J Bone Joint Surg Am. 2025 Jan 15;107(2):174-183. doi: 10.2106/JBJS.24.00390. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: Although the majority of intertrochanteric femoral fractures in the United States are now treated with cephalomedullary nailing, it remains uncertain whether differences in clinical performance by nail type exist. The purpose of this study was to compare the aseptic revision rates associated with the 3 most commonly utilized cephalomedullary nails in the United States today: the Gamma nail (Stryker), the INTERTAN (Smith+Nephew), and the Trochanteric Fixation Nail/Trochanteric Fixation Nail Advanced (TFN/TFNA; DePuy Synthes).

METHODS: Using an integrated health-care system's hip fracture registry, patients ≥60 years of age who were treated with 1 of these 3 commonly used cephalomedullary nail devices were identified. Potential confounders were identified and controlled for, including age, gender, race or ethnicity, body mass index, smoking status, American Society of Anesthesiologists classification, anesthesia type, Elixhauser comorbidities, and the operating surgeon. Multivariable Cox proportional-hazards regression was used to evaluate the risk of aseptic revision (the primary outcome measure) by cephalomedullary nail type, with mortality and revisions unrelated to the index fracture considered as competing events.

RESULTS: There were 19,215 patients included in the study sample (71.4% female, 77.0% White), including 4,421 in the Gamma nail group, 2,350 in the INTERTAN nail group, and 12,444 in the TFN/TFNA nail group. In the multivariable analysis involving nails of all lengths, the INTERTAN group was found to have a higher risk of aseptic revision compared with the TFN/TFNA group (8-year crude revision rate, 2.9% compared with 1.8%; hazard ratio [HR], 1.62 [95% confidence interval (CI), 1.15 to 2.27]; p = 0.006). The increased risk associated with the INTERTAN nail was primarily seen among the long nails (HR, 1.83 [95% CI, 1.16 to 2.87]; p = 0.009) rather than the short nails (HR, 1.36 [95% CI, 0.87 to 2.11]; p = 0.18). There were no differences in aseptic revision observed between the Gamma group and the TFN/TFNA group.

CONCLUSIONS: In this study of 19,215 patients with a hip fracture treated with cephalomedullary nailing, the INTERTAN nail was found to have a significantly higher risk of aseptic revision. Further research is required to determine whether these results could be related to the unique design of this implant.

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

PMID:39812725 | DOI:10.2106/JBJS.24.00390

J Bone Joint Surg Am. 2025 Jan 15;107(2):163-173. doi: 10.2106/JBJS.24.00184. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Complete blood cell count-based ratios (CBRs), including the neutrophil-lymphocyte ratio (NLR) and monocyte-lymphocyte ratio (MLR), are inflammatory markers associated with postoperative morbidity. Given the link between the surgical stress response and complications after total joint arthroplasty (TJA), this study aimed to evaluate whether higher preoperative CBR values predict greater postoperative benefits associated with dexamethasone utilization.

METHODS: The Premier Healthcare Database was queried for adult patients who underwent primary, elective total hip or knee arthroplasty (THA or TKA). Multivariable logistic regression models using dexamethasone exposure and CBRs as independent variables assessed primary end points of 90-day postoperative complications and length of stay (LOS) of ≥3 days. The probability difference between the dexamethasone and non-dexamethasone groups for each primary end point was determined across all values of each CBR. Probability differences were compared across CBR quartiles.

RESULTS: A total of 32,849 primary, elective TJAs (12,788 THAs [38.93%], 20,061 TKAs [61.07%]) performed between 2016 and 2021 were identified, and 22,282 (67.83%) of the patients received perioperative dexamethasone. Among patients with an NLR value of >1.00, those receiving dexamethasone had a lower probability of postoperative complications (all p < 0.05). Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients in the highest NLR quartile (≥4.67) compared with the lowest quartile (NLR <1.84) (p = 0.002). Among patients with an MLR value of ≥0.36, those receiving dexamethasone had significantly lower odds of postoperative complications. Dexamethasone was associated with lower odds of an LOS of ≥3 days among patients with an MLR of ≥0.33 (the 2 highest quartiles) compared with an MLR of <0.24 (the lowest quartile) (p = 0.039).

CONCLUSIONS: Higher NLR and MLR values were associated with greater marginal benefit from perioperative dexamethasone treatment, establishing a modifiable link between adverse outcomes and perioperative inflammation in TJA.

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

PMID:39812724 | DOI:10.2106/JBJS.24.00184

J Bone Joint Surg Am. 2025 Jan 15;107(2):144-151. doi: 10.2106/JBJS.24.00245. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: In the setting of cervical open-door laminoplasty, the question of whether or not every opened laminar level should be instrumented has not been sufficiently investigated. We postulated that the surgical outcomes of open-door laminoplasty with instrumentation of every second opened level (skip-fixation) might not be inferior to those of laminoplasty with instrumentation of every opened level (all-fixation). The purpose of the present study was to test the noninferiority of laminoplasty with skip-fixation in improving myelopathy at 2 years postoperatively compared with all-fixation. Additionally, we compared radiographic and surgical outcomes between the 2 types of procedures.

