Injury. 2025 Aug 24;56(11):112719. doi: 10.1016/j.injury.2025.112719. Online ahead of print.

ABSTRACT

BACKGROUND: Indications for stabilization of the medial collateral ligament (MCL) after repair of the lateral ulnar collateral ligament (LUCL) remain controversial. Here, we propose a standardized fluoroscopic sequence to reveal residual medial elbow instability to facilitate intraoperative decision-making.

METHODS: Eight matched cadaveric upper extremity pairs (N = 16) were mounted to simulate intraoperative positioning. Fluoroscopic images were acquired using the following: full extension, 45-degree flexion, 90-degree flexion, and full flexion with the forearm in neutral/pronation/supination. These were acquired at "baseline" and following destabilization of the LUCL/MCL. The proposed fluoroscopic sequence was then repeated following surgical fixation of the LUCL ("post-LUCL repair") followed by MCL repair ("post-LUCL & MCL repair). Blinded images were fitted using a best-fit circle to compute ulnohumeral distance (UHD, millimeters) and determine residual lateral (supination) and medial (pronation) instability defined by the presence of a drop sign (UHD>4 mm). Radiocapitellar ratio (RCR) was computed to determine radiocapitellar instability (RCR>10 %). Blinded images were also qualitatively evaluated against the contralateral baseline to simulate intraoperative assessment.

RESULTS: Apparent instability in supination status-post destabilization resolved following LUCL repair with evident residual medial-sided instability showed in pronation, which resolved after MCL fixation. Evaluation of the drop sign at 45 and 90 degrees of flexion showed comparable quantitative sensitivity at 97 % and 98 %, unlike in full extension or full flexion (sensitivity <35 %). Quantitative sensitivity was 88 % for RCR in mid-flexion. Qualitative evaluation for the drop sign and RCR resulted in sensitivity of 93 and 75 %, respectively.

CONCLUSIONS: The proposed fluoroscopic sequence provides reliable intraoperative assessment to evaluate for residual medial-sided instability in the setting of multi-ligamentous elbow injuries. After repair of the LUCL, medial residual instability due to MCL rupture is best revealed with the presence of a drop sign in full pronation and midflexion.

LEVEL OF EVIDENCE: IV.

PMID:40876110 | DOI:10.1016/j.injury.2025.112719

Injury. 2025 Aug 16;56(11):112682. doi: 10.1016/j.injury.2025.112682. Online ahead of print.

ABSTRACT

BACKGROUND: The classic surgical technique of the 15-mm incision minimally invasive approach is not suitable for AO 23-B3 distal radius fractures (abbreviated B3). We have modified this technique for B3. This study aimed to investigate the efficacy of the modified 15-mm incision minimally invasive approach with the conventional ORIF approach in the treatment of B3.

METHODS: This retrospective study included 62 patients with B3 who underwent surgical treatment from January 2020 to May 2024, including 31 patients undergoing the modified 15-mm incision minimally invasive approach (M group) and 31 patients undergoing the conventional ORIF approach (C group). The two groups had similar baseline characteristics (P > 0.05). The perioperative data, follow-up data, and imaging results of the two groups were compared. At the last follow-up, the limb function was assessed using the PRWE and DASH scores.

RESULTS: In the C group, 1 patient experienced infection and 1 patient experienced complex regional pain syndrome, whereas in the M group, there were no such patients. In the M group, the incision length, intraoperative bleeding, hospital stay, hospitalization expenses, swelling, and VAS on postoperative days 2 and 7, flexion-extension, ulnar-radial deviation and pronation-supination at postoperative 3 months, and pronation-supination ROM in 12-24 months of follow-up were superior, but the surgical and fluoroscopy time was longer compared to the C group (P < 0.05). There was no difference between the two groups in terms of fracture reduction, fracture healing time, full weight-bearing time, complications, and flexion-extension ROM, PRWE and DASH in the last follow-up (P > 0.05).

CONCLUSION: Both methods were effective for treating B3. The M group was superior in terms of aesthetic appeal of the incision, surgical trauma and associated risks, hospital stay, early recovery, and final rotational function, which are consistent with the principles of MIPO and rapid recovery, but requires longer surgical and fluoroscopy time.

PMID:40876109 | DOI:10.1016/j.injury.2025.112682

J Bone Joint Surg Am. 2025 Aug 28. doi: 10.2106/JBJS.24.00733. Online ahead of print.

ABSTRACT

➢ The use of multirod constructs (≥3 rods) in complex spine surgery has increased as its utility has been recognized over the past decade.➢ There are multiple different rod configurations that may be utilized on the basis of the desired supplemental rod function, with each type having its own advantages and clinical indications.➢ Literature has continued to demonstrate a reduced incidence of pseudarthrosis, rod fracture, and reoperation when comparing multirod constructs with traditional dual-rod constructs.➢ The use of consistent nomenclature when describing multirod constructs will allow for more productive clinical and biomechanical research.

