Int Orthop. 2025 Feb 11. doi: 10.1007/s00264-025-06441-3. Online ahead of print.

ABSTRACT

PURPOSE: There is a lack of long-term data evaluating the impact of synovectomy versus no synovectomy during total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). This study aimed to assess and compare bilateral TKA outcomes with and without synovectomy in the same patients over a similar follow-up period.

METHODS: A retrospective review was conducted on 65 bilateral staged posterior-stabilized (PS) fixed-bearing TKAs (28 men, 37 women) performed by a single surgeon on RA-affected knees, with an average follow-up of 17 years (range: 15-24 years). In the first knee, synovectomy was performed during TKA, while no synovectomy for the contralateral TKA. Outcomes assessed included Knee Society scores for knee and function, radiographic findings, complications, and patellar position using the Insall-Salvati ratio.

RESULTS: The synovectomy group had a higher rate of blood transfusion (23.3% vs. 16.6%; P < 0.01) and longer hospital stays (mean 9.60 days [95% CI: 6.56-13.63] vs. 6.51 days [95% CI: 5.50-9.52]; P < 0.001). The group without synovectomy demonstrated significantly better Knee Society Scores (89.1 vs. 80.2 points; P = 0.02) and greater range of motion (ROM) for flexion (130° vs. 102°; P = 0.01). Both groups had similar knee alignment, stability, and femoral and tibial component alignment. Patella baja was observed in six patients in the synovectomy group. Severe haematoma (n = 6) and deep infections (n = 4) were noted exclusively in the synovectomy group. Kaplan-Meier survivorship at 15 years was 81% (95% CI: 78-95) for TKA with synovectomy and 95% (95% CI: 90-100) for TKA without synovectomy.

CONCLUSION: Knees undergoing synovectomy during primary TKA exhibited reduced knee flexion, inferior Knee Society pain scores, and higher complication rates compared to contralateral knees without synovectomy. Omitting synovectomy in RA patients did not increase the risk of implant loosening.

PMID:39932578 | DOI:10.1007/s00264-025-06441-3

SICOT J. 2025;11:8. doi: 10.1051/sicotj/2025002. Epub 2025 Feb 10.

ABSTRACT

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common knee injury, and with advancements in knee arthroscopy, ACL reconstruction has become common. Techniques like single-double bundle and femoral tunnel drilling via transtibial or anteromedial portal approaches are available. This study evaluates the accuracy of femoral tunnel placement via these approaches in single-bundle ACL reconstruction.

MATERIALS AND METHODS: Forty-three ACL reconstructions using hamstring grafts were analyzed. Initially, femoral tunnels were drilled via the anteromedial portal from 09:30 to 10:00 (14:00 to 14:30 for left knees). Tibial tunnels (mean anteroposterior angle: 63.5°, sagittal: 64.2°) were then created with the same diameter, accompanied by radiological documentation. A femoral aiming device was used to place a K-wire at the center of the femoral tunnel, recorded photographically. Tunnel diameters included 7 mm (20 cases), 7.5 mm (11 cases), 8 mm (7 cases), 8.5 mm (3 cases), and 9 mm (1 case). Two observers evaluated all radiological and photographic data, focusing on the deviation of the transtibial K-wire from the femoral tunnel center.

RESULTS: Of 38 evaluated cases, the transtibial K-wire was within the femoral tunnel in 11 cases (28.9%) - 7 cases with 7 mm, 2 cases each with 7.5 mm and 8 mm diameters. In 23 cases (60.5%), the K-wire was at the perimeter or outside the femoral tunnel - 11 cases with 7 mm, 8 with 7.5 mm, 4 with 8 mm, 3 with 8.5 mm, and 1 with 9 mm diameters.

CONCLUSION: Transtibial aiming for anatomical femoral tunnel positioning is challenging. No significant correlation was found between the transtibial deviation and the tibial tunnel diameter.

PMID:39927689 | PMC:PMC11809194 | DOI:10.1051/sicotj/2025002

SICOT J. 2025;11:7. doi: 10.1051/sicotj/2025001. Epub 2025 Feb 10.

ABSTRACT

BACKGROUND: Functional knee positioning (FKP) represents an innovative personalized approach for total knee arthroplasty (TKA) that reconstructs a three-dimensional alignment based on the optimal balance of soft tissue and bony structures, but it has mostly been described for varus knee deformity.