METHODS: This prospective, multicenter, unblinded randomized controlled trial included patients ≥60 years of age who underwent C3 to C6 open-door cervical laminoplasty for the treatment of degenerative cervical myelopathy. Patients were allocated to the skip-fixation group (n = 80) or the all-fixation group (n = 75) using a permuted block method. The primary outcome was the between-group difference in the Japanese Orthopaedic Association (JOA) score at 2 years postoperatively. Secondary outcomes included surgical data, complications, 2-year change in the JOA score, Neck Disability Index (NDI), EQ-5D-5L (EuroQol 5-dimension 5-level instrument) score, visual analog scale (VAS) score for neck pain, and radiographic outcomes.

RESULTS: One hundred and thirty patients (including 66 in the skip-fixation group and 64 in the all-fixation group) completed the trial at 2 years (follow-up rate, 83.9%). The difference in the JOA score at 2 years was 0.0298 (95% confidence interval [CI], -0.706 to 0.766), which was within the noninferiority margin (p < 0.0001; noninferiority test). In the secondary analyses, laminoplasty with skip-fixation demonstrated a significantly shorter surgical time (p = 0.010; Mann-Whitney U test) and greater improvement in the VAS score for neck pain, NDI, and EQ-5D-5L score (p = 0.006, p = 0.047, p = 0.037, respectively; mixed-effect model) compared with all-fixation. There were no significant between-group differences in radiographic outcomes, including the hinge union rate.

CONCLUSIONS: Skip-fixation may be sufficient to achieve noninferior 2-year postoperative improvement in myelopathy. Additionally, laminoplasty with skip-fixation potentially can lead to improvements in terms of neck pain, neck disability, and quality of life compared with all-fixation.

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

PMID:39812723 | DOI:10.2106/JBJS.24.00245

J Bone Joint Surg Am. 2025 Jan 15;107(2):134-143. doi: 10.2106/JBJS.24.00309. Epub 2024 Nov 20.

ABSTRACT

BACKGROUND: Early knee effusion is a common phenomenon after total knee arthroplasty (TKA), with potential clinical implications. Unlike traditional alloy knee prostheses, the polyetheretherketone (PEEK) knee system has radiographic transparency on magnetic resonance (MR) scans, which allows analysis of prosthetic knee effusion. We aimed to identify the distribution and volume of knee effusion after TKA with the PEEK prosthesis with use of MR imaging and to analyze whether dynamic changes in effusion were correlated with serum inflammatory marker changes and knee function recovery.

METHODS: Nine patients with osteoarthritis who were 59 to 74 years old underwent unilateral TKA with the PEEK prosthesis between June 2021 and August 2021. Dynamic early postoperative changes in the volume and distribution of knee effusion were evaluated with use of 3D MR stereoscopic images. Serum inflammatory markers were measured via blood tests, and joint function was evaluated with use of the subjective functional score of the Knee Society Score (KSS) and knee range of motion (ROM). Linear regression analyses were performed to assess for correlations between knee effusion volume and inflammatory markers and between knee effusion volume and joint function.

RESULTS: The mean serum inflammatory marker levels increased significantly at 1 week after TKA with the PEEK prosthesis and then gradually decreased with time from 1 to 6 months. The mean total knee effusion volume gradually decreased over time. Concurrently, the mean KSS subjective functional score and mean knee ROM improved with time. Total knee effusion volume was positively correlated with C-reactive protein level (R2 = 0.16; p = 0.007) and negatively correlated with the change in KSS score between the preoperative and postoperative time points (R2 = 0.19; p = 0.003). Using the 1-week total knee effusion volume as a reference, a positive correlation was observed between the reduction in total knee effusion volume and the actual value of the ROM (R2 = 0.36; p = 0.0001) from 3 to 24 months postoperatively.

CONCLUSIONS: Through 3D MR imaging, the precise distribution and volume of, and dynamic changes in, knee effusion after TKA with the PEEK prosthesis were confirmed and were found to be correlated with inflammation and joint function in the early postoperative period. The results demonstrate the potential clinical benefit of the PEEK-based knee system for future use.

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

PMID:39812722 | PMC:PMC11717431 | DOI:10.2106/JBJS.24.00309

J Bone Joint Surg Am. 2025 Jan 15;107(2):127-133. doi: 10.2106/JBJS.23.01118. Epub 2024 Nov 22.

ABSTRACT

BACKGROUND: Antiseptic solutions are commonly utilized during total joint arthroplasty (TJA) to prevent and treat periprosthetic joint infection (PJI). The purpose of this study was to investigate which antiseptic solution is most effective against methicillin-sensitive Staphylococcus aureus (MSSA) and Escherichia coli biofilms established in vitro on orthopaedic surfaces commonly utilized in total knee arthroplasty: cobalt-chromium (CC), oxidized zirconium (OxZr), and polymethylmethacrylate (PMMA).

