We read with great interest the meta-analysis by Alshahrani et al, which compared autologous bone grafts and bone substitutes in the management of tibial plateau fractures. This comprehensive review offers valuable data; however, several methodological aspects should be carefully considered to strengthen the interpretation of its findings. Tibial plateau fractures exhibit wide variability in terms of injury mechanism and prognosis. In the included studies, fracture classification was not consistently reported, and studies on simple, mixed, and complex patterns were pooled together, which may have introduced bias. Furthermore, the bone substitutes assessed, namely, calcium phosphate cement, calcium sulfate, bioactive glass, and various composites, differ greatly in composition, mechanical properties, and degradation behavior. The primary outcome of joint depression was analyzed in very small subgroups, limiting statistical power, and was treated as continuous data despite the small sample sizes. The follow-up durations were short, although bone graft incorporation may take months to years, and shorter follow-up may miss later complications. Finally, the search strategy did not specify language criteria, which may have contributed to the inability to locate one of the included studies during our search, potentially indicating the inclusion of non-English articles. Addressing these methodological concerns would increase the robustness, validity, and clinical applicability of this important meta-analysis.

Surgical stabilization of Pauwels Type III femoral neck fractures remains a significant challenge due to high vertical shear forces. While the medial buttress plate is a recognized solution, it requires extensive deep dissection. This study aims to compare the biomechanical performance of various screw configurations combined with either a medial buttress or anteromedial support plate. Twenty-five third-generation synthetic femurs were used to create a standardized 70-degree (Pauwels III) fracture model. Specimens were divided into five groups (n = 5): (A) Inverted triangle (IT) screws with a Pauwels screw, (B) Inverted triangle (IT) with medial buttress plate (MBP), (C) Inverted triangle with anteromedial support plate (ASP), (D) L-configuration with medial buttress plate (MBP), and (E) L-configuration with anteromedial support plate (ASP). Axial loading was applied at 2 mm/min until construct failure, defined objectively by the real-time force-distance curve. Although no statistically significant difference was found between groups (p = 0.102), a large effect size was observed (η² = 0.309). Group C (IT + ASP) demonstrated the highest mean failure load (1695 ± 494.6 N). Conversely, Group E (L-configuration + ASP) exhibited the lowest stability (977.2 ± 195.4 N) with a remarkably narrow standard deviation. The majority of failures occurred as transverse subtrochanteric fractures distal to the implants. The combination of an inverted triangle screw arrangement with an anteromedial support plate demonstrated comparable biomechanical stability to the medial buttress plate, while offering a potentially safer surgical corridor. Conversely, pairing L-shaped screw configurations with anteromedial support plates resulted in the lowest mean ultimate load-to-failure among the tested constructs, likely due to potential stress riser effects.

Background Hip fractures in the elderly are associated with high 90-day mortality rates. Most existing predictive models rely solely on preoperative variables. This study aimed to develop two parallel risk score models integrating preoperative and perioperative factors to predict 90-day mortality. Methods Medical records of patients aged ≥65 years who underwent hip fracture surgery at our institution between January 2018 and December 2024 were retrospectively reviewed. Five preoperative risk factors were evaluated: Prognostic Nutritional Index <40, age ≥85 years, ≥4 comorbidities, surgical delay >5 days, and intracapsular fracture. The >5-day surgical delay threshold was determined empirically through receiver operating characteristic analysis, as the conventional 48-hour cut-off lacked discriminative capacity in this cohort where 86.8% of patients exceeded it. Model performance was assessed using logistic regression and receiver operating characteristic analysis. Results Of 388 patients enrolled, 387 constituted the analytical sample (60 deaths). The 90-day mortality rate was 15.5%. Individually, each factor showed weak to moderate discrimination. The preoperative five-factor score achieved an AUC of 0.722, and the combined six-factor score — which additionally incorporates ICU stay ≥5 days — achieved an AUC of 0.737. Each unit score increase raised mortality odds approximately 2.68-fold. In patients scoring ≥4, mortality exceeded 50%. The Hosmer-Lemeshow test confirmed adequate calibration for both models. Conclusion A two-stage scoring approach combining admission-available and postoperative variables demonstrated acceptable discrimination and calibration for 90-day mortality prediction in elderly hip fracture patients, supporting its use as a practical risk stratification tool at both preoperative and postoperative clinical decision points.

