BACKGROUND:It is undetermined whether the quality of surgical technique in a humeral shaft fracture (reduction and fixation) affects outcomes. The aim of this study was to score the quality of surgical technique performed in patients with humeral shaft fractures and to assess whether the quality of surgical technique was associated with complications and (functional) outcomes. METHOD:A panel of expert orthopedic trauma surgeons, experienced in upper extremity surgery, assessed the quality of surgical technique (good, sufficient, or poor) in patients who participated in the HUMMER study on plain radiographs. The surgical technique was well performed if the experts considered that it (at least) adhered to the Arbeitsgemeinschaft für Osteosynthesefragen principles. Quality was evaluated by 2 experts independently. In case they disagreed, consensus was reached after an expert panel discussion. The quality of surgical technique was examined for its association with functional outcomes, complications, and reoperations. Outcomes included Disabilities of the Arm, Shoulder and Hand score, Constant-Murley Score, pain (visual analog scale), quality of life (Short Form-36, EuroQoL-5D), and range of motion. RESULTS:Among 245 surgically treated patients, an expert panel of 16 orthopedic trauma surgeons from 7 countries classified surgical technique of 82% of plate cases and 60% of intramedullary nailing cases as good or sufficiently performed. Good-performed surgery was associated with a better Constant-Murley Score (Ptreatment = .003) and faster improvement of the Disabilities of the Arm, Shoulder and Hand score (Pinteraction = .014) and pain level (Pinteraction = .034). Good-performed surgical technique showed better abduction, forward flexion, external rotation of the shoulder, and pronation-supination of the forearm (Ptreatment between <.001 and .038) than poorly performed surgical technique. No significant differences were found in overall complication rates, reoperations, or nonunion between good-performed surgical technique and poorly performed surgical technique. Operative treatment with well-performed surgical technique had superior functional outcomes, and fewer complication (16% vs. 35%, P < .019) and nonunion rates (3% vs. 26%, P < .001) than nonoperative treatment. These differences did not reach statistical significance for poorly performed surgeries. Analyzing the outcomes of the well-performed surgery group still resulted in the conclusion that operative treatment is superior to nonoperative treatment, and that plate fixation is superior to intramedullary nailing. CONCLUSION:Good-performed surgical technique was associated with faster functional recovery, improvement of range of motion, and fewer complications than poor surgical technique. Although operative treatment is superior to nonoperative treatment, this is particularly demonstrated when the surgery is performed well as assessed by expert upper extremity surgeons. In cases of poorly performed surgical technique, the benefits of operative treatment over nonoperative treatment were restricted to the earliest follow-up moments.

Spinopelvic fixation (SPF), alone or combined with iliosacral or transiliac-transsacral fixation, is often used for highly unstable posterior pelvic ring injuries and some fragility fracture patterns in older adults. However, the evidence specifically describing complications after SPF in older patients with U-type sacral fractures is limited. This systematic review was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, Embase, and grey-literature sources were searched from January 1, 2000 to July 31, 2025. Eligible studies included adults aged 60 years or older with U-type sacral fractures or closely related spinopelvic dissociation/FFP IVb patterns treated with SPF, and reporting at least one complication. Because of the small number of eligible studies, probable cohort overlap, heterogeneity in fracture definitions, treatment indications, fixation constructs, and outcome reporting, findings were synthesized narratively rather than pooled quantitatively. Three studies met the eligibility criteria, comprising 157 patients overall; however, only a subset underwent SPF, and two studies were produced by the same group with probable cohort overlap. The available cohorts mixed bilateral sacral fragility fractures, FFP IVb patterns, and comparative SPF-versus-trans-sacral constructs. Reported adverse events included wound or infectious complications, urinary tract infection and other medical complications, reoperation, and mortality. Construct-specific complication rates for true SPF-treated U-type fractures in older adults could not be estimated reliably. The available literature on SPF for U-type sacral fractures in older adults is extremely limited, clinically heterogeneous, and partly overlapping. Current evidence permits only a cautious narrative description of reported complications; it does not allow reliable estimation of complication rates, meaningful comparison with alternative fixation strategies, or definitive conclusions regarding indications for routine SPF use in this population.