METHODS: MSSA and E. coli biofilms were grown on CC, OxZr, and PMMA discs for 24 and 72 hours. Biofilm-coated discs were treated with control or various antiseptic solutions for 3 minutes. Solutions included 10% povidone-iodine, a 1:1 mixture of 10% povidone-iodine plus 3% hydrogen peroxide, diluted povidone-iodine, 0.05% chlorhexidine gluconate, and a surfactant-based formulation of ethanol, acetic acid, sodium acetate, benzalkonium chloride, and water. Following treatment, discs were sonicated to quantify adherent bacteria or underwent imaging with scanning electron microscopy to identify biofilm. Antiseptic solutions were considered efficacious if they produced a 3-log (1,000-fold) reduction in colony-forming units compared with controls.

RESULTS: On both OxZr and CC, 10% povidone-iodine with hydrogen peroxide eradicated all MSSA, and it achieved clinical efficacy on PMMA at both 24-hour MSSA biofilm (p < 0.0002) and 72-hour MSSA biofilm (p = 0.002). On 72-hour MSSA biofilm, 10% povidone-iodine eradicated all bacteria on OxZr and CC, and it achieved clinical efficacy on PMMA (p = 0.04). On 24-hour MSSA biofilm, 10% povidone-iodine achieved efficacy on all surfaces (all p < 0.01). The surfactant-based formulation only achieved clinical efficacy on 72-hour MSSA biofilms on CC (p = 0.04) and OxZr (p = 0.07). On 72-hour E. coli biofilm, 10% povidone-iodine with or without hydrogen peroxide achieved clinical efficacy on all surfaces. No other solution achieved clinical efficacy on either MSSA or E. coli.

CONCLUSIONS: Antiseptic solutions vary considerably in efficacy against bacterial biofilm. The 10% povidone-iodine solution with or without hydrogen peroxide consistently removed MSSA and E. coli biofilms on multiple orthopaedic surfaces and should be considered for clinical use.

CLINICAL RELEVANCE: Clinicians should be aware of the differences in the efficacy of antiseptic solutions on different orthopaedic surfaces when treating MSSA or E. coli biofilms.

PMID:39812721 | DOI:10.2106/JBJS.23.01118

J Bone Joint Surg Am. 2025 Jan 15;107(2):113-120. doi: 10.2106/JBJS.24.01130. Epub 2024 Nov 20.

NO ABSTRACT

PMID:39812720 | DOI:10.2106/JBJS.24.01130

Injury. 2024 Dec 31;56(2):112139. doi: 10.1016/j.injury.2024.112139. Online ahead of print.

ABSTRACT

INTRODUCTION: During revision surgery for the management of patients presenting with long-bone upper extremity nonunion, it is crucial to rule out fracture-related infection (FRI). This is especially true if there are clinical signs suggestive of FRI, or if there is a history of prior FRI, open wound fracture, or surgery. This study aimed to determine the efficacy of frozen section analysis (FSA) in providing real-time diagnosis of FRI in patients with upper-limb long-bone nonunion undergoing revision surgery.

PATIENTS AND METHODS: We included previously surgically treated patients who underwent revision surgery for chronic/late-onset nonunion of the long bones of the upper limbs over a 9-year period. We retrospectively applied the FRI criteria to identify eligible patients and recorded their clinical features and demographic characteristics. In all included patients, samples for microbiological analysis and FSA were collected simultaneously during revision surgery. Patients were categorized according to intraoperative culture results as having aseptic or infected nonunion. The sensitivity, specificity, positive and negative predictive values, and accuracy of FSA test were calculated and compared using microbiological analysis as the reference standard test. The concordance rate between FSA and definitive histopathology was also determined.

RESULTS: Sixty-two patients who were surgically treated for nonunion of the arm or forearm were included in this study. Septic nonunion was diagnosed intraoperatively in 9 patients based on FSA findings, while microbiological analysis confirmed septic nonunion in 8 patients. The sensitivity and specificity of FSA were 88 % (95 % confidence interval [CI] [47, 100]) and 96 % (95 % CI [87, 100]), respectively. Positive and negative predictive values were 78 % (95 % CI [47, 93]) and 98 % (95 % CI [89, 100]), respectively, with an overall test accuracy of 95 % (95 % CI [87, 99]). Cohen's Kappa coefficient between FSA and definitive histopathology was 0.74 (95 % CI [0.5, 1]).

CONCLUSIONS: FSA showed high sensitivity and specificity for the detection of active infection during revision surgery for nonunion of the upper limb. Owing to its high negative predictive value, it can reliably rule out active infections during revision surgery. Since the results are obtained immediately during revision surgery, this approach offers the significant advantage of enabling real-time decision-making.

PMID:39809066 | DOI:10.1016/j.injury.2024.112139

Injury. 2025 Jan 11;56(2):112155. doi: 10.1016/j.injury.2025.112155. Online ahead of print.