SURGICAL TECHNIQUE: Valgus deformities present specific challenges due to altered bone remodeling and soft tissue imbalances. Using robotic assistance, FKP enables precise intraoperative assessment and correction of compartmental gaps, accommodating each individual's unique anatomy and laxities. The distal femoral cut is calibrated for 9 mm resection at the intact medial femoral condyle and adjusted on the lateral side to accommodate bone wear, while the tibial plateau resection aims for 8 mm from the medial side and 4-6 mm from the lateral side. Intraoperative evaluations of mediolateral laxities are performed at extension and 90° flexion. Adjustments are made to femoral and tibial cuts to balance gaps, aiming for 0 mm in posterior stabilized implants and minimal discrepancies in cruciate-retaining designs with lateral gap looser in flexion.

DISCUSSION: FKP emphasizes soft tissue-driven adjustments with the use of robotic platforms. Hence, intact soft tissue envelope of the knee is essential. This technique holds significant promise for managing valgus deformities in TKA, but further research is needed to evaluate its functional outcomes.

PMID:39927688 | PMC:PMC11809196 | DOI:10.1051/sicotj/2025001

Injury. 2025 Jan 31:112203. doi: 10.1016/j.injury.2025.112203. Online ahead of print.

ABSTRACT

INTRODUCTION: Traumatic brain injury (TBI) presents significant challenges in prehospital care, particularly during on-scene triage, where accurate decision-making is crucial for improving patient outcomes. This study, part of a mixed-methods project, aims to explore these challenges and identify gaps in current on-scene triage practices. Additionally, it seeks to understand paramedics' perspectives on potential diagnostic tools such as brain biomarkers, near-infrared spectroscopy, and decision aids.

METHODS: This study involved conducting semi-structured interviews by video conference, including interviews with paramedics of various experience levels who were recruited from UK ambulance trusts. The interviews were guided by a predeveloped and piloted topic guide. The interviews were audio-recorded, transcribed, and analysed using a thematic analysis approach.

RESULTS: Between June and December 2022, twenty participants (15 males and 5 females) with 4 to 24 years of experience were interviewed. Four key themes were identified. Theme 1, "Challenges in TBI Recognition," highlighted difficulties in identifying non-obvious TBI, especially in older adults or patients with comorbidities, and differentiating TBI from other conditions. Theme 2, "Need for Specific Triage and Diagnostic Tools," emphasised paramedics' need for a simple, evidence-based head injury-specific triage tool, as they felt that current tools lack the necessary specificity. Participants also highlighted the potential of new diagnostic technologies to improve decision-making. Theme 3, "Need for Evidence to Support Diagnostic Tools," stressed the importance of clinical effectiveness, feasibility, and cost before implementing new diagnostic technologies. Theme 4, "Implementation Requires Planning and Training," highlighted the need for effective implementation strategies, as well as adequate and ongoing training to ensure proficiency and proper use in the prehospital setting.

CONCLUSIONS: This study provides critical insights into the complexities of on-scene prehospital triage for patients with suspected TBI. Key recommendations include developing specific triage tools, exploring advanced technologies to support on-scene decision-making, enhancing paramedic training on TBI recognition, and addressing both barriers and facilitators to the implementation of new diagnostic technologies.

PMID:39929756 | DOI:10.1016/j.injury.2025.112203

Injury. 2025 Feb 4;56(3):112207. doi: 10.1016/j.injury.2025.112207. Online ahead of print.

ABSTRACT

This study investigates the impact of extraperitoneal pelvic packing (EPP) on the definitive surgical treatment of pelvic fractures (PF) in trauma patients. While EPP is recognized as an effective life-saving technique for controlling non-compressible retroperitoneal bleeding, concerns persist about its potential to complicate subsequent surgical interventions. A total of 220 trauma patients treated in a single First Level Trauma Centre from October 2016 to December 2021 were analysed. Demographic data, trauma mechanisms, hemodynamic stability, Injury Severity Scores (ISS), New ISS, PF classification (Tile), surgical timelines, and postoperative complications according to the Clavien-Dindo classification were collected. The study population was divided into two groups: those who underwent EPP (n = 42) and those who did not (n = 178). Statistical analyses included propensity score matching to balance baseline characteristics and reduce selection bias. Key findings show that EPP effectively improved survival rates in hemodynamically unstable patients, achieving a survival rate of 71.43 %. However, EPP was associated with delays in definitive surgical treatment and a higher incidence of major postoperative complications (41.67 % vs. 17.65 %, p = 0.014). Despite these delays, EPP did not significantly limit the possibility of achieving definitive surgery or the choice of fixation technique. Patients who underwent both EPP and open reduction internal fixation did not show a higher rate of severe complications compared to those managed without EPP. The study concludes that while EPP should be considered a practical emergency intervention for critically unstable PF patients, and even though it may affect the timing of definitive PF treatment, it does not prevent further surgical management.

