Int Orthop. 2025 Dec 16. doi: 10.1007/s00264-025-06727-6. Online ahead of print.

ABSTRACT

PURPOSE: This study aims to describe and analyse pediatric cervical spine (C-spine) trauma over 32 years at a level 1 trauma centre.

METHODS: A retrospective observational study was conducted, including patients younger than 16 years hospitalised after C-spine trauma from 1991 to 2022. Data on demographics, injury mechanisms, affected levels, associated injuries, neurological deficits (Frankel scale), treatments, and outcomes were analysed. Patients were divided into two age groups: < eight years (Group A) and nine to 16 years (Group B). Injuries were categorised as SCIWORA or skeletal, and by level-upper (C0 to C2) or lower (C3 to C7). Statistical analysis was performed using SPSS v29.0 (p < 0.05).

RESULTS: A total of 102 patients were identified (67% male; 65% > 8 years). Younger children had more upper C-spine injuries (55.6%), lower injuries were more common in Group B (53%) (p = 0.006). mechanisms included motor vehicle accidents, pedestrian accidents, falls, and sports injuries. Associated injuries were present in 59% of cases, mainly head trauma. SCIWORA occurred in 14.7% of patients, with MRI-confirmed cord contusions in 60% of these. Most patients (74.7%) underwent conservative treatment. Neurological deficits were present in 38% of patients, and 51.2% showed improvement. The mortality rate was 16.5%, significantly higher among those with neurological impairment (p = 0.004).

CONCLUSION: Pediatric C-spine trauma is uncommon. MRI is essential for detecting spinal cord injury in SCIWORA. The high prevalence and impact of associated injuries on mortality highlight the need for thorough primary evaluation. Multicenter studies are necessary to improve management strategies and outcomes.

PMID:41402532 | DOI:10.1007/s00264-025-06727-6

J Bone Joint Surg Am. 2025 Dec 15. doi: 10.2106/JBJS.25.01208. Online ahead of print.

ABSTRACT

Spine surgery in limited-resource environments is challenging due to the complexity of the procedures, which can involve often-costly implants and imaging or navigation tools that may not be available in all regions and markets. Orthopaedic and neurological surgery residents in low to middle-income countries (LMICs) are faced with limited case exposure, faculty shortages, and a lack of simulation tools, resulting in incomplete spine surgery training. International fellowships, telesurgery integration, and global collaboration can help to address these gaps. The high costs of implants, restricted use of intraoperative neuromonitoring, and limited access to advanced technologies such as robotics and endoscopy may hinder optimal surgical care. These challenges could be mediated by the implementation of cost-effective practices, the establishment of clinical guidelines, and the publication of cost-effectiveness data. LMIC contributions to spine research are limited due to a lack of funding, poor research infrastructure, and publication bias. Building research capacity through mentorship, international partnerships, and regional academic platforms is needed to advance global spine care.

PMID:41397046 | DOI:10.2106/JBJS.25.01208

Injury. 2025 Dec 5:112948. doi: 10.1016/j.injury.2025.112948. Online ahead of print.

NO ABSTRACT

PMID:41391987 | DOI:10.1016/j.injury.2025.112948

Injury. 2025 Dec 11:112954. doi: 10.1016/j.injury.2025.112954. Online ahead of print.

ABSTRACT

BACKGROUND: Significant inter-hospital variation in potentially low-value operative management of blunt solid organ injuries (SOI) has been observed but data on the impact on patient outcomes is lacking. Our primary objective was to estimate the association between potentially low-value operative management of blunt SOI and hospital mortality, complications, and length of stay (LOS). A secondary objective was to identify determinants, independent of patients' health status on arrival.

METHODS: We conducted a retrospective cohort study using the National Trauma Data Bank (2016-2019). We included adults admitted with blunt SOI eligible for nonoperative management (grade I-IV spleen/liver and grade I-III kidney, hemodynamically stable, no blood products within 6 hours). We used propensity scores to generate adjusted odds ratios (OR) of mortality and complications and geometric mean ratios (GMR) of LOS.