Introduction: Use of three-wheeled electric motorcycles is increasing in Turkey, particularly among older individuals residing in rural and summer residential areas. This study aimed to characterize the orthopedic injury patterns, treatment requirements, and clinical outcomes associated with three-wheeled electric motorcycle-related accidents. Materials and Method: This single-center retrospective study included 33 patients who presented to the emergency department following three-wheeled electric motorcycle-related accidents between January 2023 and December 2025. Pedestrian injuries and accidents involving vehicles other than threewheeled electric motorcycles were excluded. Patients were categorized as drivers or rear-seat passengers. Orthopedic injuries were analyzed by anatomical location, and treatment was classified as surgical or conservative; descriptive statistics and Fisher’s exact test were used. Results: Of 33 patients, 11 (33.3%) were male and 22 (66.7%) female. Mean age was 65.7 ± 5.1 years. Twenty-one patients (63.6%) were drivers and 12 (36.4%) rear-seat passengers. All sustained orthopedic injuries. Upper extremity injuries were identified in 28 patients (84.8%) and lower extremity in five (15.2%). The most common fractures were distal radial (n = 10, 30.3%), clavicle (n = 5, 15.2%), and proximal humeral fractures (n = 4, 12.1%). Surgical management was required in 15 (45.5%) and conservative treatment in 18 (54.5%). No patient required intensive care unit admission or died. Injury distribution and surgical requirement were similar in drivers and rear passengers (p = 0.328 and 0.469). Conclusion: Three-wheeled electric motorcycles may pose a considerable risk of trauma, especially in older individuals, underscoring the need for vehiclespecific preventive strategies, educational programs, and regulatory measures. Keywords: Off-Road Motor Vehicles; Geriatrics; Fractures, Bone.

Objective To investigate adherence rates, barriers, and complication profiles associated with thromboprophylaxis following lower limb fracture surgery, and to identify factors contributing to non-adherence in routine orthopedic practice. Methods A cross-sectional study was conducted involving 254 patients aged ≥18 years who underwent surgical fixation of lower extremity fractures and attended outpatient follow-up ≥6 weeks postoperatively at a tertiary trauma center between October 2023 and December 2024. Data were collected through structured questionnaires. Patient-reported barriers were classified according to the World Health Organization (WHO) five-dimension adherence framework. Non-adherence was defined according to ACCP-9 guidelines (<14 days for minor or <35 days for major surgeries, or irregular use). Appropriate statistical analyses were performed. Results Overall, 22.4% of patients were non-adherent to anticoagulant therapy. The most common reason was misunderstanding the intended treatment duration (63.2%). Injection-related pain (8.8%) and difficulties accessing healthcare (5.3%) were additional barriers. Adherence increased with age (p = 0.007) and was higher among hip fracture patients (p = 0.039). Pharmacist education was linked to lower adherence. Educational level showed a non-linear association (p = 0.019). DVT was rare (0.8%) and occurred only in adherent patients. Findings were consistent in sensitivity analyses. Conclusion Despite established guidelines, many patients remain non-adherent to thromboprophylaxis after lower limb fracture surgery, mainly due to misunderstanding of treatment duration. Targeted education, simplified prescribing regulations, and multidisciplinary support are warranted to improve adherence and reduce preventable thromboembolic complications in orthopedic trauma care.

Introduction: Although postoperative delirium in patients with hip fractures has been extensively studied, preoperative delirium has rarely been examined. We investigated the riskfactors for developing preoperative delirium in patients with hip fracture and their relation to mortality. Materials and Method: We retrospectively reviewed the records of 316 patients who underwent hip fracture surgery. Preoperative delirium was defined according to the Diagnostic and Statistical Manual-5 criteria, and the time of onset of delirium (0-24 hours) was recorded. We evaluated patient demographics, medical conditions, laboratory results, movement patterns, and death rates. Results: Preoperative delirium occurred in 16.5% of the patients. Most patients who experienced delirium developed symptoms during the first six hours of hospitalization. The preoperative delirium group showed lower serum albumin levels (3.2 +/- 0.5 vs 3.6 +/- 0.6 g/dL, p<0.001), lower prognostic nutritional index values (31.2 +/- 6.8 vs 36.1 +/- 7.5, p<0.001) and elevated creatine kinase levels (168 vs 92 U/L, p<0.001). Alzheimer's/dementia (odds ratio: 5.43), creatine kinase levels above 100 U/L (odds ratio: 3.65), albumin levels below 3.5 g/dL (odds ratio: 3.12), prognostic nutritional index values under 35 (odds ratio: 2.78) and dependent mobilization (odds ratio: 2.18) were independent risk factors. The multivariate logistic regression model showed suitable discrimination power through its area under curve value of 0.687 which fell within a 95% confidence interval of 0.599 to 0.774 while achieving sensitivity at 65.8% and specificity at 61.2% and accuracy at 61.7%. The preoperative delirium group experienced a 36.5% one-year mortality rate, which was significantly higher than the 18.2% mortality rate in the non-delirium group (p=0.001). Conclusion: The risk factors for preoperative delirium include low albumin levels, low prognostic nutritional index values, elevated creatine kinase, dependent mobilization, and neurocognitive impairment. The presence of preoperative delirium leads to an extended postoperative delirium duration and elevated patient mortality rates. The research results require analysis based on the study design which used a single center to collect retrospective data and the difficulties of detecting delirium through medical records analysis.