PMID:40875787 | DOI:10.2106/JBJS.24.00733

Injury. 2025 Aug 8;56(10):112659. doi: 10.1016/j.injury.2025.112659. Online ahead of print.

ABSTRACT

Train-related injuries represent a significant yet underreported public health challenge in developing countries, particularly in sub-Saharan Africa, where contemporary data are scarce. This study characterizes the epidemiology, clinical presentation, and outcomes of train-related trauma at a South African Level I trauma center, with a focus on identifying predictors of severe outcomes and informing context-specific interventions for this high-risk population.

METHOD: A retrospective analysis was conducted on 63 patients presenting to Groote Schuur Hospital between April 2008 and June 2013. Data collected included demographics, injury mechanisms, clinical findings, and outcomes. Multivariable logistic regression was performed to evaluate the association between key severity markers (GCS ≤8, hypotension, mangled extremities) and ICU admission.

RESULTS: The cohort was predominantly male (96.8 %) with a median age of 26 years (IQR: 22-33). Injuries clustered during winter months (April-October), with 62 % occurring between 4:00 PM and midnight. The most common mechanisms were boarding or alighting from moving trains (46.2 %) and interpersonal assault (33.3 %). Lacerations were the most frequent soft tissue injury (69.8 %), while lower (25.4 %) and upper limb (22.2 %) fractures were the predominant orthopedic injuries. The amputation rate was 20.6 %, strongly associated with mangled extremities. Median hospital stay was 6 days (IQR: 1-17), extending significantly for patients with spinal trauma. Severe traumatic brain injury (GCS ≤8) was independently associated with ICU admission (adjusted OR 15.0; 95 % CI: 2.7-82.4; p < 0.001). Mangled extremities and hypotension were not significantly associated with ICU requirement.

CONCLUSION: Young male commuters are more likely to sustain severe, preventable train-related injuries. Significant musculoskeletal trauma, head, and spinal injuries increased hospital stay, underscoring the need for comprehensive assessment to reduce morbidity and improve outcomes. Our findings support protocolized neurosurgical and orthopaedic triage and targeted prevention strategies in resource-limited settings.

PMID:40865178 | DOI:10.1016/j.injury.2025.112659

SICOT J. 2025;11:50. doi: 10.1051/sicotj/2025031. Epub 2025 Aug 26.

ABSTRACT

BACKGROUND: Proximal femoral megaprosthetic reconstruction is a well-established solution for extensive bone loss in the hip region. Despite its utility in limb salvage, it carries notable complication rates, reported between 30% and 40%, along with increased morbidity and mortality. This study evaluated implant and patient survival, failure modes, and associated risk factors.

METHODS: We retrospectively reviewed 165 patients who underwent proximal femoral megaprosthetic reconstruction between 2003 and 2023. Indications included primary bone tumors (n = 67), metastatic bone disease (n = 60), and non-oncologic conditions (n = 38). A total of 57 METS (Stanmore) and 108 MUTARS (Implantcast) implants were used. Median follow-up was 5 years (range: 0.25-17 years).

RESULTS: Mean implant survival was 5.13 years (range: 0.2-17 years), with an overall complication rate of 30.9%. The most common failure modes were type 1 (11.5%) and type 4 (13.3%) per Henderson classification. Five-year implant survival ranged from 60% to 70% across indications. Independent risk factors for type 4 failure included prolonged hospitalization (OR = 1.07, p = 0.020) and longer operative time (OR = 1.01, p = 0.023). Silver-coated implants showed a trend toward reduced infection (OR = 0.18, p = 0.29), though not statistically significant. METS implants were associated with lower type 1 failure risk (OR = 0.09, p = 0.020), with a soft-tissue failure rate of 3.5% versus 15.7% for MUTARS.

CONCLUSION: Proximal femoral megaprostheses remain effective for limb salvage but are linked to a substantial complication burden. Recognition of modifiable and patient-specific risk factors may improve surgical outcomes and reduce failure rates.

PMID:40857599 | PMC:PMC12380411 | DOI:10.1051/sicotj/2025031

SICOT J. 2025;11:49. doi: 10.1051/sicotj/2025043. Epub 2025 Aug 26.

ABSTRACT

INTRODUCTION: Complications arising from the patellofemoral joint (PFJ) represent the third most common cause for revision in total knee arthroplasty (TKA). Previous in vitro biomechanical studies have altered the native attachments of muscles controlling the PFJ. The purpose of this study was to design an in vitro biomechanical setup that would allow testing of both native and arthroplasty knee joints, specifically the PFJ, without disturbing the native attachments of the quadriceps and hamstrings muscles.

