Int Orthop. 2025 Feb 3. doi: 10.1007/s00264-025-06418-2. Online ahead of print.

ABSTRACT

INTRODUCTION: The development of high-frequency ultrasound technology has transformed musculoskeletal diagnostic practices, offering detailed, multi-plane visualization of superficial structures with remarkable precision and comfort. This non-invasive, pain-free modality is particularly suited for patients of all ages, including children.

PURPOSE: Ultrasound serves as a valuable adjunct to clinical evaluations by facilitating the identification of conditions such as tumours, tenosynovitis, fractures, and nerve entrapments. Portable ultrasound devices have further expanded its utility to clinical, surgical, and emergency settings. Dynamic assessments, such as nerve gliding and entrapment detection, benefit from its precision, enabling targeted therapeutic interventions with minimal risks.

METHOD: The integration of ultrasound into surgical techniques, termed ultrasonosurgery, allows for minimally invasive management of conditions like carpal tunnel syndrome and other nerve compressions. By leveraging high-resolution imaging, these procedures can be performed under local anaesthesia, minimizing traditional surgical complications.

RESULT: This innovative approach aligns with contemporary healthcare trends emphasizing wide-awake surgeries, office-based care, mini-invasive procedures, and technological advancements. Such practices not only streamline patient care but also reduce costs and improve outcomes.

PMID:39900668 | DOI:10.1007/s00264-025-06418-2

Int Orthop. 2025 Feb 3. doi: 10.1007/s00264-025-06425-3. Online ahead of print.

ABSTRACT

PURPOSE: This study aimed to compare the outcomes of conservative treatment and locking plate osteosynthesis in displaced proximal humerus fractures in elderly patients.

METHODS: The study included patients over the age of 60 who were admitted to a tertiary trauma centre between 2020 and 2023, all diagnosed with 2-, 3-, or 4-part proximal humerus fractures. A total of 45 patients underwent either conservative management or locking plate fixation. In the older cohort, patients with Neer Type 2-4 fractures were treated conservatively using Velpeau immobilization. Displaced fractures, specifically 3- and 4-part fractures per the Neer classification, were treated surgically with locking plate fixation. Functional outcomes were evaluated using the Constant Shoulder score, the Disabilities of the Arm, Shoulder, and Hand (DASH) score, and the American Shoulder and Elbow Surgeons (ASES) score, with a minimum follow-up period of one year. Radiographic assessment focused on varus collapse, medial cortex displacement, greater tubercle displacement, absence of fracture lines, and callus formation. Complications, including nonunion, malunion, and avascular necrosis, were also recorded.

RESULTS: Of the 45 patients, 22 underwent locking plate fixation (Group A), while 23 were managed conservatively (Group B). In terms of fracture type, 20 patients were classified as Neer Type 2, 23 as Neer Type 3, and 2 as Neer Type 4. The mean patient age was 73.38 years. Functional scores (DASH, ASES, and Constant) were similar between the two groups, and no significant differences were observed in radiographic parameters. However, complications were significantly more frequent in the locking plate group compared to the conservative group. Two patients who underwent surgery experienced nonunion at the humeral neck. Additionally, secondary surgery was required in one patient due to postoperative infection and in another due to screw penetration into the joint. While no correlation was found between humeral neck malunions and functional outcomes, a negative correlation was observed between tubercle malunions and functional scores.

CONCLUSION: In elderly patients with proximal humerus fractures, no significant differences in functional outcomes were observed between locking plate fixation and conservative treatment. However, locking plate fixation was associated with a higher incidence of complications and secondary surgeries. Thus, it appears that locking plate fixation does not offer superior outcomes compared to conservative management in this patient population.

PMID:39899082 | DOI:10.1007/s00264-025-06425-3

Int Orthop. 2025 Feb 3. doi: 10.1007/s00264-025-06420-8. Online ahead of print.

ABSTRACT

PURPOSE: Total knee arthroplasty (TKA) is an effective procedure for pain relief and restoration of function in patients with symptomatic end-stage knee arthritis. Kinematic problems due to conventional implant design have been postulated. The objective of this study is to determine if there was any difference in postoperative ROM and outcomes between patients undergoing MP-TKA vs PS-TKA.