Abstract I read with great interest the recently published article by Chouhan et al. examining radiological risk factors across different patterns of patellar instability. The authors investigated trochlear dysplasia, tibial tubercle–trochlear groove (TT–TG) distance, and patellar height across single-episode, recurrent, and habitual patellar dislocation phenotypes. While this phenotype-based imaging approach addresses a clinically relevant question, several methodological and conceptual considerations may limit the robustness and clinical translatability of the reported between-group differences. The analysis was performed at the knee level despite inclusion of bilateral cases, without accounting for within-patient clustering, potentially inflating statistical significance. In addition, exclusion of patients who underwent stabilization procedures, particularly among single-episode dislocators, may introduce spectrum and selection bias, exaggerating apparent phenotype contrasts. The absence of formal inter- and intraobserver reliability assessment further constrains interpretation, especially given the known measurement variability of TT–TG distance, patellar height indices, and dysplasia grading. Reported TT–TG differences between single-episode and recurrent instability were small, with substantial overlap and without confidence intervals, reliability metrics, or threshold-based analyses, limiting clinical actionability within contemporary multifactorial decision frameworks. Inclusion of habitual patellar dislocation, often a developmental condition with distinct and entrenched structural abnormalities, within the same comparative construct as episodic instability raises concerns regarding construct validity and extrapolation of management implications. In conclusion, this work tackles an important clinical topic, and its conclusions could be further consolidated by incorporating cluster-aware analyses, clearly documenting exclusion patterns and reporting measurement reproducibility and TT–TG analyses aligned with clinically actionable thresholds within a multifactorial anatomical framework.

Population aging is considered a major demographic transition in recent decades, posing a significant challenge to healthcare delivery globally. While life expectancy increases, linked to aging, musculoskeletal disorders such as sarcopenia, osteoporosis, osteoarthritis, and frailty are becoming increasingly prevalent. These conditions are closely associated with reduced mobility, functional decline, falls, fragility fractures, and loss of independent living among older adults. Beyond their clinical consequences, musculoskeletal diseases also impose a substantial socioeconomic burden through healthcare expenditures, disability, and reduced participation in social and economic life. The biological mechanisms underlying musculoskeletal aging involve complex interactions between muscle and bone, chronic low-grade inflammation, hormonal changes, and metabolic alterations. Nutritional factors, particularly adequate protein intake and optimal vitamin D and calcium levels, are also key determinants of musculoskeletal well-being. Social determinants such as physical inactivity, multimorbidity, polypharmacy, socioeconomic inequalities, and limited access to healthcare services can accelerate functional decline in older populations. Management strategies range from preventive and conservative approaches to surgical interventions when necessary. Exercise programs, nutritional optimization, pharmacological treatment for osteoporosis, and fall prevention strategies represent the core of conservative management. In advanced disease, surgical procedures such as total joint arthroplasty provide effective relief of pain and restoration of mobility. Addressing musculoskeletal aging therefore requires integrated, multidisciplinary approaches that combine prevention, treatment, rehabilitation, and equitable access to care in aging societies.

To evaluate the clinical appropriateness of ChatGPT's responses to questions frequently asked by osteosarcoma patients and their families. Ten questions frequently asked by osteosarcoma patients and their families were identified. Each question was submitted to OpenAI's GPT-5-based ChatGPT (August 2025 version) using separate user accounts. Two orthopedic oncology specialists independently evaluated the responses for clinical appropriateness using a 4-point Likert scale. Interrater agreement was analyzed with weighted Cohen kappa. Interrater agreement was found to be substantial (K = 0.667). One response was rated as an excellent response that did not require clarification, 5 responses were rated as satisfactory responses that required minimal clarification, and 4 responses were rated as satisfactory responses that required moderate clarification. There were no unsatisfactory responses requiring substantial clarification. ChatGPT's responses to osteosarcoma-related questions were found to be largely clinically appropriate. Nevertheless, given its limitations, artificial intelligence should be regarded as a supportive tool that requires physician oversight.

