Injury. 2025 Dec 3;57(2):112926. doi: 10.1016/j.injury.2025.112926. Online ahead of print.

ABSTRACT

BACKGROUND: Opioid use can be common in patients who require surgical fixation of lower extremity fractures. While common, these medications place patients at risk for developing opioid-related disorders (OD) which can in turn affect bony healing and propagate endocrinopathies. This study aims to investigate the impact of perioperative opioid-related disorders on short- and long-term outcomes following open reduction and internal fixation (ORIF) of lower extremity fractures.

METHODS: This retrospective study utilized the multicenter database TriNetX to identify patients who underwent ORIF of the lower extremity between 2003-2023 and had a minimum of 2 years follow up. The exposure of interest was the diagnosis of OD within 3 months prior to and following surgery stratifying them into two cohorts: OD cohort and control. 3986 patients were identified in the OD cohort and 211,560 patients in the control cohort. 1:1 Propensity score matching was applied for cohorts based on demographics, BMI and comorbidities resulting in 3970 patients in each cohort. Outcomes were assessed at 90 days and 2 years postoperatively. Statistical analyses calculated risk ratios (RR), confidence intervals (CI) and p-values.

RESULTS: Within 90 days, patients with OD had increased rates of pulmonary embolism (RR: 1.74, p = 0.023), deep vein thrombosis (RR: 1.47, p = 0.018), transfusion (RR: 2.27, p < 0.001), wound complications (RR: 2.18, p < 0.001), and postoperative anemia (RR: 1.94, p < 0.001). At 2 years, they had higher rates of nonunion (RR: 1.4, p = 0.004), revisions/repairs (RR: 1.59, p < 0.001), implant-related infection (RR: 2.24, p < 0.001) and amputation (RR: 1.97, p = 0.001).

CONCLUSION: Perioperative opioid related disorders are associated with greater thromboembolic events, postoperative bleeding, and greater postoperative complications such as nonunion, wound complications, amputations and revisions. Further studies are needed to understand pathophysiologic and psychosocial effects of opioid disorders on fracture and wound healing.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort.

PMID:41370960 | DOI:10.1016/j.injury.2025.112926

Injury. 2025 Dec 3;57(2):112922. doi: 10.1016/j.injury.2025.112922. Online ahead of print.

ABSTRACT

OBJECTIVES: The ankle fracture with both deltoid ligament (DL) rupture and syndesmotic diastasis was treated by fixing syndesmosis after open reduction and plate fixation of the fibular fracture. The present study aimed to evaluate the effect of deltoid ligament augmentation (DLA) replacing syndesmosis fixation for the treatment of such a fracture.

METHODS: This randomized controlled trial recruited acute ankle fracture patients with syndesmotic instability and DL rupture. Patients were randomized into DLA and trans-syndesmotic screw fixation (TSSF) groups. The primary outcome measure was the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale at 1 year post-surgery. The secondary outcome measures included Philips and Schwartz clinical scoring system of the ankle, the short-form (SF-36) questionnaire for quality of life, the range of ankle motion, the time to partial weight-bearing, the time to full weight-bearing, the time to return to previous work, the time to preinjury-level play, radiographic parameters, and complications. The analyses followed the intention-to-treat principle.

RESULTS: A total of 60 patients were randomized, and 59 were included for analysis: 30 in the DLA group and 29 in the TSSF group. The AOFAS scores at 1 year after surgery showed no statistical significance between the two groups. However, clinical scores at 3 months after surgery, including AOFAS score, Philips and Schwartz score, and subscales of SF-36 (physical function, general health, and social function), were significantly better in the DLA group than the TSSF group. Time to partial-weight-bearing, full-weight-bearing, return to work, and return to preinjury-level play were significantly reduced in the DLA group. No major complications were observed in both groups, and no difference was detected in the radiographic parameters immediately after surgery and at 1-year follow-up.

CONCLUSION: DLA achieved satisfactory clinical and radiographic outcomes at 1-year follow-up with rapid recovery post-surgery. This treatment method should be considered as an alternative option in ankle fractures associated with deltoid ligament rupture and syndesmotic diastasis.

PMID:41370959 | DOI:10.1016/j.injury.2025.112922

Injury. 2025 Dec 4;57(2):112929. doi: 10.1016/j.injury.2025.112929. Online ahead of print.

