Prism Steorra Schneider

Case: A 39‐year‐old female with Factor V Leiden sustained multiple injuries following a motor‐vehicle collision. A prophylactic inferior vena cava filter (IVCF) was placed prior to fixation of her ipsilateral intertrochanteric and diaphyseal femur fractures the morning after admission. She developed a pulmonary embolism (PE) on postinjury Day 3. She underwent fixation of her ipsilateral tibial plateau and wrist on postinjury Day 6, IVCF removal on Day 12, and was subsequently discharged with 3 months of anticoagulation. Conclusion: PE can occur despite IVCF. Our understanding of the prevention and management of de novo PE is limited and should be the focus of future research.

Background: Successful applications of artificial intelligence (AI) in healthcare have increased interest in how it could be integrated into orthopaedic surgery. However, orthopaedics surgeons’ current use of AI and attitudes toward its incorporation remain largely unexplored. The 2025 American British Canadian Travelling Fellowship Survey on AI in Orthopaedic Surgery aimed to assess AI use, knowledge, training, and attitudes among orthopaedic surgeons. Methods: The survey was administered from May 7 to September 4, 2025 to orthopaedic surgeons across Australia, New Zealand, the United Kingdom, and North America. Questions addressed demographics, AI training and use, and attitudes toward AI. Descriptive statistics summarized responses, chi-square tests compared AI use by geography and attitudes by career stage, and linear regression explored associations between demographics, AI behaviors, and outlook on AI. Results: Among 350 participants, most were trainees (45.1%) and from North America (42.9%). AI use exceeded training, and 79.9% rated their AI knowledge as average or poor. Trainees reported significantly more favorable attitudes toward AI than late-career respondents. Higher self-rated AI knowledge and AI use in clinical and research settings were associated with a more positive outlook on the future of AI in orthopaedics. Conclusions: These findings highlight the need for formal AI education, as use is widespread despite limited training, particularly among later-career surgeons. Future studies should reduce self-selection and career-stage imbalance and include additional demographic variables to improve generalizability. Level of Evidence: III . See Instructions for Authors for a complete description of levels of evidence.

Background: Venous thromboembolism (VTE) poses significant risk of morbidity and mortality in orthopaedic trauma patients. Thromboelastography (TEG) analysis has been demonstrated to provide value in demonstrating hypercoagulability and predicting the risk of post-injury VTE. The primary aim was to investigate if TEG analysis at the time of admission following severe extremity trauma predicts thromboembolic events. We hypothesized that previously described elevations in maximal amplitude (MA) on initial TEG would correlate with an increased risk of VTE. Methods: This was a secondary study of PREVENT CLOT, a multicenter, randomized trial that enrolled adult patients with an extremity fracture (from hip to midfoot or shoulder to wrist) treated operatively or any pelvic or acetabular fracture. TEG at admission was performed according to local protocols. The primary outcome of this analysis was postoperative VTE. We assessed the association between admission TEG values and VTE using bivariate and multivariable regression analyses. Statistical significance was set at p < 0.05. Results: Thousand one hundred eighty-three patients enrolled participants in the PREVENTion of CLots in Orthopedic Trauma (PREVENT CLOT) trial had TEG analysis performed on initial presentation. Of these patients, 47 (3.97%) had a symptomatic postoperative VTE at a median of 9 days (interquartile range, 4-18 days). There were no differences in VTE rates when examining MA of ≥65, ≥69, or ≥72 (p = 0.12, 0.21, and 0.19, respectively). However, on admission TEG, reaction time (R-time) was significantly higher among those who experienced a postoperative deep venous thrombosis (2.45 vs. 1.79, p < 0.01). After controlling for confounders, R-time of ≥2.0 was associated with a 2.1-fold increased odds of VTE (OR 2.13, 95% confidence interval 1.06-4.28, p < 0.001). Conclusion: In contrast to previous smaller retrospective studies, elevated admission-TEG MA values were not predictive of VTE following operative orthopaedic extremity trauma in this secondary analysis of a large multicenter prospective study. Our findings suggest that an increased R-time on the admission TEG, which is thought to be indicative of a longer time to form a clot, may be paradoxically associated with an increased VTE risk in orthopedic trauma patients. Level of Evidence: Level II . See Instructions for Authors for a complete description of levels of evidence.