METHODS: We prospectively colected the records of 600 consecutive patients with TKA performed by six senior orthopaedic surgeons between 2017 - 2021. We compared the ROM and patient-reported outcomes (Western Ontario McMaster Osteoarthritis Index WOMAC, Oxford Knee Score OKS, Knee Society Score KSS, Forgotten Joint Score FJS) between MP TKA and PS TKA.

RESULTS: There were no specific criteria for implant selection as the two groups were consecutive cohorts of patients and implant selection depended on surgeon preference. Demographics, comorbidities, diagnosis and severity of osteoarthritis were similar between MP and PS groups. The trend for OKS in our study is the same in both groups, but with higher mean values in the MP group. The trend of WOMAC pain, stiffness and disability score is the same in both groups, but with higher mean values in the PS group at one year and two years. KSS clinical and functional score is the same in both groups, but with higher mean values in the MP group. The most important score is forgetten joint score which is favourable for the MP group.

CONCLUSION: The patients who underwent the MP-TKA scored better than those who underwent the PS-TKA, particularly regarding deep knee flexion and stability of the prosthesis. This may be related to better replication of natural knee kinematics with MP-TKA.

PMID:39899081 | DOI:10.1007/s00264-025-06420-8

Injury. 2025 Jan 30;56(3):112164. doi: 10.1016/j.injury.2025.112164. Online ahead of print.

ABSTRACT

Traumatic brain injury remains a significant concern in public health, affecting millions of individuals globally and leading to long-term cognitive and physical impairments. Historically, research in this field has primarily focused on male subjects, often neglecting to consider the substantial biomechanical and anatomical differences between genders and individuals of varying ages. The present study investigates sex-specific biomechanical responses to head impacts in real-world accidents, employing an advanced female finite element head model, with a particular focus on critical brain structures such as the corpus callosum and pituitary gland. Two real-world accident scenarios were simulated: a non-fatal e-scooter collision and a fatal work-related incident involving a falling prop. A finite element analysis was conducted to determine the strain and stress distributions within the brain in response to impact conditions, assessing the potential for injury considering established failure criteria. The analysis revealed notable discrepancies in strain and stress distributions between anthropometric models. The smallest percentiles exhibited a higher risk of strain-related injury, while larger individuals demonstrated higher strain levels in key brain regions under similar impact conditions. Additionally, it was evaluated the efficacy of a safety helmet in a work-related scenario. These findings highlight the importance of subject-specific analyses in understanding TBIs and emphasise the need for continued refinement of FEHMs to improve the accuracy of injury prediction.

PMID:39893819 | DOI:10.1016/j.injury.2025.112164

Injury. 2025 Jan 17;56(3):112147. doi: 10.1016/j.injury.2025.112147. Online ahead of print.

ABSTRACT

OBJECTIVE: Metabolic bone disease (MBD, referring to osteopenia and osteoporosis) and its sequelae are associated with substantial morbidity, mortality, and healthcare costs. MBD screening and bone densitometry referral are underutilized in the general population despite published screening guidelines. Prior studies have correlated vertebral body Hounsfield unit (HU) measurements with MBD. The purpose of this study is to use this method to identify the prevalence of undiagnosed MBD in patients presenting to the hospital after high energy trauma, and to determine whether opportunistic MBD screening using this method would be valuable in this cohort.

DESIGN: Retrospective review.

SETTING: Level 1 trauma center and safety net hospital.

PATIENTS: 307 patients with a high energy femur fracture who underwent abdomen/pelvis computed tomography (CT) were identified from a trauma database.

INTERVENTION: L1 vertebral body radio density (in Hounsfield units, HU) was measured from trauma CT scans. Risk factors for MBD were identified from the medical record.

MAIN OUTCOME MEASUREMENTS: Prevalence of MBD and proportion of patients with MBD risk factors meriting further work-up.

RESULTS: The prevalence of MBD among high energy trauma patients was similar to the age-matched general population. Over half (50.5 %) of all patients had at least one risk factor for MBD. Among patients 50 to 64 years of age with any given MBD risk factor, over a third of individuals had MBD. In this population, the prevalence of MBD was highest (40.0 %) among those who used tobacco products and had a concurrent alcohol use disorder.

CONCLUSION: Opportunistic screening for MBD using a CT measurement technique can facilitate earlier diagnosis and treatment for affected individuals presenting after high energy trauma. Opportunistic screening may be particularly impactful in pre-menopausal women and in men, who frequently have MBD risk factors but who have a low referral rate for bone density testing and treatment.