ABSTRACT

BACKGROUND: Musculoskeletal injuries occur in various school-based settings. However, no information describes musculoskeletal injury risk in school-aged populations relative to age, race, season, body part, and injury classification. We sought to perform an epidemiological analysis and create estimated multinomial logistic regression (MLR) models to profile school-based musculoskeletal injuries seen and treated at United States emergency departments from 2019 through 2023.

METHODS: We retrospectively searched the National Electronic Injury Surveillance System (NEISS) database from the United States Consumer Product Safety Commission (CPSC) between 2019 and 2023 for all school-based injuries in patients between 5 and 18 years of age. Through relative risk ratio calculations and MLR modeling, we created a comprehensive epidemiological analysis and predictive risk assessment profile of school-based musculoskeletal injuries between 2019 and 2023.

RESULTS: School-based musculoskeletal injuries declined during the 3-year COVID-19 timeframe and returned to above pre-COVID levels during 2023. Middle school-aged students experienced the most injuries, with high school students experiencing the least. A total of 54.6 % of injuries were to the upper extremity, with 38.5 % of injuries occurring in the lower extremity and 6.9 % in the trunk. Our estimated MLR models indicated that the most at-risk males for school-based musculoskeletal injuries were elementary students for upper and lower arm, wrist, and finger fractures during the summer, while middle and high school females demonstrated the highest risk of sustaining strains/sprains to the wrist and ankle during the summer and winter months.

CONCLUSIONS: From the NEISS database, we described the prevalence estimations of school-based musculoskeletal injuries reported to and treated by the United States emergency departments from 2019 through 2023. With our estimated MLR models, teachers, staff, school districts, administrators, healthcare providers, and other school leaders could create education and supervision initiatives to help prevent musculoskeletal injuries sustained in school settings.

PMID:41370958 | DOI:10.1016/j.injury.2025.112929

Int Orthop. 2025 Dec 10. doi: 10.1007/s00264-025-06725-8. Online ahead of print.

NO ABSTRACT

PMID:41369903 | DOI:10.1007/s00264-025-06725-8

Int Orthop. 2025 Dec 10. doi: 10.1007/s00264-025-06723-w. Online ahead of print.

ABSTRACT

PURPOSE: This study evaluated the accuracy of intraoperative leg length and femoral anteversion measurements obtained during total hip arthroplasty (THA) using the Mako robotic system with enhanced mode.

METHODS: A total of 55 hips in four men and 51 women who underwent primary THA with the Mako system via an anterolateral approach were retrospectively evaluated. Intraoperative measurements of leg length and femoral anteversion displayed by the Mako enhanced mode were compared with postoperative CT-based measurements. Absolute errors and their distributions were calculated to assess the accuracy of intraoperative assessments.

RESULTS: The mean absolute error was 2.3 ± 1.8 mm for postoperative leg length discrepancy and 2.9 ± 2.2° for stem anteversion. Of the 55 hips, 46 (83.6%) showed leg length errors within 3 mm and 51 (92.7%) within 5 mm. For stem anteversion, 48 hips (87.3%) were within 3° and all 55 hips (100%) were within 5°. Mako enhanced mode could not be completed in 10.7% of cases because of femoral array loosening or screw penetration into the medullary canal.

CONCLUSION: Mako enhanced mode demonstrated clinically acceptable accuracy for intraoperative measurement of leg length and femoral anteversion, contributing to precise femoral stem implantation in robotic-assisted THA.

PMID:41369902 | DOI:10.1007/s00264-025-06723-w

J Bone Joint Surg Am. 2025 Dec 10. doi: 10.2106/JBJS.25.00641. Online ahead of print.

ABSTRACT

BACKGROUND: Anterior cruciate ligament (ACL) injuries may lead to long-term neuromuscular and structural adaptations in thigh muscles. Although quadriceps dysfunction is well reported, chronic changes in other muscle groups, especially in nonoperatively managed ACL-deficient individuals, remain poorly understood.

METHODS: The present cohort study utilized Osteoarthritis Initiative data to assess longitudinal thigh muscle changes in individuals with ACL tears confirmed on magnetic resonance imaging (MRI) and no history of reconstruction. A validated deep-learning model segmented muscle cross-sectional area and quantified intra-muscular adipose tissue and contractile percentage. Quantitative MRI data were obtained at baseline and at 4-year follow-up. Propensity score matching (1:2 to 1:3) controlled for baseline covariates. Strength was assessed with use of standardized Osteoarthritis Initiative protocols. Linear mixed-effects models compared longitudinal changes between ACL-deficient and ACL-intact thighs.

