CASE:A 15-year-old girl presented with significant right anterior knee pain and a varus-hyperextension gait pattern mimicking knee subluxation. Computed tomography (CT) revealed 44° of femoral anteversion and 35° of external tibial torsion. Magnetic resonance imaging and X-rays failed to demonstrate any abnormalities. Clinical examination supported by CT, EOS, and 3-dimensional gait analysis revealed axial malalignment. Femoral and tibial torsional osteotomies normalized gait, and clinical scores improved. CONCLUSION:This case highlights how torsional malalignment can produce dynamic sagittal and coronal gait dysfunction. Rotational correction resolved symptoms, emphasizing the need to include torsion assessment in patients with unexplained knee pain and gait dysfunction.

BACKGROUND:Continuous pressure measurement of traumatized muscle has been shown to be an accurate method of diagnosing acute compartment syndrome (ACS), but no baseline data have been released to show the reaction to surgery in extremity fracture. We sought to establish normal values for perioperative pressures. METHOD:We obtained pressure tracings from prospective clinical trials of forearm and tibia fractures requiring surgery. We standardized data and produced graphs using the ggplot2 library in R version 4.2.2. We generated generalized pressure curves based on the mean pressure and quantile distribution for each time point. RESULTS:We retrieved data from 79 preoperative and 50 postoperative patients. The mean age was 43 years in both groups. Patients exhibited higher pressures postoperatively whether or not they developed ACS. In both the preoperative and postoperative ACS groups, muscle pressure trended upward at an average rate of 0.078 and 0.073 mmHg per hour, respectively, but trended downward in non-ACS groups, at a rate of 0.24 and 0.27 mm Hg per hour pre- and postoperatively, respectively. Patients younger than 45 years registered the highest initial postoperative pressure. Postoperative initial pressures were higher than preoperative pressures and were higher among males than females. Females had steeper decreasing pressure curves in both pre- and postoperative scenarios. CONCLUSION:We observed trends in muscle pressure by sex, age, and diagnosis of ACS among trauma patients. Understanding these variations is essential for improving timely diagnosis of ACS.

OBJECTIVES:To determine the reproducibility of two novel bone defect classification systems, the Tetsworth classification system and the Universal Long Bone Defect (ULBD) classification system. METHODS:Two independent reproducibility studies were undertaken. A series of cases with bone defects was collected and sent to a panel of orthopaedic surgeons who were members of the OTA or LLRS who routinely manage bone defects. The surgeons were provided with a measurement calibration scale for defect length assessment. Analysis of reproducibility was performed using a Fleiss's multi rater kappa model, where a Fleiss's kappa of 0 indicated agreement no better than random chance, and 1 indicated perfect agreement. Surgeons also rated their confidence in their rating from 1 - 3, with 3 as "very confident." RESULTS:For the Tetsworth classification, Fleiss' kappa was 0.264 for the overall classification system (fair agreement) (95% CI 0.224,0.305). The kappa for the D1,D2,D3 part of the code related to defect completeness (incomplete, subcritical, or critical) was 0.557 (moderate agreement) (95%CI 0.446, 0.648). The kappa for the A,B,C part of the code related to defect shape was 0.402 (moderate agreement) (95% CI 0.323, 0.480). The mean confidence for all cases was 2.46 (range 1.86 - 3). For the ULBD classification, the Fleiss' kappa for the entire classification was 0.133 (slight agreement) (95% CI 0.123,0.144). The kappa for the location and segment was 0.568 (moderate agreement) (95% CI 0.526,0.610). The kappa for the morphology component was 0.124 (slight agreement) (95% CI 0.114, 0.135). The mean confidence for all cases was 2.0 (range 1.0 - 3.0). CONCLUSIONS:The bone defect classification system proposed by Tetsworth et al was reproducible by surgeons familiar with bone defects. The system can be considered for future research use. The ULBD classification system had low overall reproducibility.

