Introduction:Atypical femoral fractures (AFFs) are insufficiency fractures of the lateral femoral cortex and represent a rare but significant complication of long-term bisphosphonate or denosumab therapy. Our report explores the surgical techniques utilised to avoid varus malalignment in these two complex cases, both of which fulfilled the American Society for Bone and Mineral Research (ASBMR) criteria for AFFs. Case Presentation:Case 1 presents a woman in her early 60s with over 8 years of bisphosphonate use, who developed simultaneous AFFs. She underwent bilateral internal fixation with cephalomedullary nails. This was followed by revision surgery and a valgus correction for right femoral fracture nonunion.Case 2 presents a man in his late 60s with prior exposure to bisphosphonates and denosumab (< 7 years), who sustained a left AFF. Initial cephalomedullary nailing was complicated by nonunion and hardware failure, necessitating revision with a valgus correction. Conclusion:Our cases emphasise the importance of recognising symptoms during follow-up assessments and provide a detailed account of the surgical techniques employed in the revision fixation of AFFs, with a particular emphasis on achieving valgus alignment, maintaining a medial entry point and avoiding varus malalignment to optimise mechanical stability, reduce the risk of postoperative nonunion and promote fracture healing.

With easy access to the Internet, the majority of patients today often resort to online material for education. The aim of our study is to assess the quality and readability of online information relating to tibial shaft fractures (TSFs). A search of the top 50 results via three search engines was performed. The readability of these webpages was assessed using www.readable.com to generate scores for the Gunning Fog Index (GFI), Flesch Reading Ease (FRE) and Flesch–Kincaid Grade (FKG). The quality was also assessed using the DISCERN tool and the Journal of American Medical Association (JAMA) benchmark criteria. A total of 90 unique websites were noted. The mean FKG was 10.67 ± 2.44, with 70 webpages scored at a reading level which was too high. The mean GFI was 12.2 ± 3.6, with only six webpages pitched at a sixth-grade reading level. The mean FRE score was 38.13 ± 13.21, with no websites reported to be below a seventh-grade reading level. The mean DISCERN score was 49.84 ± 12.42, with an assigned score of “fair”. The majority of webpages also failed to meet any of the JAMA criteria (n = 31, 34.44

Introduction:This is the first reported case of breast carcinoma metastasizing to the clavicle, causing a pathological fracture and subsequently being treated with open reduction and internal fixation (ORIF). Case Report:A 60-year-old female presented with shoulder pain after a minor trauma while swimming. She had prodromal pain and a breast cancer history. The radiograph revealed a right clavicle fracture. She had ongoing pain and no union on radiographs, with concern for a pathological fracture. Bone biopsy was performed and consistent with metastatic breast carcinoma involving the clavicle. ORIF was performed for symptomatic control. A 14-month follow-up revealed a healed fracture and a full return to activity. Conclusion:A pathological clavicle fracture may be the presenting complaint of an unknown primary tumor or even signal recurrence of a previously treated malignancy. They can be challenging to diagnose and as such, we would urge surgeons to have a high index of suspicion in these cases. Excision of clavicular metastasis and partial or even full claviculectomy have been described in the literature. This is the first reported case of breast carcinoma metastasizing to the clavicle, causing a pathological fracture and subsequently being treated with ORIF. We would suggest that surgeons faced with this issue in the future consider it as a surgical option for pain relief and restoration of function in the otherwise fit and active patient.

Despite modern advancements in nailing techniques, delayed healing and nonunion of tibial fractures remains an important clinical problem. Tibial nonunions are reported to occur at a rate of 7–19 % based on data from North American Level 1 trauma centres. Patients may require repeated operations over a protracted period of care. These nonunions finally heal at an average of 20 months after the initial injury. Early evidence from ovine studies and clinical trials has suggested that axial micromotion mediates faster tibial fracture healing compared to rigid fixation. In this case series, we present our experience with treating tibial shaft fracture nonunion with an intramedullary micromotion nail.