RESULTS: We included 62,601 adults, of whom 1,683 (2.7%) had potentially low-value operative management. Adjusted ORs were 1.92 (95% CI 1.25-2.96) for mortality and 2.39 (1.99-2.87) for complications. The adjusted GMR was 1.52 (1.38-1.68) for LOS. Low-value operative management was more frequent in males, White non-Hispanics versus African Americans, Medicaid versus private insurance, and American College of Surgeons (ACS) level II/III and state-designated hospitals versus ACS level I.

CONCLUSIONS: In this retrospective cohort study, potentially low-value operative management of SOI was infrequent but was associated with increased mortality, complications, and LOS and was influenced by sex, race and ethnicity and insurance status. Results suggest that interventions designed to reduce low-value operative management may improve patient outcomes.

PMID:41391986 | DOI:10.1016/j.injury.2025.112954

Injury. 2025 Dec 10;57(2):112950. doi: 10.1016/j.injury.2025.112950. Online ahead of print.

ABSTRACT

BACKGROUND: Spinal fractures represent a significant cause of morbidity, requiring both acute and long-term care. Data on their epidemiology in small state settings are limited. This study aimed to describe the population burden, clinical characteristics, and healthcare impact of spinal fractures in Malta over a five-year period.

METHODS: A retrospective analysis was conducted using the Hospital Activity Analysis (HAA) database of Mater Dei Hospital, Malta, between 2019 and 2024. Data included demographics, fracture type (ICD-10), length of stay (LOS), admission and discharge source, mechanism of injury, need for intensive care unit (ITU) admission, spinal cord injury, and co-morbidities. Fracture types were grouped as cervical, thoracic, lumbar single-level, or multi-level fractures. Descriptive statistics, chi-square, t-tests, and logistic regression were applied, with p<0.05 considered significant.

RESULTS: A total of 640 spinal fractures were recorded (56% males, 44% females). Lumbar single-level fractures were most common (38%), followed by multi-level fractures (30%). Falls were the predominant mechanism (53%). While 90% were admitted directly from home, only 70% were discharged home, with 16% requiring transfer to rehabilitation. The longest LOS was for cervical single-level fractures (15.7 days, p=0.019). ITU admission was uncommon (4%), predominantly in multi-level fractures, which also had the highest spinal cord injury prevalence (36%). Co-morbidities were frequent (71%), particularly cardiovascular disease (49%). Logistic regression showed multimorbidity was positively associated with single-level fractures (OR 1.66, 95% CI: 1.04-2.67, p=0.035).

CONCLUSIONS: Spinal fractures in Malta impose a substantial burden, extending beyond acute care into rehabilitation. Falls were the leading cause, and multimorbidity significantly influenced fracture patterns. These findings underscore the need for integrated fall-prevention strategies, chronic disease management, and strengthened rehabilitation services in small-state healthcare systems.

PMID:41391271 | DOI:10.1016/j.injury.2025.112950

Injury. 2025 Dec 6;57(2):112945. doi: 10.1016/j.injury.2025.112945. Online ahead of print.

ABSTRACT

PURPOSE: Zone 2B flexor tendon injuries present unique surgical challenges, with ongoing debate regarding optimal management of concurrent flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) ruptures. This study compared functional outcomes between isolated FDP repair versus combined FDS-FDP repair in Zone 2B injuries..

METHODS: We retrospectively analyzed 69 patients (97 fingers) with complete Zone 2B flexor tendon injuries between January 2017 and December 2020. Group 1 underwent isolated FDP repair (35 patients, 49 fingers) while Group 2 received combined FDS-FDP repair (34 patients, 48 fingers). Primary outcomes included total active motion (TAM), deformity rates, and functional assessment using Tang grading at 12-month follow-up.