Objectives:Acute compartment syndrome (ACS) is a serious condition resulting from increased intracompartmental pressure (ICP) within a closed muscle compartment. There is a lack of understanding of continuous pressure trends despite being an accepted method for tracking disease. It was hypothesized that trends in pressure would determine risk of ACS. Methods:This is a retrospective review of collected data from two prospective cohort trials. Anonymized ICP pressures from 147 trauma patients with extremity fractures were gathered. Patient data from multicenter level one trauma academic hospitals was analyzed. Data was taken from trauma patients that received a continuous real-time pressure device. Statistical and observational analysis were carried out to examine trends in patients with and without resultant acute compartment syndrome. Results:Patients that developed ACS did not always have significantly higher absolute ICPs that exceed the theoretical critical 30 mmHg threshold for fasciotomy. Patients with ACS showed a consistent upward trend over time (average increase of 0.674 mmHg per hour). In contrast, non-ACS patients, even those that exceeded the previous postulated 30mmHg threshold, exhibit a natural and gradual decline in ICP over time (average decline of 0.285 mmHg per hour). Conclusions:This research highlights the limitations of single-point pressure measurements and underscores the benefits of continuous ICP monitoring for timely ACS diagnosis. Continuous pressure data enables better clinical decision-making, reducing the risk of both unnecessary and delayed fasciotomies. This study emphasizes the need for integrating continuous pressure monitoring into standard practice to improve the management and outcomes of patients at risk for ACS.

Despite advances in musculoskeletal trauma care, segmental bone loss remains a major clinical challenge. A substantial proportion of these cases are associated with fracture-related infection (FRI), which fundamentally alters the biological environment and reconstructive strategy. In this context, FRI should be considered in any patient with a segmental bone defect, and thorough surgical debridement with acquisition of multiple deep-tissue cultures represents an essential first step in management. The presence of infection reduces the likelihood of bone consolidation and eradication of disease, emphasizing the need for strict adherence to established FRI treatment principles. Depending on the extent of bone loss, host factors, and available expertise, patients may be eligible for a range of reconstructive options. Bone transport is one of these surgical methods and involves the gradual translocation of bone segments to reconstruct defects in long bones. Based on the principles of distraction osteogenesis (DO), controlled mechanical distraction promotes predictable bone regeneration according to Ilizarov's principles. Traditionally, DO has relied on circular external fixators. Recent developments involving integrated fixation, such as bone transport over a nail, have reduced morbidity and enabled faster reconstruction. Although these techniques carry a risk of contaminating the intramedullary canal, exclusive long-term use of external fixators is not harmless. Further innovations, such as motorized telescopic intramedullary nails, have led to the gradual replacement of external fixation, making the procedure less burdensome for patients. Advances in surgical skills and technology have enabled the treatment of more complex cases, making a specialized, multidisciplinary approach essential in modern clinical care.

Purpose:Tension band fixation (TBF) using screws or wires is the widely accepted standard of care for patellar fractures. This meta-analysis aims to quantitatively compare postoperative outcomes between Kirschner wire tension band fixation (KWTB) and cannulated screw tension band fixation (CSTB) to determine the optimal fixation method. Methods:A systematic review and meta-analysis were conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for comparative studies on KWTB vs. CSTB. Primary outcomes included union rate, time to union, infection, reoperation rate and pain. Secondary outcomes included range of motion, time to weight bearing, implant complications, and functional scores. Results:This meta-analysis included 10 studies with 1,272 patients. KWTB was associated with a significantly longer time to union (p = 0.02), greater pain scores (p < 0.0001), and higher infection rates (p = 0.04). However, union and reoperation rates were comparable. For secondary outcomes, CSTB had significantly improved time to full weight bearing (p < 0.00001). In addition, KWTB had higher complication rates, including implant migration/loosening (p < 0.00001), implant prominence, skin irritation (p = 0.003), and implant removal (p < 0.00001). The Lysholm score (p < 0.00001) and range of motion (p = 0.03) were significantly higher in the CSTB group. Conclusion:While union rates are comparable, CSTB for TBF in patellar fractures is associated with improved functional outcomes and a reduced complication rate compared with KWTB. Level of Evidence:Level III, systematic review and meta-analysis. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Distraction osteogenesis is the process by which tissue is created through gradual distraction at a regular rate and rhythm. It is commonly used for bone lengthening due to congenital limb differences, malunion, and bone defects. As the timing and complexity of this procedure are necessarily dependent on the length gained or transported, surgeons have utilized various healing indices to describe their results including bone healing index (BHI), lengthening index (LI), consolidation index (CI), and external fixation index (EFI). Accurate and consistent definitions are therefore needed to compare outcomes across studies to eliminate the variability in the reporting of these important indices. This review seeks to evaluate the current literature on the accuracy and consistency of how these indices are defined. METHODS:Studies using the terms BHI, LI, CI, or EFI published prior to December 31, 2025 were searched and screened using the Pubmed/Medline and Web of Science databases. Separate searches were performed for each healing index; 62 articles reporting BHI, 41 for LI, 63 for CI, and 145 for EFI, met inclusion criteria. RESULTS:Across the studies reporting on BHI, 29.0% did not explicitly define BHI and another 22.6% defined the parameter incorrectly, mostly confusing the term with EFI (78.6%). In 29.3% of the articles that included LI, a definition was not provided. Among the articles that did provide an LI definition, 55.2% were incorrect. Of these, 68.8% mistakenly equate LI with EFI. For CI, 28.6% of articles mentioning the term did not provide a definition. When CI was defined, it was frequently described in terms more consistent with BHI (66.7%). 24.4% of CI definitions were incomplete and only 4.4% were complete and correct. Conversely, EFI was accurately described in 96.7% of its studies. CONCLUSION:Significant inconsistencies exist in the definitions for healing indices across studies on distraction osteogenesis. The use of the terms BHI, and LI remains inconsistent and inaccurate across studies. The use of CI is consistently and incorrectly used interchangeably with BHI. EFI definitions were consistent. This investigation demonstrates the lack of standardized healing indices and underscores the urgent need to establish a common measure for assessing healing.

