The appeal of 3D printed splints is easy to understand. Because each device is designed from a digital scan of the individual patient’s anatomy, it can be shaped to fit precisely while remaining far lighter than a conventional cast. The printed structure can be open and lattice-like, allowing air to circulate against the skin. That improved aeration reduces the moisture buildup and skin irritation that plague cast wearers, and it also improves hygiene around the injury. Perhaps most importantly for trauma care, an open splint leaves room for wound treatment: dressings can be changed, sutures can be inspected, and infections can be managed without cutting the device off and starting over. For patients, that can mean a dramatically more comfortable recovery and fewer return visits to the emergency department.

Yet despite these advantages, patient-specific printed splints remain rare in daily clinical practice. The reason is not that the technology does not work — small studies and prototype programs have demonstrated it repeatedly — but that getting from a working prototype to a routine hospital service is genuinely hard. The Nijmegen team, which included trauma surgeons, 3D printing specialists, and a biomechanical engineer from the University of Twente, identified three intertwined categories of difficulty. There are technical and logistical challenges, such as choosing scanners, design software, and printers that can produce medically acceptable devices reliably. There are workflow adjustments, because the path from patient to finished splint must fit into the fast-paced routines of an acute care setting. And there are regulatory constraints, because a hospital that manufactures its own medical devices steps into the role of a device producer under European medical device regulation, with all the documentation and quality obligations that entails.

To confront these barriers, the researchers did something unusually practical for an academic paper: they ran the implementation on-site, at a level-one trauma center with military affiliation in the Netherlands. Rather than designing a theoretical framework in an office, they organized multidisciplinary workshops in which the people who would actually operate the service — trauma surgeons, 3D lab staff, and other stakeholders — sat down together to identify, document, and discuss every essential obstacle they encountered. The workshops served as a structured forum for surfacing problems that might otherwise remain invisible until they caused a failure: who is responsible when a printer breaks mid-production, how a scan moves from the emergency room to the design workstation, which software licenses the hospital must hold, and how the finished device is documented for regulatory purposes.

The output of this process was a taxonomy of challenges. The team categorized the difficulties into essential barriers, each with multiple subitems, and then translated every barrier into a concrete step in a roadmap. Each step specifies the stakeholders involved and the actions required, so that a hospital following the guide knows not just what must be done but who must do it. Examples of the barriers include software and hardware selection for in-house splint production — decisions that ripple outward into training needs, maintenance contracts, and quality assurance. Other barriers concern the clinical workflow, the regulatory pathway, and the organizational changes needed to make in-house manufacturing sustainable rather than a one-off demonstration project.

The regulatory dimension deserves particular attention, because it is where many hospital innovation projects stall. Under the European Medical Device Regulation, a hospital producing custom-made devices in house is not merely using a product; it is manufacturing one. That role carries requirements for documentation, production standards, and traceability that most clinical departments have never had to meet. The roadmap addresses this by embedding the regulatory steps directly into the implementation sequence, so that quality obligations are built in from the start rather than retrofitted after problems arise. This is a significant shift from the way many hospitals have approached 3D printing, treating it as a research activity with looser obligations rather than a clinical service with strict ones.

The military affiliation of the participating hospital adds an interesting layer to the work. Military medicine has long been an early adopter of portable and on-demand manufacturing, since deployed units cannot rely on supply chains for specialized equipment. The involvement of the Military Health Organisation of the Dutch Ministry of Defence, reflected in the author affiliations, suggests that the roadmap was shaped by perspectives from both civilian trauma care and military health logistics. A hospital that can print its own splints from digital scans is also a hospital that can maintain essential capability when external suppliers are unavailable — a resilience argument that resonates well beyond the trauma ward.

To make sure the roadmap was actually usable by the people it is meant for, the researchers put the finished implementation guide in front of end-users and collected their feedback through a questionnaire. This review step is more than a courtesy; it is a check on whether the document communicates clearly to clinicians and technical staff who were not part of the workshops. The team reports that the roadmap provides a structured approach to meeting the requirements for implementation into both research and daily clinical practice — a dual purpose that matters, because many hospitals will want to run a research program first, gather evidence on safety and effectiveness, and only then transition to routine service.

For hospital administrators reading the study, the practical message is that in-house 3D printing of patient-specific splints is achievable, but only with deliberate planning across multiple domains simultaneously. The roadmap’s structure — essential barriers broken into subitems, each mapped to stakeholders and actions — gives institutions a checklist for the conversations they must have before buying a single printer. Which department owns the service? Who designs the devices, and with what software? How are scans acquired, stored, and protected? What documentation satisfies the regulator? How are staff trained, and how is the service maintained when key personnel leave? None of these questions is individually difficult, but the study’s central insight is that they must all be answered together, in a coordinated sequence, for the implementation to succeed.

The broader significance of the work lies in what it represents for hospital-based manufacturing as a whole. Splints are a relatively simple class of medical device, which makes them an ideal proving ground for the organizational machinery of in-house production. A hospital that masters the workflow, regulatory, and quality challenges of printed splints has built the institutional capability to produce other custom devices — surgical guides, prosthetic components, and beyond. The Nijmegen team’s roadmap, born from the friction of real implementation rather than from theory, offers other institutions a way to skip some of that friction. As 3D printing hardware becomes cheaper and design software more accessible, the limiting factor in bringing personalized devices to patients is increasingly not the technology but the organization around it — and that is precisely the problem this study set out to solve.

Subject of Research: In-house production of patient-specific 3D printed splints in acute care

Article Title: An implementation roadmap for in-house production of patient-specific 3D printed splints in an acute care setting

Article References: van Ginkel, L. A., de Bruijn, M. A. N., Hermans, E., Maal, T. J. J., Stirler, V. M. A., & Tuijthof, G. J. M. (2026). An implementation roadmap for in-house production of patient-specific 3D printed splints in an acute care setting. 3D Printing in Medicine. https://doi.org/10.1186/s41205-026-00343-9

Image Credits: AI Generated

DOI: 10.1186/s41205-026-00343-9

Keywords: 3D printing, patient-specific splints, trauma surgery, medical device regulation, implementation roadmap, acute care, hospital manufacturing, 3D Printing in Medicine, Radboudumc, custom medical devices, clinical workflow, immobilization

The review, led by Thomas F. O’Shea and colleagues at the University of Colorado Anschutz Medical Center, systematically assembled the published experience with ECMO-assisted adult non-cardiac surgery across airway, trauma, burn, vascular, and obstetric care. The authors searched PubMed/MEDLINE, PubMed Central, and Google Scholar from database inception through July 14, 2026, and drew on case reports, case series, retrospective cohorts, database analyses, and prior reviews. Crucially, they distinguished between two clinically different scenarios: planned or enabling ECMO, initiated specifically to permit an operation that would otherwise be technically or physiologically prohibitive, and ECMO-supported surgery, in which a necessary non-cardiac operation is performed while a patient is already on ECMO for respiratory or circulatory failure.