RESULTS: Group 1 demonstrated significantly superior outcomes across multiple parameters. Deformity occurrence was markedly lower in Group 1 (28.6% vs 68.8%, p<0.001), with reduced deformity angles (p=0.008). Total active motion was significantly higher in Group 1 (p<0.001), alongside improved TAM percentages (p=0.033) and total passive motion (p<0.001). While not statistically significant, Group 1 showed trends toward higher rates of excellent outcomes (55.1% vs 33.3%) and reduced reoperation rates (8.2% vs 16.7%).

CONCLUSION: Isolated FDP repair in Zone 2B injuries yields superior functional outcomes with significantly reduced deformity rates compared to combined tendon repair. When FDS repair compromises FDP gliding, selective FDS excision appears beneficial. This supports the selective excision of FDS when FDP gliding is compromised, streamlining surgical strategy in this anatomically constrained zone.

PMID:41391270 | DOI:10.1016/j.injury.2025.112945

Injury. 2025 Dec 4:112931. doi: 10.1016/j.injury.2025.112931. Online ahead of print.

ABSTRACT

BACKGROUND: Electric bicycles (e-bikes) are becoming increasingly popular, offering higher speeds compared to traditional pedal bicycles. Despite their growing use, there is limited data on the epidemiology of e-bike related injuries in the pediatric population. Specifically, previous studies have not adequately explored the injury circumstances regarding e-bikes, particularly concerning loss of control due to speed. This study aims to assess the patterns and outcomes of e-bike injuries in children, hypothesizing that speeds higher than 20 miles per hour (MPH) result in more internal injuries necessitating hospital admission.

METHODS: This retrospective cross-sectional study analyzed data from the National Electronic Injury Surveillance System, specifically targeting pediatric ages 0-18 e-bike injuries recorded between 2019 and 2023. We utilized natural language processing techniques to extract narratives from the database, identifying words related to the circumstances of injury, and distinguishing between speed-related incidents vs. non-speed-related incidents. The cohort was divided into two groups based on the identified cause: injuries due to increased speed and injuries attributed to other causes. We then conducted bivariate analyses to compare the characteristics and outcomes between these groups, focusing on the type of injury, its severity, and the need for hospital admission.

RESULTS: A national estimate of 15,121 pediatric patients with injuries related to e-bikes (79.7% males and 71.3% adolescents aged 13-18) were identified. Injuries attributed to speed were associated with a higher incidence of head, neck, or facial injuries (49.1%¦vs 28.7%) compared to those resulting from other causes. A greater proportion of children with speed-related injuries sustained internal organ injuries (24.1%¦vs. 10.4%) and were admitted to the hospital (7.3%¦vs.4.7%). Of those injuries specified as "internal" 96.7% were head and neck injuries compared to 3.3% other anatomic sites. Over the five-year study period, the frequency of e-bike injuries showed a sharp increase, with 4.18% occurring in 2019 and 49.8% in 2023.

CONCLUSION: Pediatric e-bike injuries have increased in frequency and can be severe, requiring hospitalization. The findings highlight the risks associated with speeds higher than 20 MPH on e-bikes and the need for targeted safety measures and legislation especially related to prevention of head injuries. Future research should focus on the effectiveness of safety interventions, including helmet usage and speed control features on e-bikes.

TYPE OF STUDY: retrospective cross-sectional study.

PMID:41390298 | DOI:10.1016/j.injury.2025.112931

Injury. 2025 Dec 6;57(2):112928. doi: 10.1016/j.injury.2025.112928. Online ahead of print.

ABSTRACT

INTRODUCTION: Pediatric trauma care has traditionally utilized a Face-to-Face (F2F) model of outpatient care. The authors hypothesized that most pediatric minor trauma care could be managed definitively on initial contact within the Pediatric Emergency Department (PED), with subsequent confirmation of treatment at an orthopedics Virtual Fracture Clinic (VFC). We describe the experience of our first 10,763 children managed via a VFC pathway in the setting of a pediatric trauma service.

MATERIALS AND METHODS: Data was prospectively collected on all patients referred to the VFC from the PED. Outcome data included referral for surgery, referral to a F2F clinic, referral back to PED for further evaluation and discharge. Cost analysis was performed using established costing for a VFC within the local healthcare system.