Aim:To describe a surgical technique for the safe removal of a broken non-cannulated PRECICE bone transport nail (NuVasive Specialized Orthopedics) without compromising limb reconstruction. Background:The removal of broken non-cannulated intramedullary lengthening nails (IMLNs) is challenging. Few techniques have been described for the safe removal of these devices without compromising bone salvage. Case description:A 42-year-old male presented for complex right tibia reconstruction following a type IIIB open tibia fracture with a 92-mm bone defect. The bone defect was initially managed with an all-internal bone transport nail system (PRECICE bone transport). At the 13-month follow-up, the patient presented with a broken lengthening nail, varus limb deformity, and nonunion at the docking site. The nail components were extracted sequentially, and a burr hole was created in the distal segment of the nail through the nonunion site to facilitate removal. The residual varus deformity and tibial shaft nonunion were managed with a hexapod frame. Conclusion:The IMLN was successfully removed without compromising limb reconstruction. By sequentially removing the components of the nail and altering the distal portion of the implant through the nonunion site, safe removal of the implant without further bone loss was achieved. Clinical significance:This report describes an efficient technique for the removal of broken non-cannulated IMLNs when extractors are not available. How to cite this article:Legler J, Martel S, Mailhot P, et al. Extraction of a Broken PRECICE Bone Transport System: A Case Report and Technique for Residual Limb Salvage. Strategies Trauma Limb Reconstr 2024;19(3):171-176.

Treatment of both bone forearm fractures (BBFFs) in skeletally immature patients includes both operative and nonoperative strategies. However, there is no literature-supported consensus as to which intervention provides optimal patient outcomes. This systematic review and meta-analysis compares the outcomes of surgical and conservative treatment in the management of BBFFs in skeletally immature patients. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed across Medline, Scopus, PubMed, and CENTRAL from inception to August 2024. Studies reporting clinical outcomes of skeletally immature patients with BBFFs treated with either: 1) surgical, including intramedullary nailing and plating, or 2) nonoperative methods, i.e. casting, were included. Statistical analyses were conducted using RStudio (Posit, Boston, MA, USA). The initial search yielded 1884 studies, of which a total of 24 studies with 1,157 patients (surgical: 807, mean age: 11.40 years; conservative: 350, mean age: 8.59 years) met the inclusion criteria. Functional outcomes showed excellent results in both groups (P = .2701). The overall rate of complications, which included redisplacement, refracture, need for additional interventions, infections, and neuropraxia, was significantly higher in the conservative group (24%) compared to the surgical group (12%), with a risk ratio of 1.91 (95% CI: 1.47, 2.49). Redisplacement was also significantly higher in the conservative group (26%) compared to the surgical group (3%), with a risk ratio of 10.08 (95% CI: 2.52, 40.37). The need for additional interventions was higher in the conservative group (14%) than in the surgical group (5%), with a risk ratio of 2.66 (95% CI: 1.42, 4.99). Time to union was significantly longer in the surgical group (8.26 ± 1.66 weeks) compared to the conservative group (6.50 ± 1.29 weeks) (P < .001). Despite this, union rates were 100% in both groups. Both conservative and surgical management of pediatric BBFFs yielded high union rates and excellent functional outcomes. Surgical treatment demonstrated lower complication and redisplacement rates but was associated with a longer time to union. These findings suggest that surgical treatment may be preferable for reducing redisplacement and the need for additional interventions in older children with reduced remodeling potential. Key Concepts:(1)Both conservative and surgical treatment of pediatric both bone forearm fractures result in excellent functional outcomes and 100% union rates, which supports the effectiveness of both approaches in skeletally immature patients.(2)Surgical management is associated with significantly lower rates of redisplacement (3% vs 26%) as well as lower need for additional interventions (5% vs 14%) compared to conservative treatment, highlighting its benefit in maintaining fracture stability.(3)Although the time to union was longer with surgical treatment (8.26 vs 6.50 weeks), this did not negatively impact final functional outcomes.(4)Age-related remodeling potential remains a key determinant in treatment selection, with conservative treatment more suitable for younger children and surgical treatment preferable in older children with diminished remodeling capacity. Level of Evidence:III.