The most mature application, by far, is airway and tracheobronchial surgery. Here, ECMO is often deployed electively, before the first incision, because the operation itself would make conventional ventilation impossible. When surgeons resect the trachea or carina, the very structure that carries air to the lungs, there is no safe way to ventilate the patient through the surgical field. ECMO solves this by taking over gas exchange entirely, allowing the surgical team to work in an unobstructed field without an endotracheal tube crossing the lesion or the anastomosis. One narrative review cited in the paper summarized 168 published cases of extracorporeal life support during airway surgery, and institutional series have reported safe completion of tracheal resections with VV-ECMO support lasting as little as 10 to 31 minutes, with no in-hospital deaths in one series of seven oncologic tracheal operations.

The choice between the two main ECMO configurations follows a simple physiological logic. Venovenous ECMO, or VV-ECMO, drains deoxygenated blood from a vein, passes it through an external membrane oxygenator, and returns it to the venous system, providing gas exchange only. It is the preferred mode when the lungs, but not the heart, are the problem. Venoarterial ECMO, or VA-ECMO, returns oxygenated blood to the arterial system, providing both circulatory and respiratory support, and is chosen when hemodynamic compromise, anticipated major bleeding, or the demands of the procedure require more complete cardiopulmonary support. In the airway literature, VV-ECMO was commonly sufficient; in vascular and trauma settings, VA-ECMO predominates.

Trauma represents a different paradigm. Rather than enabling planned operations, ECMO in trauma patients is principally a stabilizing bridge that buys time for time-sensitive surgical injuries to be addressed. The review highlights striking examples: a multicenter analysis of the Trauma Registry-DGU found that 1.1 percent of patients with neurologic trauma received ECMO, with 61.8 percent surviving to discharge, challenging the historical view that brain injury is a contraindication to the therapy. One reported patient with severe respiratory distress syndrome, a large intracerebral hematoma, and multiple injuries after a fall underwent craniotomy while on VV-ECMO and was later discharged with full neurologic recovery. Small series describe femoral fracture fixation, pelvic ring fixation, and even posterior spinal fixation performed during ECMO support, with all reported femoral fixation patients surviving to discharge.

Abdominal trauma adds another layer of complexity. Damage-control laparotomy, the rapid staged approach to hemorrhage and bowel ischemia, has traditionally been viewed with suspicion in anticoagulated patients. Yet a single-center retrospective study of 52 patients supported with VV-ECMO before or after damage-control laparotomy reported an overall survival rate of 58 percent, and after adjustment for confounders, patients who could tolerate anticoagulation had improved survival. The authors concluded that damage-control laparotomy should not be considered a contraindication to VV-ECMO, or vice versa, a finding that could reshape how trauma teams think about the interplay of bleeding risk and extracorporeal support.

In burn care, the review found that ECMO has been used to support excision, debridement, and wound coverage in patients with severe inhalation injury or burn-associated respiratory distress syndrome. One burn center proposed a standardized perioperative protocol centered on multidisciplinary planning, individualized anticoagulation, and point-of-care viscoelastic coagulation monitoring, targeting a low-dose heparin regimen with an activated partial thromboplastin time of approximately 40 seconds during surgery. The dominant challenges are surgical blood loss, hypothermia, infection, and the resource intensity of repeated wound care, all compounded by the need to keep the ECMO circuit free of clots while the patient bleeds.

Vascular surgery illustrates both the promise and the risks of the technology. VA-ECMO has been used as planned support for high-risk thoracoabdominal aortic aneurysm repair and as a bridge during emergent pulmonary embolectomy, and some teams propose advantages over conventional cardiopulmonary bypass, including lower anticoagulation targets, reduced blood-air interface, and avoidance of systemic cooling. But peripheral cannulation carries its own vascular toll: a systematic review of 47 studies involving 6,583 patients reported an overall pooled vascular complication rate of 29.5 percent, with limb ischemia in 12.6 percent and significant bleeding in 15.4 percent. Preventive strategies include ultrasound-guided access, the smallest adequate arterial cannula, prophylactic distal perfusion cannulation, and serial perfusion checks by examination, Doppler, and near-infrared spectroscopy.

Obstetric applications are among the most dramatic. The literature consists primarily of cesarean delivery performed during ongoing ECMO support for severe maternal cardiopulmonary failure, with early reports dating back more than a decade and the COVID-19 pandemic expanding the experience considerably. A ten-year case series of 54 pregnant and postpartum patients requiring ECMO identified acute respiratory distress syndrome as the most common indication, and a systematic review and meta-analysis identified 1,460 reported cases of pregnant patients receiving VA- or VV-ECMO, with survival rates of 62.8 percent for VA-ECMO and 83.6 percent for VV-ECMO. These figures, however, come from heterogeneous cohorts not restricted to surgical patients and cannot be read as estimates of the effect of ECMO-facilitated delivery itself.

The review’s most important message may be its caution. The evidence base is dominated by single-patient case reports and small observational series from experienced centers, with substantial publication and selection bias: successful, unusual operations are far more likely to be reported than unsuccessful attempts or patients who were considered but not selected. No randomized studies define thresholds for ECMO use, optimal cannulation strategy, or standardized anticoagulation targets in this setting, and comparator populations are generally absent. The authors are explicit that the current literature should not be interpreted as establishing a survival or treatment-effectiveness benefit. What the review does establish is a practical framework: multidisciplinary planning, individualized cannulation and anticoagulation, hemorrhage preparedness, careful anesthetic and ventilatory management, and coordinated postoperative critical care are the recurring pillars of every successful reported case. Until robust multicenter and comparative data arrive, ECMO-assisted non-cardiac surgery remains a selective strategy for experienced teams, deployed when the patient’s physiology, the operative requirement, and the likelihood of a meaningful surgical objective all align.