RESULTS: A total of 10,763 consecutive patients were referred to the VFC from the PED over a 4-year period. There were 6012 (56 %) males and 4751 (44 %) females. The average age was 9.4 years (0.5 -17 years). A total of 0.5 % (n= 56) were referred from the VFC for immediate operative treatment, 25.2 % (n= 2706) were referred to a F2F clinic, and 69.8 % (n= 7517) of children were discharged via the VFC. 4.5 % (n= 484) were referred back to the PED. 3.5 % (n= 383) of the discharged patients required an unplanned F2F evaluation. We calculated a net saving delivered from implementation of the VFC as €704 667.

CONCLUSION: This prospective evaluation, of our first 10,763 children, has demonstrated that a VFC pathway for minor pediatric trauma is safe, effective and brings significant cost savings.

PMID:41389429 | DOI:10.1016/j.injury.2025.112928

Injury. 2025 Dec 4;57(2):112935. doi: 10.1016/j.injury.2025.112935. Online ahead of print.

ABSTRACT

OBJECTIVES: To identify and characterize space-time clusters of road traffic collisions (RTCs) involving older adults in Taiwan, with emphasis on spatial and temporal features that may inform targeted prevention strategies.

METHODS: We analyzed nationwide RTC data from Taiwan's Police Traffic Accident Report (PTAR) registry from 2014 to 2023, including 145,450 older adult victims aged ≥65 years. Six variables, including three spatial (urbanization level, crash location, and type of traffic signal) and three temporals (monsoon season, day of the week, and time of day), were selected to perform latent class analysis (LCA) for identifying distinct spatiotemporal crash clusters. Model fit indices (AIC, BIC, CAIC, ABIC, and entropy) guided the selection of the optimal number of clusters. Demographic and road user characteristics across clusters were compared using bivariate analyses.

RESULTS: Three distinct clusters were identified: (1) urban intersection crashes, (2) intersection crashes in medium- and low-urbanized areas, and (3) crashes on unsignalized road segments. Collisions were more likely to occur at intersections (n = 85,247, 58.6 %) and in highly urbanized areas, (n = 61,432, 42.2 %). Most incidents took place on weekdays (n = 103,441, 71.1 %) and during morning hours (n = 70,382, 48.4 %). Significant differences across clusters were found in age, sex, road user role, and vehicle type (all p < 0.001).

CONCLUSION: This study demonstrates the heterogeneity in spatiotemporal patterns of RTCs involving older adults in Taiwan. These findings highlight areas where further investigation into context-specific traffic safety measures could inform efforts to enhance mobility and reduce injury risk among older adults.

PMID:41389428 | DOI:10.1016/j.injury.2025.112935

Injury. 2025 Dec 9;57(2):112949. doi: 10.1016/j.injury.2025.112949. Online ahead of print.

ABSTRACT

OBJECTIVE: To develop and validate a machine learning model for postoperative sepsis in critically ill traumatic spinal injury (TSI) patients, a frequent and severe complication without dedicated predictive tools.

METHODS: Model development used the MIMIC-IV 3.1 database, with external validation in the eICU-CRD 2.0 database and a Chinese TSI cohort. Variables documented within 24 h of postoperative ICU admission were screened using univariable testing and refined through Boruta and Group-Lasso regression to identify the final predictors. Thirteen base learners were trained and combined in a stacking ensemble optimized by fivefold cross-validation and hyperparameter tuning. Performance was assessed using receiver operating characteristic (ROC-AUC), average precision from precision-recall (PR-AP), calibration, decision, and lift curves, along with accuracy, sensitivity, specificity, precision, and F1 scores. Interpretability was evaluated through SHAP analysis.

RESULTS: The development cohort comprised 808 patients, with 461 (57.1 %) sepsis cases, and the external validation cohort consisted of 358 patients, with 86 (24.0 %) events. Twelve predictors entered modeling, with the stacking model achieving an ROC-AUC of 0.918 and PR-AP of 0.938 in training and 0.889 and 0.936 in validation, maintaining close calibration, superior clinical utility confirmed by decision and lift curves, and balanced classification metrics, while most first-level models deteriorated markedly. External validation confirmed consistent performance and effective high-risk stratification. SHAP analysis underscored surgical burden, severity, hemodynamic, renal, and coagulation domains as key contributors, ensuring interpretability at cohort and individual levels.