Background:Osteogenesis imperfecta (OI) is characterized by bone fragility and deformities. Treating long bone fractures and deformities in OI patients typically involves intramedullary (IM) rods. The Simple Locking Intramedullary (SLIM) nail is a novel surgical device developed to address challenges in patients with narrow medullary canals, which are unsuitable for larger telescoping rods. This study aims to evaluate the outcomes and complications associated with SLIM nail use in pediatric patients with OI. Methods:A retrospective chart review was conducted at our institution, analyzing 23 patients (41 limbs) who underwent surgery using the SLIM nail between April 2016 and March 2022. Data on patient demographics, surgical intervention, post-operative outcomes, and complications were collected. Radiological evaluations were performed from the immediate post-operative period up to the most recent follow-up. Results:The SLIM nail demonstrated a 2-year survival rate of 82.8% and a 4-year survival rate of 77.1% in tibial applications. The most common complication was angular deformity in the distal tibia, occurring in 19 patients. Other complications included anterior cortical penetration, nail bending, and one case of nail breakage. Conclusions:The SLIM nail is a viable option for patients with narrow intramedullary canals, particularly in cases where telescoping rods are not feasible. While the SLIM nail provides adequate stabilization and reduces the need for multiple surgeries, careful monitoring is essential to manage complications such as distal angular deformity. Early revision to a larger rod, when possible, is recommended to prevent further complications as the patient grows. Level of evidence:Level IV.

BACKGROUND:Implant-based breast reconstruction (IBBR) can be performed in a single stage (direct to implant [DTI]) or 2 stages using a tissue expander (TE). Fixed costs and postoperative complications can incur a significant financial burden. In this article, we compare direct costs of DTI to TE IBBR and determine price drivers to ascertain their relative costs. METHODS:A retrospective chart review and analysis of specific cost data provided by the authors' institutional finance department of patients who underwent IBBR was conducted to evaluate differences in costs during an episode of care (EOC). Multivariable regression analysis and 1-way sensitivity analysis were conducted to determine key price drivers for each operation. RESULTS:A total of 205 patients (310 breasts) undergoing DTI ( n = 167 [54%]) or staged TE ( n = 143 [46%]) reconstruction were evaluated over their entire EOC. The DTI cohort had a lower rate of major complications (13% versus 22%; P = 0.033) but similar rates of aesthetic revisions (18% versus 19%; P = 0.835). The average cost of a DTI reconstruction ($13,719.39 ± $5499) was significantly lower than for staged TE patients ($16,589.54 ± $6586.95; P < 0.001), with lower operative costs ($10,460.2 ± $4059.81 and $12,242.87 ± $4403.81; P = 0.002) and number of postoperative visits (13.27 ± 7.76 and 23.03 ± 9.05; P < 0.001). There were no differences in operative costs from complications and aesthetic revisions. The cost of a DTI reconstruction is most sensitive to the rate of bilateral operations. For staged TE reconstruction, the episodic cost is most sensitive to the incorporation of acellular dermal matrices. CONCLUSION:DTI breast reconstruction incurs lower cost over an EOC compared with staged TE reconstruction, because of greater planned operative costs and number of postoperative follow-ups in the TE group.