LEVEL OF EVIDENCE: Diagnostic level III.

PMID:39893818 | DOI:10.1016/j.injury.2025.112147

Injury. 2025 Jan 24;56(3):112177. doi: 10.1016/j.injury.2025.112177. Online ahead of print.

ABSTRACT

BACKGROUND: Treatment of ankle and pilon fractures in the setting of diabetes mellitus (DM) is challenging due to a propensity for postoperative complications. Limb salvage is a primary concern following these injuries, as below knee amputation (BKA) occurs at an unacceptably high rate. Primary retrograde tibiotalocalcaneal (TTC) joint nailing without articular preparation has emerged as a solution to treat diabetics with ankle and pilon fractures to mitigate surgical complications and prevent BKA. The technique minimizes surgical dissection and has previously demonstrated utility in fragility fracture, however, there are few studies regarding the use of this technique in the setting of DM.

METHODS: A retrospective review of diabetic patients treated with retrograde TTC nailing without articular preparation was conducted over a seven-year period. Patients were included in the study if they were skeletally mature, diabetic, and treated with retrograde TTC nailing without articular preparation over a minimum follow up period of eight months. Treatment with other forms of fixation and pediatric or adolescents were excluded. A cohort of 25 patients met the inclusion criteria. Data was collected on demographics, injury characteristics, and surgical outcomes. The average follow up period was 2.45 years (IQR 986).

RESULTS: The averages for age, BMI, and Hemoglobin A1c (HbA1c) of the cohort were 64.6 (IQR 9.6), 36.7 (IQR 11.5), and 7.6 % (IQR 1.4), respectively. A majority of fractures were a closed supination-external rotation mechanism resulting from a fall from standing. The average LOS was 9.1 days (IQR 8). An ambulatory level was maintained in 72 % of patients. Limb salvage was achieved for 84 % of the cohort. Four patients ultimately required BKA. HbA1c and fracture-related infection (FRI) were statistically significant risk factors associated with BKA. For every 1 % increase in HbA1c, there was 2.63-fold odds of developing BKA. The surgical complication and reoperation rate were 56 %.

CONCLUSION: Although limb salvage was achieved for most patients within the cohort, high rates of postoperative complications and reoperations were observed using this technique. Prospective comparative studies are needed to further validate the use of retrograde nailing without articular preparation in the setting of DM.

PMID:39893817 | DOI:10.1016/j.injury.2025.112177

Injury. 2025 Jan 23;56(3):112181. doi: 10.1016/j.injury.2025.112181. Online ahead of print.

ABSTRACT

BACKGROUND: This systematic review aims to assess different effective hospital-based violence intervention programs (HVIP) design strategies and their effects on reducing the incidence of violence-related injuries, impact on healthcare outcomes including behavioral and psychosocial outcomes, and effects on healthcare system costs.

METHODS: A comprehensive search of five databases included studies that assessed the effects of HVIPs in adolescent and adult populations. The outcomes of interest included different effective HVIP design strategies that most effectively decreased the incidence of violence-related injuries, as well as their effects on behavior and psychosocial outcomes, effects on hospital costs, and whether they adequately addressed medico-legal aspects.

RESULTS: Following the application of inclusion and exclusion criteria, 25 studies were included in the final analysis. Effective HVIP design strategies primarily focused on mentorship and hands-on learning, contributing to successful program implementation. Overall, HVIPs significantly reduced the incidence of violence-related injuries and recidivism rates among participants. Improvements in psychosocial outcomes were observed, with increased employment rates and educational engagement reported among HVIP participants. Additionally, the included studies demonstrated that implementing HVIPs led to cost-effectiveness as well as cost savings from reduced injury recidivism. Despite the acknowledgment of medico-legal resources' importance, the absence of formal partnerships hinders HVIPs from fully addressing legal barriers to recovery, such as housing insecurity, employment discrimination, and protection from violence.

CONCLUSION: HVIPs are effective in reducing violence-related injuries, enhancing psychosocial outcomes, and offering cost savings, however, they often lack established medico-legal resources. Further research on establishing effective medico-legal partnerships within these programs is needed.

PMID:39893816 | DOI:10.1016/j.injury.2025.112181

J Bone Joint Surg Am. 2025 Jan 31. doi: 10.2106/JBJS.24.00679. Online ahead of print.