Background: Pelvic fractures in young patients are typically associated with high-energy trauma and long-term functional impairment. Young women may experience additional gender-specific sequelae following surgical treatment. This study aimed to evaluate functional outcomes and quality of life in young women following pelvic ring injuries. Methods: A retrospective cohort study was conducted including female patients of childbearing age (16-45 years) who sustained pelvic ring injuries and underwent surgical treatment at a single Level 1 trauma centre between 2009 and 2019. Validated PROMs were used to assess quality of life (EQ-5D, EQ-5D-VAS), and functional outcomes (Majeed Pelvic Score), along with a self-designed questionnaire to collect obstetric-related data. Radiographic measurements were performed to assess fracture reduction. PROM results were analysed descriptively and correlations between outcome scores were assessed using Pearson correlation. Results: A total of 32 patients completed all questionnaires and were included in the analysis. The mean EQ-5D index score was 0.61 (SD 0.31), the mean EQ-5D-VAS score was 68 (SD 24), and the mean Majeed Pelvic Score was 77 (SD 21). Most patients achieved good or excellent functional outcomes according to the Majeed score. Strong correlations were observed between PROM scores. Obstetric follow-up data were available for 21 patients; among these patients, 53% reported fear of pregnancy following the injury. Conclusions: Young women treated surgically for pelvic ring injuries demonstrated generally good pelvic-specific functional outcomes but lower quality-of-life scores compared with population norms. Obstetric concerns were commonly reported. Larger prospective studies are required to better understand long-term outcomes in this patient population.

The treatment of closed tibial plateau fractures (TPF) is complex and carries a risk of malunion. Parathyroid hormone (PTH) plays a key role in bone metabolism, and a PTH-peptide (PTH1 − 34) promotes bone healing. The objective was to evaluate the safety and efficacy of a novel PTH-based bone-graft-substitute (KUR-111) in the treatment of TPF. The study was a randomised, controlled, multicenter, open-label (dose-blinded), and dose-finding clinical trial. Subjects were randomised into 3 groups (iliac crest autograft (control); KUR-111-low; and high-dose TGplPTH1-34). The primary efficacy endpoint was the rate of union by computed tomography (CT) at 16weeks, as assessed by the Independent Radiologist Evaluation Panel (IREP). A total of 183 TPF were enrolled and treated. The primary endpoint was met, as statistical non-inferiority was demonstrated for KUR-111-high compared with autograft at 16weeks. KUR-111-high significantly (p = 0.03) increased union rates compared to KUR-111-low (83.6

Background Healthcare is an energy and resource intensive sector, imparting significant environmental burden on a global scale. Minimizing avoidable resource utilization within hospitals can help achieve environmental sustainability amongst healthcare systems. Reducing surgical complications, such as tibial fracture-related infections (FRIs), which require resource-rich healthcare activities can be an impactful approach to achieve environmental sustainability, while maintaining or advancing patient health outcomes. The objective of this study was to leverage healthcare resource utilization data to evaluate the environmental impact of tibial FRIs amongst patients undergoing surgical treatment. Methods An environmental model was developed using inputs informed from a systematic literature review and synthesized in a meta-analysis. Healthcare resource utilization data were used to compare the environmental impact for patients with and without a tibial FRI in relation to key healthcare activities such as hospital length of stay, reoperations, antibiotic therapy, and emergency room visits. A subgroup analysis was conducted to understand the environmental implications of more severe open fractures complicated by FRI, to supplement the mixed (open/closed) fracture population presented in the base case. Sustainability data was obtained from the Sustainable Healthcare Coalition’s Care Pathways Guidance document and other published sources. Outcomes assessed were greenhouse gas (GHG) emissions, water use, and waste generated. Results The results of this environmental impact assessment demonstrated that effectively preventing tibial FRIs can lead to a substantial reduction in carbon footprint. Preventing one FRI may result in an average reduction of 1,025.3kg CO2, water savings of 1,778.6 m3, and waste savings of 79.4kg. Results of the subgroup analysis, which included patients with open tibial fractures, further substantiated the environmental impact associated with tibial FRIs. Conclusion Preventing tibial FRIs may have a substantial environmental impact leading to a reduction in GHG emissions, water use, and waste generation. Interventions that reduce the incidence of tibial FRIs may contribute to the global goal of environmental sustainability. The results of this study are intended to empower healthcare providers and decision makers within the healthcare sector to make informed decisions that contribute to improved environmental sustainability, while maintaining or advancing patient health outcomes.