Orthopaedic procedures such as percutaneous pins or sutures removal represent a potential source of pain and anxiety for the paediatric patients, as well as a source of anxiety for parents and caregivers. Pain and anxiety contribute to children and families negative trauma experience with possible long-term sequelae. The aim of this trial was to examine the effect of VR distraction compared to passive distraction for pain and anxiety relief during percutaneous pins removal and/or removal of sutures in paediatric orthopaedic clinics. It was a multicenter pragmatic randomized controlled trial (RCT) using a parallel design with two groups: 1) immersive VR and 2) control - non-immersive video game on tablet in an equal ratio of participants per group. Pain and anxiety were assessed immediately before (T0) and after (T1) the procedure, as well as one week after (T2) (memory of pain) using the Numerical Rating Scale (NRS) and the Child Fear Scale (CFS) respectively. Satisfaction scale (0-10) was used for parents and children and a satisfaction survey was delivered to caregivers after the procedure. Analyses were carried out according to the intention-to-treat principle, with a significance level (α) of 0.025, considering Bonferroni's correction. Subgroups analyses were planned for age and sex. One hundred eighty-eight participants aged from six to 17 years with a mean age of 10.8 ± 3.3 years were recruited from three tertiary centers. No statistically significant differences between the two groups were observed for pain and anxiety scores at T0, T1 and T2. However, a significant difference was observed on anxiety at T1 in favor of teenage boys over 12 years in the VR group (p=0.025). Statistically higher level of satisfaction with the use of VR was reported by parents (p=0.015) and caregivers (p=0.009) with 100% of caregivers recommending immersive VR for future non-invasive paediatric orthopaedic procedures. Procedural time was comparable for the two interventions (p=0.10). This large multicenter RCT showed no statistically significant differences in reduction of pain and anxiety in children using immersive VR compared to non-immersive video game during percutaneous pins removal and/or removal of sutures in orthopaedic clinics. However, VR was efficacious in reducing anxiety in teenage boys. Parents and caregivers were highly satisfied with the use of VR during the procedure. Even if VR is probably not the only answer for reducing pain and anxiety levels, it is part of the tools available at relatively low costs for children undergoing painful and stressful procedures in paediatric orthopaedic clinics.

SUMMARY:Hexapod external fixators are a sophisticated class of devices that are commonly used in the management of complex trauma, limb deformity, limb reconstruction, and/or limb lengthening. They are distinguished using 6 length adjustable struts that typically connect a pair of ring components to one another. These rings serve as proximal and distal fixation to skeletal segments and can be very precisely manipulated with respect to one another across 6 degrees of freedom using dedicated software for planning purposes.

AIMS:To verify the efficacy of virtual reality compared to tablet games for pain and anxiety management in children undergoing percutaneous bone pin and/or suture removal procedures. DESIGN:Randomised clinical trial using two parallel groups: (1) virtual reality or (2) tablet game. METHODS:Three-center, randomised pragmatic clinical trial, using a parallel design with two groups (experimental group: immersive virtual reality; active comparator: tablet games). Children aged 6-17 requiring percutaneous pins and/or sutures were recruited between 2020 and 2022 from three outpatient orthopaedic clinics in paediatric hospitals. Pain was measured with the Numerical Rating Scale and anxiety with the Child Fear Scale before and immediately after the procedure. RESULTS:A total of 188 participants were assigned to either the virtual reality group (96 participants) or the tablet group (92 participants). At the first assessment, there was no noticeable difference between the two groups in terms of pain or anxiety levels. However, further analysis revealed that participants aged 13 and older in the virtual reality group experienced significantly lower anxiety. CONCLUSION:Virtual reality was not more efficacious than games on a tablet for pain and anxiety of children undergoing removal of bone pins or sutures. However, virtual reality demonstrated a benefit in reducing anxiety for teenagers, particularly those aged 13-older. IMPLICATION FOR THE PROFESSIONAL AND/OR PATIENT CARE:Virtual reality games provide an immersive, non-pharmacological alternative of for anxiety management of teenagers during pins and/or sutures removal. IMPACT:This study showed that a virtual reality game may help reduce anxiety during pins and/or sutures removal procedures in patients aged 13 years and older. REPORTING METHOD:We adhered to the CONSORT checklist for reporting results. PATIENT OR PUBLIC CONTRIBUTION:A patient partner reviewed the study design, methods and final manuscript. TRIAL REGISTRATION:NCT03680625.

