior hip impingement in young patients with excessive femoral version.

PMID:40879765 | DOI:10.1007/s00264-025-06646-6

Injury. 2025 Aug 25;56(11):112693. doi: 10.1016/j.injury.2025.112693. Online ahead of print.

ABSTRACT

INTRODUCTION: Although ketorolac's association with poor bone healing remains debated, no study has examined the impact of ketorolac administration in adults with proximal humerus fractures (PHFs) after open reduction and internal fixation (ORIF), limiting surgeon decision-making. Therefore, the primary aim of this study was to examine the association between short-term ketorolac administration within the first three days after ORIF for PHF and the incidence and risk of nonunion or malunion through one year.

METHODS: A pre-registered retrospective propensity-matched cohort study was performed using a large United States health records-based database (TriNetX, LLC). Patients included adults (≥18 years old) who underwent first-time proximal humerus ORIF and received either acute (≤3 days) postoperative ketorolac (ketorolac cohort) or acetaminophen (control cohort). The primary outcome was the risk ratio (RR) of nonunion through one year. Secondary outcomes explored the incidence and risk of reoperation by surgery type, other relevant postoperative adverse events (such as malunion), and RR and mean count of postoperative oral opioid prescription. Over fifteen risk factors associated with bone union were used for propensity matching.

RESULTS: There were 2143 patients per cohort (n = 4286 total) with a mean age of 55 years. Comparing the ketorolac cohort to the control cohort, there was a statistically significant increase in risk of nonunion (p = 0.040; RR: 1.46 [1.02, 2.10]; 3.3% versus 2.2%; 70 patients versus 48 patients). Individual outcomes demonstrated no statistically significant difference in risk of malunion (p = 0.288; RR: 1.28; 1.9% versus 1.5%), revision ORIF (p = 0.493), total shoulder arthroplasty (p = 0.354), or acute kidney injury (p = 0.423). There was a statistically significant decrease in risk (p = 0.015) and mean count (p = 0.033) of oral opioid prescription.

CONCLUSION: Acute postoperative ketorolac after ORIF for PHF is associated with a modest increase in risk of nonunion and reduction in opioid prescriptions, with no significant differences in malunion, reoperation, or acute kidney injury. These findings support the need for individualized decision-making to weigh risks and benefits in postoperative pain management, with future research needed on dosages.

PMID:40876112 | DOI:10.1016/j.injury.2025.112693

Injury. 2025 Aug 19;56(11):112685. doi: 10.1016/j.injury.2025.112685. Online ahead of print.

ABSTRACT

BACKGROUND: To prepare junior surgeons for possible increased trauma call burden and improve young surgeons' workplace marketability, there has been an increase in fellowship programs offering combined arthroplasty and trauma curriculums. The purpose of this study was to determine the relative importance of factors considered by applicants applying to combined programs. This information will serve program directors, who can improve applicant recruitment, along with improving the experiences of fellows.

METHODS: Survey respondents were asked to rate 23 fellowship program factors on a 1-to-5 Likert scale with 1 being "not important at all" and 5 being "critical". Respondents were also asked to list their top 5 factors in order of decreasing importance with 1 being the most important. A two-sample t-test was used to analyze subgroups. Statistical significance defined as P-value < 0.05.

RESULTS: Surveys were sent to 192 applicants, and 75 responses were received with a 39.1 % response rate. The overall highest rated factors were operative experience (mean 4.87; SD 0.34), revision total joint experience (mean 4.61; SD 0.61), periprosthetic fracture experience (mean 4.52; SD 0.60), and primary total joint experience (mean 4.17; SD 0.86). A subgroup analysis was performed by creating three groups: surgical experience, program details and history, and financial factors. Surgical experience group was ranked highest (mean 3.81; SD 1.72). Programs details and history (mean 3.12; SD 1.05) and financial factors (mean 2.35; SD 1.08) rated significantly lower than surgical experience (P-value < 0.01).

CONCLUSIONS: Applicants of combined arthroplasty and trauma fellowships value similar characteristics in a program as those applying to either arthroplasty or trauma alone. Combined fellowship programs should update their websites as applicants frequently use online sources to educate themselves on existing programs.

PMID:40876111 | DOI:10.1016/j.injury.2025.112685

Injury. 2025 Aug 24;56(11):112719. doi: 10.1016/j.injury.2025.112719. Online ahead of print.