ABSTRACT

BACKGROUND: Whether an adductor canal block (ACB) is more effective when administered before or after total knee arthroplasty (TKA) is unclear. This study compared pain, stress, and functional outcomes between patients who received the block before surgery and those who received the block after surgery.

METHODS: In this double-blinded trial, 100 patients at our hospital were randomized to receive an ACB at either 30 minutes before general anesthesia or postoperatively in the post-anesthesia care unit (PACU). All patients received periarticular local infiltration analgesia during surgery. The 2 groups were compared with respect to the primary outcome, the postoperative consumption of morphine as rescue analgesia, and in terms of the secondary outcomes, including the time from the end of surgery to the first rescue analgesia or discharge, intraoperative and postoperative stress, postoperative pain, functional recovery, the incidence of chronic pain, and complications.

RESULTS: All included patients were Asian (Chinese) in race/ethnicity. The 2 groups had similar demographic information. Compared with the postoperative ACB, the preoperative ACB was associated with significantly lower morphine consumption within the first 24 hours postoperatively and lower total morphine consumption. It was also associated with a longer time until the first rescue analgesia, lower intraoperative consumption of opioids and inhaled anesthetic, fewer episodes of hypertension during surgery, a lower rate of rescue analgesia in the PACU, lower levels of cortisol and adrenocorticotropic hormone in serum on the morning of postoperative day 1, lower pain on a visual analog scale while at rest or during motion within 12 hours postoperatively, better range of knee motion on postoperative day 1, and a lower incidence of chronic pain at 3 months postoperatively. The 2 groups did not differ significantly with respect to postoperative ambulation distance, time until discharge, or complication rates.

CONCLUSIONS: Administering an ACB before rather than after TKA may lead to lower opioid consumption during hospitalization, lower intraoperative and postoperative stress responses, better pain relief during hospitalization, and a lower incidence of chronic pain at 3 months postoperatively.

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

PMID:39888982 | DOI:10.2106/JBJS.24.00679

J Bone Joint Surg Am. 2025 Jan 31. doi: 10.2106/JBJS.24.00437. Online ahead of print.

ABSTRACT

BACKGROUND: The cause of hallux rigidus remains controversial. However, it is assumed that dysfunction of the windlass mechanism and metatarsus primus elevatus play a role in the pathology. Three-dimensional (3D) computed tomography (CT) imaging is ideal for analysis of movements of the foot, which involve 3D and rotational motion. The purpose of the present study was to compare the windlass mechanism in healthy normal feet with that in feet with hallux rigidus by 3D CT imaging.

METHODS: A total of 17 feet with hallux rigidus and 21 normal feet were selected. Hallux rigidus was classified as grade 1 or 2 with use of the Coughlin and Shurnas system. CT imaging was performed during weight-bearing and non-weight-bearing with the first metatarsophalangeal joint in a neutral position or in 30° of dorsiflexion. We measured the rotation of each joint and the height of the navicular during dorsiflexion and weight-bearing. We also compared changes in the tarsometatarsal joint and metatarsus primus elevatus in the neutral position between the non-weight-bearing and weight-bearing conditions.

RESULTS: During dorsiflexion, there were significant differences between the 2 groups in eversion and adduction at the talonavicular and talocalcaneal joints (p < 0.05), with less movement of bones in the hallux rigidus group. There was a significantly greater increase in height of the navicular in the control group than in the hallux rigidus group (1.2 ± 0.6 mm versus 0.7 ± 0.6 mm; p = 0.02). There was also a significant difference in metatarsus primus elevatus during the non-weight-bearing and weight-bearing conditions (p < 0.01).

CONCLUSIONS: Hallux rigidus restricts the movement of the Chopart joint and hindfoot associated with dorsiflexion of the first metatarsophalangeal joint, suggesting an association between hallux rigidus and windlass mechanism dysfunction.

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

PMID:39888978 | DOI:10.2106/JBJS.24.00437

Injury. 2025 Jan 22;56(3):112151. doi: 10.1016/j.injury.2025.112151. Online ahead of print.

ABSTRACT

BACKGROUND: Depression and post-traumatic stress disorder (PTSD) are becoming more prevalent among post-burn populations. With the increase in awareness of the significance of psychosocial injury adjustment for holistic health-related quality of life, beyond just physical, occupational, and functional recovery. However, the incidence of depression and PTSD in the adult population is inconsistent across published studies. To describe the baseline predictors of depression and post-traumatic stress disorder (PTSD) symptoms in hospitalised adult burn survivors over the first 12 months post-burn.

