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External hinge fixation system for leg lengthening and correction of axial deviations, / Salamehfix 1/. configuration and clinical advantages

International Orthopaedics -

Int Orthop. 2025 Sep 16. doi: 10.1007/s00264-025-06652-8. Online ahead of print.

ABSTRACT

PURPOSE: To present the design, clinical application, and outcomes of a novel three-dimensional external hinge distraction fixation system (Salamehfix 1), allowing simultaneous limb lengthening and correction of axial deviations with stable fixation, early mobility, and full weight bearing.

METHODS: Between 2000 and 2024, a total of 1103 patients (aged 4-57.5 years) underwent lower limb reconstruction using Salamehfix 1. Indications included congenital limb length discrepancy (LLD), post-traumatic and developmental deformities, stature lengthening, achondroplasia and cosmetic lengthening. Using (Salamaehfix 1), 640 patients out of the total 1103 underwent simultaneous lengthening and deformity correction and 193 patients were stature lengthening cases. The device employs three small anterior arcs with hinged distraction rods, customizable to patient anatomy and deformity pattern. Additionally, the device is an arc hinged system with pins in different angles and levels to provide a stable bone fixation and weight bearing. Outcomes were assessed in terms of gained bone's length, functional mobility, healing time, and complication rate.

RESULTS: Mean bone lengthening was 5.6 cm (range: 2-18 cm), and bone healing time of 260 days. Complications were minimal and manageable; superficial pin site infection occurred in 25 patients, contractures in 9, and deep infection in one. Stature cases (n = 193) had a mean lengthening of 6.5 cm, with excellent functional outcomes.

CONCLUSION: Salamehfix 1 is an effective, patient-friendly external fixation system enabling simultaneous correction and lengthening in a wide variety of deformities and cosmetic cases. It offers significant mechanical and clinical advantages over traditional devices.

PMID:40956411 | DOI:10.1007/s00264-025-06652-8

Augmented reality for medical education in the primary survey of burns: an exploratory study

Injury -

Injury. 2025 Sep 6:112747. doi: 10.1016/j.injury.2025.112747. Online ahead of print.

ABSTRACT

INTRODUCTION: Augmented reality (AR) technology is rapidly evolving and is finding an increasing application in education, including medical training. This feasibility study aimed to explore the usability and didactic potential of AR with the HoloLens2™ for medical students, teaching the primary survey of burn wounds.

METHODS: This feasibility study was conducted using a prospective observational cohort design. Test groups consisted of participants with limited (n = 18), moderate (n = 10), or high (n = 5) experience in burn care, and filled in a questionnaire after training with the HoloLens2™.

RESULTS: Outcomes of the questionnaires show AR to be a promising technology for educating medical students in the primary survey of burn wounds.

DISCUSSION: However promising, there is further need for development in usability and image quality. The ability to simulate realistic scenarios in a safe and scalable environment could pave the way for a new era for medical education, where AR becomes a valuable supplement or even replacement for traditional learning methods.

PMID:40947373 | DOI:10.1016/j.injury.2025.112747

Unabated violence: Evaluating the impact of the "state of exception" in Ecuador on surgical trauma admissions

Injury -

Injury. 2025 Sep 8:112758. doi: 10.1016/j.injury.2025.112758. Online ahead of print.

ABSTRACT

PURPOSE: Ecuador has seen a dramatic increase in violence, with homicides rising from 6.4 per 100,000 inhabitants in 2015 to 47.25 in 2023. In response, the government declared a state of internal armed conflict and a "state of emergency" This study aims to analyze the impact of this political measure on the admission of patients who are victims of violence to a hospital in the coastal region of the country.

METHODS: This is an analytical cross-sectional study conducted over nine months, from October 2023 to July 2024, divided into three-month periods. The independent variable was the period of surgical trauma: pre-exception, during the state of exception, and post-exception. The dependent variable was surgical trauma due to violence. A bivariate analysis was performed and a p-value of <0.05 was considered statistically significant.

RESULTS: The study included 160 cases of surgical trauma. Of the traumas reported during the nine months, 80 % (N=128) were due to violence. 78 % (N=125) of patients underwent surgery for penetrating trauma, with 77 % (96/125) of these due to firearms. The proportion of penetrating injuries due to firearms varied significantly according to period (p = 0.020). During the state of exception it fell to 60 % (21/35) from 79 % (31/39) pre-exception, but rose again in the post-exception period to 86 % (44/51).