METHODS: After finalising a prototype, a pelvis-to-toe human cadaver specimen was tested. The simVITRO platform was used to simulate movement and control force trajectories. A motion capture system was used to capture the motion of the bones and to measure knee flexion angle and patellar movement with respect to the femur. The forces applied in the PFJ were measured using a custom patella sensor.

RESULTS: Displacement of the reflective cluster attached to the femur was measured during compression loading at different flexion angles, passive flexion and stairs descent trajectory. The femur showed less than 1 mm and 3 mm displacement with respect to the femur clamp in passive flexion and stairs descent. The most translation of 8.37 mm (<2% average femur length) was observed at 90° flexion which occurred at 483 N simulated compression force.

CONCLUSION: This novel design provides a methodology for studying the biomechanics of the PFJ in vitro that preserves the soft tissues influencing the behaviour of the joint. This setup provides a biomechanics model that can be utilised to better understand and study the PFJ in vitro.

PMID:40857598 | PMC:PMC12380413 | DOI:10.1051/sicotj/2025043

SICOT J. 2025;11:48. doi: 10.1051/sicotj/2025049. Epub 2025 Aug 26.

ABSTRACT

BACKGROUND: Acetabular reconstruction during revision total hip arthroplasty (THA) with major bone loss is a complex surgical challenge. The combination of custom-made (CM) acetabular components with cemented dual mobility (DM) cups may improve postoperative outcomes in this context. This study aims to assess the clinical, functional, and radiological results of this surgical approach.

METHODS: We conducted a retrospective, single-center observational study including 16 patients (mean age 70 years) who underwent revision THA between May 2016 and December 2024 using a cemented DM cup in a CM acetabular component. All patients presented with Paprosky 3A or 3B defects, and 38% had a history of periprosthetic joint infection (PJI). Functional outcomes were measured using the Oxford Hip Score (OHS) and modified Harris Hip Score (mHHS) pre- and postoperatively. Radiographic assessment included measurement of the center of rotation (COR) deviation in both axes, as well as acetabular inclination and anteversion on postoperative CT scans. Implant survival was analyzed using Kaplan-Meier methodology.

RESULTS: At a mean follow-up of 16.2 months, overall implant survival was 75%, increasing to 93.8% when excluding isolated DM cup revisions. No postoperative infections were observed. OHS improved from 14.1 to 27.6 and mHHS from 27.4 to 52.7 (p < 0.001 for both). A significant negative correlation was observed between vertical (y-axis) COR deviation and functional scores (p < 0.01), highlighting the importance of restoring vertical COR. Mean inclination and anteversion were 41.2° and 29°, respectively, generally within target alignment zones.

DISCUSSION: The combination of cemented DM cups with CM acetabular components appears to be an effective technique in complex revision THA. Functional recovery and implant survivorship are consistent with the existing literature, and the absence of infection despite prior PJI history suggests benefit from a multidisciplinary approach. Restoration of vertical COR is a predictor of functional outcomes.

PMID:40857597 | PMC:PMC12380412 | DOI:10.1051/sicotj/2025049

J Bone Joint Surg Am. 2025 Aug 26. doi: 10.2106/JBJS.24.01333. Online ahead of print.

ABSTRACT

➢ With any study, readers should be cautious and critical when the conclusion is that "these treatments are the same."➢ If only superiority testing was performed, failing to find a difference does not mean that the treatments are the same, even when the study was adequately powered.➢ Noninferiority analysis is the correct method to compare treatments that researchers and clinicians think may be "the same" for the primary outcome.➢ The most important aspect of a noninferiority analysis is the selection of the noninferiority margin, which is the minimum difference between groups that would be considered meaningful.➢ To perform noninferiority testing, the difference in an outcome measure of interest between experimental and control groups must be examined with respect to the noninferiority margin of the same outcome measure. Assuming that a greater value indicates improvement in an outcome measure, if the lower bound of a 95% confidence interval of a difference in means based on a 1-sided test is greater than the noninferiority margin, then the experimental treatment can be considered noninferior to the control.

PMID:40857355 | DOI:10.2106/JBJS.24.01333

J Bone Joint Surg Am. 2025 Aug 25. doi: 10.2106/JBJS.24.01326. Online ahead of print.

ABSTRACT

BACKGROUND: Fourth-generation percutaneous, or minimally invasive, hallux valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of studies reporting the clinical and radiographic outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow-up, or use of non-validated outcome measures. The aim of this study was to provide a methodologically robust investigation of percutaneous transverse osteotomies for hallux valgus deformity.