ABSTRACT

BACKGROUND: Paediatric upper limb fractures are commonly treated with Kirschner (K) wire fixation, which can be buried or left exposed. Although both techniques are widely used, controversy remains regarding infection risk, complications, and other clinical outcomes between buried and exposed K-wires. This systematic review and meta-analysis aimed to compare infection rates and secondary outcomes between buried and exposed K-wires in paediatric upper limb fractures located distal to and including the elbow, and proximal to the carpus.

METHODS: A systematic review of the literature was conducted according to PRISMA guidelines, with searches performed across Medline, EMBASE, and the Cochrane Library up to July 2023. Studies were included if they directly compared buried and exposed K-wires in paediatric patients (under 18 years old) and reported on infection rates. Meta-analysis was conducted to compare overall infection rates. Pooled means were used to compare secondary outcomes. Bias was assessed using the ROBINS-I and RoB2 tools.

RESULTS: Fifteen studies involving 1,854 participants were included. The meta-analysis showed that buried K-wires were associated with a significantly lower risk of overall postoperative infection compared to exposed K-wires (RR 0.33; 95 % CI 0.22 to 0.50; p< 0.001). The risk of deep infection requiring further surgery was 1.74 % in buried K-wires (95 % CI: 0.72 % to 2.75 %) and 2.07 % in exposed K-wires (95 % CI: 0.55 % to 3.59 %). Skin erosion was a common complication of buried K-wires, with a pooled mean rate of 13.0 %. Buried K-wires were associated with a higher likelihood of requiring removal in theatre (84.4 % vs. 4.2 %). Time to K-wire removal was longer in the buried group (10.9 weeks vs. 5.3 weeks). Re-operation and bone union failure rates were similar between groups.

CONCLUSION: Our systematic review and meta-analysis suggest that, while buried K-wires are associated with lower overall infection rates, the risk of deep infection is comparable between buried and exposed K-wires. Buried K-wires show higher rates of skin erosion and increased need for removal in theatre. Given these findings, exposed K-wires offer a safe and more cost-effective option for paediatric upper limb fracture fixation. Further studies are needed to assess patient-reported outcomes and environmental impacts.

PMID:39809065 | DOI:10.1016/j.injury.2025.112155

J Bone Joint Surg Am. 2024 Sep 19. doi: 10.2106/JBJS.24.00229. Online ahead of print.

ABSTRACT

BACKGROUND: Manual compartment palpation is used as a component of the clinical diagnosis of acute compartment syndrome (ACS), particularly in obtunded patients. However, its utility and accuracy in the upper limb are unknown. The purposes of this study were to assess the accuracy of manual compartment palpation of ACS in the forearm in a cadaveric model and to assess the role of clinician experience in this setting.

METHODS: Reproducible, sustained elevation of intracompartmental pressure was established in 8 fresh upper-limb cadaveric specimens. The 3 forearm compartments (volar, dorsal, and mobile wad) were randomized to pressures of 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (ACS). This was achieved by using fluid infusion and a pressure monitoring system. Orthopaedic clinicians with varying experience (residents, registrars, and consultants) used palpation to assess forearm compartments with known intracompartmental pressures. The examiners were blinded to the compartment pressures and the other examiners' responses. After the examination, the following 3 questions were answered: (1) Was compartment syndrome present? (2) In which compartment(s) was the pressure elevated? (3) What would be the next management step (fasciotomy or observation)?

RESULTS: Manual palpation of compartment pressure had an overall sensitivity of 70%, a specificity of 56%, a positive predictive value of 24%, a negative predictive value of 90%, and a likelihood ratio (LR) of 20.3 (p < 0.001). The sensitivity was similar in detecting ACS in the volar and dorsal compartments (70% and 69%, respectively). The sensitivity and specificity of combined volar and dorsal compartment palpation were 81% and 64% (LR, 16.6; p < 0.001) when performed by residents, 72% and 46% (LR, 4.2; p = 0.040) when performed by registrars, and 58% and 63% (LR, 3.6; p = 0.057) when performed by consultants. All of the compartments that were deemed positive for ACS were recommended for fasciotomy.

CONCLUSIONS: In our study, manual palpation of compartment pressure had a low accuracy in the diagnosis of ACS of the forearm and was not improved by clinician experience.

CLINICAL RELEVANCE: We recommend against the use of manual palpation of compartment pressure in the diagnosis of forearm ACS in an obtunded patient.

PMID:39808584 | DOI:10.2106/JBJS.24.00229

SICOT J. 2025;11:2. doi: 10.1051/sicotj/2024059. Epub 2025 Jan 13.