ABSTRACT

BACKGROUND: Indications for stabilization of the medial collateral ligament (MCL) after repair of the lateral ulnar collateral ligament (LUCL) remain controversial. Here, we propose a standardized fluoroscopic sequence to reveal residual medial elbow instability to facilitate intraoperative decision-making.

METHODS: Eight matched cadaveric upper extremity pairs (N = 16) were mounted to simulate intraoperative positioning. Fluoroscopic images were acquired using the following: full extension, 45-degree flexion, 90-degree flexion, and full flexion with the forearm in neutral/pronation/supination. These were acquired at "baseline" and following destabilization of the LUCL/MCL. The proposed fluoroscopic sequence was then repeated following surgical fixation of the LUCL ("post-LUCL repair") followed by MCL repair ("post-LUCL & MCL repair). Blinded images were fitted using a best-fit circle to compute ulnohumeral distance (UHD, millimeters) and determine residual lateral (supination) and medial (pronation) instability defined by the presence of a drop sign (UHD>4 mm). Radiocapitellar ratio (RCR) was computed to determine radiocapitellar instability (RCR>10 %). Blinded images were also qualitatively evaluated against the contralateral baseline to simulate intraoperative assessment.

RESULTS: Apparent instability in supination status-post destabilization resolved following LUCL repair with evident residual medial-sided instability showed in pronation, which resolved after MCL fixation. Evaluation of the drop sign at 45 and 90 degrees of flexion showed comparable quantitative sensitivity at 97 % and 98 %, unlike in full extension or full flexion (sensitivity <35 %). Quantitative sensitivity was 88 % for RCR in mid-flexion. Qualitative evaluation for the drop sign and RCR resulted in sensitivity of 93 and 75 %, respectively.

CONCLUSIONS: The proposed fluoroscopic sequence provides reliable intraoperative assessment to evaluate for residual medial-sided instability in the setting of multi-ligamentous elbow injuries. After repair of the LUCL, medial residual instability due to MCL rupture is best revealed with the presence of a drop sign in full pronation and midflexion.

LEVEL OF EVIDENCE: IV.

PMID:40876110 | DOI:10.1016/j.injury.2025.112719

Injury. 2025 Aug 16;56(11):112682. doi: 10.1016/j.injury.2025.112682. Online ahead of print.

ABSTRACT

BACKGROUND: The classic surgical technique of the 15-mm incision minimally invasive approach is not suitable for AO 23-B3 distal radius fractures (abbreviated B3). We have modified this technique for B3. This study aimed to investigate the efficacy of the modified 15-mm incision minimally invasive approach with the conventional ORIF approach in the treatment of B3.

METHODS: This retrospective study included 62 patients with B3 who underwent surgical treatment from January 2020 to May 2024, including 31 patients undergoing the modified 15-mm incision minimally invasive approach (M group) and 31 patients undergoing the conventional ORIF approach (C group). The two groups had similar baseline characteristics (P > 0.05). The perioperative data, follow-up data, and imaging results of the two groups were compared. At the last follow-up, the limb function was assessed using the PRWE and DASH scores.

RESULTS: In the C group, 1 patient experienced infection and 1 patient experienced complex regional pain syndrome, whereas in the M group, there were no such patients. In the M group, the incision length, intraoperative bleeding, hospital stay, hospitalization expenses, swelling, and VAS on postoperative days 2 and 7, flexion-extension, ulnar-radial deviation and pronation-supination at postoperative 3 months, and pronation-supination ROM in 12-24 months of follow-up were superior, but the surgical and fluoroscopy time was longer compared to the C group (P < 0.05). There was no difference between the two groups in terms of fracture reduction, fracture healing time, full weight-bearing time, complications, and flexion-extension ROM, PRWE and DASH in the last follow-up (P > 0.05).

CONCLUSION: Both methods were effective for treating B3. The M group was superior in terms of aesthetic appeal of the incision, surgical trauma and associated risks, hospital stay, early recovery, and final rotational function, which are consistent with the principles of MIPO and rapid recovery, but requires longer surgical and fluoroscopy time.

PMID:40876109 | DOI:10.1016/j.injury.2025.112682

J Bone Joint Surg Am. 2025 Aug 28. doi: 10.2106/JBJS.24.00733. Online ahead of print.