Background:Tibial shaft fractures (TSFs) are a frequent presentation within orthopaedics, most often occurring in young males following a high energy trauma. The appropriate management of these fractures is crucial, ensuring patients have the best chance at achieving a functional recovery. In spite of the vast number of studies conducted on TSFs, the quality of scientific evidence and various trends related to this injury remains poor. The aim of our analysis is to identify these trends within the 50 most cited publications pertaining to TSFs. Methods:A bibliometric analysis was carried out using the Web of Science platform to report the 50 most cited publications associated with TSFs. The publications were screened using definite inclusion and exclusion criteria. Features such as institution, authorship, level of evidence and patient demographics were reported. Results:The 50 most cited publications in total listed 10, 407 citations, with the most cited study receiving 1075 citations. Treatment outcomes (66 %) and surgical technique (32 %) were the primary focus of the majority of the publications. Retrospective cohort and case control studies made up almost half of the studies (48 %), many being of level III evidence. The McMaster University Hospital was the institution that produced the greatest number of studies, with the Journal of Bone and Joint Surgery having published most of the articles. Conclusion:Many publications exist related to TSFs, primarily focusing on treatment outcomes and how to minimize the incidence of non-union following surgical fixation. However, a significant number of the publications were of low evidence and were identified as being retrospective in nature. Following this analysis, future research should aim to produce studies of a higher quality and focus on areas that carry the most promise or influence, such as the use of recombinant human bone morphogenetic protein-2 in intramedullary nailing of TSFs.

Background The suprapatellar (SP) approach to tibial intramedullary nailing has evolved substantially over the past three decades, transitioning from a technically innovative alternative to the infrapatellar (IP) method into a globally recognized standard for tibial shaft fracture management. This bibliometric study aimed to evaluate global publication trends, research themes, and evidence evolution surrounding SP tibial nailing between 1995 and 2025. Methods A comprehensive bibliometric and evidence-based analysis was performed using the PubMed/MEDLINE and Crossref databases. Studies published from January 1995 to October 2025 were identified using predefined search terms. Eligible articles addressing suprapatellar or semi-extended tibial nailing were screened for design, origin, citation impact, and evidence level. Results A total of 128 eligible studies were identified, including clinical trials, cadaveric analyses, and systematic reviews. Global publication output increased exponentially after 2012, coinciding with the introduction of specialized SP instrumentation. The United States, United Kingdom, Germany, China, and Australia collectively contributed over two-thirds of publications. Recent years (2020–2025) demonstrated a transition from observational studies to high-level evidence, with six randomized controlled trials and six meta-analyses identified. Quantitative trends revealed reduced operative times, improved alignment, and lower rates of anterior knee pain with SP compared to IP nailing. Conclusion Bibliometric and evidence synthesis confirms a steady progression in research quality and international collaboration in SP tibial nailing. The accumulated body of evidence supports SP nailing as a safe, efficient, and reproducible technique with distinct advantages over the infrapatellar approach. Continued longitudinal and cost-effectiveness analyses are warranted to consolidate its role in modern orthopaedic trauma practice.

Previously published literature from our institution found that patients with a fragility hip fracture were estimated to have a 4–10

Cortical screw fixation across the tibiofibular joint is the mainstay of treatment for syndesmotic injury. Dynamic fixation devices have been developed offering similar advantages to screw fixation in terms of reduction and stability of the syndesmosis. Dynamic fixation may also facilitate a more physiological movement between the tibiofibular joint and thus incur less morbidity. Patient’s rehabilitation potential is enhanced and reduces the need for hardware removal. Our systematic review aims to analyse the relevant current literature and compare screw fixation to dynamic fixation in the treatment of syndesmotic injury associated with acute ankle fractures. A literature search was performed on Pubmed and Ovid Medline to find scientific papers relating to syndesmotic fixation in acute ankle fractures. Papers were screened and included dependent on predetermined criteria. Risk of bias was assessed after screening full papers by two independent reviewers. Tables and analysis were made using Microsoft excel. A total of 8 papers with 673 patients were included. We found no functional difference between screw fixation or dynamic fixation groups at final follow-up. Three papers showed statistically significant lower rates of reoperation in the dynamic fixation group. Dynamic fixation may offer lower post operative complications and reoperation rates. Therefore, dynamic fixation may be a beneficial alternative treatment compared to traditionally used syndesmotic screws.

