Injury. 2025 May 21;56(8):112451. doi: 10.1016/j.injury.2025.112451. Online ahead of print.

ABSTRACT

OBJECTIVE: To evaluate the pros and cons of percutaneous kyphoplasty (PKP) and bone-filling mesh containers (BFC) by means of a meta-analysis in the treatment of osteoporotic vertebral compression fractures (OVCFs).

MATERIALS AND METHODS: A comprehensive search of Cochrane Library, PubMed, Embase, CNKI, Wanfang Database, and Chinese biomedical literature database was conducted to identify eligible clinical control studies comparing BFC versus PKP for OVCFs published until December 2022. Meta-analysis was performed utilizing Revman 5.3 to assess the effectiveness and safety of the two procedures.

RESULTS: Thirteen clinical controlled trials with a total of 1025 patients were enrolled, including 487 in the BFC group and 538 in the PKP group. BFC significantly reduced operation time and bone cement leakage rates compared with PKP. No significant differences were found between the two groups in terms of VAS score, ODI score, and Cobb angle at short- and long-term follow-up.

CONCLUSIONS: Both BFC and PKP are effective surgical approaches for the treatment of OVCFs, with BFC having a shorter operative time and a lower incidence of cement leakage.

PMID:40446565 | DOI:10.1016/j.injury.2025.112451

Injury. 2025 May 17;56(8):112445. doi: 10.1016/j.injury.2025.112445. Online ahead of print.

ABSTRACT

Traditionally unstable ankle fractures are surgically managed using open reduction and internal fixation (ORIF) with plate and screws. However, the operative management has gained an innovative technique. In the last decade, intramedullary (IM) nailing was introduced in local guidelines as a treatment for a selective group of elderly patients with compromised soft-tissues, as this technique is minimally invasive and less prone to wound complications including infections. Based on the authors' experience with IM nailing of the fibula using an intramedullary locking fibula nail, common technical challenges are highlighted and tips and tricks are provided to achieve optimal anatomic reduction by optimizing the entry point of the nail. Furthermore, we introduce a flow-diagram for optimal anatomic reduction using a dorsolateral entry point for the nail.

PMID:40446564 | DOI:10.1016/j.injury.2025.112445

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.01462. Online ahead of print.

ABSTRACT

BACKGROUND: The integration of artificial intelligence (AI), particularly large language models (LLMs), into scientific writing has led to questions about its ethics, prevalence, and impact in orthopaedic literature. While tools have been developed to detect AI-generated content, the interpretation of AI detection percentages and their clinical relevance remain unclear. The aim of this study was to quantify AI involvement in published orthopaedic manuscripts and to establish a statistical threshold for interpreting AI detection percentages.

METHODS: To establish a baseline, 300 manuscripts published in the year 2000 were analyzed for AI-generated content with use of ZeroGPT. This was followed by an analysis of 3,374 consecutive orthopaedic manuscripts published after the release of ChatGPT. A 95% confidence interval was calculated in order to set a threshold for significant AI involvement. Manuscripts with AI detection percentages above this threshold (32.875%) were considered to have significant AI involvement in their content generation.

RESULTS: Empirical analysis of the 300 pre-AI-era manuscripts revealed a mean AI detection percentage (and standard deviation [SD]) of 10.84% ± 11.02%. Among the 3,374 post-AI-era manuscripts analyzed, 16.7% exceeded the AI detection threshold of 32.875% (2 SDs above the baseline for the pre-AI era), indicating significant AI involvement. No significant difference was found between primary manuscripts and review studies (percentage with significant AI involvement, 16.4% and 18.2%, respectively; p = 0.40). Significant AI involvement varied significantly across journals, with rates ranging from 5.6% in The American Journal of Sports Medicine to 38.3% in The Journal of Bone & Joint Surgery (p < 0.001).

CONCLUSIONS: This study examined AI assistance in the writing of published orthopaedic manuscripts and provides the first evidence-based threshold for interpreting AI detection percentages. Our results revealed significant AI involvement in 16.7% of recently published orthopaedic literature. This finding highlights the importance of clear guidelines, ethical standards, responsible AI use, and improved detection tools to maintain the quality, authenticity, and integrity of orthopaedic research.

PMID:40446076 | DOI:10.2106/JBJS.24.01462

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.00602. Online ahead of print.