ABSTRACT

➢ The use of multirod constructs (≥3 rods) in complex spine surgery has increased as its utility has been recognized over the past decade.➢ There are multiple different rod configurations that may be utilized on the basis of the desired supplemental rod function, with each type having its own advantages and clinical indications.➢ Literature has continued to demonstrate a reduced incidence of pseudarthrosis, rod fracture, and reoperation when comparing multirod constructs with traditional dual-rod constructs.➢ The use of consistent nomenclature when describing multirod constructs will allow for more productive clinical and biomechanical research.

PMID:40875787 | DOI:10.2106/JBJS.24.00733

Injury. 2025 Aug 8;56(10):112659. doi: 10.1016/j.injury.2025.112659. Online ahead of print.

ABSTRACT

Train-related injuries represent a significant yet underreported public health challenge in developing countries, particularly in sub-Saharan Africa, where contemporary data are scarce. This study characterizes the epidemiology, clinical presentation, and outcomes of train-related trauma at a South African Level I trauma center, with a focus on identifying predictors of severe outcomes and informing context-specific interventions for this high-risk population.

METHOD: A retrospective analysis was conducted on 63 patients presenting to Groote Schuur Hospital between April 2008 and June 2013. Data collected included demographics, injury mechanisms, clinical findings, and outcomes. Multivariable logistic regression was performed to evaluate the association between key severity markers (GCS ≤8, hypotension, mangled extremities) and ICU admission.

RESULTS: The cohort was predominantly male (96.8 %) with a median age of 26 years (IQR: 22-33). Injuries clustered during winter months (April-October), with 62 % occurring between 4:00 PM and midnight. The most common mechanisms were boarding or alighting from moving trains (46.2 %) and interpersonal assault (33.3 %). Lacerations were the most frequent soft tissue injury (69.8 %), while lower (25.4 %) and upper limb (22.2 %) fractures were the predominant orthopedic injuries. The amputation rate was 20.6 %, strongly associated with mangled extremities. Median hospital stay was 6 days (IQR: 1-17), extending significantly for patients with spinal trauma. Severe traumatic brain injury (GCS ≤8) was independently associated with ICU admission (adjusted OR 15.0; 95 % CI: 2.7-82.4; p < 0.001). Mangled extremities and hypotension were not significantly associated with ICU requirement.

CONCLUSION: Young male commuters are more likely to sustain severe, preventable train-related injuries. Significant musculoskeletal trauma, head, and spinal injuries increased hospital stay, underscoring the need for comprehensive assessment to reduce morbidity and improve outcomes. Our findings support protocolized neurosurgical and orthopaedic triage and targeted prevention strategies in resource-limited settings.

PMID:40865178 | DOI:10.1016/j.injury.2025.112659

SICOT J. 2025;11:50. doi: 10.1051/sicotj/2025031. Epub 2025 Aug 26.

ABSTRACT

BACKGROUND: Proximal femoral megaprosthetic reconstruction is a well-established solution for extensive bone loss in the hip region. Despite its utility in limb salvage, it carries notable complication rates, reported between 30% and 40%, along with increased morbidity and mortality. This study evaluated implant and patient survival, failure modes, and associated risk factors.

METHODS: We retrospectively reviewed 165 patients who underwent proximal femoral megaprosthetic reconstruction between 2003 and 2023. Indications included primary bone tumors (n = 67), metastatic bone disease (n = 60), and non-oncologic conditions (n = 38). A total of 57 METS (Stanmore) and 108 MUTARS (Implantcast) implants were used. Median follow-up was 5 years (range: 0.25-17 years).

RESULTS: Mean implant survival was 5.13 years (range: 0.2-17 years), with an overall complication rate of 30.9%. The most common failure modes were type 1 (11.5%) and type 4 (13.3%) per Henderson classification. Five-year implant survival ranged from 60% to 70% across indications. Independent risk factors for type 4 failure included prolonged hospitalization (OR = 1.07, p = 0.020) and longer operative time (OR = 1.01, p = 0.023). Silver-coated implants showed a trend toward reduced infection (OR = 0.18, p = 0.29), though not statistically significant. METS implants were associated with lower type 1 failure risk (OR = 0.09, p = 0.020), with a soft-tissue failure rate of 3.5% versus 15.7% for MUTARS.

CONCLUSION: Proximal femoral megaprostheses remain effective for limb salvage but are linked to a substantial complication burden. Recognition of modifiable and patient-specific risk factors may improve surgical outcomes and reduce failure rates.