Background The diamond concept, originally articulated for bone fracture healing, defines five essential and interdependent elements for successful repair: growth factors, an osteoconductive scaffold, mesenchymal progenitor cells, an optimal mechanical environment, and adequate vascularisation. Tendons and ligaments are dense, hypovascular collagenous tissues with limited intrinsic regenerative capacity. When injured, they heal by biomechanically inferior fibrotic scarring rather than by regeneration. No unifying biological framework currently exists to guide the development of biological augmentation strategies for soft tissue repair. Framework The diamond concept can be translated to tendon and ligament healing as a Soft Tissue Diamond (ST-Diamond), with five tissue-specific vertices. At the growth factor vertex, GDF-5 (BMP-14), TGF-beta, and bFGF drive tenogenesis in tendons, whilst FGF-2, TGF-beta1, and BMP-12 govern ligament repair. At the progenitor cell vertex, tendon stem/progenitor cells (TSPCs) and ligament fibroblasts replace bone marrow mesenchymal stem cells, supplemented by exogenous cell delivery where the native population is insufficient. At the scaffold vertex, bioresorbable, mechanically compliant materials, notably three-dimensional bioprinted methacrylated collagen (ColMA), replace osteoconductive constructs. At the mechanical vertex, controlled progressive loading replaces rigid/semirigid fixation, exploiting the mechanoresponsiveness of tenocytes and ligamentocytes. At the vascularisation vertex, preservation of the paratenon and, for the medial collateral ligament (MCL), the periligamentous blood supply replace the requirement for fracture site revascularisation. The anterior cruciate ligament and MCL illustrate contrasting extremes of ligament healing capacity within this framework. A sixth, overarching dimension, host status, encompassing metabolic health, nutritional state, and comorbidities, modulates all five vertices and must be optimised for successful repair. Conclusions The ST-Diamond provides a unifying conceptual framework to identify biological evidence gaps, guide experimental design, and ultimately translate next-generation biological intervention strategies, including 3D bioprinted TSPC-scaffold constructs, from bench to bedside. Prospective trials addressing all five vertices simultaneously are now desirable to test whether the framework translates into superior clinical outcomes for patients with tendon and ligament injuries.

One of the complications of both surgical and non-surgical treatment of fractures is the development of non-union. The 5-10% incidence of non-union quoted in the international literature is thought to be an underestimate of the real magnitude of this clinical problem. The etiology of atrophic non-union is multifactorial, involving biological, mechanical, infectious, and host-related factors. Much of the evidence regarding its pathogenesis is heterogenous and largely hypothesis generating. This heterogenicity has contributed to the wide range of treatment strategies used to address an atrophic non-union, with variable success rates. This structured narrative review summarizes current insights into the pathogenesis of atrophic non-union, including the inflammatory and immune response, the role of mesenchymal stem cells, bone morphogenetic protein, and the mechanisms of remodeling and angiogenesis. It also outlines an algorithmic approach to management, including the exclusion of occult infection, assessment of mechanical stability, optimization of modifiable host factors, and, finally, a graded approach to enhance the biological and mechanical environment of the non-union.