Background Parents often access online resources to educate themselves on their child's condition. In-toeing, alsoreferred to as pigeon toeing, is a common paediatric condition that has a variety of causes and is often acause of concern for parents. With the increasing usage of the internet, parents of children with thiscondition may look to the web for answers. However, to be understood by the average adult, online healthinformation must be written at an elementary school reading level. We hypothesised that currently availableonline resources regarding in-toeing would score poorly on objective measures of readability andunderstandability. Methods Patient education materials were identified via three commonly used online search engines (Google.com,Yahoo.com, and Bing.com). The terms "intoeing" and "pigeon toeing" were used for the search. From thetop 50 search results, websites were included if directed at educating patients and their families regardingin-toeing. News articles, non-text material (video), industry websites, and articles not related to in-toeingwere excluded. The readability was analysed using a specialised website www.readable.com to produce thefollowing three scores: Gunning Fog Index (GFI), Flesch Reading Ease (FRE), and Flesch-Kincaid Grade(FKG). Understandability was calculated using the 19-point Patient Education Materials Assessment Tool(PEMAT).ResultsAfter removing duplicates, 84 unique websites were assessed for inclusion. A total of 48 websites andarticles (57.14%) met the inclusion criteria. Of note, 23 articles out of 84 (27.38%) were excluded as theywere intended for healthcare professionals. The means for the FRE, FKG, and GFI were 57.92 (+/- 12.26), 7.92(+/- 1.91), and 9.35 (+/- 2.36), respectively. Less than half of online resources had an FRE score at or higher thanthe recommended reading level for the general population. Mean understandability scores were 69.63%(+/- 11.55%), with only 45.83% of articles being greater than the 70% requirement of adequateunderstandability. Conclusion Overall, online in-toeing educational materials scored poorly with respect to readability andunderstandability. Given the popularity of online resources in patient education, we should seek to improvethis situation. Articles that are easier to read are thus more accessible to the general public and will aid in theshared decision-making process. Improved patient and parent satisfaction and overall standard of care canbe expected

Background: Acromioclavicular joint (ACJ) reconstruction is an area of interest and debate within the field of trauma and orthopaedic surgery. Citations are an indirect measure of an articles influence within that particular area. Citation density seeks to identify the articles that are trending within an area. Methods: a search of the web of data base was carried out using the following terms: "Acromioclavicular joint" OR "AC joint" (Topic) AND Reconstruction OR Repair (Topic). These articles were reviewed for relevance and the top-50 were selected for analysis. These articles were reviewed with regards citations, citation density, geographic origin of the article, year published, article type. Results: The articles were cited a total of 6,053 times. The most cited article was cited 347 times. The highest citation density was 20.02, with a mean citation density of 7.71±4.13. Seventy percent of the articles were clinical research, of these 74% were level IV [4] evidence. Conclusions: This study established a list of the 50-most cited papers relevant to ACJ reconstruction, that can be used as a resource for orthopaedic trainees. It also established that there is a paucity of articles of higher levels of evidence among the articles contained in this list. Future research in the area of ACJ reconstruction should focus on producing research that satisfies the criteria for higher levels of evidence (to ensure highest standards of care for patients).

Background Fragility fractures are described as fractures resulting from low-energy trauma and are considered diagnostic of reduced bone mineral density or osteoporosis. They often present as hip fractures with hip fractures remaining a common but devastating injury among older patients. Many factors influence a patient’s risk of hip fracture and their subsequent risk of death. Aim In this study, we examined if previous fragility fracture impacts upon mortality after hip fracture. Methods This was a retrospective single-center cohort study of patients included in the Irish Hip Fracture registry over a 5-year time period. Epidemiological data including gender, age, type of fracture, type of surgery, bone protection medication, American Society of Anesthetics (ASA) grade, and post-fracture outcomes including death at 30 days and death at 1 year were recorded. The presence or absence of a previous fragility fracture was examined to explore if a previous fragility fracture was an independent predictor of mortality. Results There were 964 patients included, and 290 of whom had sustained a previous fragility fracture; 289 patients were males and 675 females, 33 patients had died in the 30 days following their surgery, and 180 patients had died within 1 year. We found statistically significant results for gender and age but not for previous fragility fracture influencing mortality ( p value 0.230). Conclusion We found that previous fragility fracture does not impact upon mortality in a hip fracture cohort. However, gender and age did impact upon mortality in this study.