CONCLUSION: The strategies implemented did not significantly reduce trauma admissions due to violence at this hospital, underscoring the imperative for additional interventions and a comprehensive understanding of the social determinants underlying this public health issue.

PMID:40946074 | DOI:10.1016/j.injury.2025.112758

Associations between neighborhood-level gun violence and child general health status: An ECHO cohort analysis

Injury -

Injury. 2025 Sep 8;56(11):112752. doi: 10.1016/j.injury.2025.112752. Online ahead of print.

ABSTRACT

The impact of gun violence on the well-being of children in the United States is a vital public health issue. Gaps remain in characterizing the population health burden, exacerbated by gun violence data limitations and research policy restrictions. This study explores the association between neighborhood-level gun violence and the general health status of children nationwide in the Environmental influences on Child Health Outcomes (ECHO) study. 13,450 children ages 0-17 and parents reported general health status. Gun violence incidents, defined as any death or injury caused by a gun, were extracted from the publicly available Gun Violence Archive by census tract between 2020 and 2023. Census tracts were categorized as low gun violence (< 2 incidents between 2020-2023) and high gun violence (≥ 2 incidents). A generalized estimating equation logistic model with robust variance was used to estimate the association between binary general health status (Good/Fair/Poor vs. Excellent/Very good) and neighborhood-level gun violence events adjusting for individual and census tract-level sociodemographic covariates. 11,329 (84 %) reported Excellent/Very Good general health and 2121 (16 %) reported Good/Fair/Poor general health. The adjusted odds of Excellent/Very Good general health were 20 % lower among children living in census tracts with high gun violence compared to low gun violence (OR 0.804; 95 % CI: 0.721, 0.897). When stratified by age group, the odds of Excellent/Very Good general health among younger children (ages 0 - 7) were 17.3 % lower (OR 0.827; 95 % CI: 0.687, 0.997) and 19.7 % lower among older children (ages 8 - 17) among those living in census tracts with high gun violence compared to those with low gun violence (OR 0.803; 95 % CI: 0.702, 0.919). Among children living in high socioeconomic vulnerability census tracts, the odds of Excellent/Very Good general health were 23 % lower in children living in census tracts with high gun violence compared to those with low gun violence (OR 0.767, 95 % CI 0.669, 0.880). Findings underscore the importance of community violence prevention efforts and the need to strengthen our understanding of community risk factors such as gun violence that hinder optimal child growth and development.

PMID:40945226 | DOI:10.1016/j.injury.2025.112752

Bariatric surgery and distal radius fractures, a population-based study

Injury -

Injury. 2025 Sep 9;56(11):112755. doi: 10.1016/j.injury.2025.112755. Online ahead of print.

ABSTRACT

INTRODUCTION: Obesity is a growing global concern. Bariatric surgery (BS) is the only intervention which leads to significant and long-lasting weight reduction. However, it has been associated with an increased risk of fracture. We aimed to investigate the association between BS and distal radius fractures (DRF).

METHODS: A retrospective cohort study of patients with obesity who underwent BS was conducted. The incidence of DRF and the non-osteoporotic scaphoid fracture in the six-years pre-and post-BS was compared. Sub-analysis for surgical type, weight loss, nutritional supplements, and treatment modality was conducted.

RESULTS: Seventeen-thousand, nine-hundred and four patients, aged 40 (SD 2.7) were included in the study, most of whom were females (71.2%). Most underwent restrictive gastric surgery (82.6%). The incidence of both fractures increased following BS (OR 2.091, 95% CI [1.524,2.896], p<0.001 for DRF and OR 6.013, 95% CI [2.819,14.720], p<0.001 for scaphoid fracturs). Women were affected more. DRFs were less common following restrictive surgery (0.6% versus 1.15% for gastric bypass surgery, OR 0.52 95% CI [0.35,0.79], p.=0.002), and their incidence was not associated with the time elapsed from BS. A greater weight reduction was not related with increased fracture risk, regardless of the fracture type, as was nutritional supplements consumption. DRF surgery rates were not affected by BS.

CONCLUSIONS: BS was found to relate with increased risk for DRFs. The risk was greater for gastric bypass patients and independent of the increasing cohort age, the amount of weight lost, the time elapsed from surgery, and the intake of nutritional supplements.