Periprosthetic fracture following hip resurfacing arthroplasty is an uncommon but important complication and represents a distinct failure mode compared with fractures around conventional stemmed total hip arthroplasty. Existing periprosthetic fracture classifications are useful descriptively, but they do not fully address the biomechanical and biological considerations unique to hip resurfacing. Herein, the epidemiology, risk factors, mechanisms of failure, diagnostic workup, classification, and management of periprosthetic fractures following hip resurfacing arthroplasty is presented. Particular emphasis is placed on early femoral neck failure, avascular necrosis, femoral neck notching, varus component positioning, implant stability, adverse local tissue reaction, metal ion assessment, and the role of cross-sectional imaging. The article also proposes the SAVE classification, a treatment-oriented framework incorporating four key domains: Stability of the implant, Anatomical fracture location, Viability of the femoral head-neck segment, and local Environment. The SAVE classification provides a practical framework for determining whether the resurfacing construct can realistically be preserved or whether revision arthroplasty is more appropriate. By linking classification directly to treatment strategy, it may improve consistency in assessment and guide decision-making in these complex injuries.

PURPOSE:This pilot study aims to validate the "ground truth" accuracy and consistency of proximal femur fracture classification using a large radiographic image database. The project, a collaboration between expert groups from the University of Turin and the AO Foundation, seeks to ensure that expert consensus-based annotations are reliable for future artificial intelligence (AI) model development. METHODS:A cross-sectional, diagnostic accuracy study was conducted using a randomly selected subset of 300 anteroposterior pelvic radiographs from a single-center image repository created at the University of Turin within the AO Innovation Translation Center framework. Fracture classification annotations were independently provided by the local clinical expert group (LC-EG) and by an independent AO expert group of surgeons (AO-EG). To assess interrater reliability between the two groups, Cohen's kappa coefficient was calculated for categorical agreement on the presence of a fracture and AO/OTA classification. RESULTS:The comparison of annotations from LC-EG and AO-EG yielded a Cohen's kappa of 0.81 (95 % confidence interval: 0.75-0.87) and a percentage agreement of 87.67 % (95 % confidence interval: 87.63-87.70) for the classification of proximal femur fractures into three defined categories: no fracture, fracture type 31A, and fracture type 31B. These results confirm a high level of consistency between the two expert groups in annotating the image dataset. CONCLUSION:The observed interrater reliability between the LC-EG and AO-EG supports the credibility of the reference annotations, establishing a validated ground truth for proximal femur fractures. This evidence justifies using the radiographic image database as a benchmark for future studies and as a foundation for transparent, reproducible AI development and evaluation, thereby facilitating safer integration of decision support tools into orthopedic trauma workflows.

Open fractures of the lower extremity remain challenging to manage even in the most experienced surgical teams. These injuries when they present with bone loss pose even greater challenges with often unpredictable outcomes. Whilst traditionally, bone transport has been used as the surgical technique to treat open long bone injuries with bone loss, recently the Masquelet technique has gained great popularity amongst surgeons to manage these injuries. Understanding better the role of the induced membrane, its molecular signature (possessing angiogenic, osteogenic and inductive properties) and the capabilities that exist to improve the biological potency of the graft materials implanted, as well as appreciating the contribution of several tips and tricks that have been developed (membrane preservation and graft optimisation), good results can be expected. Additionally, it appears that from the health economic perspective, the technique is associated with less costs compared to bone transport. Herein the Masquelet technique is described for the management of open fractures of the lower extremity presenting with bone loss providing useful tips on how complications can be reduced whilst improving clinical outcomes.

Transsacral percutaneous fixation is increasingly seen as a safe, effective minimally invasive treatment for geriatric posterior ring fractures The use of Navigation appears a safe and efficient method for percutaneous screw placement Multiple new implants have been described for management of these injuries. Level I evidence is still lacking for treatment options in the management of posterior pelvic ring lesions with percutaneous fixation