Objective: Torsional osteotomies of the femur and tibia may be indicated in select individuals with a combination of increased femoral anteversion and external tibial torsion. This study aims to quantify the presurgery and postsurgery levels of pain, function and mobility, and gait patterns in patients with lower extremity torsional abnormalities (LETAs). Methods: Patients with LETA who underwent torsional osteotomy of the femurs and/or tibias were recruited. Before and 1 year postsurgery, participants had a gait analysis and completed patient-reported outcomes. CT torsional assessment was performed at baseline. Paired t tests and statistical parametric mapping were used to assess presurgery and postsurgery changes. Results: Ten participants (18 ± 2 y) completed the study. Participants had 29 ± 10 degrees of femoral anteversion and 45 ± 11 degrees of external tibial torsion. The hip rotational arc and transmalleolar axis improved towards norms following surgery. The major deviations found in the kinematic were observed in the transverse plane, and they improved towards norms postsurgery. The patient-reported outcomes were below norm presurgery but improved significantly postsurgery. Conclusions: Results from this study suggest that LETA can be diagnosed based on radiologic, gait, and physical abnormalities. Postsurgery results showed that torsional osteotomy alleviated pain, restored physical function, and normalized gait patterns. Level of Evidence: Level IV.

Derotational osteotomies of the femur or tibia may be indicated in patients with torsional abnormalities (increased femoral anteversion, increased tibial torsion) that do not respond to nonsurgical management1. To clarify surgical indications and recommend optimal treatment algorithms, the surgical impact on mobility, pain, and function must be elucidated. This study aims to quantify the level of pain, function, mobility, and gait patterns of patients with torsional deformities of their lower limbs. The changes associated with surgery were also measured. Patients between 14 and 21 years-old with a combination of increased femoral anteversion and external tibial torsion who underwent a derotational osteotomy of their femurs and/or tibias were recruited. Their rotational profiles were measured with CT scan before surgery. Before and at one-year post-surgery, the Pediatric Data Collection Instrument (PODCI), a patient-reported outcome score, was collected. In addition, quantitative gait analysis and clinical examinations were completed. Paired t-test or Wilcoxon-Signed Rank test were used to assess pre-post-surgery changes. To assess the kinematic and kinetic gait analysis data, statistical parametric mapping (SPM) was performed. Ten female participants aged 17 ± 2 years completed the study. Participants had a femoral anteversion of 29° ± 10° and external tibial torsion of 45° ± 11°. For the physical examination, participants improved towards norms following the surgery for the ROM assessing rotation: hip internal rotation (pre: 65°±12°; post: 49°±8°), hip external rotation (pre: 30°±12°; post: 48°±11°), and the transmalleolar axis (pre: 31°±8°; post: 23°±7°). The major deviations found in the kinematic were observed in the transverse plane and they improved towards norms at one-year post-surgery (figure 1). Statistically significant improvements were observed in the following domains of the PODCI (score/100): sports and physical function (pre-surgery: 50 ± 18, post-surgery: 70 ± 20), pain and comfort (pre-surgery: 35 ± 16, post-surgery: 76 ± 19), and global function (pre-surgery: 68 ± 10, post-surgery: 86 ± 11). Results from this study suggest that this condition causes radiological, gait and physical abnormalities that impact the quality of life of individuals with torsional deformities of their lower limbs. Post-surgery results at one-year, demonstrate that derotational osteotomy is effective to alleviate pain, restore physical function, and normalize gait pattern. For any figures or tables, please contact the authors directly.

Integrated fixation is an emerging technique for the treatment of posttraumatic tibial bone defects that reduces external frame duration by combining external fixation with internal fixation to minimize complications. This systematic review focuses on integrated fixation strategies and assesses outcomes when managing posttraumatic tibial bone defects. A systematic review following PRISMA guidelines was conducted across MEDLINE®, EMBASE®, and PubMed®. Studies published between 1975 and 2025 reporting integrated fixation techniques in skeletally mature patients with posttraumatic tibial defects were included. Outcomes assessed included union rates, complications, external fixation duration, Association for the Study and Application of Methods of Ilizarov (ASAMI) function and bone scores, and pain. Following identification of 699 studies and removal of 86 duplicates, 38 articles underwent full-text screening. Six studies, including 64 patients (mean age 41.2 years), met inclusion criteria. Integrated fixation demonstrated a combined union rate of 97