PMID:40857599 | PMC:PMC12380411 | DOI:10.1051/sicotj/2025031

SICOT J. 2025;11:49. doi: 10.1051/sicotj/2025043. Epub 2025 Aug 26.

ABSTRACT

INTRODUCTION: Complications arising from the patellofemoral joint (PFJ) represent the third most common cause for revision in total knee arthroplasty (TKA). Previous in vitro biomechanical studies have altered the native attachments of muscles controlling the PFJ. The purpose of this study was to design an in vitro biomechanical setup that would allow testing of both native and arthroplasty knee joints, specifically the PFJ, without disturbing the native attachments of the quadriceps and hamstrings muscles.

METHODS: After finalising a prototype, a pelvis-to-toe human cadaver specimen was tested. The simVITRO platform was used to simulate movement and control force trajectories. A motion capture system was used to capture the motion of the bones and to measure knee flexion angle and patellar movement with respect to the femur. The forces applied in the PFJ were measured using a custom patella sensor.

RESULTS: Displacement of the reflective cluster attached to the femur was measured during compression loading at different flexion angles, passive flexion and stairs descent trajectory. The femur showed less than 1 mm and 3 mm displacement with respect to the femur clamp in passive flexion and stairs descent. The most translation of 8.37 mm (<2% average femur length) was observed at 90° flexion which occurred at 483 N simulated compression force.

CONCLUSION: This novel design provides a methodology for studying the biomechanics of the PFJ in vitro that preserves the soft tissues influencing the behaviour of the joint. This setup provides a biomechanics model that can be utilised to better understand and study the PFJ in vitro.

PMID:40857598 | PMC:PMC12380413 | DOI:10.1051/sicotj/2025043

SICOT J. 2025;11:48. doi: 10.1051/sicotj/2025049. Epub 2025 Aug 26.

ABSTRACT

BACKGROUND: Acetabular reconstruction during revision total hip arthroplasty (THA) with major bone loss is a complex surgical challenge. The combination of custom-made (CM) acetabular components with cemented dual mobility (DM) cups may improve postoperative outcomes in this context. This study aims to assess the clinical, functional, and radiological results of this surgical approach.

METHODS: We conducted a retrospective, single-center observational study including 16 patients (mean age 70 years) who underwent revision THA between May 2016 and December 2024 using a cemented DM cup in a CM acetabular component. All patients presented with Paprosky 3A or 3B defects, and 38% had a history of periprosthetic joint infection (PJI). Functional outcomes were measured using the Oxford Hip Score (OHS) and modified Harris Hip Score (mHHS) pre- and postoperatively. Radiographic assessment included measurement of the center of rotation (COR) deviation in both axes, as well as acetabular inclination and anteversion on postoperative CT scans. Implant survival was analyzed using Kaplan-Meier methodology.

RESULTS: At a mean follow-up of 16.2 months, overall implant survival was 75%, increasing to 93.8% when excluding isolated DM cup revisions. No postoperative infections were observed. OHS improved from 14.1 to 27.6 and mHHS from 27.4 to 52.7 (p < 0.001 for both). A significant negative correlation was observed between vertical (y-axis) COR deviation and functional scores (p < 0.01), highlighting the importance of restoring vertical COR. Mean inclination and anteversion were 41.2° and 29°, respectively, generally within target alignment zones.

DISCUSSION: The combination of cemented DM cups with CM acetabular components appears to be an effective technique in complex revision THA. Functional recovery and implant survivorship are consistent with the existing literature, and the absence of infection despite prior PJI history suggests benefit from a multidisciplinary approach. Restoration of vertical COR is a predictor of functional outcomes.

PMID:40857597 | PMC:PMC12380412 | DOI:10.1051/sicotj/2025049

J Bone Joint Surg Am. 2025 Aug 26. doi: 10.2106/JBJS.24.01333. Online ahead of print.

ABSTRACT

➢ With any study, readers should be cautious and critical when the conclusion is that "these treatments are the same."➢ If only superiority testing was performed, failing to find a difference does not mean that the treatments are the same, even when the study was adequately powered.➢ Noninferiority analysis is the correct method to compare treatments that researchers and clinicians think may be "the same" for the primary outcome.➢ The most important aspect of a noninferiority analysis is the selection of the noninferiority margin, which is the minimum difference between groups that would be considered meaningful.➢ To perform noninferiority testing, the difference in an outcome measure of interest between experimental and control groups must be examined with respect to the noninferiority margin of the same outcome measure. Assuming that a greater value indicates improvement in an outcome measure, if the lower bound of a 95% confidence interval of a difference in means based on a 1-sided test is greater than the noninferiority margin, then the experimental treatment can be considered noninferior to the control.