METHOD: A total of 274 participants, aged 18 years or over, with burn injuries, were hospitalized and treated at a tertiary burns centre in Queensland, Australia between October 2015 and December 2017. Additional follow-up data collected at 3-, 6- and 12-months post-burn injury. Dataset was analysed using gamma generalized mixed effects modelling techniques to assess the predictors of depression (PHQ-9) and PTSD (PCL-C) symptoms over time. Baseline predictors from personal, environmental, burn injury and burn treatment factors were assessed.

RESULTS: Both mental health outcomes followed a similar trend, with the largest decrease in symptom severity occurring between 3- and 6-months. A smaller decrease then occurred between 6- and 12-months. The baseline predictors of depression and PTSD symptoms post-burn in adults varied, however, the common predictors were increased age, a pre-injury mental health diagnosis and financial insufficiency. In addition to these predictors, intentional injury and recreational drug use were also statistically significant predictors of increased PTSD symptoms, while previous trauma exposure, longer hospital length of stay (LOS) and, surprisingly, stable housing status were also predictors of higher PHQ-9 depression scores. All predictors included in the final models were statistically significant with a p-value < 0.10.

CONCLUSION: Overall, mental health symptoms in burns survivors generally improved over the 12 months of follow-up, with the largest improvement noted between 3 and 6 months. Age, pre-injury mental health diagnosis and insufficient financial status, however, were all found to be associated with poorer mental health outcomes over the first 12 months post-burn.

PMID:39883967 | DOI:10.1016/j.injury.2025.112151

Injury. 2025 Jan 22;56(3):112168. doi: 10.1016/j.injury.2025.112168. Online ahead of print.

ABSTRACT

OBJECTIVES: The purpose of this study was to systematically review available strategies for diagnosing traumatic arthrotomy.

METHODS: A comprehensive literature search was conducted on October 8th, 2023 using Ovid Medline, Cochrane Central Register of Controlled Trials, Embase, and Embase Classic. Studies were included in the review if they evaluated a diagnostic strategy for traumatic arthrotomy.

RESULTS: There were 26 studies included after application of the exclusion criteria. 12 studies investigated traumatic arthrotomy of the knee, 8 of the elbow, 4 of the shoulder, 4 of the wrist, and 5 of the ankle. 23 studies implemented the saline load test as a diagnostic strategy, 7 considered CT scan, 1 study used x-ray, and 1 study used ultrasound. Of the studies that considered saline load tests, 8 of them also used methylene blue. CT scans were found to have 100% sensitivity when diagnosing traumatic arthrotomy of the knee. Saline load test was shown to have 60% to 100% sensitivity when diagnosing traumatic arthrotomies of the elbow. Saline load tests had sensitivities ranging from 75% to 100% when considering a shoulder traumatic arthrotomy. The saline load test was able to diagnose traumatic arthrotomies of the wrist, and ankle with sensitivities up to 100% and 99%, respectively.

CONCLUSIONS: When considering the infectious risks associated with undiagnosed traumatic arthrotomy, clinicians should seek modalities with the highest diagnostic performance. The saline load test has long been considered the gold standard for diagnosing traumatic arthrotomy, however, imaging modalities hold appeal as a less invasive and technically challenging procedure. Although diagnostic performance is joint-dependent, this review indicates that the saline load test continues to be the most reliable method for diagnosing most traumatic arthrotomies other than the knee.

LEVEL OF EVIDENCE: III.

PMID:39883966 | DOI:10.1016/j.injury.2025.112168

Int Orthop. 2025 Jan 30. doi: 10.1007/s00264-025-06417-3. Online ahead of print.

ABSTRACT

PURPOSE: This narrative review identifies and summarizes current evidence for diagnostic ultrasonographic evaluation of upper extremity dynamic compressive neuropathies affecting athletes.

METHODS: Relevant literature was identified using the PubMed database and then summarized.