Isolated ulnar diaphyseal fractures are relatively uncommon, with an incidence of 0.02 to 0.04 per 1,000. Despite being uncommon, complications surrounding this injury are frequent, including high non-union rates, decreased forearm pronation and supination, decreased elbow range of motion, radioulnar synostosis, and prolonged pain. Research investigating the best treatment option for this injury is scarce, and there is no consensus on optimal treatment methods. Therefore, this large randomized controlled trial (RCT) aims to compare clinical, radiographic, and functional outcomes between open reduction and internal fixation (ORIF) and non-operative treatment in patients with isolated ulnar diaphyseal fractures. This is a multi-centre, open-label, parallel RCT of patients with isolated, closed AO/OTA type 22-A and 22-B injuries, without extension into the proximal or distal radio-ulnar joints. Patients were excluded if the fracture was displaced 30-degrees of angulation. Eligible patients were randomized to one of the two treatment arms: non-operative treatment with closed reduction and below-elbow casting, or surgical treatment with ORIF with a limited contact dynamic compression plate and screw construct. Randomization was conducted electronically with a 1:1 ratio using variable block sizes and stratification by recruiting site. The primary outcome measure is the Disability Shoulder, Arm, Hand (DASH) score at 12 weeks post-injury. In addition, the Short Form 36 (SF-36) and Pain Visual Analogue Scale (VAS) are used to compare functional outcomes between groups. The secondary outcome measures include clinical (range of motion, grip strength), radiologic (time to union), and economic outcomes, assessed throughout patient follow-up until 12 months post-injury. Descriptive statistics will be used to characterize the study population. Intention-to-treat analysis will be performed with independent samples t-tests to compare the mean DASH, SF-36, and VAS questionnaire scores and for time to return to work. For secondary analysis, analysis of variance (ANOVA) and pairwise comparisons will be completed for the DASH, SF-36, and ROM data at each follow-up time interval. Independent samples t-test will be used for time to union data. Exploratory subgroup analyses are planned to examine treatment effects for covariates including age, sex, site, handedness, and injury classification. A total of 100 participants were enrolled and randomized (49 ORIF and 51 non-operative) across 11 participating sites (Table 1). The mean age of the overall cohort is 40.0 (± 18.0) years, with 72% being male. The final follow-up for this large, multi-centre RCT will be completed in March 2023; therefore, the study final results will be available for the 2023 COA meeting. This will be the largest RCT of operative compared with non-operative management of isolated ulnar diaphyseal fractures. This is a multi-centre study with a large loss to follow-up rate included in the sample size calculation, in order to ensure appropriate statistical power, given historical difficulty in following this patient population. Patients were enrolled at 11 participating sites to maximize generalizability of the study findings. For any figures or tables, please contact the authors directly.