PMID:39929088 | DOI:10.1016/j.injury.2025.112207

J Bone Joint Surg Am. 2025 Feb 10. doi: 10.2106/JBJS.24.00460. Online ahead of print.

ABSTRACT

BACKGROUND: In recent years, orthopaedic surgeons have attempted to decrease opioid consumption through multimodal pain management. However, a limited effort has been made to eliminate opioids entirely in the perioperative period. The purpose of this study was to compare the efficacy and safety of a novel opioid-free pain management pathway with that of an opioid-containing pathway across 5 common orthopaedic subspecialty surgical procedures.

METHODS: In a 1:1, unblinded fashion, 315 patients were randomized to a perioperative pain management pathway that was either opioid-free (n = 157) or opioid-containing (n = 158). Pain was measured with a numeric rating scale (NRS) for pain of 0 to 10 at 6 hours, 12 hours, 24 hours (the primary outcome assessing noninferiority), 2 weeks, 6 weeks, and 1 year after the surgical procedure. Data on patient characteristics, deviations from the pain management pathway, morphine milligram equivalents (MME), readmissions, adverse events, and patient-reported outcomes were collected.

RESULTS: There were 315 patients in the final group, with a mean age of 63.6 years. Of the patients in the study, 59.7% were female, 85.7% were White, 12.4% were Black/African-American, 1.0% were Hispanic/Latino, 0.6% were American Indian, and 0.3% were unknown. At 24 hours, the median NRS for pain in the opioid-free group (2 [interquartile range (IQR), 0 to 4]) was statistically noninferior (p < 0.0001) to the opioid-containing group (4 [IQR, 2 to 6]). Pain levels were significantly lower in the opioid-free group than in the opioid-containing group at 12 hours (p = 0.0173) and 2 weeks (p = 0.0003). Pain scores at 6 hours, 6 weeks, and 1 year were similar. Patients in the opioid-free group reported significantly greater comfort at 24 hours (p = 0.0392) and higher satisfaction with pain control (p = 0.0355) at 6 weeks. There were no reported adverse events or unplanned readmissions. Demographic characteristics were similar between the 2 groups.

CONCLUSIONS: Across 5 common orthopaedic subspecialty procedures, an opioid-free pain management pathway was safe and effective and provided noninferior pain control at 24 hours compared with the opioid-containing pathway.

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

PMID:39928724 | DOI:10.2106/JBJS.24.00460

J Bone Joint Surg Am. 2025 Feb 10. doi: 10.2106/JBJS.24.00955. Online ahead of print.

ABSTRACT

BACKGROUND: Orthopaedic surgery is a critical field, impacting global health-care expenditure and patient outcomes. Despite substantial research funding, issues of transparency and reproducibility persist, undermining the credibility of published in-print findings. Data-sharing initiatives aim to address these challenges by promoting accessibility and enhancing research reliability. We aimed to assess the landscape of data-sharing practices within the field of orthopaedic surgery, focusing on the top orthopaedic journals from 2020 to 2023.

METHODS: Original research articles from 10 of the top orthopaedic journals were screened and analyzed for data-sharing statements (DSSs). Furthermore, we identified variables that were influential on the inclusion of DSSs in orthopaedic clinical studies, and thematically analyzed DSS content to identify prevalent themes. Lastly, corresponding authors were contacted to assess their willingness to share their data.

RESULTS: Of the 1,084 reviewed articles, only 14% included a DSS. The Journal of Bone & Joint Surgery demonstrated the highest proportion of articles with a DSS. Over time, clinical trials exhibited an increasing trend in DSS adoption, contrasting with consistently low rates among cohort studies. Thematic analysis identified the gatekeeper role and conditional data availability as predominant themes in orthopaedic DSSs. Of the 115 emails sent to corresponding authors, only 22 (19.1%) yielded responses, and of those who responded, only 12 (54.5%) expressed a willingness to share their data.

CONCLUSIONS: Our findings underscore a substantial disparity in data-sharing practices across orthopaedic journals, highlighting the need for standardization and mandates for DSSs. Adopting the Transparency and Openness Promotion (TOP) Guidelines can enhance accountability and foster a culture of open science within the field. By addressing these shortcomings, orthopaedic journals can improve research reproducibility and advance scientific knowledge effectively.