PMID:40945225 | DOI:10.1016/j.injury.2025.112755

Outcomes of DAIR for early fracture related infection: Clinical remission, recurrence, and bone healing in a retrospective cohort

Injury -

Injury. 2025 Sep 5;56(11):112749. doi: 10.1016/j.injury.2025.112749. Online ahead of print.

ABSTRACT

BACKGROUND: Fracture related infection (FRI) is a serious complication of orthopedic trauma. The DAIR (Debridement, Antibiotics, and Implant Retention) approach has been used as a limb- and implant-sparing strategy in selected early infections, but the factors associated with clinical success and bone healing remain incompletely defined.

OBJECTIVE: To evaluate the effectiveness of DAIR in treating early FRI and to identify clinical, surgical, and microbiological factors associated with infection remission, recurrence and fracture consolidation.

METHODS: This retrospective cohort study included adult patients diagnosed with early FRI and treated with DAIR between 2017 and 2023. Clinical remission was defined as infection resolution without further surgery or suppressive antibiotic therapy at 12-month follow-up. Recurrence was defined as clinical or microbiological evidence of infection reappearance. Fracture consolidation was evaluated radiographically. Univariate analyses were performed using logistic regression, Fischer's exact text, chi-square, and t-test where appropriate.

RESULTS: A total of 59 patients were included. Clinical remission was achieved in 86.4 % of cases, while recurrence occurred in 32.2 %. All patients with recurrence had failed clinical remission (p < 0.001). Remission was significantly lower in patients with prior external fixation (72.7 % vs. 94.6 %; p = 0.031) and lower extremity infections (77.1 % vs. 100 % for pelvis and upper limb; p = 0.002). Fracture consolidation was observed in 86.4 % of patients. Although not statistically significant, trends indicated better consolidation in those with remission (90.2 % vs. 62.5 %) and lower healing in patients with comorbidities, or polymicrobial infections.

CONCLUSIONS: DAIR is effective treatment for early FRI, achieving high clinical remission and consolidation rates. Remission is a strong predictor of both infection control and bone healing. Prior external fixation and lower limb involvement were associated with reduced treatment success.

PMID:40945224 | DOI:10.1016/j.injury.2025.112749

Quantifying Changes in 3D Acetabular Morphology in Normal Hips Based on the Development of Secondary Ossification Centers

JBJS -

J Bone Joint Surg Am. 2025 Sep 12. doi: 10.2106/JBJS.25.00428. Online ahead of print.

ABSTRACT

BACKGROUND: Acetabular development in pediatric hips is driven by growth from the triradiate cartilage (TRC) and secondary ossification centers (SOCs) of the os pubis, os ischium, and os ilium. These SOCs appear and fuse at different ages, with sex-specific differences affecting their morphology. This study quantifies the impact of SOCs on acetabular coverage, version, tilt, and surface area during adolescence.

METHODS: Three-dimensional (3D) surface reconstructions of 540 normal hips (in 128 male and 142 female patients) aged 8 to 19 years with no hip pathology were generated from computed tomography (CT) scans. Acetabular parameters, including coverage angles in predefined octants, version, tilt, and surface area, were extracted with use of a previously published algorithm. The Proximal Femur Maturity Index (PFMI) was used to assess skeletal maturity. Contributions to acetabular morphology from the 3 SOCs were analyzed using generalized linear mixed models. Significance was defined as p < 0.05.

RESULTS: PFMI grades strongly correlated with chronological age (rs = 0.91; p < 0.001). Os ilium ossification was significantly associated with increased superior coverage (p < 0.001), and os ischium ossification was associated with increased posterior coverage (p < 0.001). Superior coverage demonstrated a strong correlation with lateral tilt (rs = 0.837; p < 0.001), and posterior coverage was strongly correlated with anteversion (rs = 0.788; p < 0.001). Female patients exhibited greater acetabular anteversion (17.7° ± 6.4° versus 12.2° ± 6.4°; p < 0.001) and lateral tilt (38.5° ± 4.7° versus 36.6° ± 5.7°; p < 0.001), whereas male patients demonstrated larger acetabular surface area (31.9 ± 6.4 versus 28.8 ± 4.2 cm2; p < 0.001). We did not find a significant association between os pubis ossification and increased anterior coverage in male (p = 0.38) or female (p = 0.065) patients, nor did we find a correlation between anterior coverage and age (p = 0.115).