ABSTRACT

INTRODUCTION: Extraarticular deformity (EAD) with knee arthritis is a complex condition involving tri-planar bone deformity with pathological malalignment and chronic soft tissue contracture or laxity in the knee joint. Intraarticular correction by TKA, which was previously performed with conventional manual jig by mechanical alignment technique, had its limits and difficulties especially extensive soft tissue release and risk of jeopardizing the collateral ligaments. Robotic technology allows for reproducible and precise execution of surgical plan and allows adjustment to various new personalised alignment philosophy including functional alignment (FA). FA technique involves the adjustment of components positioning that least compromise the soft tissue envelope while restoring the limb alignment and joint obliquity to create a balanced knee. The aim is to study the outcome of intra-articular correction by robotic assisted TKA using Functional Alignment (FA) technique.

METHODOLOGY: This is a single surgeon series of 8 patients with extraarticular deformity who underwent robotic assisted total knee arthroplasty (TKA) with FA technique. Soft tissue release was gradually released and followed by adjustments of implant positioning in order to achieve a balanced medio-lateral gap.

RESULTS: Postoperatively, the lower limb alignment of all patients were restored within 6° (mean 4.54°) based on functional alignment boundaries. Knee phenotype and joint line obliquity (JLO) were restored in comparison to contralateral lower limb. There were 6 varus and 2 valgus malalignment. 7 patients were implanted with posterior stabilized implants while 1 was implanted with cruciate retaining implant. Arc of knee flexion and extension improved (P = 0.002). There was a large postoperative improvement in the Knee Society Score (KSS) (P < 0.001).

DISCUSSION: Intraarticular correction by TKA for EAD with knee arthritis is technically reliable with robotic technology. It allows intraoperative adjustment following functional alignment philosophy, thereby, restoring pre-arthritic alignment, knee phenotype and joint line obliquity.

PMID:39803978 | PMC:PMC11727079 | DOI:10.1051/sicotj/2024059

SICOT J. 2025;11:1. doi: 10.1051/sicotj/2024058. Epub 2025 Jan 13.

ABSTRACT

PURPOSE: To clarify the location of the popliteal artery (PA) is relative to the tibial osteotomy plane in patients with medial and lateral unicompartmental knee osteoarthritis (KOA) undergoing UKA.

METHODS: Preoperative MRI and postoperative radiographs obtained from 50 patients with unicompartmental KOA who underwent fixed-bearing UKA were analyzed. The amount of tibial resection was determined from the surgical records, and a line was drawn parallel to the tibial posterior tilt angle on the sagittal MR image to create a virtual tibial cut line. The tibial resection width measured from the anteroposterior image of the postoperative radiograph was projected onto the transverse plane containing the intersection between the virtual tibial cut line and the posterior tibial cortex, after which a line was drawn parallel to the medial or lateral intercondylar ridge. We then determined whether the PA was within an extension of the osteotomy area. The shortest distance (Distance 1) between the posterior tibial cortex and the PA within the osteotomy area was measured. In addition, the shortest distance between the line extending the osteotomy posteriorly and the PA was measured (Distance 2).

RESULTS: The medial UKA (group M) and lateral UKA (group L) group comprised 41 and 9 cases. The percentage of PA located behind the osteotomy plane was significantly higher in group L than in group M [6/9 knees (66.7%) vs. 2/41 knees (4.9%); P < 0.001]. The distance 1 was 12.6 (4.3) mm in group M and 7.9 (3.7) mm in group L (P = 0.004). The distance2 was 11.1 (4.9) mm in group M and 2.6 (3.5) mm in group L (P < 0.001).

CONCLUSION: During lateral UKA, the PA was often located behind the tibial osteotomy plane and close to the posterior tibial cortex. Nearly 5% of medial UKAs, the artery was located behind the osteotomy plane.

LEVEL OF EVIDENCE: Retrospective comparative LEVEL III study.

PMID:39803977 | PMC:PMC11727081 | DOI:10.1051/sicotj/2024058

Injury. 2025 Jan 12;56(2):112150. doi: 10.1016/j.injury.2025.112150. Online ahead of print.

ABSTRACT

INTRODUCTION: Injuries and violence are among the most prominent public health problems in the world. As well as being a leading cause of mortality - particularly among children and young adults - many of the millions of non-fatal injuries result in life-long disabilities and health consequences. The aim of this study was to estimate the prevalence of unintentional injuries and violence, and their associated factors among high school students.

METHODS: This cross-sectional study included a total of 1218 high-school students in Turkey. Data were collected through a facilitated self-administered questionnaire with questions adapted from the Global School-based Student Health Survey instrument. Data were analyzed in IBM SPSS Statistics 28.0 using chi-square test to find statistical significance if any. The significant variables from the chi-square test were selected for multiple logistic regression analysis.

RESULTS: The overall prevalence of physical attack, physical fighting, and serious injuries were 8.3 %, 14.8 %, and 11.7 %, respectively. In a multiple regression analysis, student truancy and lateness, worry, suicide attempts, and not having close friends were found to be associated with physically attacked, physical fight, and serious injuries.