PMID:39928713 | DOI:10.2106/JBJS.24.00955

J Bone Joint Surg Am. 2025 Feb 10. doi: 10.2106/JBJS.24.00359. Online ahead of print.

ABSTRACT

BACKGROUND: In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS.

METHODS: Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods.

RESULTS: We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73).

CONCLUSIONS: For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia.

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

PMID:39928712 | DOI:10.2106/JBJS.24.00359

Int Orthop. 2025 Feb 10. doi: 10.1007/s00264-025-06436-0. Online ahead of print.

ABSTRACT

Compressive neuropathies of the upper extremity are a common cause of pain, weakness, and functional impairment, often resulting from chronic mechanical compression or entrapment of peripheral nerves in anatomical regions such as osteofibrous tunnels, fibrous bands, or muscular pathways. While traditional diagnostic methods, including clinical evaluation and electrophysiological studies, are essential, they are limited in localizing lesions and identifying underlying causes. Advances in ultrasonography (US) and magnetic resonance imaging (MRI), particularly MR neurography and high-resolution 3D volumetric imaging, have significantly improved the evaluation of peripheral nerves by enabling detailed visualization of nerve anatomy, adjacent structures, and muscle denervation patterns. This article reviews the role of these imaging techniques in diagnosing and managing compressive neuropathies affecting the brachial plexus, suprascapular, axillary, median, ulnar, and radial nerves, highlighting key imaging findings such as nerve thickening, signal abnormalities, and muscle changes. The integration of advanced imaging modalities into clinical practice enhances diagnostic accuracy, facilitates surgical planning, and improves treatment outcomes for patients with peripheral nerve compression.

PMID:39928139 | DOI:10.1007/s00264-025-06436-0

Int Orthop. 2025 Feb 10. doi: 10.1007/s00264-025-06433-3. Online ahead of print.

ABSTRACT

INTRODUCTION: The implementation of Virtual Reality technology is approaching a breakthrough within the medical, and rehabilitation fields. The level of immersion in the virtual environment is profound and the potential applications are vast.

METHODS: This article reviews the capabilities of Virtual Reality in conjunction with the rehabilitation of nerve entrapments in sport athletes and examines the interactions between our body and brain within the virtual realm. In clinical practice it could be used as a complement to face-to-face therapy to asynchronous use by the patient in any location as a telerehabilitation system.

CONCLUSION: The use of Virtual Reality is a novel, potential, and promising tool in the treatment of nerve entrapments, even possible in the form of telerehabilitation. The response of body and brain in a virtual setting is good, the evolutions in technology can only improve this and this need to be substantiated by further scientific research.

PMID:39928138 | DOI:10.1007/s00264-025-06433-3

Int Orthop. 2025 Feb 8. doi: 10.1007/s00264-025-06444-0. Online ahead of print.

ABSTRACT

PURPOSE: Total hip arthroplasty (THA) with severe acetabular bone defect remains a challenge in clinic. The purpose of this study is to investigate the treatment technique by using the three-dimensional (3D) printing technology, and analyze the feasibility and preliminary effect of 3D printed personalized titanium blocks for acetabular defect reconstruction in primary THA.

METHODS: The clinical data of 35 patients with Paprosky type 3 acetabular defect, who underwent initial THA with 3D-printed titanium implants in our hospital from January 2017 to December 2019, were retrospectively analyzed. Among them, 21 cases were Paprosky type 3 A bone defects and 14 cases were Paprosky type 3B bone defects. The Harris Hip Score (HHS) was used to evaluate clinical outcomes, while imaging results were analyzed by hip rotation centres (V-COR and H-COR). In addition, postoperative complications were recorded.

RESULTS: The mean follow-up was 79.4 months (ranging from 63 to 94 months) and no patient was lost to follow-up. The total in-hospital blood loss of all patients was 462.9 ± 227.8 mL, accompanied with a blood transfusion rate of 31.4%. HHS improved from 44.5 ± 10.0 preoperatively to 85.1 ± 7.4 at the last follow-up (p < 0.001). Postoperative X-rays exhibited a good match between the 3D-printed titanium block and the acetabulum. V-COR decreased from 50.1 ± 4.7 mm preoperatively to 19.7 ± 1.8 mm postoperatively (p < 0.001). Similarly, H-COR improved from 33.1 ± 11.8 mm preoperatively to 29.7 ± 1.7 mm postoperatively (p > 0.05). Additionally, there were no significant changes in V-COR and H-COR at the last follow-up (p > 0.05). During follow-up, three cases of complications were observed, including two cases of wound redness and one case of partial sciatic nerve paralysis.