ABSTRACT

BACKGROUND: Bone marrow aspirate concentrate (BMAC) augmentation at the time of hip arthroscopy is a potential solution to improve functional outcomes in patients with cartilage damage concomitant with acetabular labral tearing; however, follow-up functional scores to date have not exceeded 24 months. Therefore, the present study compares minimum 5-year outcomes in patients treated with or without BMAC augmentation to address chondral damage during arthroscopic labral repair.

METHODS: This was a prospective cohort study analyzing patients who underwent acetabular labral repair performed by a single surgeon. Patients were stratified into either the BMAC cohort or the control cohort depending on whether BMAC was utilized in conjunction with arthroscopic labral repair. Demographic and intraoperative variables, including chondrolabral junction breakdown and articular cartilage damage, were compared between cohorts, as were patient-reported outcome measures (PROMs) at enrollment and at 3, 6, 12, 24, and 60 months postoperatively.

RESULTS: Eighty-one hips were included for analysis: 39 (38 patients) in the BMAC cohort and 42 (39 patients) in the control cohort. Univariate analyses demonstrated similar baseline characteristics between groups, including body mass index, Tönnis angle, lateral center-edge angle (LCEA), and alpha angle (p > 0.05 for each). Patients treated with BMAC and patients in the control group reported similar PROMs between enrollment and the 12-month follow-up. By the 24-month follow-up, patients treated with BMAC reported significantly higher scores for the modified Harris hip score (mHHS) (p = 0.004), the International Hip Outcome Tool-33 (iHOT-33) (p = 0.012), and the Hip Outcome Score-Activities of Daily Living (HOS-ADL) (p = 0.008). This trend persisted over time, with the BMAC cohort demonstrating significantly higher scores for the mHHS (p < 0.001), iHOT-33 (p = 0.006), and the Hip Outcome Score-Sports Subscale (HOS-SS) (p = 0.012) at 60 months.

CONCLUSIONS: Patients undergoing acetabular labral repair with BMAC augmentation reported significantly greater functional improvements compared with patients undergoing repair without BMAC. These differences generally did not become significant until 24 months after surgery, at which point they increased in magnitude until the 60-month follow-up. These findings, the first intermediate-term outcomes reported following hip arthroscopy with BMAC, therefore suggest favorable benefit at an extended follow-up.

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

PMID:40446023 | DOI:10.2106/JBJS.24.00602

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.00083. Online ahead of print.

ABSTRACT

BACKGROUND: Skin tenting is a commonly utilized surgical indication for clavicular fractures. The impact of skin tenting on fracture outcomes has not been investigated in adolescents. The present study compared the clinical and patient-reported outcome measures (PROMs) of nonoperatively and operatively treated adolescent clavicular fractures with skin tenting at presentation.

METHODS: Patients 10 to 18 years old with completely displaced midshaft clavicular fractures managed at 8 participating institutions from 2013 to 2022 were filtered to identify a cohort with either of 2 categories of skin tenting at initial presentation: (1) "skin tenting" or (2) "skin-at-risk for necrosis" (i.e., tented, white, and hypovascular). Demographics, fracture characteristics, treatment, complications, time to return to sport, and PROMs (i.e., American Shoulder and Elbow Surgeons score; Quick Disabilities of the Arm, Shoulder and Hand; Marx Shoulder Activity score; and European Quality of Life visual analog scale [EQ-VAS]) were analyzed at a minimum of 1-year follow-up.

RESULTS: A total of 88 (12%) of 764 prospectively enrolled adolescents with completely displaced midshaft clavicular fractures presented with skin tenting. Patients with skin tenting had older age and greater comminution, shortening, and superior displacement than those without skin tenting. A total of 58 patients with skin tenting (66%) underwent open reduction and internal fixation (ORIF), and 30 (34%) underwent nonoperative treatment, none of whom developed skin-related complications. However, 3 patients in the nonoperative cohort (10%) underwent early conversion to ORIF at a mean of 27 days (range, 6 to 62 days) post-injury. Although the nonoperative cohort was an average of <1 year younger than the ORIF cohort (nonoperative cohort, 14.5 years; ORIF cohort, 15.4 years; p = 0.04), there were no differences in sex (p = 0.23), shortening (p = 0.13), superior displacement (p = 0.14), or comminution (p = 0.32) between groups. PROMs were available for 63% of patients 1 or 2 years post-injury, with no differences in the PROMs European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L) and EQ-VAS, complications (p = 0.76), or time to return to sport (p = 0.80) between treatment groups.