Subject of Research: Use of extracorporeal membrane oxygenation to facilitate adult non-cardiac surgery

Article Title: ECMO-facilitated adult non-cardiac surgery: a structured narrative review

Article References: O’Shea, T. F., Bashian, E. J., Park, S. Y., Carpenter, R., Hoffman, J. R. H., Cain, M. T., Kowalsky, M., Abrams, B., Clendenen, N., Teman, N. R., & Wilkey, B. (2026). ECMO-facilitated adult non-cardiac surgery: a structured narrative review. Frontiers in Anesthesiology, 5, Article 1944652. https://doi.org/10.3389/fanes.2026.1944652

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1944652

Keywords: ECMO, non-cardiac surgery, airway surgery, trauma surgery, burn surgery, vascular surgery, obstetrics, anticoagulation, VV-ECMO, VA-ECMO, perioperative care, critical care

The research, led by Belal Abdo and Markus Rupp of the Department of Trauma, Hand and Reconstructive Surgery together with microbiologists at Justus Liebig University Giessen, was published in the Journal of Bone and Joint Infection. The team conducted a retrospective single-center study covering the years 2016 to 2023, screening 287 cases in which explanted osteosynthesis material had been analyzed by sonication. After applying strict inclusion criteria, 157 patients remained in the final analysis. Every included patient had undergone implant removal because of confirmed or suspected fracture-related infection, and every case had results from both peri-implant tissue culture and sonication fluid culture, allowing a direct, paired comparison of the two techniques in the same patients.

The technical logic behind the comparison is straightforward. Peri-implant tissue culture, the current standard, relies on surgeons taking small samples of tissue from immediately around the hardware during revision surgery. These samples are processed in the microbiology laboratory and incubated to see what grows. The weakness of this approach is that biofilm bacteria concentrate on the implant surface itself, not necessarily in the surrounding tissue, and prior antibiotic treatment can suppress growth in culture. False-negative microbiological results occur in up to 35 percent of cases despite clinically manifest infection, according to previous research cited by the authors. Sonication takes a different route: the removed implant is placed in a sterile container filled with 0.85 percent sodium chloride solution and exposed to ultrasound for one minute at 80 percent intensity. The sound waves dislodge biofilm organisms from the metal surface into the fluid, which is then centrifuged, concentrated, and inoculated into a panel of liquid and solid culture media, including aerobic, anaerobic, and fungal media, all incubated for up to 14 days.

The head-to-head results were strikingly balanced. Peri-implant tissue culture detected pathogens in 60.5 percent of the 157 cases, while sonication fluid culture achieved 57.3 percent. Statistically, the difference between the two methods was not significant, a finding confirmed by McNemar’s test for paired binary outcomes. Yet the overlap between the methods was far from complete. Sonication identified additional pathogens that tissue culture had missed in 17.8 percent of cases, while tissue culture uniquely detected organisms in 22.9 percent of cases. When the results of both methods were combined, the overall pathogen detection rate climbed to 70.1 percent. In other words, roughly one in ten additional infections were unmasked simply by running both tests rather than relying on either one alone.

The pathogen spectrum revealed by the two methods overlapped substantially, with methicillin-sensitive Staphylococcus aureus and coagulase-negative staphylococci predominating in both. Most positive cultures were monomicrobial, though polymicrobial growth was observed in 14.4 percent of sonication-positive cases and 21.1 percent of tissue-culture-positive cases, a numerical difference that did not reach statistical significance. Resistant organisms were rare but clinically important: methicillin-resistant Staphylococcus aureus appeared in four cases with each method, and one multidrug-resistant Enterobacterales strain was detected by each approach. The predominance of plate osteosynthesis systems, which accounted for 61.1 percent of removed implants, and screws at 18.5 percent, reflected the typical hardware profile of a trauma center population. The mean patient age was 57.4 years, and late infections occurring more than ten weeks after surgery were the most common presentation at 42.7 percent of cases.

One of the most clinically pressing questions the study addressed was whether prior antibiotic therapy undermines either diagnostic method. At the time of implant removal, 51 of the 157 patients were on ongoing antibiotic treatment or had received antibiotics within the previous 14 days, excluding routine perioperative prophylaxis. The concern is well founded: antibiotics circulating in tissue can suppress bacterial growth in culture, potentially producing misleading negative results. In this cohort, however, ongoing antibiotic therapy was not associated with a statistically significant difference in pathogen detection between the two methods. Tissue culture did show a numerically higher diagnostic yield than sonication among patients receiving antibiotics, but the authors caution that this observation should be interpreted carefully given the limited subgroup size. The finding contrasts with some earlier studies, including work by Dudareva and colleagues, who reported that both methods lost sensitivity after antibiotic exposure, and with the landmark 2007 study by Trampuz and colleagues, which found sonication particularly valuable after prior antibiotics in prosthetic joint infection.

The therapeutic consequences of the microbiological findings may be the most consequential part of the analysis. Antibiotic therapy was actually modified after revision surgery in 47.8 percent of cases. Most of these modifications, 38.9 percent of the entire cohort, were based on concordant findings from both diagnostic methods working together. Only 4.5 percent of patients had their treatment changed exclusively because of sonication results, and an identical 4.5 percent solely because of conventional culture findings. When the researchers asked a slightly different question, namely in how many cases a therapy modification would have been possible on microbiological grounds, the combined findings supported potential adjustment in 93 cases, with 8.3 percent attributable exclusively to sonication and 7.6 percent exclusively to tissue culture. The pattern is clear: the clinical value of each method lies less in replacing the other than in adding pieces to a diagnostic puzzle that neither can complete alone.