METHODS: We studied a prospective series of consecutive patients undergoing fourth-generation metatarsal extracapsular transverse osteotomy performed by a single surgeon (P.L.) between November 2017 and January 2023. The primary outcome was clinical foot function assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated patient-reported outcome measure. Secondary outcomes included the radiographic deformity (the hallux valgus angle [HVA], 1-2 intermetatarsal angle [IMA], and sesamoid position) assessed according to American Orthopaedic Foot & Ankle Society (AOFAS) guidelines as well as a visual analog scale for pain and radiographic evidence of deformity recurrence (defined as an HVA of >20° at final radiographic follow-up). P values of <0.05 were considered significant.

RESULTS: Seven hundred and twenty-nine feet (483 patients; 456 female and 27 male; mean age, 57.9 ± 11.9 years) underwent fourth-generation metatarsal extracapsular transverse osteotomy. Radiographic data were available at a vminimum of 12 months postoperatively for 99.7% of the feet, which were followed for a mean of 2.6 ± 1.3 years (range, 1.0 to 5.7 years). There was a significant improvement (p < 0.05) in both the HVA (from 29.5° ± 8.5° preoperatively to 7.3° ± 6.7° at final follow-up) and the IMA (from 12.9° ± 3.3° to 4.6° ± 2.5°). All MOXFQ domains showed significant improvement (p < 0.05), with the MOXFQ Index improving from 36.9 ± 18.9 to 13.4 ± 15.8, Pain improving from 40.5 ± 22.0 to 17.2 ± 18.3, Walking/Standing improving from 32.3 ± 23.1 to 12.0 ± 18.2, and Social Interaction improving from 40.4 ± 20.4 to 11.0 ± 15.2. The recurrence rate was 4.5% (n = 33). The complication rate was 6.1%, which included a screw removal rate of 2.9%.

CONCLUSIONS: This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence.

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

PMID:40854004 | DOI:10.2106/JBJS.24.01326

Injury. 2025 Aug 7;56(10):112657. doi: 10.1016/j.injury.2025.112657. Online ahead of print.

ABSTRACT

BACKGROUND: Nonunion is a significant complication following nonoperative treatment of displaced midshaft clavicle fractures, potentially leading to impaired shoulder function, pain, and decreased quality of life. This study aims to identify predictors of nonunion in adults treated nonoperatively to optimize treatment decisions and improve outcomes.

METHODS: A retrospective cohort study was conducted using data from 374 patients treated nonoperatively between 2012 and 2024. Patient and fracture characteristics, including age, sex, smoking, diabetes mellitus, and fracture comminution, were assessed. Univariable and multivariable logistic regression analyses identified predictors of nonunion. Model performance was assessed using the area under the receiver operating characteristic (ROC) curve (AUC). Diagnostic statistics and number needed to screen (NNS) were calculated.

RESULTS: Of 374 patients, 72 (19.3 %) developed nonunion. Multivariable analyses revealed that increasing age (odds ratio [OR]: 1.03, 95 % confidence interval [CI]: 1.01-1.04, p = 0.002) and smoking (OR: 2.49, 95 % CI: 1.31-4.71, p = 0.005) were independently associated with increased risk of nonunion. Fracture comminution was associated with reduced risk (OR: 0.34, 95 % CI: 0.20-0.58), p < 0.001). The model's AUC was 0.70. At a probability threshold of 0.4, the NNS was 6.

CONCLUSIONS: This study highlights the potential of predictive models to identify patients at risk for nonunion. Age and smoking increase the risk of nonunion, while comminution showed a protective effect. These findings support personalized care to optimize treatment decisions and improve patient outcomes. Further refinement and inclusion of additional risk factors are essential to improve the model's accuracy and clinical applicability.

PMID:40850009 | DOI:10.1016/j.injury.2025.112657

Injury. 2025 Aug 5;56(10):112646. doi: 10.1016/j.injury.2025.112646. Online ahead of print.

ABSTRACT

BACKGROUND AND AIMS: Complex open tibial fractures with soft tissue defects in children represent a major clinical challenge due to high risks of infection, osteomyelitis, and long-term functional impairment. This study aimed to evaluate the effectiveness of a combined orthopedic and reconstructive approach using external fixation and free anterolateral thigh (ALT) flaps in pediatric patients.

METHODS: In this prospective, controlled clinical trial, 78 children (mean age 12.4 ± 3.1 years) with open tibial fractures and extensive soft tissue loss from road traffic accidents were enrolled. Patients were randomized into two groups: the experimental group (n = 40) received Ilizarov external fixation with microsurgical ALT flap reconstruction; the control group (n = 38) underwent conventional internal fixation with standard wound management. Renal function markers (creatinine, urea, GFR) were monitored to assess the impact of trauma, systemic inflammation, and nephrotoxic antibiotic exposure. Healing was evaluated using the Zygo-Scale at 7, 30, 60, 90 days, and 12 months. Incidence of osteomyelitis, joint ankylosis, flap complications, and revision surgeries was recorded.