CONCLUSION: This study demonstrated that the prevalence of unintentional injuries and violence among high school students is a major public health problem in Turkey. This study results can have important implications for school administration, parents, and policymakers alike to plan appropriate anti-violence strategies and interventions.

PMID:39805210 | DOI:10.1016/j.injury.2025.112150

Injury. 2025 Jan 5:112144. doi: 10.1016/j.injury.2025.112144. Online ahead of print.

ABSTRACT

BACKGROUND: Older adults with rib fractures pose an increasing clinical and financial burden on healthcare. Identifying and addressing the increased risk of adverse outcomes has been a key objective in geriatric co-management of surgical patients. The Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) is a useful predictor of complications and mortality in older adults, but its value in rib fracture management remains unclear. This study investigates the association between FI-CGA and short- and long-term outcomes of older adults with rib fractures.

METHODS: Rib fracture patients ≥65 years, with a FI-CGA score available, were retrospectively identified from a single level-I trauma center between 2018 and 2022. FI-CGA scores were categorized as pre-frail (<0.20), mild frailty (0.20-0.29), moderate frailty (0.30-0.39), and severe frailty (≥0.40). Outcome measures included mortality up to two years, length of stay (LOS), complications, and 30-day readmission.

RESULTS: 288 patients were included for analysis (57 pre-frail; 66 mildly frail; 61 moderately frail; 104 severely frail). Compared to the pre-frail group, only severely frail patients were at higher risk of 90-day (OR 5.71 [CI 1.29 - 52.67]) and 1-year mortality (OR 6.66 [CI 2.18 - 27.37]), while 2-year mortality was higher in mild (OR 3.77 [CI 1.30 - 12.57]), moderate (OR 4.28 [CI 1.46 - 14.51]) and severe (OR 6.42 [CI 2.43 - 20.11]) frailty groups. Hospital (p=0.183) and ICU LOS (p=0.131) was similar across groups. Severely frail patients were at risk of pneumonia (OR 3.50 [CI 0.95 - 19.48]) and delirium (OR 4.16 [CI 1.33 - 17.40]), while other complications were similar between groups (p=0.679). Adjusted proportional hazard ratios for mortality were significantly higher for moderate frailty (HR 1.99 [CI 1.02 - 3.89]) and severe frailty (HR 2.66 [CI 1.10 - 3.73]). FI-CGA was also a significant predictor if used per 0.01 point (HR 1.03 [CI 1.01 - 1.04)]) and per 0.1 point (HR 1.29 [CI 1.12 - 1.47]).

CONCLUSION: FI-CGA can identify vulnerable rib fracture patients at risk of in-hospital complications, and short- and long-term mortality. Continuous FI-CGA scores provide a granular and individualized risk assessment. In severely frail patients with rib fractures, FI-CGA may assist in aligning treatment with individual patients' needs and goals of care.

PMID:39800638 | DOI:10.1016/j.injury.2025.112144

Injury. 2025 Jan 8;56(2):112146. doi: 10.1016/j.injury.2025.112146. Online ahead of print.

ABSTRACT

INTRODUCTION: Intertrochanteric fractures are common in older adults and pose significant challenges in terms of morbidity and mortality. Accurate reduction and optimal implant positioning during operative stabilisation of these fractures reduce the rates of complications and reoperations while improving functional outcomes in this population. This study aimed to assess the effects of a structured educational intervention on the radiographic outcomes, reduction quality, and revision rates of intertrochanteric fractures.

METHODS: We initiated a training program that included an instructional video on interpreting intraoperative fluoroscopic views, as well as instructions and an algorithm for reducing and stabilising intertrochanteric fractures and mandated its implementation for all operating surgeons. We thus established an intervention cohort (n = 209) of patients who underwent surgery after the program's introduction, which we compared with a historical control cohort (n = 207) of patients who had undergone surgery before the program's implementation. The analysed postoperative radiographic parameters included the Baumgaertner reduction index, tip-apex distance (TAD), restoration of the caput-collum-diaphyseal angle, and calcar displacement. Mortality and the need for revision surgery were monitored for 2 years postoperatively.

RESULTS: We observed significant improvements in the intervention cohort, particularly among the less experienced surgeons. The TAD was reduced by 7 %, indicating improved implant positioning. Similarly, the Baumgaertner reduction index revealed an increase in 'good' reductions (40.2% vs. 37.2 %). Additionally, the rates of revision surgery (4.8% vs. 11.1 %) and mechanical complications (1.9% vs. 6.3 %) were lower in the intervention cohort than in the control cohort.

CONCLUSION: Implementation of the structured training program led to better radiographic outcomes for intertrochanteric fractures, especially among less experienced surgeons. The observed improvements in reduction quality and decrease in revision rates underscore the potential benefits of incorporating educational interventions in orthopaedic trauma treatment.

PMID:39799872 | DOI:10.1016/j.injury.2025.112146

Injury. 2025 Jan 9;56(2):112159. doi: 10.1016/j.injury.2025.112159. Online ahead of print.