Hip fractures are an epidemic and despite thromboprophylaxis, venous thromboembolism (VTE) rates remain high (2.5–5%). Serial thrombelastography (TEG) analysis can quantify hypercoagulable state and increased VTE risk. Injury, surgery, and immobility result in a prolonged hypercoagulable state beyond current thromboprophylaxis guidelines with 46% of VTE occurring 6 weeks after surgery or later. TEG-based platelet mapping (PLM) can activate platelets at the adenosine diphosphate (ADP) receptor or the thromboxane A2 (AA) receptor, to evaluate clot strength when platelets are activated through those specific receptors. This study aimed to evaluate platelet contribution to hypercoagulability and to evaluate the effect of acetylsalicylic acid (ASA) following hip fracture surgery. Consecutive adult patients undergoing acute hip fracture surgery were enrolled in this prospective cohort study. Exclusion criteria were prior VTE, active malignancy, or pre-injury therapeutic anticoagulation. Following informed or surrogate consent, serial TEG and PLM analysis was performed at admission, post-operative day (POD) 1, 3, 5, 7 and at 2-, 4-, 6-, and 12-weeks post-operatively, using the TEG6s hemostasis analyzer (Haemonetics Corporation). All patients received thromboprophylaxis for 28 days post-operatively. Hypercoagulability was defined as maximal amplitude (MA; a measure of clot strength) over 65 mm. Platelet hyperactivity was defined as MA via the ADP or AA pathway over 55 mm. T-tests were used to compare MA values with the hyperactivity threshold and between those receiving ASA or not. One-sample t-test used for MA compared with the threshold values at each timepoint. Two sample t-tests at each timepoint and chi-square analyses for demographics were used to compare between those on ASA and those not. A total of 101 patients were enrolled with a mean age of 77.3 (± 11.5) years and 65% being female. Eighteen patients (17.9%) received ASA post-operatively, while the rest received low molecular weight heparin (LMWH). There was no statistically significant difference in age (p = 0.9), sex (p = 0.2), or surgical treatment type (p = 1.0) between those receiving ASA and those who were not. TEG analysis demonstrated prolonged hypercoagulability (MA > 65mm) for over 50% of patients at four weeks post-operatively, when thromboprophylaxis is discontinued. PLM analysis identified prolonged platelet-mediated hypercoagulability based on elevated ADP-MA and AA-MA, with more pronounced platelet contribution via the AA pathway. Patients who received ASA post-operatively demonstrated reduced platelet hyperactivity, with statistically significant reduction on POD 5 and POD 7 (p This study confirmed prolonged hypercoagulability and increased VTE risk beyond four weeks for over 50% of patients undergoing hip fracture surgery based on serial TEG analysis. Additionally, TEG-based PLM analysis identified prolonged platelet-mediated hypercoagulability, with more pronounced platelet contribution via the AA pathway. PLM analysis also demonstrated that ASA thromboprophylaxis can significantly reduce platelet hyperactivity. This study supports further investigation into the safety and efficacy of prolonged thromboprophylaxis for some patients and the investigation of antiplatelet thromboprophylaxis, such as ASA, following hip fracture surgery.

Recovery from injury, including pain-free range of motion (ROM), is important for return to work and function. This study aimed to evaluate the return of shoulder, elbow, and forearm range of motion (ROM) following a humeral diaphyseal fracture. This is a prespecified secondary analysis from a large randomized controlled trial (RCT) comparing open reduction and internal fixation (ORIF; plates and screws) with non-operative treatment (functional bracing) of humeral diaphyseal fractures. Standardized ROM measurements for the shoulder, elbow, and forearm were taken using a goniometer at 6 weeks, then at 4-, 6-, and 12-months post injury. Patient-reported return to baseline level of work was assessed at each follow-up. T-tests and a two-way ANOVA (time and treatment group) were used to compare between the treatment groups. A total of 168 patients were enrolled (n=84 per treatment group), with an 85% 1-year follow-up rate. The ORIF treatment group demonstrated significantly improved ROM over time for shoulder abduction (p = ± 71.7) days, compared to those in the non-operative group, at an average of 138.3 (± 98.1) days (p = 0.005). Return to work and function are important to stakeholders including patients, their family members, and their employers. This large RCT provides return to function and work information that can help guide shared decision making between patients and surgeons, as earlier recovery of ROM and return to work were demonstrated in the ORIF treatment group.