RESULTS: The experimental group demonstrated significantly faster and more complete soft tissue healing (p ≤ 0.05), with lower rates of osteomyelitis at 6 and 12 months (2.5 % and 0 % vs. 10.5 % and 5.25 %, respectively; p < 0.05). Joint ankylosis scores were also significantly reduced (p = 0.02 and p = 0.01). Flap survival rate was 95 %, with no cases of total necrosis. Donor site morbidity was minimal. While renal function improved in both groups, a modest but significant difference in creatinine levels at 12 months favored the experimental group (p = 0.03). The combined approach was associated with shorter healing times and fewer complications.

CONCLUSION: The integration of Ilizarov fixation with ALT flap reconstruction is a safe and effective strategy for managing severe pediatric lower limb injuries, enhancing healing, reducing infections, and improving functional outcomes. Monitoring renal markers provides insight into systemic stress and antibiotic safety in trauma care.

PMID:40850008 | DOI:10.1016/j.injury.2025.112646

Injury. 2025 Aug 7;56(10):112663. doi: 10.1016/j.injury.2025.112663. Online ahead of print.

ABSTRACT

AIMS: This study aimed to explore safety and feasibility of at-home softcast removal in children with displaced injuries undergoing manipulation; understand caregiver experience; and determine its impact on service at our tertiary centre.

METHODS: Paediatric patients (<16 years) with any fracture requiring application of a circumferential softcast, later removed at home without planned routine follow-up, were retrospectively analysed from two time-points: July-September 2022; February-April 2023. Demographic data including age, fracture location, angulation, whether manipulation was undertaken, and unplanned re-attendances were recorded. Caregivers completed a telephone Likert questionnaire (1=extremely positive, 5=extremely negative) reviewing cast removal time and qualitative descriptors of experience. Cost analysis was performed based on use of consumables, staff and clinical areas.

RESULTS: 77 caregivers completed the questionnaire at mean 93.4 days post-injury. Mean patient age was 7.6 years at time of injury. 41 (53.2 %) were distal radius, 20 (26.0 %) forearm and 16 (20.8 %) were elbow, hand or tibia fractures. Mean sagittal angulation was 24.7 degrees and 40 (52.0 %) injuries underwent manipulation under sedation. 13 (16.9 %) patients re-attended with cast problems. Caregivers estimated a mean 13.3 min to remove the cast. 83.1 % found it 'extremely' or 'somewhat' easy. 75.3 % were 'extremely' or 'somewhat' satisfied. 71.4 % were 'extremely' or 'somewhat' likely to recommend it. Qualitative descriptors ranged from "traumatic" to "easy". Since introduction of this practice, subsequent clinic attendances for children diagnosed with a fracture in the Emergency Department has reduced by >50 %, equating to savings of approximately £22,600 per annum.

CONCLUSION: Our experience confirms at-home softcast removal without further orthopaedic follow-up is safe and feasible, even in displaced injuries undergoing manipulation. The majority of families reported positive experiences. However, this was not universal and adequate patient education was integral to this.

PMID:40850007 | DOI:10.1016/j.injury.2025.112663

Injury. 2025 Aug 7;56(10):112660. doi: 10.1016/j.injury.2025.112660. Online ahead of print.

ABSTRACT

INTRODUCTION: The incidence of postoperative neurocognitive disorder (PND) in elderly patients with hip fractures poses a significant clinical challenge, with current management strategies offering limited efficacy in prevention or resolution. This prospective study evaluated the effectiveness of pre-and postoperative electroacupuncture (EA) intervention in mitigating PND in this patient cohort.

METHODS: A double-masked, randomized controlled trial was conducted involving 60 elderly patients (≥65 years) with fragility hip fractures scheduled for surgical repair. Participants were randomly assigned to either the EA intervention group (Group A) or a non-stimulated control group (Group C). Mini-Mental State Examination (MMSE) scores were recorded at baseline and 1, 3, and 7 days postoperatively, while ELISA was used to assess IL-1β, IL-6, and S-100β levels. Time-varying MAP, SpO2, and HR were measured. Adverse cardiovascular events, extubation duration, recovery room stay, VAS scores, analgesia pump use, postoperative adverse responses, and hospitalization length were recorded.