ABSTRACT

Traumatic brain injury (TBI) remains a leading cause of morbidity and mortality among trauma patients. The care of these patients continues to be a complex endeavor with prevention of associated complications, often requiring as much attention as that of the treatment of the primary injury. Paramount among these are venous thromboembolic events (VTE) due to their high incidence, additive effect on the risk of morbidity and mortality, and the careful balance that must be utilized in their diagnosis and treatment to prevent progression of the brain injury itself. In this review, we have synthesized the most recent major studies detailing the ideal choice of chemoprophylactic agent, the timing of initiation, and continued monitoring and management strategies through the hospital course and beyond. Additional discussion is provided for subpopulations in which management can vary significantly, including the elderly, critically ill, and obese. Ultimately, current literature supports the use and safety of low molecular weight heparin over unfractionated heparin, especially when dosed using newer assays including anti-Xa levels. The timing of prophylaxis remains important, as the risk of VTE increases with each day that prophylaxis is held. Consensus findings favor initiation within 24-72 h, in the absence of documented progression, life threatening bleeding, or need for major surgical intervention. Despite available data, there continues to be significant variability in practice patterns which we hope to address with this review.

PMID:39799871 | DOI:10.1016/j.injury.2025.112159

Injury. 2025 Jan 5;56(2):112137. doi: 10.1016/j.injury.2024.112137. Online ahead of print.

ABSTRACT

Treatment algorithms for fracture nonunion depend on the presence or absence of bacterial infection. However, it is often impossible to identify infection preoperatively. While some infections may present with clinical signs of infection, low-grade infections lack infection signs and have a clinical presentation similar to aseptic nonunion. The clinical relevance of low-grade infection in nonunion is not entirely clear. Therefore, the aim of this study was to evaluate the role of low-grade infection in the development and management of lower extremity nonunion. A prospective multicenter clinical study enrolled patients with femoral or tibial shaft nonunion and regular healed fractures, scheduled for nonunion revision and routine implant removal, respectively. Preoperatively, serum markers including C-reactive protein (CRP), leukocytes, and procalcitonin were determined, clinical infection signs were recorded, and a suspected septic or aseptic diagnosis was made prior to surgery and further diagnostics. Tissue samples were collected for microbiology and histopathology, and osteosynthesis material for sonication. Nonunion patients were followed for twelve months, during which the definitive diagnosis of "septic" or "aseptic" nonunion was made according to diagnostic criteria for fracture-related infection. One hundred and ten patients with nonunion and 34 patients with regular healed fractures were included. Sixty-two nonunion patients were diagnosed as aseptic, 22 with expected and confirmed infection, and 23 with unexpected low-grade infection. Three patients had an unclear diagnosis. Low-grade infection was detected in 28 % of presumed aseptic nonunion patients. Sensitivity and specificity for the suspected diagnosis were 49 % and 95 %, respectively. The suspected diagnosis had a significant impact on revision strategy. All medians of the preoperative blood values were within the reference ranges except for CRP, which was slightly elevated in the expected and confirmed infected nonunion group. Expected and confirmed septic nonunion and unexpected low-grade infected nonunion demonstrated a similar bacterial spectrum. While 10 % of patients with aseptic nonunion required follow-up surgeries, re-operation rates were higher in patients with low-grade infection and expected and confirmed infection at 30 % and 64 %, respectively. Patients with low-grade infections were treated less frequently with systemic antibiotics and for a shorter duration than patients with expected and confirmed infections, with no significant difference in healing rate which was 83 % in low-grade and 62 % in expected and confirmed infections. The healing rate of aseptic nonunion was 90 %. A limitation of this study is the limited number of tissue samples for microbiological and histopathological diagnostics in the suspected aseptic nonunion cohort, which may have led to an underestimation of the low-grade infection rate. Our findings suggest that unexpected low-grade infection is frequently associated with nonunion. While expected and confirmed infected nonunion differs significantly from aseptic nonunion, low-grade infected nonunion is very similar to aseptic nonunion, except for intraoperative bacterial detection. In addition to antibiotic therapy, surgical nonunion revision with implant exchange and debridement appears to be highly effective in achieving consolidation of low-grade infected nonunion.

PMID:39799870 | DOI:10.1016/j.injury.2024.112137

Injury. 2025 Jan 5;56(2):112143. doi: 10.1016/j.injury.2025.112143. Online ahead of print.

ABSTRACT

INTRODUCTION: In the United States, deep vein thrombosis (DVT) and pulmonary embolism (PE) ranked high in terms of possibly preventable hospital deaths. Victims of trauma were at a higher risk of developing thromboembolic complications, and thus various agents were used for prophylaxis. Multiple studies recommended holding these agents in the perioperative period to decrease the potential complications of additional bleeding, wound issues, hematoma etc. However, the data regarding the timing and duration of withholding these agents was not consistent and at times surgeon specific. The aim of this study was to compare the incidence of DVT/PE in trauma patients before and after a June 2022 policy intervention to operate through prophylactic anticoagulation at an academic trauma center.