CONCLUSIONS: In this large cohort of prospectively enrolled adolescent patients with clavicular fractures, 12% of patients with completely displaced clavicular fractures presented with skin tenting, approximately one-third of whom were definitively treated nonoperatively, though 10% of the initial nonoperative cohort underwent early conversion to ORIF. Adolescents with skin tenting treated nonoperatively demonstrated no differences in PROMs, complications, or time to return to sport, compared with patients who underwent ORIF.

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

PMID:40446020 | DOI:10.2106/JBJS.24.00083

J Bone Joint Surg Am. 2025 May 30. doi: 10.2106/JBJS.24.00844. Online ahead of print.

ABSTRACT

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

PMID:40446013 | DOI:10.2106/JBJS.24.00844

J Bone Joint Surg Am. 2025 May 29. doi: 10.2106/JBJS.24.00822. Online ahead of print.

ABSTRACT

BACKGROUND: The use of opioids to manage pain after anterior cruciate ligament (ACL) reconstruction remains problematic. This study evaluated the impact of opioid-limiting perioperative pain management education and counseling on postoperative opioid consumption.

METHODS: A parallel-arm, randomized controlled trial was conducted at a single academic institution. We included patients ≥14 years old who underwent ACL reconstruction surgery. Patients undergoing revision ACL surgery or open cartilage procedures, or who had a history of heroin use or opioid use requiring treatment, were excluded. A computer-based system randomly assigned participants in a 1:1 ratio to receive opioid-limiting perioperative pain management education and counseling with instructions to take opioids only as a last resort (treatment group) or traditional perioperative pain management with instructions to take opioids as needed for severe pain to "stay ahead of the pain" (control group). The primary outcome was the total morphine equivalents (TMEs) consumed in the 3 months after surgery. Secondary outcomes included pain measured with the Numeric Rating Scale, sleep quality, opioid prescription refills, and patient satisfaction.

RESULTS: The trial enrolled 121 patients, with a mean age (and standard deviation [SD]) of 29 (12) years (67 [55%] male; 35 African American, 10 Asian, 69 White, and 7 other). Within 3 months after surgery, 60 patients assigned to the treatment group consumed a mean of 46.0 mg of TMEs (SD, 126.1) and 61 patients assigned to the control group consumed 63.6 mg of TMEs (SD, 83.4; p < 0.001). The average score on the Numeric Rating Scale for pain in the first 14 days was 2.5 (95% confidence interval [CI], 2.0 to 2.9) in the treatment group and 2.4 (95% CI, 1.9 to 2.9) in the control group (p = 0.82). Four patients (6.7%) in the treatment group and 6 patients (9.8%) in the control group refilled their oxycodone prescriptions within 3 months after surgery (p = 0.53). Sleep quality and patient satisfaction were similar between groups.

CONCLUSIONS: Among patients undergoing ACL reconstruction surgery, opioid-limiting pain management education and counseling reduced opioid consumption with no observed increase in postoperative pain. Clinicians should consider this easily implementable approach to reduce opioid use among patients undergoing this common procedure.

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

PMID:40440513 | DOI:10.2106/JBJS.24.00822

J Bone Joint Surg Am. 2025 May 29. doi: 10.2106/JBJS.25.00304. Online ahead of print.

NO ABSTRACT

PMID:40440496 | DOI:10.2106/JBJS.25.00304

Injury. 2025 May 22:112446. doi: 10.1016/j.injury.2025.112446. Online ahead of print.

ABSTRACT

BACKGROUND: Currently, there is a lack of literature reporting on the risk factors associated with various types of subdural effusion (SDE). The purpose of this study is to investigate the incidence, risk factors, and prognosis of different types of SDE that occur secondary to unilateral decompressive craniectomy (DC) in patients with traumatic brain injury (TBI).

METHODS: A total of 417 patients who met the inclusion criteria were analyzed. The incidence, treatment, and prognosis of various types of SDE were examined. Risk factors associated with different types of SDE were identified through univariate analysis followed by multivariable logistic regression analysis.

RESULTS: The overall incidence of SDE was 50.6 %. There was no statistically significant difference in GOS scores among the various types of SDE (P = 0.511). Age (per 10-year increase) (OR, 1.471; 95 % CI, 1.201-1.802; P < 0.001), alcoholism (OR, 2.027; 95 % CI, 1.021-4.022; P = 0.043), combined with contralateral subdural hematoma (OR, 4.874; 95 % CI, 2.676-8.878; P < 0.001), and contralateral pneumocephalus after surgery (OR, 4.051; 95 % CI, 1.837-8.934; P = 0.001) were identified as independent risk factors for the occurrence of contralateral SDE. The type of injury (acute subdural hematoma, ASDH) (OR, 1.918; 95 % CI, 1.367-2.690; P <0.001), was an independent risk factor for the occurrence of ipsilateral SDE. Combined with contralateral subdural hematoma (OR, 2.669; 95 % CI, 1.161-6.139; P = 0.021) and contralateral pneumocephalus after surgery (OR, 2.271; 95 % CI, 1.177-4.381; P = 0.014) were independent risk factors for the occurrence of interhemispheric SDE.