Patients with a non-O blood type are at increased risk for venous thromboembolism (VTE) based on data from large non-orthopaedic studies. The association between non-O blood type and major provoked VTE, including symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) following major orthopaedic surgery is less well defined, especially in trauma patients with different injury types. Therefore, the aim of this study was to compare blood group and VTE incidence in trauma patients who required surgical treatment. Consecutive adult patients undergoing surgery for acute acetabular, pelvic, hip, femur, or humerus fractures at a Level 1 trauma centre were included from several prospective cohort studies. Exclusion criteria were prior VTE, pre-injury therapeutic anticoagulation, or pregnancy. Following informed or surrogate consent, patients underwent blood work that included blood typing and patients were followed for 3-months post-operatively. All patients received low-molecular weight-heparin (LMWH) thromboprophylaxis for 14 days post-operatively for upper extremity injuries, or 28 days for pelvic or lower extremity injuries. VTE was defined as symptomatic and image-confirmed PE or DVT, or asymptomatic DVT found on screening Doppler ultrasound on postoperative day three. T-tests, chi-square and Fisher's Exact tests were used to compare between those with and without VTE and logistic regression was used to evaluate potential risk factors for VTE. A total of 268 patients were included in this pre-planned analysis. There was a total of 13 VTE events (4.9%) in this cohort. There were no differences in age and sex between those with and without VTE (Table 1). Compared with type-O blood type, type-A blood carried a 16-fold increased risk for VTE, type-B carried a 17-fold, and type AB carried at 61-fold increased risk for VTE (Table 2). Sustaining an acetabular fracture was associated with the highest VTE risk, based on fracture type (Table 2). This study supports that non-O blood type is associated with a higher risk of provoked VTE following major orthopaedic fracture requiring surgical intervention. Further investigation, including von Willebrand factor and factor VIII levels, is warranted to better understand this relationship. For any figures or tables, please contact the authors directly.

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3–5% of all fractures. Nonunion remains a common complication following humeral diaphyseal fractures, with reports of 4% nonunion rates for surgically treated fractures and up to 33% for non-operative treatment. Prior risk factors from small studies or retrospective reviews have suggested advanced age, current smoking status, obesity, and unstable fracture pattern as possible risk factors for nonunion. This study aimed to systematically evaluate risk factors for humeral diaphyseal nonunion. This is a prespecified secondary analysis from a large randomized controlled trial (RCT) comparing open reduction and internal fixation (ORIF) with non-operative treatment (functional bracing) of humeral diaphyseal fractures. Inclusion criteria were patients 18 years or older with a displaced humeral diaphyseal fracture (AO/OTA 12-A, B, C) amenable to both treatments and presentation within 21 days from injury. Patients were excluded if there was an open fracture, multiple injuries, or nerve injury requiring repair. Eligible patients were followed clinically and radiographically for 1-year post-injury. Non-union was defined as lack of radiographic progression of fracture healing on orthogonal radiographs combined with failure to improve clinically. T-tests and chi-square were used to compare those with and without nonunion, and logistic regression was used to evaluate potential risk factors for nonunion. A total of 168 adult patients were enrolled (n=84 per treatment group), with an 85% 1-year follow-up rate. There were no significant differences between treatment groups for age, sex, smoking status, body mass index (BMI), or fracture classification (Table 1). Time to union was achieved earlier in the ORIF group (p=0.02). There were 13 patients diagnosed with nonunion, with 12 (92.3%) being in the non-operative treatment group. There was no difference between age for those who went on to nonunion (46.7 ± 16.2 years) and those who healed without complication (43.3 ± 17.0 years; p = 0.62). Sex distribution between those with (53.8% female) and without nonunion (37.4%) was similar (p = 0.48). All nonunions occurred in simple AO/OTA A-type fractures (A1 = 38.5%, A2 = 23.1%, and A3 = 38.5%). Regression analysis identified elevated BMI (OR = 1.12; 95% CI = 1.02 to 1.25; p = 0.027) as a risk factor for nonunion. There were 32 current smokers, with three patients experiencing nonunions (9.4%; p = 0.16). Surgical intervention for nonunion management in those initially treated non-operatively occurred at an average of 18.3 (± 10.5) weeks after their initial fracture. Our large, multi-centre RCT reported improved function with ORIF for 4–6 months and inferior outcomes have been reported for non-operatively treated humeral fractures requiring subsequent surgical treatment; therefore, early identification of risk factors for nonunion is important in guiding decision making. This large RCT confirms that elevated BMI is a risk factor for nonunion, that all nonunions in this cohort occurred in simple transverse, short oblique, or spiral fracture patterns, and that non-operative treatment carries a minimum of 15% risk for nonunion. For any figures or tables, please contact the authors directly.