RESULTS: The compressive neuropathies affecting athletes we identified included: neurogenic thoracic outlet syndrome, pectoralis minor syndrome, quadrilateral space syndrome, suprascapular nerve entrapment, proximal median nerve entrapment or bicipital aponeurosis/lacertus fibrosus (lacertus syndrome), radial tunnel syndrome, and cubital tunnel syndrome. Symptoms may develop only during specific sport activity, after specific sport-related trauma, or in setting of overuse during sport. Diagnostic ultrasound strategies assessing compressive neuropathies focus on static evaluation of nerves and surrounding structures, as well as dynamic evaluation of these structures in certain degrees of shoulder abduction, elbow flexion, or forearm pronation.

CONCLUSION: Ultrasonography can be used as a diagnostic tool in assessing upper extremity dynamic compressive neuropathies. Ultrasound allows for dynamic evaluation of these rare conditions, especially for athletes who primarily develop symptoms during movement or participation in sport.

PMID:39883178 | DOI:10.1007/s00264-025-06417-3

Injury. 2025 Jan 19;56(3):112165. doi: 10.1016/j.injury.2025.112165. Online ahead of print.

ABSTRACT

PURPOSE: Standard operating procedures aim to achieve a standardized and assumedly high-quality therapy. However, in orthopaedic surgery, the aspect of temporal urgency is often based on surgical tradition and experience. At a time of evidence-based medicine, it is necessary to question these temporal guidelines. The following review will therefore address the most important temporal guidelines in orthopaedic surgery and discuss their practical relevance and potential need for optimization.

METHODS: The systematic review features a literature review by database search in "PubMed" (https://pubmed.ncbi.nlm.nih.gov) for time to surgery in terms of (1) "proximal femoral fractures", (2) "femoral neck fractures", (3) "proximal humeral fractures", (4) "ligament and tendon injuries", (5) "spinal cord injuries", (6) "open fractures" and (7) "fracture-related infections". For every diagnosis, hypotheses on timing were set up and checked for evidence.

RESULTS: There is solid clinical evidence supporting the initiation of treatment within 24 h for specific conditions like the surgical treatment of proximal femur fractures and prompt decompression of spinal cord injuries. However, for other scenarios such as the 6-hour rule for open fractures, joint-preserving femoral neck fractures, timing of ligament injuries, humeral head fractures and fracture-related infections there is currently no reliable evidence to guide prompt surgical treatment.

CONCLUSION: Based on the current data, resource-adapted surgical planning seems reasonable. Further research in these areas is necessary to determine the best timing of treatment and address existing doubts.

PMID:39879862 | DOI:10.1016/j.injury.2025.112165

Injury. 2025 Jan 25;56(3):112183. doi: 10.1016/j.injury.2025.112183. Online ahead of print.

ABSTRACT

PURPOSE: Reduction and intraoperative maintenance of fracture fragments during minimally invasive plate osteosynthesis (MIPO) pose technical difficulties, particularly when the interposed fragment is angulated, prompting surgeons to attempt reduction due to concerns about nonunion or malunion. We aimed to compare the clinical and radiological outcomes of MIPO for mid-shaft clavicular fractures based on the reduced status of the interposed fragments.

METHOD: Fifty-seven patients who underwent MIPO for acute mid-shaft Robinson type 2B clavicular fractures were divided into two groups based on the alignment of the interposed fracture fragment. A vertical fracture fragment was defined as one tilted by >45° relative to the long axis of the proximal clavicular shaft. Radiological outcomes were evaluated using time to union, clavicle thickness, and length ratio after union compared with the healthy side. Clinical outcomes were assessed using the visual analog scale (VAS); the Korean Shoulder Score (KSS); Disability of the Arm, Shoulder, and Hand (DASH) score; and shoulder range of motion (ROM). Continuous variables were analyzed using Student's t-test or Mann-Whitney U test, based on data distribution.

RESULT: The vertical fragment group comprised 21 patients, and the nonvertical fragment group comprised 36. The mean time to union was similar between the vertical (4.48 ± 1.20 months) and nonvertical group (4.64 ± 1.17 months, p = 0.162). The groups showed comparable clavicular length and thickness ratios: 0.992 ± 0.040 vs. 1.076 ± 0.045 (p = 0.175), 1.189 ± 0.102 vs. 1.186 ± 0.271 (AP view, p = 0.165), and 1.121 ± 0.238 vs. 1.112 ± 0.230 (Lordotic view, p = 0.655), respectively. At 12 months, no significant differences were observed in VAS (0.3 ± 0.7 vs. 0.8 ± 0.8, p = 0.667), KSS (97.10 ± 6.30 vs. 96.75 ± 6.77, p = 0.940), and DASH (1.44 ± 3.64 vs. 2.00 ± 4.05, p = 0.501), or in ROM forward flexion (165.24 ± 9.28 vs. 162.78 ± 12.56, p = 0.464) and external rotation (60.95 ± 13.00 vs. 60.00 ± 13.47, p = 0.965).