Introduction:The complement system has an important role in physiological bone healing, as studied mainly in animal models and local bone tissues. However, the role of the complement system in human fractures, particularly at the systemic level, remains insufficiently characterized. This study aimed to investigate the activation levels of the serum complement system during three healing phases (inflammation, repair and remodeling) of normal healing of long bone fractures and in patients diagnosed with fracture non-union. Methods:Blood samples were obtained from two groups of long bone fracture patients (normal healers and non-union) and healthy controls with no fractures. Blood samples from patients with normally healed fractures were collected at 1 week, 1 month, and 4-6 months post-fracture. Blood samples from patients diagnosed with non-union were collected at 1-year post-fracture. The serum samples were processed using mass spectrometry to quantify the complement protein expression. The ELISA was used for validation. Ingenuity Pathway Analysis (IPA) software was used for molecule-pathway interactions. Results:The classical complement pathway components, complement C1s and C1r, were significantly increased during the inflammation phase of normally healed fractures but reduced subsequently. The levels of serum C3, C3a, and C9 were significantly greater in the inflammatory phase than in the other phases. No significant differences were observed for other complement pathway components, complement factor B (CFB), complement factor H and I (CFH, CFI), ficolin 2 and 3 (FCN2, FCN3) and mannan-associated serine protease-1 (MASP1) when comparing the three phases. In fracture non-union, the serum MASP1 level was significantly higher than that of normal fracture healers and healthy controls. The IPA analysis showed a link between MASP1 as a part of the lectin pathway and damage in bone and cartilage. Discussion:Collectively, our data indicate temporal changes of the serum complement system with activation via the classical pathway, particularly during the inflammatory phase of normal healing of human bone fractures. Furthermore, systemic MASP1 levels were high in non-united fractures, indicating that the lectin pathway plays a unique role in abnormal fracture healing. This data will offer fresh avenues for utilizing complement system components, such as follow-up biomarkers and therapeutic targets, in bone injuries and diseases.

Traumatic testicular dislocation is a rare complication of high-energy blunt trauma, most commonly occurring in motorcycle collisions. When associated with pelvic ring injuries, diagnosis may be delayed due to haemodynamic instability, soft-tissue swelling and distracting injuries. We report a 20-year-old man who sustained an unstable anteroposterior compression pelvic ring injury following a motorcycle accident, complicated by bilateral extra-scrotal testicular dislocation. Initial clinical assessment was limited by extensive scrotal haematoma. Cross-sectional imaging and Doppler ultrasonography demonstrated bilateral displacement of the testes into the superficial inguinal regions with reduced perfusion. The patient underwent combined orthopaedic and urological surgical management, including definitive pelvic fixation and bilateral orchidopexy. Postoperative imaging confirmed restoration of normal testicular position and blood flow. At 12-month follow-up, normal urogenital, endocrine and sexual function were preserved.

Background/Objectives: Avascular necrosis of the femoral head is a debilitating condition that, if left untreated, leads to progressive arthritis necessitating total hip replacement (THR). In the younger adult population, there is a drive towards joint-preserving procedures, particularly where alternative techniques such as core decompression or vascularised bone grafting are anticipated to fail. Proximal femoral osteotomy is a technique that aims to remove the necrotic segment from the weight bearing area. The presented review aims to examine the efficacy of this technique in the management of avascular necrosis of the femoral head, reporting both rates of conversion to total hip replacement and patient reported outcomes. Methods: This systematic review was conducted according to PRISMA guidelines. A search was conducted of PubMed, Ovid Medline, EMBASE, and the Cochrane Library using pre-defined search terms. Data were extracted, and descriptive data presented. Quality of each study was assessed using the NIH quality assessment tool for case series studies. Results: Fifty-three studies with data for 2686 osteotomies are presented. Progression of radiological arthrosis was present in 40% of cases, with 20.3% of patients having undergone conversion to THR at a mean of 75.4 months (range 20–132 months). Patient-reported outcome measures were recorded in 1416 patients, of which the Harris Hip Score was the most commonly utilised. This score improved from a mean of 58.3 to 84.4 at a mean follow-up of 102 months. Conclusions: Osteotomy represented a valid head-preserving technique in the armamentarium against avascular necrosis of the femoral head, with conversion to THR required in 20.3% of patients at 7 years. In those patients who did not require THR, PROMS were similar to the arthroplasty population.