These results place fracture-related infection diagnostics in useful context. Sonication has long been an established component of the diagnostic algorithm for periprosthetic joint infection, where multiple studies have shown higher sensitivity than conventional tissue cultures, with reported sonication sensitivities ranging from roughly 52 to 100 percent depending on population and technique. For fracture-related infection, however, the evidence has been more contested. A 2018 systematic review by Onsea and colleagues concluded that sonication fluid culture may serve as a useful adjunct to tissue culture without strong evidence of superiority, and subsequent studies have split on which method performs better. The Giessen data align with the complementary view. Trenkwalder and colleagues similarly reported in 2023 that in septic and aseptic nonunion, sonication fluid culture showed lower sensitivity than tissue culture but higher sensitivity than histopathology, supporting a multimodal approach.

The study is honest about its limitations, and they matter for interpretation. Nearly half of the potentially eligible cases, 130 of 287, were excluded, mostly because they did not meet FRI criteria or because documentation was incomplete during a transition to a new hospital data system, so selection bias cannot be excluded. The retrospective design meant the exact number of intraoperative tissue samples could not always be verified, and because microbiological culture is itself part of the FRI Consensus Definition used as the reference standard, some incorporation bias is unavoidable. The single-center design also limits generalizability. Even so, the central conclusion stands on firm ground: nearly 30 percent of clinically confirmed infections remained culture negative even with both methods combined, underscoring that microbiology must be interpreted within the broader FRI diagnostic framework, which integrates clinical signs, intraoperative findings, histopathology, and culture results.

For surgeons and infectious disease specialists, the practical message is refreshingly concrete. When hardware comes out because of suspected infection, send the implant for sonication and take peri-implant tissue samples, and treat the two results as complementary rather than competing. The combined approach improved pathogen detection irrespective of prior antibiotic exposure, supported targeted antimicrobial management in nearly half of patients, and cost relatively little beyond standard laboratory processing. In an era when biofilm-embedded bacteria routinely defeat single diagnostic tests, the humble strategy of shaking the metal and swabbing the tissue, then reading both answers together, may be the most reliable tool clinicians have for turning invisible infections into treatable ones.

Subject of Research: Diagnostic comparison of implant sonication and peri-implant tissue culture for detecting fracture-related infection

Article Title: Sonication versus peri-implant tissue culture in fracture-related infection: diagnostic performance and therapeutic consequences in a single-center cohort

Article References: Abdo, B., Strack, D., Schäuffele, M., Tüngler, T. L., Imirzalioglu, C., Windhorst, A., Fritzenwanker, M., Heiss, C., & Rupp, M. (2026). Sonication versus peri-implant tissue culture in fracture-related infection: diagnostic performance and therapeutic consequences in a single-center cohort. Journal of Bone and Joint Infection, 11(4), 555-563. https://doi.org/10.5194/jbji-11-555-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-555-2026

Keywords: fracture-related infection, sonication, biofilm, peri-implant tissue culture, osteosynthesis, diagnostic sensitivity, antibiotic therapy, orthopedic surgery, implant infection, microbiology, trauma surgery, pathogen detection

Fracture-related infection, often abbreviated FRI, occurs when bacteria colonize the site of a broken bone, frequently around the plates, screws, or nails used to stabilize the fracture. The condition is estimated to affect roughly one to two percent of closed fractures, but the risk climbs dramatically in severe open injuries, exceeding thirty percent in Gustilo-Anderson type III open fractures depending on the anatomical site and injury severity. Treating these infections demands meticulously staged surgical protocols, prolonged hospitalization, and extended courses of antimicrobial therapy, all aimed simultaneously at eradicating the infection and restoring the biomechanical integrity of the skeleton. Reported eradication rates range widely, from twenty-nine to eighty-seven percent, and treatment failure can leave patients with irreversible functional compromise or even amputation.

The human toll of this complication extends well beyond the operating theatre. Traumatic injury alone can provoke adverse psychological outcomes, but the superimposition of a bone infection amplifies those effects through prolonged immobility, treatment uncertainty, and financially destabilizing periods of work incapacity. Infection recurrence portends intensified morbidity, extended therapy, and a profound deterioration in quality of life. Yet until now, the long-term effects of FRI on quality of life and mental health had remained murky, scattered across studies that used different instruments, definitions, and follow-up periods.

To bring order to this fragmented literature, the Regensburg team conducted a search compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, scanning PubMed, Web of Science, and Google Scholar for studies published between 2010 and August 2025. The initial search identified 7,808 articles, which the researchers whittled down through systematic screening to fifteen studies meeting strict inclusion criteria: adult patients with FRI, more than five participants, validated quality-of-life instruments, and a minimum follow-up of twelve months. Methodological quality was appraised using the Methodological Index for Non-Randomised Studies, known as MINORS, and risk of bias was assessed with the ROBINS-I framework, with discrepancies resolved through consensus meetings.

What the quality assessment revealed was a field built on shaky foundations. The evidence base was dominated by retrospective cohort studies, with no study achieving level I evidence, the gold standard of randomized trials. Studies achieved on average only 66.4 percent of the maximum MINORS score, and the average loss to follow-up was nearly twenty percent, ranging as high as 57.3 percent in one study. Ten of the fifteen studies carried a moderate risk of bias, three a high risk, and only two a low risk, with confounding identified as the principal source of bias because retrospective designs rarely fully account for factors that shape outcomes.

The quantitative findings nonetheless paint a coherent picture. In a meta-analysis of three studies covering 125 patients tracked before and after surgery, the physical component score of the SF-36 and SF-12 questionnaires rose by an average of 5.81 points at twelve months or more, an improvement that did not reach statistical significance. The mental component score rose by 3.86 points, also non-significant. More striking were the pooled long-term estimates drawn from seven studies comprising 262 patients: a mean physical component score of 38.9 and a mean mental component score of 51.2. When compared against normative data from the United States general population, where the mean physical score sits at 49.22, the FRI patients’ physical quality of life was significantly reduced, while the difference in mental quality of life was not statistically significant.

The psychological analysis added a troubling dimension. Three studies assessing 118 patients with the ICD-10-based Symptom Rating questionnaire, or ISR, found that the weighted mean depression score reached 1.08, crossing the cut-off value for a mild psychological symptom burden, a finding the researchers call caseness. The total ISR score of 0.68 also surpassed the caseness threshold, and sensitivity analyses confirmed that the depressive symptom finding was robust to the removal of any single study. Anxiety, compulsive, eating, and somatoform symptom scores, by contrast, remained below clinical thresholds, suggesting the psychological burden concentrates specifically in the depressive domain.