RESULTS: A total of 1,207 thighs were analyzed, including 92 with ACL tears and 1,115 controls, with a mean patient age of 61 ± 9 years. Over 4 years, ACL-deficient thighs exhibited progressive hamstring atrophy (-28.18 mm2/year; 95% confidence interval, -42.43 to -13.92; p < 0.001) and sartorius atrophy (-3.02 mm2/year; 95% confidence interval, -5.15 to -0.89; p = 0.006). No significant differences were observed in quadriceps or adductor cross-sectional area. Hamstring force decreased significantly (-3.49 N/year; 95% confidence interval, -6.62 to -0.36; p = 0.029), whereas quadriceps force and specific force showed no significant changes. Intra-muscular adipose tissue and contractile percentage did not significantly differ between groups. Findings had been similar in unmatched patients.

CONCLUSIONS: The present findings highlight selective muscle deterioration in the posterior thigh muscles following ACL injury, with minimal changes in quadriceps morphology, over time. These results underscore the importance of long-term, targeted rehabilitation strategies focusing on hamstring preservation. This study represents the first longitudinal matched-cohort analysis of muscle morphology and fat infiltration in unreconstructed ACL-deficient knees.

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

PMID:41370366 | DOI:10.2106/JBJS.25.00641

J Bone Joint Surg Am. 2025 Dec 10. doi: 10.2106/JBJS.25.00797. Online ahead of print.

ABSTRACT

Hospital technology approval remains a formidable barrier to the adoption of surgical innovations. Despite compelling clinical evidence, technology requests frequently face rejection based on flawed economic models that emphasize the pricing of incumbent technology and time savings in the operating room over genuine value creation. This article provides a strategic framework for winning hospital approval by applying Economic Value to the Customer (EVC) principles and strategies to address managerial agency problems. This approach transforms technology evaluation from frustrating cost-focused rejection to value-centric approval that benefits surgeons and patients seeking access to innovation and vendors requiring market penetration.

PMID:41370365 | DOI:10.2106/JBJS.25.00797

Injury. 2025 Dec 4;57(2):112946. doi: 10.1016/j.injury.2025.112946. Online ahead of print.

ABSTRACT

OBJECTIVES: This study aimed to evaluate the association between hospital arrival time/day and mortality in pediatric patients with severe trauma.

METHODS: This retrospective observational study was conducted using data retrieved from the Japan Trauma Data Bank from January 2004 to May 2019. Patients younger than 18 years and with an Injury Severity Score of 16 or higher were included. Patients' hospital arrival time was categorized into daytime (9:00 am to 4:59 pm) and nighttime (5:00 pm to 8:59 am), and hospital arrival day was categorized into weekdays (Monday to Friday, except for national holidays) and weekends/holidays (Saturday, Sunday, and national holidays). The main outcome was in-hospital mortality. Multiple imputation was used to address missing values. Subsequently, inverse probability of treatment weighting was applied to compare in-hospital mortality rates between the two sets of groups: (1) nighttime and daytime arrival groups and (2) weekend/holiday and weekday arrival groups.

RESULTS: Overall, 6562 patients were included in this study, and the crude in-hospital mortality rate was 6.8%. The odds of in-hospital mortality were significantly higher in the nighttime arrival group than in the daytime arrival group (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.09-1.68). In contrast, no significant difference was observed between the weekend/holiday arrival group and the weekday arrival group (aOR, 0.95; 95% CI, 0.79-1.13).

CONCLUSIONS: Nighttime hospital arrival was associated with higher odds of in-hospital mortality in pediatric patients with severe trauma but weekend/holiday arrival was not.

PMID:41365281 | DOI:10.1016/j.injury.2025.112946

Int Orthop. 2025 Dec 9. doi: 10.1007/s00264-025-06702-1. Online ahead of print.

ABSTRACT

PURPOSE: Lenke type 3 and 6 scoliosis present a significant challenge due to the presence of two structural curves. Traditional surgical approaches provide adequate correction for one curve but often leave the secondary curve undercorrected, leading to residual deformity. This study evaluates the efficacy of the novel Simultaneous Independent Rod Derotation (SIRD) technique in treating adolescent idiopathic scoliosis (AIS) with Lenke type 3 and 6 curves.