METHODS: We compared DVT/PE rates in trauma patients requiring surgery prior to and following policy change at our institution. The query included charts from January 1, 2018, through December 31, 2023. Clinical information relating to trauma date, surgery date, injury type, anticoagulant administration, DVT/PE development, and death, if applicable, was obtained from patient charts. We conducted a chi-square post hoc analysis to evaluate the incidence of DVT or PE before and after a policy change. The analysis focused on two categories: the presence or absence of DVT/PE.

RESULTS: DVT/PE development was 14.553 times more likely pre-policy change when anticoagulation was held prior to surgery compared to post-policy change when anticoagulation was administered before surgery (X2 (3, N = 374) =14.553, p=.002). Mortality related to DVT/PE showed no significant difference between pre-policy and post-policy groups (X2 (1, N = 374) = 0.130, p = .718). After excluding patients over age 65, analysis of MVA blunt trauma charts showed no statistical difference in blood transfusions pre policy v. post policy (X2 (1, N = 174) = 0.2198, p = .639).

CONCLUSION: Findings suggested that DVT/PE rates have significantly decreased post policy change without a significant increase in mortality and bleeding risk.

PMID:39798393 | DOI:10.1016/j.injury.2025.112143

Injury. 2025 Jan 7;56(2):112153. doi: 10.1016/j.injury.2025.112153. Online ahead of print.

ABSTRACT

BACKGROUND: Falls are some of the most common childhood injuries. However, for vulnerable children in low- and middle-income countries (LMICs) such as India, mortality from a fall is nearly three times that of high-income countries. Despite fall being a leading cause of paediatric injury, detailed data from LMICs remain sparse. This study aims to assess fall-related patterns of injury and mortality in children in urban India.

METHODS: We conducted a retrospective analysis from the Towards Improved Trauma Care Outcomes (TITCO) database, comprising 16,000 trauma patients admitted to four tertiary centres in India, between July 2013 and December 2015. We analysed demographics, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), and the pattern of injury sustained for patients under 18-years admitted with fall and assessed survival probability in different age groups using Kaplan-Meier survival analysis and log-rank tests.

RESULTS: Of 1281 children admitted after a fall, two-to-five-year-olds formed the majority (40 %). Nearly all children (99 %) had blunt trauma. The median ISS was 9 (IQR 9-11) and median GCS was 15. Overall in-hospital mortality was 7.8 % and isolated traumatic brain injury (TBI) was the most common (71 %) injury in those who died. Mortality was significantly higher in male children (9 %) than in female children (5 %) (p = 0.009). There was no significant difference in survival between age groups (p = 0.9).

CONCLUSION: The majority of paediatric patients admitted to urban hospitals in India after a fall were between the ages of two-to-five years, with isolated TBI and male sex associated with greater mortality. These findings have the potential to aid age-specific fall prevention strategies and resource allocation towards targeted initiatives to improve access to care, and consequently, mortality from fall in urban India.

PMID:39793303 | DOI:10.1016/j.injury.2025.112153

Int Orthop. 2025 Jan 11. doi: 10.1007/s00264-025-06410-w. Online ahead of print.

NO ABSTRACT

PMID:39794532 | DOI:10.1007/s00264-025-06410-w

Injury. 2024 Dec 31;56(2):112091. doi: 10.1016/j.injury.2024.112091. Online ahead of print.

ABSTRACT

BACKGROUND: Severe metaphyseal comminution and sizable bone defect of the distal femur are high risks of fixation failure. To date, no exact magnitude of comminution and bone loss is determined as an indication for augmentation of fixation construct. The present study aimed to investigate the influence of metaphyseal gap width, working length, and screw distribution on the stability of the fixation construct.

METHODS: A finite element model of a fractured femur with 0-80 mm metaphyseal gap width stabilized by an 11-hole distal femur locking compression plate (LCP-DF) was generated. The different working length and screw distribution were created by three different screw configurations: 9-10-11 (long working length, cluster screw), 8-10-11, and 7-9-11 (short working length, spreading screw). Physiological loading conditions were applied to evaluate biomechanical performance including equivalent von Mises (EQV) stress, bone stress, and fracture strain.

RESULTS: The EQV stress increased accordingly to a metaphyseal gap width of 0-20 mm. The EQV stress values were at the same levels for 30-mm metaphyseal gap width and higher, particularly in screw configuration 9-10-11. Screw configuration 7-9-11 produced the lowest elastic strain. A 0-mm metaphyseal gap width presented the lowest bone stress. Bone stress values were in a similar magnitude across a 10-80 mm metaphyseal gap.

CONCLUSION: The 30-mm and wider metaphyseal gap width with a long working length presented a risk of varus collapse and fixation failure. Short working length with spreading screw provided low EQV stress, low bone stress, and high fracture stability.

PMID:39787783 | DOI:10.1016/j.injury.2024.112091