CONCLUSION: This first validated model for postoperative sepsis in critically ill TSI patients shows relatively robust performance and interpretability, enabling early risk stratification and supporting clinical decision-making.

PMID:41389427 | DOI:10.1016/j.injury.2025.112949

Injury. 2025 Dec 4;57(2):112947. doi: 10.1016/j.injury.2025.112947. Online ahead of print.

ABSTRACT

INTRODUCTION: While radiographic reduction quality is considered a key determinant of outcome in intraarticular calcaneal fractures, its quantification remains inconsistent and often unidimensional. Existing radiographic parameters only partially reflect the complex joint surface restoration while gradings often lack correlation to clinical outcomes. This study introduces the Calcaneal Fracture Outcome Score (CFOS), a composite score integrating joint-specific deformities and patient-level prognosticators to improve outcome prediction.

MATERIAL AND METHODS: Postoperative CT scans from 80 patients with surgically treated calcaneal fractures were evaluated for residual step, gap, and angulation at the posterior facet (PF) and calcaneocuboid (CC) joint. Additional parameters included Boehler's angle, Gissane's angle, Sanders classification, smoking status, and comorbidity burden. All variables were z-standardized and entered into a LASSO regression with 5-fold cross-validation. A weighted score (CFOS) was computed per patient and correlated with PROMS (VAS-FA; SF-12).

RESULTS: Higher CFOS grades were associated with significantly worse outcomes, i.e. posttraumatic osteoarthritis (p<0.001), VAS-FA (p=0.035) and SF-12 PCS (p=0.010), outperforming the traditional grading established by Kurozumi et al and adapted by Nosewicz et al. with a mean positive predictive value of 90 %.

CONCLUSIONS: The CFOS offers a clinically intuitive, multidimensional assessment of reduction quality and provides robust predictive value for postoperative functional outcome.

LEVEL OF EVIDENCE: III.

PMID:41389426 | DOI:10.1016/j.injury.2025.112947

Injury. 2025 Dec 4;57(2):112944. doi: 10.1016/j.injury.2025.112944. Online ahead of print.

ABSTRACT

INTRODUCTION: Kirschner wires (K-wires) are frequently used for pediatric fracture fixation. Infectious complications range from 1 % to 20 %, but the few available studies mostly focus on the adult population. The severity of infection varies from minor pin tract infections (PTIs) to severe osteomyelitis. Current literature on this topic is limited, especially regarding the pediatric population.

METHODS: In this retrospective observational study, we enrolled children (0-18 years old) with traumatic bone fractures treated with smooth (unthreaded) K-wires at the Orthopedics Unit of Meyer Children's Hospital in Florence between January 1, 2020, and December 31, 2024. The aim was to evaluate infection rates at our institution, describe clinical presentations and risk factors, identify the most frequent pathogens, and assess the treatment strategies adopted.

RESULTS: A total of 1386 patients were included, of whom 1349 (97.3 %) had fractures of the upper extremities (including the hand) and 37 (2.7 %) had fractures of the lower extremities (including the foot). We recorded 33 infections, with an infection rate of 2.4 %. PTIs were the most common infectious complication (16/33, 48.5 %), followed by osteomyelitis (11/33, 33.3 %) and deep soft tissue infections (3/33, 9.1 %). Fever of unknown origin (FUO), associated with elevated inflammatory markers, was observed in 3/33 (9.1 %) patients. The most common pathogen was Staphylococcus aureus, with no cases of methicillin-resistant strains. Children younger than 9 years were 2.8 times more likely to develop an infectious complication, as confirmed by both univariate (p = 0.012) and multivariate analysis (p = 0.036). Surgery during the summer season was significantly associated with a twofold increased risk of infection in univariate (p = 0.014) and multivariate analysis (p = 0.033). The timing of surgery, number of wires, fracture site, and type of reduction were not associated with a higher risk of infection.