CONCLUSIONS: Various types of SDE do not significantly affect the prognosis of patients with traumatic brain injury (TBI). Independent risk factors for the occurrence of contralateral SDE include age, alcoholism, and the presence of contralateral subdural hematoma and contralateral pneumocephalus following surgery. The type of injury being ASDH is the only risk factor for ipsilateral SDE. Combined with contralateral subdural hematoma and contralateral pneumocephalus after surgery were independent risk factors for the occurrence of interhemispheric SDE.

PMID:40436708 | DOI:10.1016/j.injury.2025.112446

J Bone Joint Surg Am. 2025 May 28. doi: 10.2106/JBJS.24.01052. Online ahead of print.

ABSTRACT

BACKGROUND: The outcomes of bone grafting for severe glenoid defects in reverse shoulder arthroplasty (RSA) are unpredictable. The purpose of this study was to describe the intermediate-term outcomes of glenoid bone grafting in RSA for severe glenoid defects utilizing a baseplate with a long central post.

METHODS: All patients who underwent glenoid bone grafting for severe glenoid defects during RSA from 2008 to 2018, with a minimum of 5-year follow-up, were included. Preoperative, immediate postoperative, and minimum 5-year postoperative American Shoulder and Elbow Surgeons (ASES) scores and visual analog scale (VAS) pain scores and radiographs were obtained and reviewed. Baseplate failure was defined as gross radiographic baseplate cutout or baseplate revision due to implant loosening.

RESULTS: Of the 56 shoulders that underwent bone grafting, 14 were not available because the patients had died and 1 was excluded because of infection, leaving 41 shoulders available for follow-up. There were 4 shoulders in which the patients were lost to follow-up; therefore, the final follow-up rate was 90% (37 of 41) at a mean of 6.8 ± 2.4 years. There were 17 revision procedures and 20 primary procedures performed. Autograft humeral head was utilized in 16 shoulders, and femoral head allograft was utilized in 21 shoulders. Overall, 8 baseplates failed (allograft, 7 [33.3% failure] of 21; autograft, 1 [6.3% failure] of 16; p = 0.104). Revision surgery (7 [41.2%] of 17) was associated with a higher rate of baseplate failure (p = 0.014) than primary procedures (1 [5%] of 20). The mean time to baseplate failure was 2.1 ± 1.5 years, with 2 cases having failure after 4 years postoperatively. Male sex and a lower Charlson Comorbidity Index were associated with baseplate failure (all p < 0.05). The 5-year overall baseplate survivorship was 78.4%.

CONCLUSIONS: Glenoid bone grafting with RSA for severe glenoid defects had an overall baseplate survivorship rate of 78.4% at the intermediate-term follow-up. Primary RSA with autografting for severe defects yielded survivorship of 95%, whereas revision RSA with allograft reconstruction had poorer survivorship (58.8%). Although primary RSA with autograft reconstruction resulted in a high success rate, revision RSA with allograft reconstruction using a central-post baseplate had an elevated baseplate failure rate and alternative surgical solutions for revision RSA should be considered.

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

PMID:40435212 | DOI:10.2106/JBJS.24.01052

SICOT J. 2025;11:32. doi: 10.1051/sicotj/2025027. Epub 2025 May 27.

ABSTRACT

INTRODUCTION: Under functional knee positioning (FKPos) principles, residual varus or valgus alignment of the tibia and femur may be maintained, resulting in loading conditions that differ from those observed with mechanical alignment. Consequently, there is a need for evidence regarding implant fixation (cemented or cementless) in this context. This study aimed to evaluate the impact of implant fixation type (cemented versus cementless) on clinical outcomes, complications, and implant survival in robotic-assisted total knee arthroplasty (TKA) guided by FKPos principles.

METHODS: A retrospective comparative analysis of 393 patients who underwent robotic-assisted primary TKA was performed. Patients were divided into two groups: cemented (n = 85) and cementless (n =276) fixation. Radiographic alignment, functional outcomes using the Knee Society Score (KSS) and Forgotten Joint Score (FJS), complication rates, and implant survival were assessed at a minimum 2-year follow-up. Subgroup analyses based on femoral and tibial fixation types were also conducted.