RESULTS: Among 60 randomized patients (mean age 74.02 years; 54.7 % male), 53 were analyzed for primary outcomes. Postoperative day 1 PND incidence was significantly lower in Group A (25.0 %) than Group C (56.0 %; P < 0.05), persisting on day 3 (Group A: 14.3 %, Group C: 48.0 %; P < 0.05). By day 7, PND incidence was similar in both groups. Time-group interactions were significant for IL-1β, IL-6, and blood pressure (P < 0.05). Group A exhibited a lower VAS score at 24 h postoperatively (2.65 ± 0.94 vs. 3.96 ± 0.96; P < 0.05). Adverse events were reported in 26 Group A and 32 Group C cases. Postoperative nausea and vomiting (PONV) significantly differed (Group A: 3.7 %, Group C: 30.8 %).

CONCLUSIONS: The findings suggest that pre- and postoperative EA stimulation may significantly reduce the risk of PND, modulate inflammatory responses, and lower blood pressure. Furthermore, EA intervention was associated with reduced postoperative pain and a marked decrease in the incidence of PONV in elderly patients with hip fractures. These results highlight the potential therapeutic benefits of EA in managing PND in this vulnerable patient population and warrant further investigation. SUBJECT WORDS: electroacupuncture, transcutaneous electrical acupoint stimulation, hip surgery, perioperative neurocognitive disorders, pain, postoperative nausea and vomiting.

PMID:40848689 | DOI:10.1016/j.injury.2025.112660

Injury. 2025 Aug 15;56(10):112684. doi: 10.1016/j.injury.2025.112684. Online ahead of print.

ABSTRACT

BACKGROUND: Humeral shaft fractures are common in young adults following high-energy trauma. While open fractures often result in infections, infections in closed fractures are rare, making such cases particularly challenging to manage when they occur.

CASE PRESENTATION: We report a unique case of a 25-year-old pregnant female who sustained a closed humeral shaft fracture after a high-energy injury. Although there was no initial open wound, a purulent infection was discovered at the fracture site during surgery a few days after the injury. Cultures identified Haemophilus influenzae as the causative organism. This report details the management of the fracture and associated infection, highlighting the diagnostic challenges and therapeutic steps taken to address this acute osteomyelitis-like infection in a closed fracture.

DISCUSSION: This case represents the first documented instance of an acute Haemophilus influenzae infection in a closed adult humeral fracture, a pathogen traditionally associated with pediatric respiratory infections. Contributing factors may have included the patient's complex medical and social background, including pregnancy, polysubstance abuse, homelessness, and the use of immunomodulatory medications. This case highlights the importance of heightened vigilance, the need for modifications in surgical decision-making, and possibly revised empirical antibiotic protocols in the management of closed fractures in immunocompromised patients.

CONCLUSION: Acute infections in closed humeral fractures, though rare, pose significant diagnostic and therapeutic challenges, particularly in immunocompromised individuals. This case prompts a reconsideration of management strategies in similar contexts, advocating for a broad differential diagnosis and tailored antimicrobial strategies to address atypical pathogens in complex clinical scenarios.

PMID:40848688 | DOI:10.1016/j.injury.2025.112684

Injury. 2025 Aug 10;56(10):112680. doi: 10.1016/j.injury.2025.112680. Online ahead of print.

ABSTRACT

Hip fractures in the older persons are associated with high morbidity and mortality rates, with a growing incidence due to an aging population. Early readmission increases dependence and healthcare costs, and identifying the factors associated with readmission could improve care. This study aims to identify factors associated with 30-day readmission following hip fracture in patients aged 75 and older, as well as to explore the relationship between various clinical variables. A multicentric, retrospective observational study was conducted using data from the National Hip Fracture Registry (NHFR) involving 57,544 patients admitted from January 1, 2017, to December 31, 2022. Patients were excluded if they had died during acute hospitalization or were lost to follow-up. Key demographic, clinical, and surgical variables were collected and analysed. Statistical analyses were performed using RStudio, employing both univariate and multivariate regression models to identify predictors of 30-day readmission. The study revealed a 30-day readmission rate of 5.18 %. Factors significantly protective against readmission included female gender (OR 0.84 p < 0.001), intertrochanteric (OR 0.81 p < 0.008) and subtrochanteric (OR 0.74 p < 0.007) fracture type, neuraxial anaesthesia (OR 0.82 p < 0.015), and increased length of stay (OR 0.98 p < 0.001). Conversely, ASA IV (OR 1.93 p < 0.05), ASA V (OR 5.59 p < 0.05) and discharge to residential care were associated with increased readmission risk. Notably, patients discharged home showed a reduced risk of readmission compared to those transferred to other care facilities such as residential care (OR 1.26 p < 0.001), acute hospitalization (OR 35.46 p < 0.001) and long-term care hospital(OR 2.36 p < 0.001). The readmission rate observed was lower than the reported by comparable registries. Identifying patients at high risk of early readmission following hip fracture is critical for enhancing patient care, and specific variables can serve as effective predictors, enabling targeted interventions to reduce readmission rates.