Objectives: Prosthetic joint infection (PJI) is a serious complication following arthroplasties. This study assessed the clinical outcomes, readmission rates and financial impact of PJIs treated with outpatient parenteral antimicrobial therapy (OPAT).Methods: The study used prospectively collected data from the OPAT patient database at a tertiary care Irish hospital for PJI cases managed between 2015 and 2020. Data was analyzed using IBM-SPSS.Results: Forty-one patients with PJIs were managed via OPAT over five years, with median age of 71.6 years. Median duration of OPAT was 32 days. Hospital readmission occurred in 34% of cases. Reasons for readmission included progression of infection in 64.3%, unplanned reoperation in 21.4% and planned admission for joint revision in 14.3%. Type 2 Diabetes Mellitus (T2DM) was found to have a statistically significant association with unplanned readmission (OR 8.5, CI 95% 1.1-67.6; p < 0.01). OPAT saved a mean of 27.49 hospital-bed days per patient. 1,127 bed days were saved in total, estimating a total savings of 963,585 euros and median savings of 26,505 euros. Conclusions: The readmission rate observed was comparable to international data. Most read-missions were related to primary infections rather than due to OPAT-specific complications. Our main findings were that patients with PJIs can be safely managed via OPAT, and the finding of association between T2DM and increased risk of readmission.

Background: Patients are increasingly accessing health information via the internet. Our aim was to assess the quality and readability of online patient education materials regarding metatarsal stress fractures. We hypothesised that this information would be too difficult for the average patient to read and of a lesser quality than desired. Methods: A search of the top 50 results on 3 search engines (Google, Bing, Baidu) was completed (MeSH “metatarsal stress fracture”, “metatarsal stress fractures”). Readability of these websites was calculated using www.readable.com, producing 3 scores: Gunning-Fog (GF), Flesch Reading Ease (FRE) and Flesch-Kincaid Grade (FKG). Quality of the retrieved webpages was analyzed using Journal of American Medical Association (JAMA) benchmark criteria and the Health On the Net (HON) code toolbar extension. Results: In total, 77 unique websites were identified. The mean scores were: FRE 56.34±16.1, FKG 8.36±2.8 and GF 9.35±3.4. This corresponds with most webpages being pitched to a grade 8–12 reading level. Most webpages per the FRE score (n=47, 61%) were pitched at a grade 10 reading level and above. The GF index identified 20 webpages (26%) aimed towards readers of a grade 7 level or below. Approximately 13% (n=10) displayed a current HONcode certificate. Most websites (n=35, 45.5%) didn’t meet any of the JAMA criteria. Conclusions: This study uncovers the high difficulty and poor quality of online health materials relating to metatarsal stress fractures (MSFs), potentially contributing to negative health outcomes. Given the relationship of health literacy and patient outcomes, it is vital that we address these deficiencies swiftly.

Background: Currently, patients use the internet for health information relating to surgery. The aim of this study is to assess the readability and quality of online health information relating to acromioclavicular joint reconstruction. We hypothesize that the information will be of poor quality and be too difficult to read for the average patient. Methods: The top 50 results from Google, Bing, and Yahoo [Medical Subject Headings (MeSH) “acromioclavicular joint reconstruction”, “ac joint reconstruction”] were used for analysis. Readability was assessed using 3 scores [Gunning FOG (GF), Flesch Kincaid Grade (FKG), and Flesch Reading Ease (FRE)], these scores were generated using an online calculator (www.readable.com). Quality was assessed using HONcode Google toolbar extension and JAMA benchmark criteria. Results: A total of 116 Uniform Resource Locators (URLs) were subject to analysis. The mean GF was 12.11±2.88. The mean FKG was 10.59±2.15. The mean FRE was 38.86±13.27. FRE score found no website pitched at 6th grade level, and only 4 (3.4%) and 2 (1.7%) of the websites were pitched at this level according to the GF and FKG scores respectively. The mean JAMA score was 1.91±1.51. Only 10 websites had HONcode certification. Conclusions: The quality of online patient information pertaining to acromioclavicular joint reconstruction is of poor quality and is too difficult to read. Providing high quality online information, that is easy to read for the average patient, will lead to better patient contribution to the shared-decision making process, and thus better patient outcomes.