The authors are careful to caution against over-interpretation. Heterogeneity across the pooled studies was extreme, with the I-squared statistic reaching approximately 85.7 percent for the physical component score and a staggering 97.8 percent for the mental component score, indicating that study-specific, clinical, and methodological factors strongly influence observed outcomes. The pooled estimates, the researchers argue, should be read as descriptive reference benchmarks rather than precise predictions. Moreover, the depression findings cannot be attributed to infection itself, because the analysis lacked an appropriately matched control group of patients with comparable fractures, trauma exposure, or chronic conditions. It remains unclear whether the observed symptoms reflect the effects of the infection or the broader consequences of severe musculoskeletal injury and prolonged treatment.

Another complication is that the studies span more than fifteen years, a period during which the conceptual understanding and diagnostic framework of FRI evolved considerably. International consensus on a standardized definition of the condition emerged only recently, and earlier investigations often relied on less-standardized criteria, injecting further variability into the evidence base. Most cohorts also originated from German healthcare systems while the normative comparison data came from the United States, a mismatch the authors note is softened by previous work showing broad agreement between German and American SF-36 reference values, but which may still color the observed differences.

Perhaps the most clinically resonant insight emerges from the longitudinal data: successful eradication of infection does not inevitably restore patient-reported health. While two studies reported improved quality of life after treatment, the largest cohort actually demonstrated a decline following surgery, a discrepancy that underscores how the surgical battle against infection and the patient’s subjective recovery can diverge. The authors call for prospective, properly blinded studies using standardized FRI definitions, validated quality-of-life instruments, longitudinal follow-up, integrated psychological assessment, and carefully selected control groups to clarify whether the observed impairments arise primarily from the infection, the severe trauma, the surgical treatment, or the cumulative burden of recovery. In the meantime, they suggest, regular psychological screening of FRI patients deserves a place in routine follow-up care, because the wounds this complication leaves behind are not always visible on an X-ray.

Subject of Research: Long-term quality of life and depressive symptoms after fracture-related infection treatment

Article Title: Investigating long-term quality of life and depressive symptoms following fracture-related infection: a systematic review with meta-analysis of heterogeneous evidence

Article References: Betker, J. A., Walter, N., Rupp, M., Baertl, S., & Alt, V. (2026). Investigating long-term quality of life and depressive symptoms following fracture-related infection: a systematic review with meta-analysis of heterogeneous evidence. Journal of Bone and Joint Infection, 11(5), 569-577. https://doi.org/10.5194/jbji-11-569-2026

Image Credits: AI Generated

DOI: 10.5194/jbji-11-569-2026

Keywords: fracture-related infection, quality of life, depression, systematic review, meta-analysis, orthopaedic surgery, osteomyelitis, patient-reported outcomes, SF-36, mental health, trauma surgery, psychological screening

The study, published in Global Surgical Education, the Journal of the Association for Surgical Education, emerged from a problem that will feel familiar to clinicians everywhere. Secure messaging embedded within the electronic medical record has become the standard channel for continuous communication among multidisciplinary teams, replacing pagers and phone calls with a searchable, auditable, and legally compliant record. Yet the same features that make these platforms attractive, their immediacy and their low barrier to sending a message, also make them prone to overuse. At the trauma center in question, investigators identified high secure chat volume and fragmented communication as concrete barriers to efficiency, resident education, and interprofessional collaboration between surgeons and nurses.

The consequences of message overload are not merely anecdotal. A growing body of research has linked electronic health record stress to clinician burnout, and studies of clinical decision support systems have documented how repeated alerts produce a phenomenon known as alert fatigue, in which users become desensitized to notifications and may begin ignoring them. Direct observation studies in emergency departments have shown that interruptions and multitasking are associated with task errors among physicians, while prospective observational research has tied workflow interruptions to increased workload for hospital doctors. For surgical residents, whose training depends on sustained engagement in the operating room and at the bedside, the stakes are particularly high: every ping during an operation or a teaching moment represents a potential disruption of intraoperative learning.

To understand the scale of the problem, the research team, led by Jackson A. Fos of the University of Tennessee Health Science Center College of Medicine in Chattanooga, together with colleagues at Erlanger Health, began with measurement rather than assumption. Baseline data were extracted from the electronic medical record’s secure chat logs over two separate 72-hour audit periods, providing a quantitative portrait of who was messaging whom, and how often, across the trauma surgery service. This audit-driven approach is a hallmark of rigorous quality improvement methodology: rather than relying on impressions of being overwhelmed, the team established an objective numerical baseline against which any intervention could be judged.

The intervention itself was designed by a multidisciplinary quality improvement team that included resident surgeons, advanced practice providers, and nursing leadership, ensuring that the people affected by the workflow shaped its redesign. The core insight was one of triage and routing: not every message directed at a resident needed to reach a resident. During daytime hours, defined as 06:00 to 16:00, nursing communications were rerouted to advanced practice providers rather than to the resident surgeons. The APPs, who are experienced clinicians embedded in the trauma service, would address messages falling within their scope of practice directly, and escalate only unresolved or genuinely resident-level concerns to the appropriate provider. This created a filtering layer that preserved the clinical content of communication while shielding trainees from routine traffic.

Rerouting messages was only one strand of a broader communication restructuring. The intervention package also included structured handoffs, which standardize the transfer of patient information between shifts and reduce the need for clarifying messages later in the day. Multidisciplinary rounds were enhanced, bringing nurses, APPs, and residents into the same physical conversation at the bedside so that questions could be answered synchronously rather than through asynchronous chat threads. Finally, the team delivered education on communication expectations, establishing shared norms about what belongs in a secure message, who should receive it, and when an alternative channel is more appropriate. A three-month implementation period was deliberately established before post-intervention audits, allowing the new workflow to bed in and avoiding the trap of measuring a system mid-transition.

The results, measured against the baseline audits, were substantial. Residents demonstrated a 27.7 percent reduction in the average number of messages received per 24-hour period. Nursing-related communications to residents fell by 35.9 percent, and during the targeted daytime window of 06:00 to 16:00, the nursing communications received by residents dropped by 31.3 percent. The authors attribute this daytime improvement to the APP management of routine concerns, enhanced communication during rounds, and improved utilization of the secure messaging platform itself. In other words, the intervention did not simply shift burden silently onto someone else’s shoulders; it changed how the whole team communicated, making the messaging system more purposeful for everyone involved.