Distal femoral fractures are increasingly observed in the elderly population, often presenting with osteoporotic bone characteristics. Surgical fixation remains the gold standard, with lateral locking plates being the most commonly used method. To prevent hardware failure and varus collapse in osteoporotic bone, various surgical techniques and augmentation strategies have been proposed. We describe a surgical technique for managing osteoporotic, comminuted distal femur fractures using a fibular strut allograft in combination with a lateral-only locking plate, along with outcomes in patients treated with this approach. When an intra-articular component was present, it was addressed first. Through the zone of comminution and a cortical window created in the lateral condyle, a fibular strut allograft was inserted into the femoral canal extending into the epiphysis. Once satisfactory alignment and reduction were confirmed radiographically, a lateral locking plate was applied, bridging any existing proximal implants. Proximal screws were inserted percutaneously, while multiple screws were directed through the fibular graft for enhanced stability. The combination of a fibular strut allograft with a lateral locking plate offers a reliable option for treating comminuted distal femur fractures with osteoporotic features, minimizing displacement and reducing the risk of implant failure without necessitating additional medial support or secondary implants.

Background Baseline data for extremity compartment pressure after trauma have only been looked at in small cohorts with historically inaccurate technology. Newer technology has enabled continuous, accurate pressure monitoring for the diagnosis of acute compartment syndrome (ACS). This study used data from prospective cohort trials with modern pressure sensors to examine baseline pressure values. Particularly, there was a comparison of the effects of age, sex, and fracture location on continuous trend behaviors in extremity trauma patients. Methodology Intracompartmental pressures (ICPs) from 129 non-ACS trauma patients with extremity fractures were examined. The trends in patients were analyzed with respect to age, sex, and anatomical fracture location. Results Younger patients exhibited higher mean ICPs compared to older patients at all time points. Both groups experienced the same rates of decline in pressure over time from trauma. Both older and younger patient groups experienced a steady linear decrease in pressure over the course of monitoring. The younger age group had a decrease of 0.202 mmHg per hour (y = 26.4 - 0.202x), and the older age group showed the same rate of decrease (y = 23.9 - 0.202x). Males and females initially had similar ICPs, but females showed a steeper decline over time, with the pressure in the female group decreasing at a mean rate of 0.303 mmHg/hour compared to 0.163 mmHg/hour in the male group. Tibia fractures were associated with a higher initial pressure and steeper declines in ICP compared to forearm fractures. Conclusions There are variances for continuous ICP measurements associated with age, sex, and fracture location in trauma patients who do not develop ACS. Continuous ICP monitoring offers a better understanding of pressure trends, allowing for more accurate and individualized assessments. Recognizing these trends is crucial in ACS assessment.

Background:. Three-dimensional (3D) printing has proven to be effective in orthopaedic surgery, improving both surgical planning and outcomes. Despite its increasing use in surgical programs, reviews evaluating its educational impact are sparse. Therefore, the aim of this review was to provide educators with evidence-based findings on 3D printing's potential in training junior surgeons, as well as discuss its benefits in enhancing patient communication. Methods:. A comprehensive search using PubMed and Web of Science databases was performed to identify articles related to orthopaedics, 3D printing, and education. After removing duplicates, 2,160 articles were screened, 152 underwent full-text review, and 50 met inclusion criteria. Articles discussed the impact of 3D-printed models on comprehension or surgical performance. Data on publication details, sample size, teaching focus, learning outcomes, costs, and conclusions were extracted. Learning effects in the control (didactic) and experimental (3DP) groups were compared. Results:. In fracture management training, studies demonstrated significantly improved fracture classification accuracy, surgical performance, and interobserver classification agreement with 3D models compared with didactic learning and traditional imaging modalities. These benefits were particularly evident in cases of complex fractures and junior trainees. In arthroscopy, 3D-printed simulators improved procedural accuracy and were more cost-effective than virtual reality simulators and cadaveric laboratory results. Three-dimensionally printed simulators were also assessed for skills related to spine surgery, in which trainees demonstrated clear learning curve improvements for pedicle screw placement and osteotomy techniques, as well as a better understanding of vital paraspinal structures. The application of 3D printing in patient education was equally promising, as it facilitated the process of informed consent, ultimately promoting shared decision making. Conclusion:. The use of 3D-printed models offers effective and customizable methods for developing essential surgical skills. Future research should focus on larger, more diverse study populations and should include long-term follow-up to better assess the impact of 3D printing on education and patient outcomes.