PMID:40848687 | DOI:10.1016/j.injury.2025.112680

Injury. 2025 Aug 12;56(10):112667. doi: 10.1016/j.injury.2025.112667. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare prevalence and severity of sacral dysmorphism in Indigenous and non-Indigenous Australian populations.

METHODS: We performed a single centre retrospective matched cohort study in consecutive Indigenous and non-Indigenous Australian patients who received a CT scan of the pelvis between January and March 2024 at our institution. Patients were excluded if they were under the age of 18 at the time of the scan or had a history of pelvic fractures or fixation. CT scans were assessed for both qualitative and quantitative features of sacral dysmorphism. The primary outcome of interest was the prevalence and severity of sacral dysmorphism in Indigenous and non-Indigenous Australian populations.

RESULTS: 120 patients were included in the study - 60 Indigenous and 60 non-Indigenous Australians. All patients exhibited at least one characteristic of sacral dysmorphism. There was no difference in the prevalence of qualitative sacral dysmorphism between the two groups. Compared to their non-Indigenous counterpart, Indigenous patients demonstrated a lower S1 transsacral corridor coronal diameter (20.50 vs. 21.85 mm, p = 0.005), S1 oblique corridor axial diameter (17.90 vs. 19.60 mm, p = 0.028), S1 pelvic width (144.85 vs. 158.70 mm, p < 0.001), S2 transsacral corridor coronal diameter (13.70 vs. 14.95 mm, p = 0.013), S2 transsacral corridor axial diameter (10.60 vs. 11.55 mm, p = 0.013), and S2 pelvic width (126.60 vs 136.00 mm, p < 0.001). Additionally, in Indigenous patients, S1 and S2 transsacral and oblique S1 iliosacral fixation lengths were shorter. Where an S1 trans-sacral osseous corridor was not present, the S2 corridor was significantly larger in coronal, axial measurements across both groups (p < 0.001).

CONCLUSIONS: Indigenous Australian patients exhibited more severe forms of sacral dysmorphism when compared to their non-Indigenous counterparts. Additionally the overall prevalence of sacral dysmorphism across this Australian population was amongst the highest reported in the literature. This may present significant technical challenges and warrants consideration when performing percutaneous iliosacral screw fixation.

PMID:40848686 | DOI:10.1016/j.injury.2025.112667

Int Orthop. 2025 Aug 23. doi: 10.1007/s00264-025-06621-1. Online ahead of print.

ABSTRACT

This editorial explores the marginalization of women in medieval French surgical practice through a prosopographical analysis of guild records, tax rolls, and legal texts. While women were present in various medical roles-such as barbers and "miresses"-their visibility declined as surgery became a formalized and male-dominated profession. By examining documents like the Livre de la Taille and Livre des Métiers, as well as royal ordinances, the study highlights how linguistic shifts and guild regulations gradually excluded women from professional recognition. The trial of Perette la Pétone in 1410 serves as a case study of this exclusion, marking the transition from informal acceptance to institutional rejection. Although some women maintained workshop privileges, especially as widows, the broader trend reflects a tightening of gender boundaries in the medical field. This study underscores how prosopography can illuminate structural changes in professional identity and reveal the gendered dynamics underlying medieval medical history.

PMID:40847223 | DOI:10.1007/s00264-025-06621-1

Injury. 2025 Aug 7;56(10):112650. doi: 10.1016/j.injury.2025.112650. Online ahead of print.

ABSTRACT

OBJECTIVES: In acknowledgement of the ongoing transition of surgical education from a time-based approach to competency-based curricula, this study aimed to identify key parameters for assessing the performance of surgical trainees in open reduction and internal fixation (ORIF) of a simple ulnar shaft fracture (AO/OTA classification 2U2A3.B).

METHODS: A 4-round Delphi process regarding seven different orthopedic osteosynthesis surgeries was conducted with an international panel of orthopedic surgeons involved in surgical education. This manuscript focuses on compression plating of isolated ulna fractures. Round 1 focused on item generation, round 2 on importance rating, round 3 on defining optimal intervals and borderline error values for a specific fracture model (not reported in this manuscript), and round 4 on assigning weights to each parameter. Data collection was carried out online.

RESULTS: Ninety-eight surgeons agreed to participate in the study. Round 1 generated 30 assessment parameters. In round 2 and 3, these were reduced to 26 parameters. In round 4, parameters received an overall mean weight of 8.27 out of 10 (SD 0.66) with a range of individual parameter mean weights from 6.7 to 9.4. The assessment parameters that achieved the highest weights were anatomical fracture reduction and assessment of forearm range of motion after fixation. In the final list of parameters, five were related to fracture reduction, three to hardware choice, five to plate placement, nine to screw placement, and four to concluding the procedure.