What makes these findings resonate beyond a single trauma service is the way they reframe the problem of communication fatigue. Much of the discourse around electronic health records treats message volume as a byproduct of software design, something to be solved by vendors building better interfaces. This study suggests that a significant portion of the burden is organizational rather than technological. The same platform, with the same features, produced dramatically different message loads once the team clarified roles and routing. The intervention required no new software, no capital expenditure, and no change to the medical record itself, only a deliberate redistribution of communication responsibilities that leveraged the existing expertise of advanced practice providers.

The educational implications deserve particular attention. Surgical residency is built on apprenticeship, and the operating room is its most protected classroom. When residents are tethered to a buzzing device, answering routine questions about laboratory values or discharge logistics, the threads of intraoperative teaching unravel. By reducing message volume by more than a quarter, the workflow change returned a measurable slice of cognitive bandwidth to trainees during precisely the hours when most elective and trauma operations take place. The authors emphasize that these findings highlight the impact of communication restructuring on the resident workflow and the educational environment within academic surgical services, positioning message management as a matter of curriculum protection, not just administrative convenience.

There are also lessons here for interprofessional collaboration, an area where poorly designed communication systems can quietly breed friction. Nurses need timely responses to patient concerns; residents need uninterrupted focus; APPs occupy a clinical middle ground that is often underused as a communication hub. By formally recognizing APPs as the first point of contact for daytime nursing communications, the trauma center did not merely offload work, it clarified a professional role and, according to the study’s acknowledgements, the APPs’ willingness to assume an expanded role in frontline communication management was essential to the project’s success. The result was a system in which each message reached the person best positioned to act on it, the definition of communication efficiency in a complex clinical environment.

For hospital leaders watching message volumes climb on their own services, the study offers a replicable template: audit the actual traffic, convene a multidisciplinary team to identify workflow inefficiencies, reroute routine communications to appropriate intermediaries, standardize handoffs and rounds, set explicit communication expectations, and then wait through a genuine implementation period before measuring again. The 27.7 percent overall reduction and the 35.9 percent drop in nursing-related messages achieved in Chattanooga demonstrate that meaningful relief from message fatigue is achievable with modest, well-targeted changes. As secure messaging continues its spread through healthcare, the question is shifting from whether to use these platforms to how to use them well, and this study provides one of the clearest answers yet: less ping, more purpose.

Subject of Research: Reducing secure messaging burden and communication fatigue among surgical residents through workflow restructuring

Article Title: Less ping, more purpose: reducing message fatigue and boosting collaboration through secure chat optimization

Article References: Fos, J. A., Jones, J. M., Mezick, H. M., Rippy, M. G., Nunez, N., Buerster, K. B., Zeringue, A., Holder, L., Pairitz, M., Urevick, A., Cox, E. S., Spain, S., Holladay, J., Giles, W. H., & Bhattacharya, S. D. (2026). Less ping, more purpose: reducing message fatigue and boosting collaboration through secure chat optimization. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 187. https://doi.org/10.1007/s44186-026-00603-6

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00603-6

Keywords: secure messaging, communication fatigue, surgical residency, electronic medical record, advanced practice providers, quality improvement, trauma surgery, interprofessional communication, resident education, workflow optimization, alert fatigue, multidisciplinary rounds

The biomechanics of a horse kick explain why such injuries deserve serious respect. Studies of equine impact forces have measured strikes reaching up to 7,000 newtons, roughly equivalent to the weight of a 700-kilogram mass, delivered through a small hoof contact area in a fraction of a second. That concentration of energy over a narrow surface is what makes horse kicks capable of tearing bowel, fracturing ribs, and rupturing solid organs. Yet, paradoxically, the external evidence of such a blow can be minimal. In modern societies, routine contact with horses has become less common, but riding clubs, farms, and stables keep the risk alive, and emergency physicians may see such cases rarely enough that the injury pattern is not immediately at the front of their minds.

On arrival, the patient was alert and her vital signs were reassuring: blood pressure of 148/79 mmHg and a heart rate of 62 beats per minute. Her abdomen, however, told a different story. Examination revealed generalized tenderness with rebound tenderness and muscular guarding, the classic signs of diffuse peritoneal irritation, indicating that the lining of the abdominal cavity was inflamed, often a signal of leaking bowel contents or blood. Most strikingly, the emergency team noted a faint, horseshoe-shaped contusion in the left lower quadrant, a subcutaneous hemorrhage whose curved shape mirrored the contour of the hoof that struck her. The bruise was photographed at presentation, and no other external injuries such as lacerations or fractures were found.

Laboratory results added to the diagnostic puzzle. Her white blood cell count was elevated at 13,400 per microliter, consistent with an inflammatory response, but hemoglobin, platelets, liver enzymes, renal function, and C-reactive protein were all within normal ranges. A focused assessment with sonography for trauma, the bedside ultrasound scan widely used to detect free fluid in injured patients, was negative. Arterial blood gas analysis showed a lactate of 2.4 mmol/L and a base excess of minus 0.9 mmol/L, values suggesting only mild physiological stress. Her overall Injury Severity Score was calculated at 9, a figure that on its own would not suggest a life-threatening injury. This is precisely the trap that trauma surgeons warn about: stable vital signs and modest laboratory abnormalities can coexist with a perforated hollow organ quietly leaking intestinal contents into the peritoneal cavity.

The decisive test was contrast-enhanced computed tomography of the abdomen. The scan demonstrated intraperitoneal free air, an unmistakable marker of bowel perforation, along with focal thickening of the small bowel wall and increased contrast enhancement located directly beneath the horseshoe-shaped contusion. Crucially, there was no injury to the liver, spleen, or any other solid organ. The anatomical correspondence between the skin bruise and the underlying bowel damage was remarkable: the hoof had compressed the jejunal loop against the spine and pelvic ring, crushing the bowel wall at exactly the point where the contusion marked its impact. In blunt abdominal trauma, solid organ injuries are far more common than hollow viscus injuries, so in a patient without hemorrhagic findings, clinical attention can easily drift toward the liver and spleen while a perforated intestine goes unnoticed until peritonitis or sepsis sets in.