CONCLUSIONS: The 3D-printed personalized titanium block revealed accurate reconstruction, satisfactory radiographic and clinical outcomes, and low complication rates. This technique provides a reliable treatment strategy for primary THA in patients with severe acetabular bone defect.

PMID:39921749 | DOI:10.1007/s00264-025-06444-0

Int Orthop. 2025 Feb 8. doi: 10.1007/s00264-025-06431-5. Online ahead of print.

ABSTRACT

PURPOSE: No previous studies have reported the presence of sleep disturbances or their association with baseline factors in elderly patients with distal radius fracture (DRF). This study aimed to describe the proportion of patients with sleep disturbances and analyze their association with baseline factors in patients older than 60 years with conservatively treated DRFs.

METHODS: This prospective observational study included 220 patients with extra-articular DRFs who completed the Pittsburgh Sleep Quality Index at two time points: two weeks after cast removal and at the one year follow-up. Sociodemographic, anthropometric, clinical, radiological, and patient-reported outcome measures were analyzed as baseline predictors, with measurements performed two weeks after cast removal.

RESULTS: At two weeks after cast removal, 166 (75.5%) patients had sleep disturbances. Sleep disturbances were associated with the affected dominant hand (β = 1.6; p = 0.04), high-energy injury (β = 3.8; p < 0.001), extra-articular comminuted metaphyseal DRFs (β = 2.3; p < 0.001), higher Tampa Scale of Kinesiophobia scores (β = 2.4; p < 0.001), higher Pain Catastrophizing Scale scores (β = 2.4; p < 0.001), higher Pain Anxiety Symptoms Scale-20 scores (β = 2.1; p < 0.001), and higher visual analogue scale scores (β = 4.1; p < 0.001). At the one year follow-up, 85 (38.6%) patients had sleep disturbances, which were associated with higher Tampa Scale of Kinesiophobia scores (β = 2.6; p < 0.001), higher Pain Catastrophizing Scale scores (β = 2.5; p < 0.001), and higher Pain Anxiety Symptoms Scale-20 scores (β = 1.8; p = 0.02).

CONCLUSIONS: A high proportion of elderly patients with DRF experienced sleep disturbances. Expanding our understanding of the interplay between sleep disturbances and baseline risk factors may lead to improved care and clinical outcomes for these patients. Future studies should incorporate the clinical management of sleep disturbances in patients with DRFs.

PMID:39921748 | DOI:10.1007/s00264-025-06431-5

Int Orthop. 2025 Feb 8. doi: 10.1007/s00264-025-06442-2. Online ahead of print.

ABSTRACT

PURPOSE: Cutibacterium is commonly isolated from deep tissue samples taken at the time of revision shoulder arthroplasty, but the significance of these positive cultures is debated, and the impact of increasing bacterial loads on clinical outcomes is unclear. The objectives of this study were to (1) identify factors independently associated with high bacterial loads, and (2) compare patient-reported outcomes (PROs) and revision rates in patients found to have high Cutibacterium loads.

MATERIALS AND METHODS: Male patients undergoing single stage exchange with a minimum 2-year follow-up were included. Culture data were semi-quantitatively scored with the total Cutibacterium score (TShCuS). Two groups were compared: patients with a High Cutibacterium Load (HCL) group and those with Low Cutibacterium Load (LCL) group. PROs and revision rates were compared, and a multivariable analysis was conducted.

RESULTS: Of 68 male patients that underwent revision shoulder arthroplasty, 29 (42.6%) met the inclusion criteria for the HCL group, while 27 patients (39.7%) were in the LCL group. Mean follow-up was 4.7 ± 3 years. Patients with intraoperative humeral loosening had an 18.4 times increased risk of having high Cutibacterium loads (95% CI 2.1-154.4, p < 0.001). There were no significant differences in PROs or re-revision rates between the HCL and LCL groups.

CONCLUSIONS: Intraoperative humeral loosening was independently associated with high Cutibacterium loads found at the time of revision shoulder arthroplasty. Male patients with high bacterial loads treated with complete single stage exchange and antibiotics had patient-reported outcomes similar to those of patients with minimal to no load.

LEVEL OF EVIDENCE: III.

PMID:39921747 | DOI:10.1007/s00264-025-06442-2

Injury. 2025 Feb 1:112202. doi: 10.1016/j.injury.2025.112202. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma care frequently happens in emergency departments (ED) outside of major trauma centers. Many injuries often exceed the specialty capabilities of referring hospitals, requiring transfer to larger trauma centers. However, the proportion of patients discharged home without admission from receiving facilities remains unclear, suggesting potential overutilization of transfers. We sought to determine the proportion of transfer patients that are discharged home from the receiving ED.

