OTA international : the open access journal of orthopaedic trauma最新文献

Rehabilitation after musculoskeletal trauma is globally acknowledged as essential for restoring function and improving quality of life; however, significant variation exists in rehabilitation frameworks and services worldwide. Although certain principles-such as early intervention, structured care pathways, and multidisciplinary approaches-are universally recognized as important determinants of outcomes in trauma patients, their implementation and effectiveness vary considerably due to differences in health care infrastructure, economic resources, policy frameworks, and cultural contexts. Drawing on comparative analyses of rehabilitation frameworks across regions, including North America, Latin America, Europe, Asia-Pacific, and Africa, this paper identifies structural variations, systemic challenges, and innovations that can inform global rehabilitation efforts. Strategic international collaboration focusing on shared learning, standardized protocols, technology integration, and targeted investments is key to creating equitable and sustainable rehabilitation models, especially in resource-limited settings and aging populations.

For the last 2.5 years, Ukrainian surgeons have faced a vast number of war casualties generated by the Russian full-scale invasion in 2022. Despite being a middle-income country with limited medical resources, both the military and civilian Ukrainian health care systems were forced to respond to save lives and limbs of those injured by the destructive battlefield munitions. Development of educational resources to include on-line platforms were used on an unprecedented scale to educate civilian surgeons in the principles of war injury care, which differ from most civilian care practices. War trauma care principles of initial stabilization, debridement, external fixation with conversion to internal fixation where appropriate with bone and soft tissue defect management principles were implemented. Infection control measures were also important in mitigating infections associated with these severe injuries. These models and lessons can be useful in other conflict zones across the globe.

The management of open fractures in Colombia is influenced by special conditions shaped by the unique medical, social, and infrastructural environment that exists within the many varied regions of the country. These factors make the treatment of open fractures and associated injuries particularly complex.

The introduction of 3D technology in pelvic and acetabular surgery has the potential to change preoperative and intraoperative management. This technology is being developed in a number of areas, including improved preoperative planning and the development of patient-specific implants, and intraoperative visualization and assistance in traditionally technically challenging procedures. This expanding field holds exciting avenues for future changes in practice but requires knowledge of its limitations for appropriate application.

Introduction: Gustilo-Anderson type IIIB open tibial fractures carry a high risk of fracture-related infection (FRI) due to extensive soft tissue damage and frequent delays in coverage. Although early orthoplastic intervention lowers infection rates, many trauma centers lack the resources for same-day or early flap coverage. This study aimed to assess the relationship between timing of flap coverage and FRI risk in a young, healthy population, and to define a clinically relevant therapeutic window.

Materials and methods: A retrospective cohort study was conducted at a single Level I trauma center (2012-2023). Patients with GA IIIB tibial fractures were treated under a standardized protocol with strict inclusion criteria. Timing of flap coverage was analyzed using Levene test, Student t test, and ROC curve analysis with the Youden index to determine the optimal infection-risk threshold.

Results: Out of 332 open tibial fractures, 41 patients with GA IIIB injuries met inclusion criteria. Mean time to coverage was 24.6 days. FRI occurred in 15 patients (36.6%). Delayed coverage was significantly associated with FRI (P < 0.001). ROC analysis showed an AUC of 0.83; the Youden index identified <12 days as the optimal cutoff (100% sensitivity, 34.6% specificity). None of the 10 patients treated within 12 days developed FRI, versus 56.6% in those treated later (P < 0.05).

Conclusions: Coverage within 12 days minimizes infection risk in GA IIIB tibial fractures. Although immediate coverage remains ideal, a defined 12-day window offers practical guidance, especially where early orthoplastic care is not feasible.

Objective: This review reports on the radiologic and functional outcomes and complications of managing adult traumatic femur shaft fractures (FSFs) with intramedullary nailing (IMN) in Low-and-Middle-Income Countries (LMICs) and evaluates the quality of existing evidence.

Methodology: A thorough literature search was conducted across several databases, including reference lists of selected articles. Screening was done per the PRISMA guidelines. Peer-reviewed articles published in English between January 2011 and December 2022 that reported radiologic or functional outcomes in adults with isolated traumatic FSFs managed with IMN in LMICs were included for review. The quality and level of evidence were assessed using modified Critical Appraisal Skills Program checklists and the modified Oxford Centre for Evidence-Based Medicine criteria.

Findings: Forty studies from 13 LMICs were included in this review. The mean time to union was 15.4 weeks, with a mean union rate of 88.1%. Functional outcomes scores showed >70% excellent outcomes. The Radiographic Union Scale in Tibia score and Thoresen criteria were the most used assessment tools. Mean infection rates were 4.8%, and limb shortening (of varying amounts) occurred in 3.5% of patients. The findings revealed variability in measuring and reporting IMN outcomes in FSFs, but overall, the existing evidence was of satisfactory quality.