CONCLUSION: Favorable radiological and clinical outcomes were achieved in all patients who underwent MIPO for mid-shaft clavicular fractures, regardless of whether the interposed fracture fragment after reduction was vertical.

PMID:39879861 | DOI:10.1016/j.injury.2025.112183

Injury. 2025 Jan 21;56(3):112178. doi: 10.1016/j.injury.2025.112178. Online ahead of print.

ABSTRACT

INTRODUCTION: Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS: An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS: In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION: The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

PMID:39879860 | DOI:10.1016/j.injury.2025.112178

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.24.00561. Online ahead of print.

ABSTRACT

BACKGROUND: Magnetic resonance imaging (MRI) has not been routinely used for infants with brachial plexus birth injury (BPBI); instead, the decision to operate is based on the trajectory of clinical recovery by 6 months of age. The aim of this study was to develop an MRI protocol that can be performed without sedation or contrast in order to identify infants who would benefit from surgery at an earlier age than the age at which that decision could be made clinically.

METHODS: This prospective multicenter NAPTIME (Non-Anesthetized Plexus Technique for Infant MRI Evaluation) study included infants aged 28 to 120 days with BPBI from 3 tertiary care centers. Subjects had nonsedated non-contrast rapid volumetric proton density MRI on 3-T scanners. Neuroradiologists at each site calculated the NAPTIME nerve root injury score for subjects at their site. Interrater reliability was performed on a subset of subjects. All of the subjects were evaluated with routine clinical examinations up to 6 months of age, by which time the treating surgeon determined whether to offer nerve surgery. Surgeons were blinded to the MRI results. The ability of the NAPTIME score to discriminate surgeon indication for surgery was evaluated using the receiver operating characteristic (ROC) curve, by estimating the area under the curve (AUC) across the range of NAPTIME scores.

RESULTS: Sixty-five infants successfully completed the NAPTIME MRI; 18 (28%) ultimately met the clinical criteria for nerve surgery. The interrater reliability for the NAPTIME score was moderate at 0.703 (95% confidence interval [CI], 0.582 to 0.818). The median NAPTIME score for subjects who met the criteria for nerve surgery was 16.2 (interquartile range [IQR], 9.9 to 18.9), while the median score for those who did not was 7.0 (IQR, 5.0 to10.5). The NAPTIME score predicted meeting the criteria for surgery with an AUC of 0.812 (95% CI, 0.688 to 0.936). A score of >13 offered a specificity of 0.94 and a sensitivity of 0.61 for surgical indication.

CONCLUSIONS: Non-contrast MRI without sedation is a useful tool in determining the severity of injury in BPBI. The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically.

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

PMID:39879284 | DOI:10.2106/JBJS.24.00561

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.24.001193. Online ahead of print.

NO ABSTRACT

PMID:39879283 | DOI:10.2106/JBJS.24.001193

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.23.01451. Online ahead of print.

ABSTRACT

BACKGROUND: The accurate inclusion of patient comorbidities ensures appropriate risk adjustment in clinical or health services research and payment models. Orthopaedic studies often use only the comorbidities included at the index inpatient admission when quantifying patient risk. The goal of this study was to assess improvements in capture rates and in model fit and discriminatory power when using additional data and best practices for comorbidity capture.

METHODS: Hip fracture care was used as an exemplary case of an inpatient condition in a population typically having multiple comorbidities. Cohorts were built from 3 administrative resources: (1) Medicare, (2) all-payer, and (3) private-payer. Elixhauser comorbidities were calculated first using only the index admission and subsequently by adding inpatient and outpatient data from the previous year. Comorbidities identified on outpatient records required 2 instances occurring ≥30 days apart. Model fit and discriminatory power for in-hospital metrics (death, length of stay, and costs or charges) and post-discharge metrics (90-day readmission and surgical site infection, and 90-day and 1-year death) were compared among capture strategies.

