Publications by Year: 2026

Fracture-related infections (FRIs) remain a significant challenge in orthopaedic trauma, as they are a consistent source of poor patient outcomes and elevated health care costs. FRIs have traditionally been diagnosed using findings from physical examination, blood tests, and advanced imaging, and the mainstay of treatment has been bony debridement, removal of hardware, and local and systemic antibiotic therapy. Although patients with FRIs were historically treated with IV antibiotics, randomized clinical trials have since demonstrated that oral antibiotics can be just as effective while mitigating the risks associated with prolonged IV antibiotics. Emerging biomarkers for infection, including molecular methods such as transcriptomics, proteomics, metabolomics, and next-generation sequencing, offer the ability to more precisely identify infection from a wider range of microbes. Fluorescence-guided debridement surgery presents a strategy to better visualize infected tissue and decrease surgeon reliance on subjective intraoperative findings. The purpose of this review is to present emerging tools and treatment algorithms that might be able to increase the accuracy and precision with which FRIs are diagnosed and managed.

INTRODUCTION: Global orthopaedics includes collaborative efforts to improve clinical care, education, research, and capacity across international settings, with an emphasis on equitable, bidirectional, and sustainable partnerships. Interest in global orthopaedics among North American residents continues to grow, yet structured opportunities for clinical, educational, and research engagement in low- and middle-income countries (LMICs) remain limited. This study evaluated the availability of global orthopaedic opportunities within residency programs and assessed resident experiences, perceptions, and interest in expanding these initiatives.

METHODS: A cross-sectional survey was distributed to orthopaedic surgery residents in the United States and Canada through the Consortium of Orthopaedic Academic Traumatologists (COACT)-affiliated faculty and resident leads. Residents from postgraduate years 1 to 5 were eligible. Survey domains included prior global health experience, opportunities available at home institutions, resident satisfaction with existing resources, and interest in future global orthopaedic engagement. Descriptive statistics were performed.

RESULTS: Thirty of 35 residency programs (85.7%) participated, with 299 of 300 residents completing the survey (99.7%). Forty-six respondents (15.4%) reported prior or current participation in global orthopaedic activities, most commonly through organized teaching or clinical experiences (50.0%), research collaborations (41.3%), and elective international clinical rotations (37.0%). Nearly one third of residents (30.1%) reported that their residency program offered no global orthopaedic opportunities. Residents expressed dissatisfaction with the availability of mentorship, elective international rotations, and global outreach opportunities at their home institutions. Despite limited access, interest in expanding opportunities in LMICs was notable, particularly for mentorship and guidance (73.2%), elective international rotations (72.9%), and collaborative research (54.8%).

CONCLUSIONS: North American orthopaedic residents demonstrate substantial interest in global orthopaedic engagement that exceeds the opportunities currently available. These findings support expanding structured mentorship, international partnerships, and centralized networks such as COACT to facilitate sustainable global clinical, educational, and research opportunities during residency.

Lower limb soft tissue defects remain a major reconstructive challenge due to frequent exposure of critical structures and compromised vascularity. In complex cases where local tissue is insufficient, free tissue transfer is required. Advances in supermicrosurgery have enabled perforator-to-perforator (P-to-P) anastomoses allowing reliable perfusion while preserving major axial vessels and minimizing donor-site morbidity. A retrospective review was conducted of five patients who underwent P-to-P free flap reconstruction for lower limb defects between January 2018 and January 2023. Preoperative CT angiography and intraoperative duplex ultrasound were used for perforator mapping. Two anterolateral thigh, one medial sural artery perforator, and two gracilis muscle flaps were utilized. Anastomoses were hand-sewn using 10-0 to 12-0 nylon under high-magnification microscopy. Flap perfusion was monitored with Vioptix Tissue Oximeter. The mean age was 60.8 years and defect sizes ranged from 5 × 4 cm to 20 × 8 cm. All flaps survived without partial or total loss. One patient developed minor wound dehiscence that healed without intervention. Reconstruction was successful across varied etiologies including infection, chronic wounds, and postoperative defects, with low morbidity and no re-explorations. P-to-P supermicrosurgical reconstruction offers a reliable, vessel-preserving approach for complex lower limb defects. This technique maintains major vascular axes, minimizes donor-site morbidity, and achieves outcomes comparable to conventional microsurgical methods across diverse etiologies such as infection, chronic wounds, and postoperative defects. In our series, flap survival was universal with no re-explorations and minimal morbidity. Wider clinical adoption and continued experience may further define its role in contemporary lower extremity reconstruction.