METHODS: We studied patients ≥15 years captured in the Trauma Quality Improvement Program (TQIP) database who were transferred from a referring institution and were subsequently discharged home from the receiving ED without additional services planned.

RESULTS: From 2020 to 2022, there were 744,623 patients ≥15 years of age, of which, 82,316 (11 %) were discharged home with (1 %) or without (99 %) additional services planned. The median age was 40 (26-60), and 70 % were male. The most common mechanism of injury was a collision (40 %), followed by falls (30 %). The median composite injury severity score was 5 (1-5). Serious injury by body region was most frequent for the craniomaxillofacial (11 %) followed by the thorax (5 %). Most of the transfers were to level 1 centers (85 %). The most frequently performed procedures were CT brain followed by a CT cervical spine, abdominal ultrasound, MRI cervical spine, hand laceration repair, ocular evaluation, scalp repair, forearm fracture reduction, assessment of ocular pressure, and MRI of the lumbar spine. The most frequent diagnoses were nasal fracture, orbital floor fracture, macular fracture, subdural hematoma, dental fracture, pneumothorax, rib fracture, hand laceration, burns, and vertebral fracture.

CONCLUSIONS: We found that approximately 1 in 9 patients transferred to a higher level of care are discharged home from the ED, with most requiring neurosurgical, ophthalmologic, dental and craniomaxillofacial services. These findings suggest that virtual communication technology could reduce unnecessary transfers and associated costs.

PMID:39920022 | DOI:10.1016/j.injury.2025.112202

Injury. 2025 Jan 31;56(3):112198. doi: 10.1016/j.injury.2025.112198. Online ahead of print.

ABSTRACT

Unstable ankle injuries often comprise multiple fracture lines; including a posterior malleolus fracture in up to 40% of cases. Surgical fixation of such injuries often requires multiple incisions. The configuration of the posterior malleolus fracture can also vary greatly, and the presence of this fracture is known to poorly affect patient outcomes. In this paper, the authors describe a modified posterolateral approach to the ankle which provides three windows for fixation of complex ankle fractures.

PMID:39919672 | DOI:10.1016/j.injury.2025.112198

J Bone Joint Surg Am. 2025 Feb 7. doi: 10.2106/JBJS.24.00427. Online ahead of print.

ABSTRACT

BACKGROUND: Magnetic resonance imaging (MRI) has proven to be a valuable noninvasive tool to evaluate graft integrity after anterior cruciate ligament (ACL) reconstruction. However, MRI protocols and interpretation methodologies are quite diverse, preventing comparisons of signal intensity across subsequent scans and independent investigations. The purpose of this study was to create an artificial intelligence (AI)-based index (Thessaly Graft Index [TGI]) for the evaluation of graft integrity following ACL reconstruction.

METHODS: The cohort study included 24 patients with an isolated ACL injury that had been treated with a hamstring tendon autograft and followed for 1 year. MRI was performed preoperatively and 1 year postoperatively. The clinical and functional evaluations were performed with use of the KT-1000 and with the following patient-reported outcome measures (PROMs): the Knee Injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Subjective Knee Function form (IKDC), the Lysholm score, and the Tegner Activity Scale (TAS). An AI model, based on the YOLOv5 Nano version, was designed to compute the probability of accurately detecting, in the sagittal plane, a healthy ACL (on a percentage scale) and was trained on healthy and injured knees from the KneeMRI dataset. The model was used to assess the integrity of ACL grafts, with a maximum score of 100. The results were compared with the MRI assessment from an independent radiologist and were correlated with PROMs and KT-1000 laxity.

RESULTS: The mean preoperative and postoperative TGI scores were 64.21 ± 8.96 and 82.37 ± 3.53, respectively. A mean increase of 15% in the TGI scores was observed between preoperative and postoperative images. The minimum threshold for TGI to categorize a graft as healthy on the postoperative MRI was 79.21%. Twenty-two grafts were characterized as intact and 2 as reruptured, with postoperative TGI scores of 71% and 42%. The radiologist's assessment was in total agreement with the TGI scores. The correlation of the TGI ranged from moderate to good with the TAS (0.668), IKDC (0.516), Lysholm (0.521), KOOS total (0.594), and KT-1000 (0.561).