RESULTS: The index admission missed 9.3% to 65.6% of individual Elixhauser comorbidities for the Medicare cohort, 2.9% to 39.0% for the all-payer cohort, and 14.1% to 57.9% for the private-payer cohort compared with data from the index admission plus the previous year. Using prior inpatient and outpatient data provided substantial improvements in model fit and explanatory power for post-discharge outcomes, whereas information from the index admission was sufficient for in-hospital death and length of stay. The utility of outpatient data was greatest when complete outpatient claims were captured compared with only ambulatory surgery claims.

CONCLUSIONS: The comorbidity capture strategies demonstrated in this study, namely including all available data for post-discharge outcomes, using a 1-year lookback period, and requiring outpatient codes to appear on 2 claims ≥30 days apart, are relevant for improved risk adjustment in orthopaedic clinical or health services research and quality improvement and payment models.

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

PMID:39879281 | DOI:10.2106/JBJS.23.01451

Int Orthop. 2025 Jan 30. doi: 10.1007/s00264-025-06426-2. Online ahead of print.

ABSTRACT

PURPOSE: The spine research within India has seen significant advancement, yet detailed examinations of its impact and evolution still need to be made sparse. To conduct a comprehensive scientometric review of the most frequently cited papers in Indian spine research from 1995 to 2024, aiming to map the field's evolution and its global impact.

METHODS: Utilizing the Scopus database, a search was performed with keywords related to spine research, identifying 105 highly cited papers. This study focused on trends in publications, document types, affiliations, collaboration networks, and citation patterns.

RESULTS: The period between 2005 and 2014 saw a significant increase in publications, with a notable emphasis on international collaborations, especially with the United States and Canada. Clinical research, particularly on the lumbar spine and surgical advancements, emerged as the primary focus. The average citations per document stood at 102.37, with original research articles constituting 73.33% of the total. Collaboration spanned across 31 countries, with the United States being the foremost partner. Indian institutions like Ganga Hospital, Coimbatore, and the All India Institute of Medical Science, New Delhi, were among the top contributors. Indian authors, notably with S. Rajasekaran leading, followed by AK Jain.

CONCLUSION: The findings highlght the pivotal role of Indian spine research in contributing to the global knowledge base, highlighting significant areas of strength and opportunities for future research. The study offers valuable insights for researchers, policymakers, and healthcare planners, aiming to enhance spinal health care in India and internationally.

PMID:39881023 | DOI:10.1007/s00264-025-06426-2

Injury. 2025 Jan 20;56(3):112174. doi: 10.1016/j.injury.2025.112174. Online ahead of print.

ABSTRACT

OBJECTIVES: Long bone fractures with concomitant vascular injury have the potential to be life and limb threatening injuries, with increased risk for limb loss. There is currently no established surgical order of operations for orthopaedic and vascular intervention. This study compares injury classification, warm ischemia time and patient outcomes in patients with long bone fractures and associated vascular injury after orthopaedic versus vascular primary intervention.

METHODS: Design: Retrospective review Setting: Level 1 Trauma Center Patient Selection Criteria: Included were patients treated between 2016 and 2021 with fractures of the femur, tibia, fibula, or knee dislocation (OTA/AO 32, 33, 41, 42 and 43) with associated vascular injury necessitating vascular repair. Outcome Measures and Comparisons: Warm ischemia time, intraoperative transfusion requirements, readmission, definitive amputation, fasciotomy, infection, need for vascular revision, and return to weight bearing were compared between the two groups (primary vascular intervention (VP) and primary orthopaedic intervention (OP)).

RESULTS: 35 patients were included with 29 patients in the VP group and 6 patients in the OP group. There was no significant difference in the warm ischemia time between groups (p = 0.52) or total operative time (p = 0.13). 3/29 patients in the VP group required definitive amputation and 0/6 patients in the OP group required amputation (p = 1.00). There were no statistically significant differences in rates of infection, fasciotomy, readmission, length of stay, vascular revision, or time to weight bearing between groups.

CONCLUSIONS: This study demonstrates collaborative care between surgical teams to minimize warm ischemia time is crucial in patients with lower extremity fractures associated with vascular injury. There is no significant difference in patient outcomes including definitive intraoperative transfusion requirements, amputation, time to weight bearing or infection when comparing primary orthopaedic versus vascular intervention.

PMID:39874867 | DOI:10.1016/j.injury.2025.112174