PMID:40857355 | DOI:10.2106/JBJS.24.01333

J Bone Joint Surg Am. 2025 Aug 25. doi: 10.2106/JBJS.24.01326. Online ahead of print.

ABSTRACT

BACKGROUND: Fourth-generation percutaneous, or minimally invasive, hallux valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of studies reporting the clinical and radiographic outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow-up, or use of non-validated outcome measures. The aim of this study was to provide a methodologically robust investigation of percutaneous transverse osteotomies for hallux valgus deformity.

METHODS: We studied a prospective series of consecutive patients undergoing fourth-generation metatarsal extracapsular transverse osteotomy performed by a single surgeon (P.L.) between November 2017 and January 2023. The primary outcome was clinical foot function assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated patient-reported outcome measure. Secondary outcomes included the radiographic deformity (the hallux valgus angle [HVA], 1-2 intermetatarsal angle [IMA], and sesamoid position) assessed according to American Orthopaedic Foot & Ankle Society (AOFAS) guidelines as well as a visual analog scale for pain and radiographic evidence of deformity recurrence (defined as an HVA of >20° at final radiographic follow-up). P values of <0.05 were considered significant.

RESULTS: Seven hundred and twenty-nine feet (483 patients; 456 female and 27 male; mean age, 57.9 ± 11.9 years) underwent fourth-generation metatarsal extracapsular transverse osteotomy. Radiographic data were available at a vminimum of 12 months postoperatively for 99.7% of the feet, which were followed for a mean of 2.6 ± 1.3 years (range, 1.0 to 5.7 years). There was a significant improvement (p < 0.05) in both the HVA (from 29.5° ± 8.5° preoperatively to 7.3° ± 6.7° at final follow-up) and the IMA (from 12.9° ± 3.3° to 4.6° ± 2.5°). All MOXFQ domains showed significant improvement (p < 0.05), with the MOXFQ Index improving from 36.9 ± 18.9 to 13.4 ± 15.8, Pain improving from 40.5 ± 22.0 to 17.2 ± 18.3, Walking/Standing improving from 32.3 ± 23.1 to 12.0 ± 18.2, and Social Interaction improving from 40.4 ± 20.4 to 11.0 ± 15.2. The recurrence rate was 4.5% (n = 33). The complication rate was 6.1%, which included a screw removal rate of 2.9%.

CONCLUSIONS: This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence.

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

PMID:40854004 | DOI:10.2106/JBJS.24.01326

Injury. 2025 Aug 7;56(10):112657. doi: 10.1016/j.injury.2025.112657. Online ahead of print.

ABSTRACT

BACKGROUND: Nonunion is a significant complication following nonoperative treatment of displaced midshaft clavicle fractures, potentially leading to impaired shoulder function, pain, and decreased quality of life. This study aims to identify predictors of nonunion in adults treated nonoperatively to optimize treatment decisions and improve outcomes.

METHODS: A retrospective cohort study was conducted using data from 374 patients treated nonoperatively between 2012 and 2024. Patient and fracture characteristics, including age, sex, smoking, diabetes mellitus, and fracture comminution, were assessed. Univariable and multivariable logistic regression analyses identified predictors of nonunion. Model performance was assessed using the area under the receiver operating characteristic (ROC) curve (AUC). Diagnostic statistics and number needed to screen (NNS) were calculated.

RESULTS: Of 374 patients, 72 (19.3 %) developed nonunion. Multivariable analyses revealed that increasing age (odds ratio [OR]: 1.03, 95 % confidence interval [CI]: 1.01-1.04, p = 0.002) and smoking (OR: 2.49, 95 % CI: 1.31-4.71, p = 0.005) were independently associated with increased risk of nonunion. Fracture comminution was associated with reduced risk (OR: 0.34, 95 % CI: 0.20-0.58), p < 0.001). The model's AUC was 0.70. At a probability threshold of 0.4, the NNS was 6.

CONCLUSIONS: This study highlights the potential of predictive models to identify patients at risk for nonunion. Age and smoking increase the risk of nonunion, while comminution showed a protective effect. These findings support personalized care to optimize treatment decisions and improve patient outcomes. Further refinement and inclusion of additional risk factors are essential to improve the model's accuracy and clinical applicability.