CONCLUSIONS: The TGI is an AI tool that is able to accurately recognize an ACL graft rupture. Moreover, the TGI correlated with the KT-1000 postoperative values and PROM scores.

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

PMID:39919170 | DOI:10.2106/JBJS.24.00427

J Bone Joint Surg Am. 2025 Feb 7. doi: 10.2106/JBJS.24.00243. Online ahead of print.

ABSTRACT

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) is often recommended for treatment of an ACL injury; however, the literature reports similar outcomes for those undergoing rehabilitation alone. We assessed the clinical, functional, sports participation, and osteoarthritis outcomes following our treatment algorithm, and compared 10-year outcomes among participants who chose progressive rehabilitation alone, early ACLR, or delayed ACLR.

METHODS: We included 276 participants who had a unilateral ACL injury without substantial concomitant knee injuries in a prospective cohort study. Treatment choice was based on shared decision-making after a 5-week progressive rehabilitation program. At the 10-year follow-up, we assessed patient-reported outcomes (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF], Knee injury and Osteoarthritis Outcome Score [KOOS], and patient acceptable symptom state [PASS] achievement), quadriceps strength, hop performance, sports participation, and weight-bearing radiographs.

RESULTS: Sixty-nine percent of the participants (191 participants; 99 male and 92 female; 6 African American, 7 Asian, 59 Caucasian, 119 unknown) attended the 10-year follow-up, including 98% (53) of 54 participants who had rehabilitation alone, 68% (114) of 167 with early ACLR, and 69% (24) of 35 with delayed ACLR. Among the entire cohort, 78% (126 of 162) reported having a PASS, 72% (109 of 151) had symmetrical quadriceps strength, ≥85% (≥116 of ≤137) had a symmetrical hop performance, 93% (162 of 174) were still engaged in some kind of sports, only 1% (1 of 139) had symptomatic osteoarthritis, and 12% (17 of 139) had radiographic evidence of osteoarthritis. We found similar outcomes after rehabilitation alone and early ACLR. The participants who underwent delayed ACLR had similar outcomes to the other 2 groups except for significantly lower KOOS Sports scores, KOOS Quality of Life scores, and hop performance (p ≤ 0.03). Participants who had rehabilitation alone were older, less active, and more likely to have concomitant lateral meniscal injuries than those who underwent ACLR.

CONCLUSIONS: Participants who followed our treatment algorithm after ACL injury had high percentages of satisfaction and of symmetrical quadriceps strength and hop performance, high sports participation rates, and low prevalences of osteoarthritis. Participants who chose progressive rehabilitation alone, despite being older and less active, had similar clinical, functional, sports participation, and osteoarthritis outcomes compared with those who chose early ACLR. Participants who underwent delayed ACLR scored lower on KOOS Sports, KOOS Quality of Life, and hop performance compared with both other groups.

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

PMID:39919167 | DOI:10.2106/JBJS.24.00243

Int Orthop. 2025 Feb 7. doi: 10.1007/s00264-025-06423-5. Online ahead of print.

ABSTRACT

PURPOSE: Early major complications following total hip replacement (THR) occur rarely, but given the high volumes of THR, represent a major burden to patients and the system. The purpose of this study was to determine the influence of hospital-level surgical practices on early major complications across Ontario.

METHODS: We conducted a population-based retrospective cohort study of all adults in Ontario, Canada who underwent primary THR for osteoarthritis between January 1, 2009 and December 31, 2019. The primary outcome was early major surgical complications (composite of deep infection, periprosthetic fracture, dislocation, or revision surgery occurring within 1 year of surgery). Medical complications (thromboembolism, myocardial infarction, pneumonia) occurring within 30 days of surgery also were assessed. THR performed at centres with very low volumes were excluded a priori. Two-level hierarchical logistic regression models adjusted for age, sex and Charlson co-morbidity score were used to calculate each hospital's unique adjusted complication rate and 95% confidence interval.

RESULTS: During the study period, 95,912 patients (mean [SD] age 67 [11.0] years; 51,216 (53.4%) women) underwent THA at 56 hospitals across Ontario. Overall, 1,656 (1.7%) patients had a major surgical complication within 1 year. Major surgical complication rates varied seven fold between hospitals from 0.6 to 4.1%. After adjustment, 4 of 56 hospitals were low outliers (adjusted complication rate significantly below average) and 5 of 56 were high outliers (adjusted complication rate significantly above average). There were no hospital outliers for medical complications.