BACKGROUND: Pediatric giant cell tumor (GCT) of bone is rare and remains poorly characterized. Skeletally immature patients may demonstrate increased metaphyseal involvement and higher recurrence rates, but existing data are limited to small single-institution series. We evaluated the clinical and surgical characteristics of pediatric GCT and compared recurrence by physeal status.

METHODS: A retrospective review of patients younger than 19 years of age with histologically confirmed GCT of bone treated surgically at 3 tertiary centers from 1997 to 2022 was performed. Clinical, radiographic, and surgical data, including physeal status, were collected. Local recurrence-free survival (LRFS) was estimated using Kaplan-Meier analysis and compared by physeal status using the log-rank test. Recurrence rates were compared using the Fisher exact test, with significance set at P<0.05.

RESULTS: Forty-two patients with a median age of 16 years (62% female) were included. Most tumors (76%) involved long bones, most commonly the femur (29%), with a median size of 5 cm. The overall local recurrence rate was 45%, with a median time to recurrence of 7 months. Recurrence was observed in 55% (6/11) of patients with open physes compared to 38% (8/21) with closed physes (P=0.50). Preoperative magnetic resonance imaging (MRI) was available in 27 patients, including 15 (56%) with tumors demonstrating bone marrow edema (BME). BME was associated with a higher recurrence (67% vs. 17%; P=0.019). Metastatic disease was rare (5%). LRFS rates at 12, 24, and 60 months were 71.4%, 61.7%, and 52.6%, respectively. Patients with closed physes demonstrated higher LRFS across all time points compared to those with open physes, though these differences did not reach statistical significance.

CONCLUSIONS: Local recurrence rates were high in pediatric GCT and numerically higher in patients with open physes, although the difference did not reach statistical significance. BME on preoperative MRI was associated with higher recurrence and warrants further study. Individualized treatment and vigilant early surveillance may improve local control while preserving growth potential.

LEVELS OF EVIDENCE: Level IV.

OBJECTIVES: To determine whether circumferential cerclage wiring for fracture reduction during lateral locked plating (LLP) of Vancouver B1 and C periprosthetic femur fractures is associated with nonunion.

METHODS: Design: Retrospective cohort study.

SETTING: Three academic Level I trauma centers.

PATIENT SELECTION CRITERIA: Patients aged >50 years with a Vancouver B1 or C periprosthetic femur fracture (OTA/AO IV.3B1 and IV.3C) who underwent open reduction and internal fixation with a single LLP with or without circumferential cerclage for fracture reduction from 2010-2023 were included.

OUTCOME MEASURES AND COMPARISONS: The primary outcome was nonunion. The association between cerclage use and nonunion was assessed using multivariable logistic regression controlling for age, sex, ASA classification, and Vancouver classification. Secondary outcomes included deep infection and implant revision.

RESULTS: 141 patients were included: 102 patients (72%; median age 78 years [IQR, 70-87]; 67% female) were treated with cerclage for fracture reduction and 39 patients (28%; median age 82 years [IQR, 70-89]; 85% female) were not. More patients treated with cerclage sustained a Vancouver B1 than Vancouver C fracture (n=78/102 [76%] vs. n=24/39 [24%]; P<0.001). Plates were longer (16 holes [IQR, 13-18] vs. 14 holes [IQR, 13-16]; P=0.02), stainless steel (n=91/102 [89%] vs. n=27/39 [69%]; P<0.01), and used in neutralization mode (n=96/102 [94%] vs. n=28/39 [72%]; P=0.001) in patients treated with cerclage. Nonunion occurred in 4 patients (4%) treated with cerclage and 4 patients (10%) without (P=0.30). Cerclage use was not associated with developing nonunion in multivariable regression (adjusted odds ratio, 0.3; 95% CI, 0.1-1.8; P=0.19). Infection occurred in 6 patients (6%) treated with cerclage and 0 patients (0%) without (P=0.28). Implant revision occurred in 8 patients (8%) treated with cerclage and 6 patients (15%) without (P=0.31).

CONCLUSIONS: While baseline between-group differences were noted in Vancouver classification, the judicious use of circumferential cerclage wiring for fracture reduction and stabilization in Vancouver B and C periprosthetic femur fractures with stable implants was not associated with nonunion. No differences were noted in incidence of deep infection or implant revision following cerclage use in this population.

LEVEL OF EVIDENCE: Therapeutic Level III.