PMID:40850009 | DOI:10.1016/j.injury.2025.112657

Injury. 2025 Aug 5;56(10):112646. doi: 10.1016/j.injury.2025.112646. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Complex open tibial fractures with soft tissue defects in children represent a major clinical challenge due to high risks of infection, osteomyelitis, and long-term functional impairment. This study aimed to evaluate the effectiveness of a combined orthopedic and reconstructive approach using external fixation and free anterolateral thigh (ALT) flaps in pediatric patients.

METHODS: In this prospective, controlled clinical trial, 78 children (mean age 12.4 ± 3.1 years) with open tibial fractures and extensive soft tissue loss from road traffic accidents were enrolled. Patients were randomized into two groups: the experimental group (n = 40) received Ilizarov external fixation with microsurgical ALT flap reconstruction; the control group (n = 38) underwent conventional internal fixation with standard wound management. Renal function markers (creatinine, urea, GFR) were monitored to assess the impact of trauma, systemic inflammation, and nephrotoxic antibiotic exposure. Healing was evaluated using the Zygo-Scale at 7, 30, 60, 90 days, and 12 months. Incidence of osteomyelitis, joint ankylosis, flap complications, and revision surgeries was recorded.

RESULTS: The experimental group demonstrated significantly faster and more complete soft tissue healing (p ≤ 0.05), with lower rates of osteomyelitis at 6 and 12 months (2.5 % and 0 % vs. 10.5 % and 5.25 %, respectively; p < 0.05). Joint ankylosis scores were also significantly reduced (p = 0.02 and p = 0.01). Flap survival rate was 95 %, with no cases of total necrosis. Donor site morbidity was minimal. While renal function improved in both groups, a modest but significant difference in creatinine levels at 12 months favored the experimental group (p = 0.03). The combined approach was associated with shorter healing times and fewer complications.

CONCLUSION: The integration of Ilizarov fixation with ALT flap reconstruction is a safe and effective strategy for managing severe pediatric lower limb injuries, enhancing healing, reducing infections, and improving functional outcomes. Monitoring renal markers provides insight into systemic stress and antibiotic safety in trauma care.

PMID:40850008 | DOI:10.1016/j.injury.2025.112646

Injury. 2025 Aug 7;56(10):112663. doi: 10.1016/j.injury.2025.112663. Online ahead of print.

ABSTRACT

AIMS: This study aimed to explore safety and feasibility of at-home softcast removal in children with displaced injuries undergoing manipulation; understand caregiver experience; and determine its impact on service at our tertiary centre.

METHODS: Paediatric patients (<16 years) with any fracture requiring application of a circumferential softcast, later removed at home without planned routine follow-up, were retrospectively analysed from two time-points: July-September 2022; February-April 2023. Demographic data including age, fracture location, angulation, whether manipulation was undertaken, and unplanned re-attendances were recorded. Caregivers completed a telephone Likert questionnaire (1=extremely positive, 5=extremely negative) reviewing cast removal time and qualitative descriptors of experience. Cost analysis was performed based on use of consumables, staff and clinical areas.

RESULTS: 77 caregivers completed the questionnaire at mean 93.4 days post-injury. Mean patient age was 7.6 years at time of injury. 41 (53.2 %) were distal radius, 20 (26.0 %) forearm and 16 (20.8 %) were elbow, hand or tibia fractures. Mean sagittal angulation was 24.7 degrees and 40 (52.0 %) injuries underwent manipulation under sedation. 13 (16.9 %) patients re-attended with cast problems. Caregivers estimated a mean 13.3 min to remove the cast. 83.1 % found it 'extremely' or 'somewhat' easy. 75.3 % were 'extremely' or 'somewhat' satisfied. 71.4 % were 'extremely' or 'somewhat' likely to recommend it. Qualitative descriptors ranged from "traumatic" to "easy". Since introduction of this practice, subsequent clinic attendances for children diagnosed with a fracture in the Emergency Department has reduced by >50 %, equating to savings of approximately £22,600 per annum.

CONCLUSION: Our experience confirms at-home softcast removal without further orthopaedic follow-up is safe and feasible, even in displaced injuries undergoing manipulation. The majority of families reported positive experiences. However, this was not universal and adequate patient education was integral to this.

PMID:40850007 | DOI:10.1016/j.injury.2025.112663