RESULTS: Both fixation methods achieved comparable functional outcomes (KSS and FJS) and implant survivorship, with no significant differences in revision rates. Hematomas were significantly more frequent in the cementless group (12.32% vs. 8.24%, p = 0.02). Subgroup analyses of femoral and tibial implants showed no significant differences in functional outcomes.

DISCUSSION: This study is the first to assess the influence of fixation type on outcomes in robotic-assisted TKA performed under FKPos principles. Both cemented and cementless fixation methods are safe and effective.

PMID:40421867 | PMC:PMC12108099 | DOI:10.1051/sicotj/2025027

Injury. 2025 May 17:112447. doi: 10.1016/j.injury.2025.112447. Online ahead of print.

ABSTRACT

INTRODUCTION: Open cardiopulmonary resuscitation (OCPR) is a critical treatment for severe torso trauma. While OCPR has shown survival benefits for patients with penetrating traumatic cardiac arrest, its efficacy in blunt trauma patients remains unclear.

MATERIALS AND METHODS: This retrospective cohort study analyzed pulseless blunt chest trauma patients from the National Trauma Data Bank (NTDB) in the United States during 2014-2015. The study excluded patients under 18 years of age, those without initial signs of life, and those with burns, penetrating trauma, unknown mechanisms, incomplete records, severe head injuries, or transportation times over 60 min. The primary outcome was Emergency Department (ED) survival, and the secondary outcome was overall survival.

RESULTS: Out of 1358 pulseless blunt chest trauma patients, 420 met the inclusion criteria, and 15.5 % (65/420) received OCPR. ED survival was significantly greater in the OCPR group (81.5 % [53/65] vs. 46.8 % [166/355], p < 0.001), whereas overall survival was not significantly different between the groups (9.2 % [6/65] vs. 12.4 % [44/355], p = 0.626). A subset analysis of patients with cardiac injuries showed better ED survival (81.3 % [13/16] vs. 40.5 % [17/42], p = 0.012) and a trend of better overall survival (25.0 % [4/16] vs. 3.4 % [2/42], p = 0.086) for those who underwent OCPR.

CONCLUSION: OCPR does not improve overall survival in all pulseless blunt chest trauma patients, but it offers significant benefits for those with cardiac injuries. Further research is needed to refine management strategies for these patients.

PMID:40425418 | DOI:10.1016/j.injury.2025.112447

J Bone Joint Surg Am. 2025 May 27. doi: 10.2106/JBJS.24.00938. Online ahead of print.

ABSTRACT

➢ Three-dimensional (3D) printing and virtual modeling, using computed tomographic (CT) scans as a base for the 3D-printed model, help surgeons to visualize relevant anatomy, may provide a better understanding of fracture planes, may help to plan surgical approaches, and can possibly simulate surgical fixation options.➢ Navigation systems create real-time 3D maps of patient anatomy intraoperatively, with most literature in orthopaedic trauma thus far demonstrating efficacy in percutaneous screw placement using preoperative imaging data or intraoperative markers.➢ Augmented reality and virtual reality are new applications in orthopaedic trauma, with the former in particular demonstrating the potential utility in intraoperative visualization of implant placement.➢ Use of 3D-printed metal implants has been studied in limited sample sizes thus far. However, early results have suggested that they may have good efficacy in improving intraoperative measures and postoperative outcomes.

PMID:40424369 | DOI:10.2106/JBJS.24.00938

J Bone Joint Surg Am. 2025 May 26. doi: 10.2106/JBJS.24.01275. Online ahead of print.

ABSTRACT

BACKGROUND: The use of a 2-stage exchange remains a common management strategy for periprosthetic joint infection (PJI). The use of an "antibiotic holiday" before the second stage to confirm the clearance of infection is often employed, but there is little evidence to guide this practice. The aim of this review was to systematically map the literature reporting on the use of an antibiotic holiday as part of a 2-stage revision for chronic PJI and to answer the question: is there a role for an antibiotic holiday in patients undergoing 2-stage exchange arthroplasty for PJI?

METHODS: Given the heterogeneity of the literature on this topic, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant scoping review was conducted. Two reviewers developed and refined the search strategy and study eligibility criteria and pilot-tested the data charting form prior to data extraction. Data were analyzed descriptively.