Conclusion: Despite the data limitations, methodological differences, and outcome discrepancies, this review demonstrates a trend favoring IMN for FSFs, with low failure rates in low-resources settings. However, more robust studies using standardized radiographic and functional outcomes measures in LMICs are needed.

The Orthopaedic Trauma Association (OTA/AO) 2024 International Trauma Care Forum held in Montreal focused on the management of gunshot-related extremity trauma in both conventional and irregular warfare. Key presentations addressed the full-scale Russo-Ukrainian war and Colombia's enduring internal conflict, emphasizing the disproportionate burden of complex civilian injuries. In Ukraine, since the 2022 invasion, high-velocity ballistic and explosive trauma has resulted in injuries with extensive skeletal and soft tissue damage, often necessitating staged surgical debridement, external fixation, limb reconstruction, or amputation. Innovative techniques, including 3D-printed implants and regional or free flap coverage, have been incorporated into multidisciplinary protocols, despite significant limitations in subspecialty access and surgical resources. Conversely, Colombia's conflict-ongoing for over 7 decades-has resulted in over 2 million registered victims who have sustained physical injuries caused by bullets, explosions, or other war-related trauma, including both combatants and civilians. Urban areas primarily see low-energy gunshot wounds, whereas rural zones are affected by higher-energy injuries caused by improvised landmines and other unconventional weapons. Treatment is complicated by delayed evacuation, lack of trauma system infrastructure, and biologically contaminated injuries leading to high infection rates. The forum highlighted the importance of adaptable, evidence-based protocols, antimicrobial stewardship, and long-term rehabilitation strategies. The consensus of the expert panel was that the persistent burden of extremity trauma in conflict settings demands coordinated global trauma systems and equitable access to limb preservation and reconstructive care.

Pelvic fractures associated with hemodynamic instability present a major challenge in trauma care, carrying mortality rates up to 30%. Successful management requires a multidisciplinary approach focused on resuscitation, mechanical stabilization, and hemorrhage control. Based on the 2024 International Orthopaedic Trauma Association (IOTA) Annual Meeting Pelvic Symposium, this review summarizes current recommendations for the management of hemodynamically unstable patients with pelvic fractures. Initial skeletal stabilization typically involves noninvasive pelvic binding devices, such as sheets or commercially available binders, employed in both pre-hospital and hospital settings. Subsequent resuscitation strategies include hypotensive resuscitation-restricting fluid administration to maintain lower blood pressure until bleeding is controlled-and damage control resuscitation-consisting of rapid surgical interventions aimed at achieving hemostasis. Current best practice also includes early empirical administration of balanced transfusion products guided by massive transfusion protocols, with targeted adjustments based on point-of-care testing results. Hemorrhage control methods vary depending on available resources: angioembolization effectively manages arterial bleeding in well-resourced facilities, whereas preperitoneal pelvic packing offers a quick, accessible solution for venous and bone-related hemorrhage, particularly in low-resource environments. Although the timing of pelvic binder removal and definitive invasive skeletal stabilization remains controversial, recent evidence supports early definitive internal fixation within 24 hours post-injury.

The Fracture Nonunion Symposium presented at the 2024 Orthopaedic Trauma Association Basic Science Focus Forum featured invited speakers who discussed current perspectives on this topic. Clinical approaches, diagnostic advancements, basic science perspectives, and novel treatment strategies were discussed. This symposium was curated to highlight this common and challenging clinical problem faced by orthopaedic and musculoskeletal practitioners from around the globe.

Polytrauma represents one of the most challenging scenarios in modern trauma care, with fracture healing outcomes that defy conventional expectations. Although isolated fractures typically follow predictable healing patterns, the presence of multiple injuries creates complex interactions that can either accelerate or severely impair bone regeneration. Remarkably, patients with traumatic brain injury often demonstrate enhanced fracture healing with rapid callus formation and shorter time to union, whereas those with systemic inflammatory burden from thoracic or multiorgan trauma frequently experience delayed healing and complications. These paradoxical outcomes reflect distinct biological pathways that are only beginning to be understood. Malnutrition, affecting up to one-third of hospitalized orthopaedic patients, further complicates recovery by impairing both soft tissue and bone healing. Emerging research has identified key molecular mediators including complement factors, inflammatory cytokines, and potentially leptin as critical determinants of healing trajectories. However, translating these laboratory findings into clinical practice remains challenging because of the heterogeneous nature of polytrauma populations and the complexity of coordinating multicenter research. The purpose of this review is to synthesize current understanding of nutritional optimization strategies in polytrauma, delineate the molecular mechanisms underlying both accelerated and delayed fracture healing, explore the unique effects of traumatic brain injury on bone regeneration, and describe the development of collaborative research infrastructure necessary to advance the field.