Bone defect treatment represents one of the most challenging clinical conditions for restoring the bone that is missing in a timely fashion without the need of re-interventions. Currently, the two most commonly used techniques for the treatment of bone defects greater that 4cm are bone transport and the masquelet 2-sage technique. The masquelet technique requires bone grafting to be implanted during the second stage of the procedure which over of period of time with the support of the induced membrane vascularises and integrates with the host restoring bone continuity and function. Noteworthy, the minimum requirements to be present for a successful bone healing response have been described by the so called ‘diamond concept’ including of cellular elements, an osteoconductive matric (scaffold) and inductive molecules (growth factors). Inductive molecules promote osteoinduction by providing important signals to progenitor cells to undergo the process of mitogenesis and differentiation to osteoblasts. Currently in the clinical setting two growth factors are available for implantation, bone morphogenic protein-2 (BMP-2) and platelet rich plasma (PRP). The use of either of these two molecules in bone defect treatment depends on the extend of the biological deprivation of the local environment (number of previous surgeries, state of quality of muscle, periosteum and bone tissues), length of the defect, and the co-morbidities and characteristics of the host. Clinical cases will be presented to demonstrate their applications and the effectiveness of growth factors in the treatment of bone defect situations. Different surgical techniques will also be presented to allow a better understanding of the issues and challenges that one must overcome to enable a successful clinical outcome.

Introduction: Cold welding is an anecdotally well-known complication of removal of metalwork, most commonly at the screw–plate interface, and can often complicate extraction of implants after fracture fixation. Even though this phenomenon is familiar amongst the orthopedic community, there is relatively little formalized discussion or literature pertaining to its identification and management clinically. In addition, as far as we can establish, there does not seem to be a paper that discusses the various techniques described in the literature that are employed to combat cold welding. Methods: A systematic review was carried out in accordance with the PRISMA guidance, with two independent reviewers and a third person to arbitrate for any discrepancies. Manuscripts were identified using a search of PubMed/MEDLINE and Google Scholar. Studies eligible for inclusion were tabulated and the results categorized qualitatively with respect to the technique described for removal of the implants. Results: A total of 272 manuscripts were identified using a search of PubMed/MEDLINE and Google Scholar, and of these 14 were ruled to be eligible for inclusion reporting on 292 patients. Common locations of the cold-welded screws included femur, tibia, distal radius and clavicle. The most common technique for metalwork removal was using either bolt cutters or burrs to cut the plates between the screws and mobilize the screw and plate as one unit. Other techniques included using specialized removal tools and cutting between the screw head and body. There was no appreciable correlation between the specific anatomic location of the welded implant and the technique used in its removal. From the studies, it was found that, of the total number of screws (n = 1654), 58 (3.5%) were cold welded. The mean time to metalwork removal was 1104 days (36.8 months). Conclusions: As far as we can tell, this is the first systematic review pertaining to the phenomenon of cold welding specifically, and with this project we have collated the techniques used to remove implants affected by cold welding from a variety of different articles. Our work aims to highlight the relative paucity of literature in this area and provide a number of accessible and safe techniques to facilitate the removal of cold-welded implants in fracture fixation.

Impaction femoral head fractures are seldom diagnosed or treated, even though they can be present in between 39% and 57% of acetabular-fracture dislocations or hip dislocations. These fractures can cause residual hip pain, instability, avascular necrosis (AVN) and early joint wear, potentially necessitating a total hip arthroplasty. Treatment options range from expectant management, which carries a high risk of AVN, to controlled hip dislocation and mosaicplasty, the latter demonstrating variable results.We present the case of a woman in her 50s with an impaction femoral head fracture treated via closed reduction with a bent rod using a predrilled tunnel created with the dynamic hip screw reamer, followed by biological stabilisation with allografts, bone morphogenetic protein-2 and stem cells to provide the appropriate environment for bone healing. This minimally invasive technique offers a viable treatment option for impaction femoral head fractures, with low morbidity and favourable short and mid-term follow-up outcomes. Further studies can validate the results of this technique.