RESULTS: Three databases were screened, with 504 full-text articles retrieved for review after screening 2,579 titles and abstracts. Of these, 243 were included for data charting. Most studies (238 of 243; 97.9%) were case series, and the remaining 5 (2.1%) were cohort studies that incorporated a direct comparison between continuous therapy and an antibiotic holiday. Most case series (202 of 238; 84.9%) utilized an antibiotic holiday. The proportion of patients who experienced treatment failure in the continuous therapy group (271 of 2,074 patients; 13.1%) was lower than that in the antibiotic holiday group (2,843 of 17,329 patients; 16.4%; p < 0.001). There was a greater proportion of studies with a between-stage interval of <3 months among case series utilizing continuous antibiotic therapy (66.7%) compared with those utilizing an antibiotic holiday (27.2%; p < 0.001).

CONCLUSIONS: There is no proven superiority of an antibiotic holiday during a 2-stage exchange to treat chronic PJI. Due to the need to extend the duration of the interval between the first and second stages in order to accommodate an antibiotic holiday, patients may be subjected to unnecessary prolongation of their treatment duration without an improvement in outcome.

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

PMID:40418706 | DOI:10.2106/JBJS.24.01275

Int Orthop. 2025 May 26. doi: 10.1007/s00264-025-06564-7. Online ahead of print.

ABSTRACT

INTRODUCTION: Since the introduction of videogames and augmented reality technology, injuries associated with e sports have garnered increased attention from researchers and healthcare professionals. This review articles examines the spectrum of injuries associated with videogames and augmented reality and describes the nuances of the diagnoses associated with gaming injuries.

MATERIALS AND METHODS: An online-based questionnaire of 25 items was distributed to all the members of the Italian Society of Orthopedic Surgery and Traumatology (SIOT) regarding their indications, usual practices, and complications encountered with hardware removal in upper and lower limbs. The survey was open from July 2024 to October 2024. Exclusion and inclusion criteria were applied.

RESULTS: Five hundred answers were received. While implant removal is primarily achieved in symptomatic patients, in the case of asymptomatic patients, it is not routinely performed, with a slightly higher tendency of removal in those aged 16-40 years old. These tendencies were registered both for the upper and lower limbs, with more reticence in hardware removal in the upper limbs. 96% of respondents declared the lack of hospital guidelines regarding this kind of surgery. The most feared intraoperative complications during the removal concerned screw stripping and implant breakage, with only 0.6% of respondents reporting no intraoperative difficulties. While patient discomfort and avoidance of future complications were the main indications for removal, postoperative complications occurred as wound scarring concerns, persistence of symptoms and bleeding. Despite not being considered a "procedure for the resident", when residents were specifically questioned, in 76% of cases they felt self-confident ≥ 7 on a scale from 1 to 10. Lastly, according to 62% of the respondents, titanium implants are more difficult to remove than stainless steel ones.

CONCLUSION: This survey describes a general tendency to not routinely remove implants, even in younger patients in the lower and especially upper limbs, unless in case of symptoms. Hardware removal could evolve from a simple procedure into a more complex surgery due to intraoperative technical difficulties. A lack of universal policy and guidelines exists throughout the Italian territory.

PMID:40415005 | DOI:10.1007/s00264-025-06564-7

Injury. 2025 May 14:112437. doi: 10.1016/j.injury.2025.112437. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma-related preventable death is considered death as a consequence of moderate to severe injury under (sub)optimal trauma care conditions and is used as a criterion to evaluate the management and quality of trauma care worldwide. A validated definition of trauma-related preventable death is still lacking due to differences in classification. To reach consensus on a definition and assess the necessity of an additional trauma prediction algorithm, a Delphi procedure was performed.

METHODS: A digital three-round Delphi procedure was performed. Trauma surgeons, neurosurgeons, forensic medicine physicians, anesthesiologists, and emergency care physicians working at a Level 1 or affiliated trauma center in the Netherlands were invited to participate. An electronic questionnaire was administered to assess the most suitable category of trauma-related preventable death (clinical definition, trauma prediction algorithm, clinical definition and trauma prediction algorithm or other) and the additional benefit of a trauma prediction algorithm.

RESULTS: Fifty-four panelists completed the study: 23 trauma surgeons, 13 emergency care physicians, 10 anesthesiologists, 4 neurosurgeons and 4 forensic medicine physicians. In the first round, a clinical definition and a clinical definition and trauma prediction algorithm (Trauma Score and Injury Severity Score and a combination of algorithms) were favored. The results were fed back to the panelists. In the final round, there was a tendency towards group consensus in favor of a clinical definition and trauma prediction algorithm (63 %). Consensus was reached on the most suitable algorithm: the Trauma Score and Injury Severity Score combined with the Probability of survival.