The aim of this study was to identify the radiographic parameters associated with failure of tension band wiring (TBW) in the treatment of transverse patellar fractures, with the goal of guiding surgical decision-making. A total of 76 patients underwent surgical treatment for patellar fractures at Trakya University between January 2013 and December 2022. We retrospectively analyzed 32 patients who met the study’s inclusion criteria for transverse fractures (AO Type 34- C1) treated with TBW. Radiographic parameters assessed included patellar width, inter-K-wire distance, K-wire-to-patella ratios, knot configuration, and K-wire length, all evaluated for their potential association with fixation failure. Failure was defined as cerclage wire slippage or breakage. Statistical analyses were conducted using SPSS and Jamovi software. Descriptive statistics, t-tests, chi-square or Fisher’s exact tests, logistic regression, and ROC analysis were performed. A p-value < 0.05 was considered significant. The mean age was 50 years ± 15.8 (range 26–80), with 8 women (25

Objectives: This study aimed to evaluate the rates and risk factors associated with revision amputation following ischemic lower major limb amputations, focusing on cases related to peripheral arterial disease. Patients and methods: This retrospective study included 253 patients (174 males, 79 females; mean age: 73.1 +/- 12.2 years; range, 44 to 99 years) who underwent ischemic foot amputation between December 2012 and December 2022. Eligible patients were over 18 years old and had major lower extremity amputations due to peripheral arterial disease or chronic arterial occlusion. Exclusions were made for amputations due to diabetic foot conditions, trauma, tumors, or osteomyelitis and minor lower extremity amputations. Results: Above-knee amputations were the most common type of amputation, accounting for 56.5% (n=143) of cases. Revision amputations occurred in 27.3% (n=69) of patients, with significantly higher rates in those with open wounds at first admission (chi-square [chi(2) ]=9.81, p=0.002). Patients with occlusion at the popliteal artery level had a higher rate of revision amputation following below-knee amputation (p=0.034). Each additional year of age decreased the likelihood of revision amputation by 2.3% (p=0.049). Vacuum-assisted closure therapy was associated with higher revision rates (chi(2) =22.71, p<0.001). Patients who developed infections (n=40) had a significantly higher rate of revision amputations (n=26, p<0.001). Elevated preoperative C-reactive protein levels were also correlated with an increased risk of revision (p=0.006). Conclusion: Patients with ischemic lower limb amputations, particularly those presenting with open wounds, are at higher risk for revision amputation. Elevated preoperative C-reactive protein levels, infections, age, and the initial level of amputation significantly impact the likelihood of reamputation.

Objectives: This study aimed to compare the AO, Schatzker, and Three-Column classification systems for tibial plateau fractures, focusing on their prognostic and functional outcome prediction and influence on clinical decisions across different trauma types. Patients and methods: In this retrospective study, we examined 49 patients (36 males, 11 females; mean age: 40.6 +/- 11.8 years; range, 19 to 67 years) with tibial plateau fractures between January 2011 and January 2017. The fractures were classified using the AO, Schatzker, and three-column systems. The main outcome measurements included functional scores (Knee Injury and Osteoarthritis Outcome Score [KOOS], Hospital for Special Surgery [HSS]), range of motion (ROM), duration of hospitalization, thigh atrophy, operation time, and the development of osteoarthritis. The impact of smoking was also assessed. Results: According to the AO classification, type B fractures obtained higher KOOS and HSS scores compared to type C fractures (p=0.013 and p=0.007, respectively). According to the Schatzker classification low-energy fractures achieved higher KOOS and HSS scores than high-energy fractures (p=0.013 and p=0.026, respectively). One-column fractures had higher KOOS and HSS scores compared to two-column and three-column fractures (p=0.007 and p=0.001, respectively). Two-column fractures had a lower ROM compared to other column fractures (p=0.022). Shorter hospital stays were recorded for Schatzker low-energy fractures (p=0.016), whereas higher thigh atrophy was found in Schatzker high-energy fractures (p=0.022) and AO type C fractures (p=0.018). Longer operation times were observed in AO type C fractures (p=0.037) and Schatzker high-energy fractures (p=0.017). According to the Kellgren-Lawrence classification, AO type C fractures and three-column fractures yielded worse outcomes (p=0.039 and p=0.001, respectively). Smoking had a negative impact on functional KOOS and HSS scores across all groups (p=0.022 and p=0.001, respectively). Conclusion: This study highlights the predictive value of the AO, Schatzker, and Three-Column classification systems in determining functional outcomes and clinical data in tibial plateau fractures. Each system provides unique insights into different outcomes, suggesting their concurrent application may yield a more comprehensive prognosis.