With diffuse peritoneal irritation and clear CT evidence of free air, the surgical team made the call for emergency laparotomy, performed approximately six hours after the injury. Through a midline incision, they systematically explored the entire gastrointestinal tract. The culprit was found: a fingertip-sized perforation on the antimesenteric border of the jejunum, the segment of small bowel richest in blood supply, located about 70 centimeters distal to the ligament of Treitz. The injury was classified as Grade III on the American Association for the Surgery of Trauma bowel injury scale. Notably, the surrounding bowel wall appeared viable, without extensive contusion, ischemia, or mesenteric vascular compromise, and no other injuries were found anywhere in the abdomen.

The repair itself was elegantly straightforward, a fact that underscores how early detection changes outcomes. After irrigating the abdominal cavity with 10 liters of normal saline, the surgeons debrided the edges of the injured bowel wall and closed the perforation primarily with simple interrupted 4-0 polydioxanone sutures, an absorbable monofilament that retains tensile strength for weeks. The fascia was closed with heavy #1 polyglactin sutures, the subcutaneous wound was washed with a further 2 liters of saline, and the skin was closed with buried subcuticular stitches. Because the perforation was caught before extensive contamination developed, a bowel resection and stoma, procedures that carry far greater morbidity, were avoided entirely. The horseshoe bruise, in effect, had pointed the surgeons directly to the injury.

Recovery was not entirely smooth. The patient experienced a transient postoperative ileus, a temporary paralysis of bowel function that is a common complication after abdominal surgery, and she received intravenous piperacillin/tazobactam, a broad-spectrum antibiotic combination, for seven days to guard against infection. Oral intake resumed on postoperative day six, and after gradual dietary advancement and confirmation of stable bowel function, she was discharged on postoperative day eleven. At a one-month follow-up visit, she reported no abdominal symptoms, no pain, and no signs of bowel obstruction. For an injury that, if missed, could have progressed to fecal peritonitis, septic shock, and death, the outcome represents the best-case scenario that prompt imaging and timely surgery make possible.

The case also fuels an ongoing debate in trauma surgery about operative strategy. The team chose open laparotomy because of diffuse peritoneal irritation and concern for hollow viscus injury, the traditional and safest approach when bowel perforation is suspected. But the authors note that in hemodynamically stable patients in whom the injury can be reasonably localized, diagnostic and therapeutic laparoscopy may be a reasonable alternative, provided that a thorough exploration of the entire bowel can be achieved and the threshold for converting to an open procedure remains low. Minimally invasive exploration could reduce wound complications and hospital stay, but it demands surgical judgment and institutional capability, and the diffuse peritoneal signs in this patient justified the more definitive open approach.

The broader message for readers is one that emergency physicians and horse handlers alike should take to heart. Isolated small bowel perforation after blunt trauma can present with subtle or nonspecific early findings, and delayed recognition has been repeatedly associated with increased postoperative complications and mortality. Previous reports have described a range of small-bowel injuries from horse kicks, including jejunal perforation and complex injuries involving the mesentery and abdominal wall, but this case stands out for its isolated nature, the striking anatomical match between the horseshoe-shaped contusion and the perforation beneath it, and the early CT diagnosis that enabled simple primary repair. Localized external findings, however reassuring they may appear, do not reliably exclude significant internal injury when abdominal pain or peritoneal signs persist. After any high-energy localized impact, whether from a hoof, a handlebar, or a seatbelt, persistent abdominal pain should trigger early cross-sectional imaging, and when bowel injury is suspected, timely surgical intervention remains the difference between a straightforward suture repair and a catastrophic outcome.

Subject of Research: Isolated jejunal perforation following blunt abdominal trauma from a horse kick

Article Title: Jejunal Perforation Associated With a Horseshoe‐Shaped Abdominal Contusion After a Horse Kick: A Case Report

Article References: Yoshida, J., Hanaki, T., Sakano, Y., & Fujiwara, Y. (2026). Jejunal Perforation Associated With a Horseshoe‐Shaped Abdominal Contusion After a Horse Kick: A Case Report. Clinical Case Reports, 14(10), Article e73687. https://doi.org/10.1002/ccr3.73687

Image Credits: AI Generated

DOI: 10.1002/ccr3.73687

Keywords: horse kick, jejunal perforation, blunt abdominal trauma, hollow viscus injury, computed tomography, emergency laparotomy, peritonitis, trauma surgery, case report, bowel injury, abdominal contusion, injury severity score

The study, led by Lina Schreiber, Henrik Teuber, Hans-Christoph Pape, and Christiane Barthel from the Department of Traumatology at Universitätsspital Zürich, with Barthel also affiliated with Schulthess Klinik in Zurich, set out to answer two deceptively simple questions: how available and structured is trauma bay training for residents, and how do these junior physicians perceive the two dominant educational tools in the field, Advanced Trauma Life Support courses and simulation-based training? ATLS, a standardized, internationally recognized framework developed to systematize the early care of injured patients, has long been considered the backbone of trauma education, while simulation training places teams in realistic, often high-fidelity mock resuscitations where errors can be made and corrected without any risk to a living patient.

To capture the reality on the ground, the researchers designed a cross-sectional, web-based survey that was voluntary and anonymous. Participants were resident physicians involved in trauma bay care across three countries, and the self-developed questionnaire probed their training exposure, their perceived preparedness, and selected organizational aspects of trauma bay management, comparing responses across specialties and training levels. A total of 124 residents completed the survey, a sample that, while modest, spans a meaningful range of hospital environments, from large university centers to smaller regional institutions, and therefore offers a rare window into how educational opportunity is distributed in real-world health systems.

The statistical findings are telling. Participation in ATLS courses or trauma bay simulation training was significantly associated with the type of hospital where a resident worked, with a p-value of 0.033, and with the resident’s training level, at p = 0.002. In practical terms, this means that whether a young doctor has access to formalized trauma education is not simply a matter of personal initiative but is strongly shaped by institutional context and seniority. Residents at certain hospitals and at certain stages of training are systematically more likely to receive structured preparation, while others may face their first real polytrauma resuscitation with little more than observation and on-the-job learning.