CONCLUSIONS: Utilizing a Delphi process, expert consensus was reached generating a comprehensive list of 26 assessment parameters that can be used to assess surgeon performance in open reduction and internal fixation of an isolated adult ulnar shaft fracture. This will allow educators to provide standardized feedback (formative assessment) to trainees and use a mastery-learning training approach (summative assessment).

PMID:40845526 | DOI:10.1016/j.injury.2025.112650

J Bone Joint Surg Am. 2025 Aug 22. doi: 10.2106/JBJS.24.01236. Online ahead of print.

ABSTRACT

BACKGROUND: Tranexamic acid (TXA) and absorbable hemostat (AH) are widely used to reduce perioperative blood loss in total knee arthroplasty (TKA). However, the efficacy of single-method hemostatic strategies is increasingly insufficient for meeting clinical demands. This study tested the efficacy and safety of TXA combined with AH for perioperative blood management in TKA.

METHODS: Hemostatic efficacy was preliminarily evaluated through in vitro dynamic coagulation assays, lactate dehydrogenase activity measurements, and scanning electron microscopy, as well as in vivo using a rabbit liver bleeding model. The in vivo biocompatibility was also measured. Subsequently, the efficacy and safety of TXA combined with AH were further evaluated in a prospective, blinded study involving 149 individuals who were randomized to receive TXA, AH, or TXA+AH during TKA. The primary outcomes were perioperative blood loss, blood transfusion, hemoglobin and hematocrit levels, maximum hemoglobin change, anemia, and postoperative complications. Secondary outcomes included perioperative inflammation, coagulation function, and knee joint function.

RESULTS: Coagulation assays and the liver hemostasis model demonstrated that TXA combined with AH effectively promoted coagulation, with satisfactory biocompatibility. The clinical results of 114 Han Chinese (East Asian) patients indicated that the combination significantly reduced perioperative blood loss in TKA (564.51 ± 136.26 mL in the TXA+AH group, 879.35 ± 85.62 mL in the TXA group, and 692.70 ± 96.06 mL in the AH group; p < 0.001) without an increase in thromboembolic events or wound-related complications. Additionally, the combination accelerated early postoperative knee function recovery without significantly affecting pain scores or inflammatory markers.

CONCLUSIONS: The combination of TXA and AH effectively reduced perioperative blood loss in TKA, accelerated early patient recovery, and did not increase the rate of complications.

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

PMID:40845176 | DOI:10.2106/JBJS.24.01236

J Bone Joint Surg Am. 2025 Aug 22. doi: 10.2106/JBJS.25.00090. Online ahead of print.

ABSTRACT

BACKGROUND: Glycation stress has been implicated in frozen shoulder, potentially inducing oxidative stress through advanced glycation end products (AGEs) and their receptor (RAGE). As the role of oxidative stress in frozen shoulder remains undetermined, this study examined the expression of related genes: NOX, SOD, and PRDX.

METHODS: Thirty-eight participants 35 to 70 years old (23 men and 15 women; all ethnic Japanese) were included; 16 had frozen shoulder, and 22 had a rotator cuff tear without range-of-motion limitations. Tissue samples were collected from the rotator interval capsule and the middle glenohumeral ligament during surgical procedures. Oxidative stress was evaluated by quantifying dihydroethidium (DHE) fluorescence intensity and protein carbonyl levels. Expression levels of genes associated with oxidative stress (SOD1, SOD2, SOD3, PRDX5, NOX1, NOX4), matrix turnover and remodeling (COL1, COL3, MMP1, MMP3, MMP13), and glycation stress (RAGE, RELA) were measured using real-time polymerase chain reaction. Superoxide dismutase (SOD) activity was also evaluated.

RESULTS: In the frozen shoulder group, oxidative stress was indicated by elevated DHE fluorescence and protein carbonyl levels in tissue samples from both the rotator interval capsule and the middle glenohumeral ligament. NOX4, RELA, and MMP13 were significantly upregulated, while SOD1 was significantly downregulated, in the rotator interval capsule and middle glenohumeral ligament in the frozen shoulder group compared with the rotator cuff tear controls. PRDX5, RAGE, and COL1 were significantly upregulated and SOD2 was significantly downregulated in the rotator interval capsule in the frozen shoulder group. SOD activity was significantly downregulated in the rotator interval capsule and middle glenohumeral ligament in the frozen shoulder group.

CONCLUSIONS: The frozen shoulder group showed increased expression of glycation stress genes and NOX along with decreased SOD expression and activity, indicative of oxidative stress. Oxidative stress, in addition to glycation stress, could be involved in the pathogenesis of frozen shoulder.

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

PMID:40845125 | DOI:10.2106/JBJS.25.00090