MATERIALS AND METHODS: A retrospective analysis was conducted on 24 AIS patients (Lenke type 3 and 6) treated between January 2020 and September 2022. Patients were divided into two groups: SIRD group (n = 9) and Standard Single Rod Derotation (SRD) group (n = 15). Preoperative and postoperative radiographs were analyzed to assess the correction of major and minor curves. Intraoperative parameters, including surgical time, blood loss, and postoperative recovery, were evaluated as well.

RESULTS: The SIRD technique demonstrated significantly greater correction in both major and minor curves compared to SRD. The mean percentage reduction in major curves was 78.95% ± 7.09% in the SIRD group versus 68.79% ± 10.05% in the SRD group (p = 0.014). For minor curves, the reduction was 82.71% ± 8.87% in the SIRD group compared to 68.02% ± 13.44% in the SRD group (p = 0.0082). No significant differences were observed in surgical time, intraoperative blood loss, or hospital stay between groups.

CONCLUSION: The SIRD technique overcomes the limitations of conventional methods by effectively correcting both curves in Lenke type 3 and 6, offering a more balanced and comprehensive solution for scoliosis cases. Further studies are needed to confirm these findings.

PMID:41364341 | DOI:10.1007/s00264-025-06702-1

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.24.01377. Online ahead of print.

ABSTRACT

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PMID:41364773 | DOI:10.2106/JBJS.24.01377

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.25.00485. Online ahead of print.

ABSTRACT

BACKGROUND: The goals of this study were to develop an artificial intelligence (AI)-driven automated preoperative planning system for anterior cruciate ligament (ACL) reconstruction by integrating deep learning with computed tomography (CT)-magnetic resonance imaging (MRI) image fusion and segmentation, and to evaluate its accuracy.

METHODS: Structures on CT and MRI scans of 200 knee joints from patients with an intact ACL (aged 18 to 50 years, 81.0% male, all ethnic Chinese) were manually annotated. Fusion of the CT and MRI images was performed using a Dual-UNet registration architecture incorporating multiscale information fusion, enabling dynamic 3D reconstruction of the fused images for ACL insertion site identification and isometry assessment. A deep-learning framework was trained to analyze the fused image to precisely optimize ACL tunnel positioning, including identifying the entrances and exits of the femoral and tibial tunnels. Criteria in the automated planning included proximity to the ideal point, coverage of the anatomical footprint area, and isometric length variation of <2 mm. The accuracy of the AI system was then validated in 36 ACL reconstructions performed in bone models by comparing the drilled femoral and tibial tunnel lengths and graft length between the tunnels with the planned values. Finally, clinical feasibility was tested in 36 patients undergoing ACL reconstruction surgery using 3D-printed patient-specific guides derived from the AI planning, with 36 conventional surgeries as controls. Deviation of tunnel positions from the planned positions was compared between the 2 groups.

RESULTS: CT-MRI image fusion was able to generate an individualized 3D model with high segmentation accuracy (Dice coefficient = 0.864). The AI planning required 192 ± 90.2 seconds per case. In the bone model validation, the mean deviation between the planned and executed values was <1 mm for the femoral and tibial tunnel lengths and graft length between the tunnels (all p > 0.05). In the clinical testing, the AI-guided group demonstrated significantly smaller deviations from the ideal point compared with the conventional group in the deep-to-shallow (D-S), high-to-low (H-L), medial-to-lateral (M-L), and anterior-to-posterior (A-P) directions (all p < 0.05).

CONCLUSIONS: The AI-driven segmentation of CT-MRI fusion images and automatic preoperative ACL reconstruction planning demonstrated the capability to automatically, precisely, and reproducibly generate plans for nearly ideal tunnel entry and exit points with isometric, anatomical, and individualization characteristics. This technology is expected to hold clinical potential for ACL reconstruction, including reduced complication and revision rates and enhanced postoperative function.

PMID:41364772 | DOI:10.2106/JBJS.25.00485

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.25.00907. Online ahead of print.

ABSTRACT

BACKGROUND: Lateral extra-articular tenodesis (LET) is increasingly used to augment anterior cruciate ligament reconstruction (ACLR), particularly in patients with high-grade rotatory instability. Despite demonstrated biomechanical advantages, the long-term effect of LET on posttraumatic osteoarthritis (OA) remains unclear.