CONCLUSIONS: Os ilium and os ischium ossification were associated with increased superior and posterior acetabular coverage, respectively, during adolescence. In contrast, os pubis ossification was not associated with changes in anterior coverage. The timing of SOC appearance and closure aligns with key developmental changes in acetabular morphology, reinforcing the role of SOCs in determining hip stability.

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

PMID:40939009 | DOI:10.2106/JBJS.25.00428

Modern Alignment Strategies in Total Knee Arthroplasty and How to Best Achieve Them

JBJS -

J Bone Joint Surg Am. 2025 Sep 12. doi: 10.2106/JBJS.25.00480. Online ahead of print.

ABSTRACT

➢ Adherence to accepted definitions of the various alternative total knee arthroplasty alignment strategies is important for research and communication between surgeons.➢ Technological advances, including robotics and navigation-assisted systems, have made precise execution of alternative alignment strategies feasible.➢ Modern studies have suggested that minor deviations (±3°) from neutral mechanical alignment do not significantly impact long-term total knee arthroplasty implant survivorship.➢ Individualized alignment strategies, such as kinematic, restricted kinematic, and functional alignment, aim to respect native anatomy and soft-tissue balance.➢ The majority of studies comparing intermediate-term outcomes of kinematic and mechanical alignment suggest noninferior outcomes with kinematic alignment; however, some studies have suggested superior outcomes with kinematic alignment.

PMID:40938970 | DOI:10.2106/JBJS.25.00480

The Broken Wing Sign: A New Clinical Test to Detect Gluteus Medius Pathology with and without Fatty Infiltration

JBJS -

J Bone Joint Surg Am. 2025 Sep 12. doi: 10.2106/JBJS.25.00427. Online ahead of print.

ABSTRACT

BACKGROUND: Gluteus medius tears and atrophy cause lateral hip pain, limp, and functional impairment. We developed the "broken wing sign," a novel physical examination test for detecting gluteus medius tendon tears and muscle degeneration. This study evaluated its diagnostic accuracy and clinical utility against magnetic resonance imaging (MRI) and intraoperative findings.

METHODS: We prospectively examined 59 patients (75 hips; mean age, 69.5 ± 10.8 years; 48 women) with suspected hip abductor insufficiency. The broken wing sign was tested with patients prone, the knee flexed at 90°, and the hip actively extended. A positive sign involved ≥10° of compensatory external hip rotation, visible as an inward drift of the foot, indicating gluteus medius (and resulting internal rotation) weakness. MRI served as the reference standard for classifying gluteus medius integrity as no tear, partial, full-thickness, or massive. Fatty infiltration was graded (Goutallier grades 0 to 4), quantified, and analyzed for a correlation with the examination findings. Diagnostic accuracy metrics were calculated.

RESULTS: The broken wing sign demonstrated high accuracy (sensitivity, 81.8%; specificity, 80.0%; positive predictive value [PPV], 91.8%; negative predictive value, 61.5%; diagnostic odds ratio, 17.8). An external rotation threshold of ≥30° yielded 100% specificity and 100% PPV for a tear. The sign detected acute tears with no or minimal fatty infiltration (100% sensitivity for massive tears). The degree of the external rotation angle was strongly correlated with muscle atrophy with fatty infiltration, showing 88.0% sensitivity for Goutallier grade ≥3 and 100% sensitivity for grade 4.

CONCLUSIONS: The broken wing sign is clinically useful for diagnosing gluteus medius tendon tears and muscle atrophy, particularly massive tears and advanced fatty degeneration. It effectively guides MRI utilization and surgical planning, serving as a valuable initial diagnostic tool in the clinical setting.

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

PMID:40938961 | DOI:10.2106/JBJS.25.00427

Hip and Knee Arthroplasty in Patients with Obesity

JBJS -

J Bone Joint Surg Am. 2025 Sep 12. doi: 10.2106/JBJS.25.00131. Online ahead of print.

ABSTRACT

➢ Obesity is associated with increased postoperative complications and reoperation following total joint arthroplasty.➢ Meaningful functional improvement can be achieved with appropriate measures.➢ Preoperative measures include medical optimization, weight management, and consideration of bariatric surgery and glucagon-like peptide-1 receptor agonists.➢ Perioperative optimization requires an experienced multidisciplinary team and awareness of technical considerations for patients with obesity undergoing total joint arthroplasty.

PMID:40938955 | DOI:10.2106/JBJS.25.00131

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