PURPOSE: This work evaluated a combined multinuclear solid-state magnetic resonance imaging (ssMRI) technique using 1H and 31P acquisitions for quantitative, non-ionizing assessment of bone matrix and mineral densities, and to determine whether this approach can differentiate normal bone from osteoporosis and renal osteodystrophy (ROD) in rat models.

METHODS: Fifteen rats were assigned to control (CON), ovariectomized (OVX), and vitamin-D-deficient/5-6 nephrectomy (VIT-D) groups. Femurs were imaged ex vivo using a custom double-tuned 1H/31P RF coil on a 7T system. Water- and fat-suppressed 1H ssMRI quantified organic matrix density, while 31P ssMRI quantified bone mineral density. The Extent of Bone Mineralization (EBM) was calculated as the mineral-to-matrix ratio. Validation was performed using μCT and gravimetric analyses. MANOVA and multinomial logistic regression were used to assess group differences and classification accuracy.

RESULTS: MRI-derived matrix and mineral densities showed strong correlations with gravimetric and μCT measures (r = 0.85-0.89, p < 0.001). Cortical vMATMRI and vBMDMRI decreased progressively from CON to OVX to VIT-D, while trabecular values reflected greater microarchitectural heterogeneity. EBM remained near normal in OVX but was markedly altered in VIT-D, consistent with impaired mineralization. MANOVA confirmed significant effects of group and bone region (p < 0.001). Combined cortical-trabecular ssMRI predictors achieved 86.7% cross-validated accuracy in classifying the three bone conditions.

CONCLUSION: Multinuclear 1H/31P ssMRI provided quantitative, non-ionizing estimates of bone matrix and mineral density and, in this ex-vivo proof-of-concept, distinguished the osteoporotic from the osteomalacic phenotype by jointly evaluating matrix, mineral, and EBM. Because acquisition currently requires several hours per specimen, these findings establish analytical feasibility rather than clinical readiness; substantial acceleration and in-vivo validation are required, and EBM is best regarded as a promising candidate compositional marker pending validation in larger cohorts.

Radiographs do not entirely capture the complexity of acetabular morphology. The purpose of this study was to establish normative three-dimensional (3D) acetabular morphology in young adults without hip disease and identify sex-specific differences in acetabular coverage. We analysed 3505 hips from 1856 asymptomatic subjects aged 18-25; 48% were female (n = 890), who had undergone pelvic computed tomography (CT) scans for abdominal pain. We used a custom software to automatically segment the CT data and create 3D models. The centre-edge angle (CEA) and acetabular rim lateral extension (ARLE) were assessed at various clock-face positions around the acetabulum and sex-related differences were calculated. Females had greater acetabular coverage posteriorly, with higher mean CEA values at 9 o'clock (12° versus 9°; P < .001) and 10 o'clock (23° versus 20°; P < .001) and higher ARLE at 9 o'clock (0.54 versus 0.51; P < .001), 10 o'clock (0.63 versus 0.60; P < .001), and 11 o'clock (0.71 versus 0.70; P < .001). Males exhibited greater superior and anterior coverage, with higher CEA values at 12 o'clock (36° versus 34°; P < .001), 1 o'clock (28° versus 26°; P < .001), and 2 o'clock (4° versus 2°; P < .001) and higher ARLE at 12 o'clock (0.74 versus 0.73; P < .001), 1 o'clock (0.67 versus 0.66; P < .001), and 3 o'clock (0.25 versus 0.24; P = .01). Using automatic computational 3D modelling we found greater posterior acetabular coverage in females, whereas males exhibited more extensive superior and anterior coverage. Detailed 3D mapping of acetabular morphology may enable the development of standardized, sex-specific models to improve diagnosis and guide surgical planning of acetabular dysplasia and pincer femoroacetabular impingement.

STUDY DESIGN: Systematic review and meta-analysis.

OBJECTIVE: To determine whether venous thromboembolism (VTE) prophylaxis is necessary after spine trauma and to assess the efficacy and safety profiles of anticoagulation agents.

SUMMARY OF BACKGROUND DATA: Venous stasis, endothelial disruption, hypercoagulability, and orthopedic injury in spine trauma predispose 12%-64% of patients to deep vein thrombosis (DVT). Recent guidelines provide insufficient evidence to support or oppose routine VTE prophylaxis in this population.

METHODS: A systematic search was conducted in Medline, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials from inception to March 2023. Controlled vocabulary, key terms, and synonyms related to spinal trauma and anticoagulation were used. Studies comparing different classes of anticoagulants or anticoagulation versus no anticoagulation were included. Four reviewers independently performed abstract screening, full-text review, and data extraction, resolving conflicts by consensus. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality.