METHODS: We hypothesized that adding LET to ACLR reduces development of long-term moderate-to-severe radiographic OA, particularly after meniscectomy. We performed a PRISMA-compliant systematic review and meta-analysis, which was registered with PROSPERO. PubMed, Cochrane CENTRAL, and Scopus were searched through March 2025. Eligible randomized controlled trials (RCTs) or comparative cohort studies reported radiographic moderate-to-severe OA after ACLR with versus without LET, with a minimum follow-up of 5 years. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model.

RESULTS: Six studies with 444 patients (mean follow-up, 13.1 years) were included. LET was associated with a significant reduction in moderate-to-severe OA in the lateral compartment. Subgroup analysis showed a significant reduction in lateral OA as measured using both the Kellgren-Lawrence (K-L) (OR, 2.87; 95% CI, 1.2 to 6.9; p = 0.02) and International Knee Documentation Committee (IKDC) classifications (OR, 4.38; 95% CI, 1.5 to 12.7; p = 0.01). In contrast, no significant difference was found in the medial compartment for either the K-L (OR, 1.26; 95% CI, 0.7 to 2.4; p = 0.49) or IKDC classification (OR, 2.06; 95% CI, 0.6 to 6.8; p = 0.24). In meniscectomized knees, LET significantly reduced OA risk, especially as measured with the IKDC (OR, 6.14; 95% CI, 1.7 to 22.6; p = 0.01) compared with the K-L classification (OR, 3.61; 95% CI, 1.1 to 12.3; p = 0.04). In contrast, although LET also reduced OA risk in non-meniscectomized knees, the difference was not significant. Compartment-specific OA data were unavailable within the meniscal subgroups.

CONCLUSIONS: This meta-analysis, the first to assess the long-term effect of LET on OA, indicated that LET significantly reduces moderate-to-severe OA risk, particularly in the lateral compartment and among meniscectomized knees. Findings support selective LET use during ACL reconstruction, especially in cases with compromised meniscal integrity, to help mitigate OA progression.

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

PMID:41364753 | DOI:10.2106/JBJS.25.00907

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.25.00499. Online ahead of print.

NO ABSTRACT

PMID:41364752 | DOI:10.2106/JBJS.25.00499

J Bone Joint Surg Am. 2025 Dec 9. doi: 10.2106/JBJS.25.00536. Online ahead of print.

ABSTRACT

BACKGROUND: The effect of tourniquet use on cement penetration in primary total knee arthroplasty (TKA) remains controversial. Current assessments rely primarily on radiograph-based 2D measurements, which limit the precision and comprehensiveness of analysis. Therefore, this study investigated the effect of tourniquet use on 3D cement penetration and the association of tourniquet use with mid-term implant stability.

METHODS: In this prospective randomized controlled trial, 141 Han Chinese (East Asian) patients (mean age, 68.3 years; 85% female) were allocated to 1 of 3 groups: tourniquet (Group A), no tourniquet (Group B), and tourniquet during cementation only (Group C). The primary outcomes were 3D cement penetration (thickness, volume, surface area) and mid-term implant stability assessed on the basis of radiolucent lines (RLLs) and survivorship. Cement penetration metrics across femoral and tibial components were systematically quantified through 3D morphological analysis of metal artifact reduction-computed tomography (MAR-CT) images reconstructed using Avizo software (Thermo Fisher Scientific). Secondary outcomes included blood loss, inflammatory and muscle-injury biomarkers, pain scores, functional scores, postoperative length of stay, and complication rates.

RESULTS: All participants were followed for 5 years. No significant intergroup differences in cement penetration (thickness, volume, surface area) around the tibial (p = 0.847, p = 0.473, and p = 0.395, respectively) and femoral (p = 0.203, 0.201, 0.399) components were observed. Cement thickness correlated with preoperative knee deformity but not with implant size. Additionally, Group B demonstrated superior clinical outcomes versus Groups A and C: lower levels of inflammatory and muscle-injury biomarkers, lower early pain scores, and a shorter hospital stay, with enhanced 3-month knee function demonstrated in Groups B and C versus Group A. Total blood loss, mid-term outcomes, and complication rates were comparable. No RLLs or revisions were observed, and the 5-year implant survival rate was 100%.

CONCLUSIONS: Tourniquet use showed no significant effect on cement penetration and mid-term implant stability in primary TKA, and omitting intraoperative tourniquet use was associated with better early postoperative functional recovery in patients undergoing TKA.

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

PMID:41364748 | DOI:10.2106/JBJS.25.00536