Introduction The COVID-19 pandemic has profoundly impacted global healthcare systems, necessitating substantial shifts in patient care strategies. The pandemic’s onset led to drastic operational changes in hospitals, including reduced bed capacity and staffing levels, which could have further influenced the mortality outcomes for geriatric patients. The study aimed to assess the impact of the COVID-19 pandemic on 1-year mortality rates of surgically treated geriatric hip fractures. Methods This retrospective, single-center cohort study included 346 participants aged 65 and above who underwent surgical treatment for hip fractures. We compared mortality rates between the pre-COVID and COVID eras. Data included demographics, treatment, complications, and COVID-19 status. The independent samples t test and Chi-square tests (or Fisher’s exact test) were used for comparisons for era cohorts. Survival probabilities were assessed using Kaplan-Meier, while multivariate analysis identified mortality predictors. Results 175 patients were included in the pre-COVID era, and 171 patients were included in the COVID era. During the COVID era, the 30-day mortality rate was 11.7% (compared to 13.7% in the pre-COVID era, p = 0.573), and the 1-year mortality rate was 43.9% (compared to 49.1% in the pre-COVID era, p = 0.325). The overall 1-year mortality rate was 46.5%. Patients who underwent surgery within 48 hours had a higher 1-year survival rate (60.5%) compared to those with delayed surgery (51.2%), p = 0.031. Additionally, patients not admitted to the ICU had a higher 1-year survival rate (74.7%) than those who were admitted (44.9%), p < 0.001. 70.1% of the total deaths occurred within the first 90 days. Conclusion Elderly patients with hip fractures experienced high mortality rates before and during the pandemic. This study demonstrates that the 1-year mortality rates of geriatric hip fractures were not significantly affected by the pandemic. The findings emphasize the importance of pandemic preparedness and prompt surgeries and attentive ICU care in reducing mortality rates.

Abstract Background Periprosthetic joint infection presents a significant challenge due to biofilm formation, necessitating effective detection methods. While traditional tissue and implant cultures are commonly used, the efficacy of sonication fluid culture (SFC) in identifying causative agents has been evaluated in numerous studies. Methods In this study, three cultures were evaluated for diagnosing periprosthetic joint infection intraoperative periprosthetic tissue culture, implant culture, and SFC. The sensitivity, specificity, and predictive values were calculated for each method, using the 2018 definition of periprosthetic hip and knee infection and clinical evaluation as references. Results Of the 92 patients who had implants removed, 49 were for mechanical reasons and 43 for infection. Positive cultures were obtained in 13 out of 49 patients with mechanical issues and 31 out of 43 with infections. The sensitivity of periprosthetic tissue cultures (53.5%) is slightly higher than SFC (48.8%), suggesting better detection of positive cases. However, SFC's specificity (83.7%) is higher, indicating more accurate identification of negative cases compared to periprosthetic cultures (73.5%). However, SFC identified additional pathogens in patients with negative periprosthetic tissue and implant cultures. Examination of the infected knee and hip prostheses showed that SFC enhanced pathogen detection, particularly in patients with negative implant cultures. Despite this, SFC was not statistically superior to other methods. Conclusion This study supports the combined use of periprosthetic tissue culture and SFC for identifying causative microorganisms in implant infections. Despite not being statistically superior, SFC provides additional pathogen detection, especially when other methods fail, thereby enhancing overall diagnostic accuracy.

Spine tumors comprise a small percentage of reasons for back pain and other symptoms originating in the spine. The majority of the tumors involving the spinal column are metastases of visceral organ cancers which are mostly seen in older patients. Primary musculoskeletal system sarcomas involving the spinal column are rare. Benign tumors and tumor-like lesions of the musculoskeletal system are mostly seen in young patients and often cause instability and canal compromise. Optimal diagnosis and treatment of spine tumors require a multidisciplinary approach and thorough knowledge of both spine surgery and musculoskeletal tumor surgery. Either primary or metastatic tumors involving the spine are demanding problems in terms of diagnosis and treatment. Spinal instability and neurological compromise are the main and critical problems in patients with tumors of the spinal column. In the past, only a few treatment options aiming short-term control were available for treatment of primary and metastatic spine tumors. Spine surgeons adapted their approach for spine tumors according to orthopaedic oncologic principles in the last 20 years. Advances in imaging, surgical techniques and implant technology resulted in better diagnosis and surgical treatment options, especially for primary tumors. Also, modern chemotherapy drugs and regimens with new radiotherapy and radiosurgery options caused moderate to long-term local and systemic control for even primary sarcomas involving the spinal column.