CONCLUSION: This study describes the infection rate following K-wire fixation in a large pediatric cohort at a tertiary care facility. Based on our findings, these complications are rare, and patient education on wound and cast care may play a role in reducing their occurrence.

PMID:41389425 | DOI:10.1016/j.injury.2025.112944

Injury. 2025 Nov 1:112873. doi: 10.1016/j.injury.2025.112873. Online ahead of print.

NO ABSTRACT

PMID:41387072 | DOI:10.1016/j.injury.2025.112873

Injury. 2025 Dec 3;57(2):112939. doi: 10.1016/j.injury.2025.112939. Online ahead of print.

ABSTRACT

OBJECTIVES: Distal femur fractures in the elderly population are challenging to manage surgically. Treatment methods have traditionally focused on open reduction internal fixation (ORIF). More recently, distal femur replacement (DFR) has emerged as an alternative treatment method for geriatric distal femur fractures.

METHODS: DESIGN: Retrospective observational study.

SETTING: Data derived from TriNetX, a multicenter insurance claims database.

PATIENT SELECTION CRITERIA: 15,933 patients aged 65 years and older who sustained distal femur fractures and were treated with either DFR or ORIF within 30 days of injury were identified and matched, resulting in balanced cohorts of 584 patients each.

OUTCOME MEASURES AND COMPARISONS: Outcomes were analyzed at postoperative days 7, 30, and 90 as well as years 1 and 5. Endpoints were transfusion requirements, infections, revision surgery, and mechanical complications. The cohorts were matched using a greedy nearest neighbor algorithm, and the data was evaluated using relative risk (RR).

RESULTS: After matching, at days 7, 30, and 90 postoperative, the DFR cohort showed an increased risk of transfusion when compared to the ORIF cohort (p = 0.025, p = 0.008, and p = 0.005, respectively). At 90 days postoperative, the DFR cohort had an increased rate of infection (p = 0.028). At postoperative years 1 and 5, the matched DFR cohort was found to have a significantly higher risk of revision surgery (p < 0.001) and mechanical complications (p < 0.001) compared to the ORIF cohort.

CONCLUSION: This study found that the treatment of distal femur fractures with DFR is associated with a significantly higher risk of transfusion, infection, revision surgery, and mechanical complications compared to ORIF. This suggests that ORIF results in lower risk of complications in elderly patients with distal femur fractures.

PMID:41385827 | DOI:10.1016/j.injury.2025.112939

Int Orthop. 2025 Dec 12. doi: 10.1007/s00264-025-06717-8. Online ahead of print.

NO ABSTRACT

PMID:41385094 | DOI:10.1007/s00264-025-06717-8

SICOT J. 2025;11:E3. doi: 10.1051/sicotj/2025059. Epub 2025 Dec 10.

NO ABSTRACT

PMID:41380039 | PMC:PMC12698073 | DOI:10.1051/sicotj/2025059

Injury. 2025 Dec 5;57(2):112940. doi: 10.1016/j.injury.2025.112940. Online ahead of print.

ABSTRACT

PURPOSE: To analyze characteristics, accident mechanisms, injury patterns, and treatment of pedelec accidents, focusing on older riders (≥65 years) and those requiring intensive care.

METHODS: This descriptive single-center study included all patients presenting after a pedelec accident at a level I trauma center (January 2017-December 2023). Data included demographics, accident mechanisms, injuries, and treatments. A subgroup analysis was performed for patients requiring intensive care.