Currently, patients use the Internet for health information relating to surgery. The aim of this study is to assess the readability and quality of online health information relating to acromioclavicular joint reconstruction. We hypothesise that the information will be of poor quality and be too difficult to read for the average patient. The top 50 results from Google, Bing, and Yahoo (MeSH “acromioclavicular joint reconstruction”, “ac joint reconstruction”) were used for analysis. Readability was assessed using three scores (Gunning FOG (GF), Flesch–Kincaid Grade (FKG), and Flesch Reading Ease (FRE)); these scores were generated using an online calculator ( www.readable.com ). Quality was assessed using a HONcode Google Toolbar extension and JAMA benchmark criteria. One hundred sixteen webpages were subject to analysis. The mean GF was 12.1 ± 2.9. The mean FKG was 10.6 ± 2.15. The mean FRE was 38.9 ± 13.3. FRE score found no webpage pitched at the 6th grade level, and only 4 (3.4%) and 2 (1.7%) of the webpages were pitched at this level according to the GF and FKG scores, respectively. The mean JAMA score was 1.9 ± 1.5. Only 10 webpages had HONcode certification. The quality of online patient information pertaining to acromioclavicular joint reconstruction is of poor quality and is too difficult to read. Physicians and health information providers should conform to health literacy standards. Health information providers should meet the minimum standards of verified assessment tools.

Carroll, Patrick FRCS; Murphy, Ben MRCSI; O' Neill, Áine MB BCh, BAO; Abdulkarim, Ali FRCS; Chhabra, Jatinder FRCS, RCS Author Information

: Asher’s original description of Munchausen’s syndrome was characterised by pathological lying, feigning illness and wandering from hospital to hospital. Munchausen’s syndrome—orthopaedic variant has been rarely reported in the literature. A young male presented to a nearby hospital with a left shoulder dislocation after an alleged kickboxing injury. The patient reported worrying clinical findings including excruciating pain and absent sensation distally. Reduction was successful but his shoulder re-dislocated shortly after. His reported symptoms worsened and he was transferred to our institution. Imaging findings were not immediately concerning and he went to theatre the next day for an examination under anaesthetic. His shoulder was re-located easily and an immobiliser applied. Less than an hour later, the patient managed to re-dislocate his shoulder in recovery. He was subjected to another general anaesthetic and successful reduction. He absconded the following day after being declined multiple and increasing doses of opioid analgesia. He re-presented three weeks later with similar clinical findings but a different mechanism of injury. Further exploration of his collateral history revealed that he had been using a false identity. He had presented to all hospitals in our city within the previous 6 months. Once confronted, he did not return to these hospitals. He was also capable of self-relocating his shoulder. This case bore a striking resemblance to a case described by Warren in 2000 of a young lady with an apparently dislocated shoulder presenting to multiple city hospitals looking for analgesia and general anaesthetics. We wished to highlight the diagnostic and ethical challenges associated with these patients. They are vulnerable and so a high index of clinical suspicion is needed on the part of the surgeon to avoid unnecessary interventions. Effective communication between orthopaedic departments is a key recommendation from this case to mitigate risk of harm to these patients.

Abstract Background Patients are increasingly accessing health information via the internet. Our aim was to assess the quality and readability of online patient education materials regarding metatarsal stress fractures. We hypothesised that this information would be too difficult for the average patient to read and of a lesser quality than desired. Method A search of the top 50 results on 3 search engines (Google, Bing, Baidu) was completed (MeSH “metatarsal stress fracture”, “metatarsal stress fractures”). Readability of these websites was calculated using www.readable.com, producing 3 scores: Gunning-Fog (GF), Flesch Reading Ease (FRE) and Flesch-Kincaid Grade (FKG). Quality of the retrieved webpages was analyzed using Journal of American Medical Association (JAMA) benchmark criteria and the Health On the Net (HON) code toolbar extension. Results 77 unique websites were identified. The mean scores were: FRE 56.34+/- 16.1, FKG 8.36 +/- 2.8 and GF 9.35 +/-3.4. This corresponds with most webpages being pitched to a grade 8–12 reading level. Most webpages per the FRE score (n = 47, 61%) were pitched at a grade 10 reading level and above. The GF index identified 20 webpages (26%) aimed towards readers of a grade 7 level or below. 10 websites (13%) displayed a current HONcode certificate. Most websites (n = 35, 45.5%) didn’t meet any of the JAMA criteria. Conclusion This study uncovers the high difficulty and poor quality of online health materials relating to MSFs, potentially contributing to negative health outcomes. Given the relationship of health literacy and patient outcomes, it is vital that we address these deficiencies swiftly.