CONCLUSION: The identification of trauma-related preventable death is essential in the evaluation of trauma care. This study elucidates the difficulty of multidisciplinary consensus. However, a propensity towards consensus on a clinical definition, and consensus on the additional benefit of the PS, based on the TRISS, seems to be present.

PMID:40413123 | DOI:10.1016/j.injury.2025.112437

Injury. 2025 May 14;56(8):112427. doi: 10.1016/j.injury.2025.112427. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma video review (TVR), whereby resuscitations in the trauma bay are audio-visually recorded, has not been investigated within the orthopaedic context. The purpose of this study was to evaluate the utility of TVR as a practical method to evaluate the delivery of orthopaedic care and resident competency in the trauma bay.

MATERIALS AND METHODS: This was a retrospective study of 15 trauma resuscitations performed at an academic, level I trauma center between May - June 2024. TVR was used to evaluate the quality of orthopaedic care delivered in the trauma bay and to assess resident competency using Accreditation Council for Graduate Medical Education (ACGME) milestones and American Board of Orthopaedic Surgery (ABOS) Knowledge, Skills and Behavior criteria.

RESULTS: TVR allowed for quantification of multiple orthopaedic time-based metrics. TVR identified themes to prompt institutional quality improvement initiatives in the future. Importantly, TVR provided a unique opportunity to evaluate the resident interacting as part of an impromptu multidisciplinary team in a high stress environment. TVR effectively provided a method to assess competency using ACGME and ABOS criteria.

CONCLUSIONS: TVR is a practical tool to evaluate and improve the quality of orthopaedic care provided in the trauma bay. It offers a unique opportunity to assess resident competency by ACGME and ABOS criteria.

PMID:40412348 | DOI:10.1016/j.injury.2025.112427

Injury. 2025 May 15;56(8):112441. doi: 10.1016/j.injury.2025.112441. Online ahead of print.

ABSTRACT

OBJECTIVES: To address the conflicting evidence in the literature regarding time to surgery and its impact on outcomes for distal femoral fractures.

METHODS: This is a retrospective review of the American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP®) database, that collects data from 680 hospitals across the United States. The database was queried from 2010-2021. Case selection was done by use of ICD-9 & ICD-10 codes for native distal femoral fractures and periprosthetic distal femur fractures, along with CPT codes for surgical fixation of distal femur, total knee arthroplasty and revision knee arthroplasty. Pre-operative, operative and post-operative factors were compared for patients undergoing surgery on hospital day 0 or 1 (HD ≤ 1) to patients undergoing surgery after hospital day 1(HD > 1). Primary outcome measure was 30-day mortality. Chi-square and logistic regression were used for univariable and multivariable analyses, respectively.

RESULTS: A total of 6857 cases were identified (mean age of 71.5 years). 84.5 % underwent surgery on HD ≤ 1, and 15.5 % on HD > 1. Rate of mortality was 1.37 % and 3.26 %, respectively. Patients who underwent surgical fixation of distal femoral fracture on HD ≤ 1 had a 40 % decrease in odds of mortality compared to fixation on HD > 1 (OR 0.587; p = 0.031). A multi variable analysis revealed that presence of dyspnea (OR 4.338, p = 0.005), preoperative blood transfusion (HR 2.32, p = 0.001) and bleeding disorder (OR 1.727, p = 0.03) were associated with increased mortality at 30-days on multivariable analysis, while younger age (OR 0.216; p = 0.001) had a protective effect.

CONCLUSIONS: Delayed surgical fixation is associated with increased odds of 30-day mortality for patients with distal femoral fractures. Further studies will help determine if the increased mortality is caused by the delay itself or by other confounding variables not identified in this study that may be associated with the reason for the delay.

LEVEL OF EVIDENCE: Level III.

PMID:40412347 | DOI:10.1016/j.injury.2025.112441

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01327. Online ahead of print.

ABSTRACT

BACKGROUND: An intraoperative midsubstance injury to the medial collateral ligament (MCL) is a devastating complication of total knee arthroplasty (TKA). No single treatment method has been shown to yield optimal stability. This cadaveric study compared primary MCL repair, increasing prosthetic constraint, and a combination of both techniques on tibiofemoral compartment gapping after an iatrogenic MCL injury.