RESULTS: Between 2017 and 2023, 103 pedelec riders were injured, with annual cases rising steadily, peaking at 45 in 2023. Patients were predominantly male (57 %) with a mean age of 53 ± 19 years; 30 % were ≥65 years. Helmet use was documented in 34 %, alcohol in 10 %, and anticoagulant therapy in 15 %. Most accidents occurred during warmer months (66 %), in the afternoon (47 %), and were caused by rider errors (36 %) or car collisions (17 %). A total of 229 injuries were recorded (2.2 per patient), mainly affecting the head (33 %) and upper extremities (29 %). Thirty patients (30 %) required surgery, 41 (40 %) were hospitalized, and 11 (11 %) needed ICU care. The predominant reason for ICU admission was severe traumatic brain injury (TBI) with intracranial hemorrhage, present in 91 % of ICU patients. These patients were significantly older (mean 77 ± 13 years; OR 1.11 per year, 95 % CI [1.05-1.20]; p = 0.002), more often on anticoagulants (45 %; OR 5.33, 95 % CI [1.37-20.80]; p = 0.022), and none wore a helmet (0 %; OR 0.07, 95 % CI [0.00-1.23]; p = 0.015, Haldane correction). Males ≥65 years had a 25-fold increased ICU admission risk (OR 25.07, 95 % CI [4.89-128.53]; p < 0.001). Helmet use was associated with a 16.4 % absolute risk reduction (ARR) for ICU admission with a Number Needed to Treat (NNT) of 6. In-hospital mortality was 1.9 %.

CONCLUSION: Pedelec accidents have sharply increased, with injuries to the head and upper extremities most common. Older adults, especially men ≥65, face the highest risk of severe outcomes, including traumatic brain injury requiring ICU admission. Two-thirds of riders did not wear a helmet; helmet use significantly reduced critical injury risk. Focused prevention efforts-particularly promoting helmet use and rider safety education-are urgently needed.

PMID:41380375 | DOI:10.1016/j.injury.2025.112940

Injury. 2025 Dec 4;57(2):112943. doi: 10.1016/j.injury.2025.112943. Online ahead of print.

ABSTRACT

INTRODUCTION: Infection is one of the major complications associated with intramedullary nailing. Aim of this study is to analyze the outcome of infection after fixation of tibia and femur with intramedullary nailing and to compare the outcome in patients treated with nail retention versus removal.

PATIENTS AND METHODS: This is a retrospective cohort study including consecutive adult patients treated at our institution between 01/2015 and 03/2022 for infection involving the intramedullary nail used for fixation of femur or tibia fractures. Characteristics of infection and outcome data were evaluated by actively contacting the patients with a standardized questionnaire. Uniform predetermined definitions were used. The probability of infection-free survival was estimated using the Kaplan-Meier method and compared between the groups using log-rank test.

RESULTS: Fifty-one patients (37 males, 14 females) with infection associated with femur (n = 37) or tibia (n = 14) nail were included. The pathogen was identified in 45 (88 %) episodes, including 30 monomicrobial and 15 polymicrobial infections. The predominant pathogens in monomicrobial infections were coagulase-negative staphylococci (n = 11) and in polymicrobial infections gram-negative bacteria. The intramedullary nail was removed in 35 (69 %) patients and retained in 16 (31 %) patients. At follow-up (median follow-up 28 months; IQR 21-38 months), 19 of 31 (61 %) evaluable patients were infection-free. In patients with nail removal, 14 of 22 (64 %) were infection-free, whereas those with nail retention, 5 of 9 (56 %) were infection free.

DISCUSSION: The fact that patients in the nail retention group were of higher age, experienced earlier infection after surgery, and were mainly caused by high virulent pathogens suggest a potential selection bias. Nevertheless, it appears that certain infections may be treated successfully with nail retention, reducing the number of interventions for the patient, and increasing cost effectiveness.

CONCLUSIONS: Overall cure of infected intramedullary nails was 61 %. No significant difference in the infection eradication of infected intramedullary nails were observed, irrespective of the time of occurrence after nail implantation. These results should be confirmed in a larger prospective cohort.

PMID:41380374 | DOI:10.1016/j.injury.2025.112943

Injury. 2025 Dec 6;57(2):112930. doi: 10.1016/j.injury.2025.112930. Online ahead of print.