CONCLUSIONS: There was significant variation in early major surgical complication rates between Ontario hospitals that persisted after adjustment for patient age, sex and medical comorbidity. Feeding back adjusted outcomes in benchmarking reports may enable individual hospitals and surgeons better consider their own performance and scale up best practices from low outlier hospitals, which can play a role in educating other centres in their region.

PMID:39918565 | DOI:10.1007/s00264-025-06423-5

Injury. 2025 Jan 31;56(3):112196. doi: 10.1016/j.injury.2025.112196. Online ahead of print.

ABSTRACT

INTRODUCTION: Open lower limb fractures can carry significant morbidity and are typically managed with a well-defined care pathway. Thankfully such injuries are less frequent in paediatric populations. Management for children is the same as it is for adults. The aim of this study was to analyse paediatric patients undergoing treatment for open lower limb fractures at a UK major trauma centre over a ten-year period.

METHOD: A retrospective analysis was performed on all paediatric patients with an open lower limb fracture that required soft tissue coverage, presenting to a major trauma centre with orthoplastic services from December 2011 to February 2023. Patient data was analysed according to demographics, co-morbidities, injury classification, time to wound excision, time to definitive surgery, soft-tissue reconstruction type and size, types of anastomoses used, grades of operators, peri‑operative use of inotropes and blood products, return to theatre in 24 h, flap survival and long-term complications.

RESULTS: We treated 94 patients with a mean age of 11 years old and mean weight of 46 .21kg The majority were ASA Grade I (80 %), additional co-morbidities included asthma, obesity and ADHD. Open tibial fractures were most common (61 %) followed by open foot fractures (18 %). Admission was within 24 h for 84 of the 86 patients for whom there was data, with 71 % having definitive fixation within 72 h of injury. The scapular or scapular/parscapular flap was most used (52 %) followed by an anterolateral thigh flap (29 %). A consultant was main operator in 70 % and a microsurgical fellow in 15 % of the cases recorded. Five cases out of 78 we had data for returned to theatre within the first 24 h of definitive surgery. with a mean of 18.5 h. In long term follow up there was 1 total flap failure and 1 flap that survived 60 % out of 53 patients there was data for. There were no deep bone infections.

CONCLUSION: Paediatric patients should be treated as aggressively as adults with an open lower limb fracture. Scapular and scapular/parascapular flaps offer a more cosmetically and functionally appealing option. Prompt IV antibiotics, combined specialist orthopaedics and plastics experience help to reduce deep bone infections.

PMID:39914251 | DOI:10.1016/j.injury.2025.112196

J Bone Joint Surg Am. 2025 Feb 6. doi: 10.2106/JBJS.24.00260. Online ahead of print.

ABSTRACT

BACKGROUND: A lumbosacral hemivertebra (LSHV) presents a complex challenge in treating congenital scoliosis. Previous studies have proven the effectiveness of posterior LSHV resection. However, they have primarily focused on coronal balance, neglecting the sagittal alignment, which is crucial for spinal function. The aim of this retrospective study was to assess preoperative sagittal imbalance in patients with an LSHV and to evaluate the evolution of sagittal alignment following posterior hemivertebra resection and short-segment fusion.

METHODS: A retrospective analysis was performed that included 58 patients with LSHV who underwent posterior LSHV resection between 2010 and 2020 and had a mean follow-up duration of 7.5 years. All patients were Han Chinese, and 30 of the 58 patients were female. The mean age was 7.3 years. Sagittal balance parameters were measured preoperatively and at multiple postoperative time points. Clinical outcomes were assessed with use of the Scoliosis Research Society (SRS)-22 questionnaire.

RESULTS: Preoperatively, 60.3% of patients presented with sagittal imbalance (defined as a sagittal vertical axis [SVA] of >20 mm). Postoperatively, the mean SVA significantly improved, decreasing to <20 mm at the 1-year follow-up (p = 0.016). The pelvic incidence-lumbar lordosis mismatch (PI-LL) also showed significant improvement at the immediate postoperative time point (p = 0.012) and at the last follow-up (p = 0.013). Patients who underwent anterior column reconstruction demonstrated better postoperative global sagittal balance than those who did not (SVA, p = 0.015; PI-LL, p < 0.001). SRS-22 total, self-image, and satisfaction scores significantly (p < 0.001) improved postoperatively.

CONCLUSIONS: This study highlighted the prevalence of preoperative sagittal imbalance in patients with an LSHV and emphasized the impact of LSHV resection (particularly when accompanied by anterior column reconstruction) in achieving postoperative sagittal balance and in enhancing patient quality of life during the long-term follow-up period.

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

PMID:39913624 | DOI:10.2106/JBJS.24.00260