METHODS: We performed 16 cadaveric, robotic-assisted TKAs (CORI; Smith+Nephew) and recorded tibiofemoral gap measurements at 10°, 30°, 60°, and 90° of flexion with a posterior-stabilized (PS) prosthesis as the control group. The experimental groups had no MCL repair and a PS component, no MCL repair and a varus-valgus constrained (VVC) component, MCL repair with a PS component, and MCL repair with a VVC component. The MCL was repaired with 2 figure-8 nonabsorbable sutures. Gap measurements were manually tensioned by the same surgeon for all specimens. The mean medial tibiofemoral gap with the 3 different methods of interest (the no MCL repair with VVC component group, the MCL repair with PS component group, and the MCL repair with VVC component group) was compared with the control group for the rate of deficit (RD) and was compared with the no MCL repair and PS component group for the rate of improvement (RI). Simple statistics were used to calculate the mean medial balance for the groups, and analysis of variance (ANOVA) modeling was used to determine the mean changes in RD and RI, with significance set at p < 0.05.

RESULTS: The mean RD was highest for the no MCL repair with PS component group at 621.13%, demonstrating an approximately 6-fold increase in medial tibiofemoral gapping compared with the control group. This was followed by the no MCL repair with VVC component group at 93.02%, the MCL repair with PS component group at 65.66%, and the MCL repair with VVC component group at 20.01% (p < 0.001). The mean RI for the MCL repair with VVC component group was highest at 83.08%, meaning that the combination of VVC component and MCL repair resulted in an 83% improvement in medial tibiofemoral gapping from no MCL repair with PS component. This was followed by the MCL repair with PS component group at 76.62% and the no MCL repair with VVC component group at 72.95% (p < 0.001).

CONCLUSIONS: This cadaveric study demonstrates that primary MCL repair with VVC component was the best for minimizing the deficit after an MCL injury and provided the highest RI. MCL repair with PS component and no MCL repair with VVC component were less effective reconstructive choices. This study supports the combination of a simple MCL repair with VVC component as the most stable reconstructive option following an intraoperative MCL injury.

PMID:40408512 | DOI:10.2106/JBJS.24.01327

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01353. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with apical spinal cord deformity have been shown to be at a greater risk for intraoperative neuromonitoring (IONM) alerts when undergoing posterior spinal instrumented fusion (PSF) for adolescent idiopathic scoliosis (AIS). The use of intraoperative traction during deformity correction has also been associated with an increased risk of IONM alerts. With use of the Spinal Cord Shape Classification System (SCSCS), we investigated the interaction between spinal cord type and the use of intraoperative traction and their impact on IONM alerts during the surgical correction of AIS.

METHODS: A total of 441 consecutive patients who underwent PSF or combined PSF plus anterior spinal fusion (ASF) for AIS between 2003 and 2022 were retrospectively reviewed. Those with major thoracic curves of ≥70° and available preoperative magnetic resonance images (MRIs) were included. Charts were reviewed for IONM alerts and the use of intraoperative traction. Spinal cord morphology was determined using the SCSCS. A multivariable regression model was used to assess the risk factors for an IONM alert.

RESULTS: Preoperative MRIs were available for 102 patients. Type-3 cords were present in 15 (14.7%) of the 102 patients. Intraoperative traction was used in 15 (14.7%) of the 102 patients, including 5 with type-3 cords. Patients with type-3 cords were more likely to have an IONM alert than those with type-1 or 2 cords (40.0% [type 3] versus 12.6% [type 1 or 2]; odds ratio [OR], 4.60; 95% confidence interval [CI], 1.34 to 15.53). No such difference was observed between patients with type-1 cords and those with type-2 cords (12.5% and 12.7%, respectively; p > 0.9999). All patients with type-3 cords placed in intraoperative traction experienced IONM alerts, whereas only 10% of patients with type-3 cords not placed in traction experienced such alerts (p = 0.002). Multivariable regression modeling revealed intraoperative traction to be the only independent risk factor for an IONM alert (OR, 9.37; 95% CI, 2.47 to 38.24).

CONCLUSIONS: This study demonstrated that 14.7% of patients with AIS and curves of ≥70° had a type-3 cord. Intraoperative traction carried a ninefold increased risk of an IONM alert. When intraoperative traction is used for type-3 cords, surgeons should expect IONM alerts to occur. The SCSCS can be condensed into 2 groups for a pediatric population.

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

PMID:40408508 | DOI:10.2106/JBJS.24.01353