ABSTRACT

INTRO: Clinically significant pediatric cervical spine injuries (CSIs) are rare, and most literature focuses on operatively managed cases. However, many children with persistent neck pain after trauma are discharged in rigid collars despite normal or equivocal CT findings. This group remains poorly characterized. We aimed to characterize injury patterns, imaging findings, and management of pediatric CSI patients, with a specific focus on those discharged in rigid collars.

METHODS: We performed a retrospective cohort study of pediatric trauma patients (<18 years) at a Level 1 Pediatric Trauma Center from 2012 to 2021. Patients were included if they underwent cervical spine imaging (radiograph, CT, and/or MRI) and were diagnosed with a CSI. Demographics, injury mechanisms, imaging results, and treatments were collected. Subgroup analysis was performed on patients discharged in rigid collars. Univariate logistic regression stratified by injury level assessed associations between age and operative intervention.

RESULTS: Among 4477 pediatric trauma patients who underwent cervical spine imaging, 309 (6.9 %) were diagnosed with a CSI. Of these, 60 (19 %) underwent surgical intervention, 138 (45 %) were observed without immobilization, and 106 (34 %) were discharged in rigid collars. Operative intervention was associated with increasing age (p = 0.006) and high-energy trauma (p = 0.012), particularly for subaxial injuries. Most patients discharged in collars had persistent pain despite normal or mild CT findings and underwent MRI or neurosurgical consultation prior to discharge. CT identified all patients ultimately discharged in collars. Five injuries initially concerning to the trauma team were reviewed by a pediatric spine surgeon and determined not to be unstable; MRI showed ligamentous strain or normal variants, and none required surgery.

CONCLUSION: A substantial proportion of pediatric CSI patients are managed nonoperatively with rigid collars due to persistent symptoms. CT identified all patients needing further evaluation, and MRI clarified soft tissue injuries in symptomatic cases. Spine surgeon review confirmed these injuries were not unstable and did not require surgery. These findings highlight CT as an effective screening tool, the value of MRI in select cases, and the importance of clinical judgment and multidisciplinary evaluation in managing children discharged in collars.

PMID:41380373 | DOI:10.1016/j.injury.2025.112930

Injury. 2025 Dec 4;57(2):112933. doi: 10.1016/j.injury.2025.112933. Online ahead of print.

ABSTRACT

INTRODUCTION: The Ilizarov method is an established technique for complex cases. Decisions about circular frame removal are imprecise, with no fully reliable method to confirm union. Errors can lead to complications such as refracture, deformity, and non-union. Traditionally, radiological union is assessed by "dynamisation," a period of systematic frame destabilisation before removal. This study evaluates an institutional shift to selective dynamisation, where patients at perceived lower risk of non-union underwent same-day removal after destabilisation.

MATERIALS AND METHODS: A retrospective review was conducted on a continuous series of prospectively identified patients from the institutional frame database. All adults with tibial frames applied between April 2020 and February 2022 were included. Patients were grouped into dynamised and non-dynamised cohorts. The primary outcome was refracture within six weeks or non-union at any point after removal.

RESULTS: Among 207 patients, non-union or refracture rates did not differ significantly between non-dynamised and dynamised groups (3 [3.7%] vs 2 [1.7%], p = 0.38). Frame removal without dynamisation was non-inferior to removal with dynamisation (margin 5%). Mean frame time was 34 days shorter in the non-dynamised group (185 vs 151 days, p = 0.002). Treatment failure was more common in patients with a distraction gap vs no bone loss (14% vs 1%, p < 0.01) and in open vs closed fractures (7% vs <1%, p < 0.05), indicating higher risk in these subgroups.

CONCLUSION: Omitting outpatient dynamisation for tibial frames did not increase non-union or early refracture rates. In this cohort, dynamisation was 96% specific but only 25% sensitive for union. Outpatient dynamisation may benefit higher risk fractures, such as open fractures or those with bone loss. However, for most patients, removal without dynamisation appears safe and offers advantages: shorter frame time, fewer outpatient visits, and reduced radiation exposure.

PMID:41370961 | DOI:10.1016/j.injury.2025.112933