RESULTS: Our search yielded 2948 articles, with 103 advancing to full-text review and 16 meeting inclusion criteria. Bias assessment using MINORS for 10 retrospective studies resulted in an average score of 16.8 ± 1.6, whereas 6 prospective studies had NOS scores >6, indicating high-quality evidence. Anticoagulation was significantly associated with lower odds of DVT (OR: 0.40; P =0.0013), with low heterogeneity (I² = 2%). Low-molecular-weight heparin (LMWH) was associated with significantly lower odds of DVT (OR: 0.78; P =0.0050) and PE (OR: 0.66; P =0.0013) compared with unfractionated heparin (UH). No significant difference in major bleeding was found (OR: 0.52; P =0.1397). LMWH was linked to reduced mortality (OR: 0.43; P <0.0001).

CONCLUSION: Chemical anticoagulants reduce DVT risk in spine trauma patients. LMWH provides superior protection against DVT, pulmonary embolism, and mortality compared with UH, with no significant increase in major bleeding.

Study DesignSystematic review and meta-analysis.ObjectiveTo evaluate the timing of anticoagulation in acute spinal trauma, specifically assessing the efficacy and safety of early (<48 hours) vs delayed administration for chemical venous thromboembolism prophylaxis.MethodsA systematic search of Medline, EMBASE, Web of Science, and Cochrane was conducted through February 2023 for studies comparing early vs delayed anticoagulation in acute spinal trauma patients. Studies reporting deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and mortality were included. Three reviewers independently screened and extracted data. Risk of bias was assessed using MINORS and the Newcastle-Ottawa Scale. The protocol was registered on PROSPERO (CRD42023397717).ResultsFive studies, comprising a total of 13,110 patients, compared anticoagulant administration within 48 hours of trauma vs after 48 hours, reporting DVT and PE as outcomes. Early administration was associated with significantly lower odds of DVT (OR: 0.20 [95% CI: 0.17-0.25], P = .0001, I2 = 34%) and PE (OR: 0.46 [95% CI: 0.34-0.62], P = .0001, I2 = 0%). Four studies evaluated major bleeding as an outcome and found slightly lower odds with early initiation, though the association was not statistically significant (OR: 0.85 [95% CI: 0.66-1.09], P = .1992). Similarly, 4 studies assessed mortality, with results that were also nonsignificant.ConclusionsThe current evidence indicates that early initiation of chemical anticoagulation within 48 hours of injury in spine trauma patients is associated with favorable outcomes in preventing thromboembolic complications, without significantly increasing the risk of bleeding or mortality.

Study DesignTranslational rodent study.ObjectivesTo investigate (1) chemokine-mediated mesenchymal stem cell mobilization and homing to the intervertebral disc and (2) using this technique to mitigate intervertebral disc degeneration in a rat model.Methods(1) Recruitment of mesenchymal stem cells (MSCs) to intervertebral discs (IVD) was investigated using intradiscal chemokines. Hydrogel containing SDF-1, RANTES, MCP-1, or empty control was injected intradiscally, followed by near-infrared (NIR) imaging to observe MSC localization. (2) A rat IVD degeneration model was induced by annular puncture. Intradiscal RANTES injection and/or systemic AMD3100 injection was performed. Longitudinal imaging and histological analyses including Rutges Score (histologic degeneration) assessed IVD degeneration mitigation post-treatment up to 12-weeks. Statistical analyses included ANOVA and mixed-effects models to evaluate recruitment, retention, and regenerative potential of MSCs.Results(1) 24 rats were included in the investigation of MSC recruitment. In vivo NIR signal on 1-day post-intervention was highest with RANTES (P < .05). Ex vivo NIR signal at 14-days post-intervention was highest with RANTES (P < .05). (2) 36 IVD degeneration model rats underwent intradiscal RANTES and/or AMD3100 injection. AMD3100-treated groups showed larger nucleus pulposus (NP) volumes and reduced histologic damage, with lower Total Rutges scores (P = .004). RANTES treatment alone reduced Total Rutges scores (P = .009) and protected against IVD height loss at 6 weeks.ConclusionsIntradiscal delivery of RANTES/CCL5 promotes a sustained and targeted recruitment of MSCs to the IVD. In a rat model of IVD degeneration, administration of systemic AMD3100 and intradiscal RANTES mitigates IVD degeneration.