Perhaps the most striking number in the study concerns perceived safety. Residents who had attended ATLS courses reported significantly higher self-assessed safety in trauma bay management than those without such training, with mean scores of 3.67 versus 2.91 on the survey scale, a difference the authors report as statistically significant at p = 0.0024. While self-reported confidence is not the same as measured competence, the gap is substantial and aligns with a broader body of literature suggesting that standardized trauma courses translate into providers who feel, and often perform, more securely in the resuscitation room. Earlier work cited by the authors, including long-term follow-up of ATLS programs and systematic reviews of high-fidelity team-based simulation in acute care settings, supports the idea that structured training builds both technical skill and the non-technical abilities, such as communication and leadership, that trauma care demands.

Yet access to that training remains the exception rather than the rule for many residents. Fewer than half of the survey respondents reported having access to regular trauma bay simulation training, a finding that will surprise few who have worked in resource-constrained hospitals but that carries real weight for educators and policymakers. Simulation is expensive and logistically complex: it requires mannequins or in-situ setups, protected time for multidisciplinary teams that include surgeons, anesthesiologists, and emergency physicians, and trained instructors who can debrief effectively. The survey’s data suggest that these resources are concentrated unevenly, leaving the quality of a resident’s trauma education partly dependent on the postal code of their hospital.

The study also examined the quieter, organizational details of trauma bay culture that rarely make headlines but shape daily practice. Functional identification badges, which clarify each team member’s role during a resuscitation, were most commonly used in university hospitals and were viewed positively by 63.0 percent of participants. Supervisory support was generally rated as good or very good, an encouraging signal that senior staff are present and engaged when juniors take on trauma responsibilities. On the more troubling side, unprofessional communication within trauma teams was reported by a minority of respondents, though most described it as occurring rarely. Even infrequent unprofessional behavior in a high-stakes environment is not trivial; crisis resource management research has long emphasized that clear, respectful communication is a safety-critical component of team performance under pressure.

The authors are careful about what their data can and cannot show. As a descriptive, cross-sectional survey, the study captures perceptions and self-reported exposure at a single point in time rather than measuring objective performance or patient outcomes. The association between ATLS participation and perceived safety, for example, could reflect the genuine benefit of the courses, but could also reflect selection effects, since residents at better-resourced institutions may both receive more training and feel more confident for related reasons. Still, the authors argue that these descriptive data provide a foundation for future discussions on how postgraduate trauma education should be organized and delivered, particularly in health systems where trauma bay staffing and training structures vary widely between hospital types.

The findings land at a moment when trauma education is evolving rapidly. The literature the authors draw on includes studies of virtual reality simulation to enhance ATLS training, randomized controlled trials of extended reality simulators, and interprofessional in-situ simulation programs modeled on ATLS principles that have demonstrated measurable learning gains. If immersive technologies continue to lower the cost and logistical barriers of realistic team training, the inequities documented in this survey could become easier to correct, allowing smaller hospitals to offer their residents simulation experiences once reserved for major academic centers. Conversely, without deliberate policy attention, the association between hospital type and training access may persist or widen.

For now, the study’s central message is hard to ignore: a resident’s readiness to manage a crashing polytrauma patient should not be a lottery of institutional circumstance. With fewer than half of surveyed residents reporting regular simulation access, and with ATLS participation clearly linked to greater perceived safety, the authors’ data give educators across Switzerland, Austria, Germany, and beyond a concrete benchmark. The trauma bay will always be an unforgiving classroom, but the survey suggests that with standardized courses, consistent simulation, clear role identification, and supportive supervision, the medical profession can make its steepest learning curve a far safer one for both doctors and the patients who depend on them.

Subject of Research: Simulation-based trauma bay training and ATLS education for resident physicians

Article Title: Advancing trauma training: a survey study on simulation training and trauma bay management for resident doctors

Article References: Schreiber, L., Teuber, H., Pape, H.-C., & Barthel, C. (2026). Advancing trauma training: a survey study on simulation training and trauma bay management for resident doctors. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 128. https://doi.org/10.1007/s44186-026-00533-3

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00533-3

Keywords: trauma bay, simulation-based training, ATLS, resident physicians, polytrauma, medical education, trauma surgery, perceived safety, survey study, residency training, Switzerland, Germany

Adipokines have long been the province of metabolic research rather than emergency medicine. These molecules, secreted by white adipose tissue, act as chemical messengers that influence appetite, insulin sensitivity, and immune activity throughout the body. Among the most studied are adiponectin, which generally exerts anti-inflammatory and protective effects on blood vessels and kidneys, and resistin, which in humans is produced largely by immune cells and is strongly associated with inflammatory activation. Leptin and retinol-binding protein 4 round out the panel, each carrying its own metabolic and immunological signatures. What has remained unclear is how this hormonal ensemble behaves in the acute chaos of major trauma, and whether its behavior carries any clinical meaning for patients fighting for their lives in intensive care.

To find out, the Ulm team, led by Lena Schütte and Rebecca Halbgebauer, conducted a secondary retrospective analysis of a longitudinal observational cohort, drawing on prospectively collected plasma samples and clinical data from 67 patients with an Injury Severity Score of at least 16, a threshold defining severe polytrauma. They compared these patients with 31 healthy volunteers. Blood was drawn at four time points: on admission to hospital, and then on days one, five, and ten. At each point, the researchers measured circulating levels of resistin, adiponectin, leptin, and retinol-binding protein 4, alongside a battery of inflammatory markers and clinical indicators of organ function.

The statistical approach was deliberately rigorous. Because adipokine levels are known to vary with body composition, age, and sex, the team used linear mixed-effects models adjusted for age, sex, body mass index, and waist-to-hip ratio, the latter derived from computed tomography scans as a measure of body-fat distribution. Associations with inflammatory markers and organ dysfunction were assessed using partial Spearman correlations, and the researchers applied false discovery rate correction to guard against spurious findings that arise when many comparisons are made simultaneously. Exploratory receiver-operating characteristic analyses were then used to ask whether adipokine measurements could classify clinically meaningful outcomes, including length of hospital stay, length of intensive care stay, shock severity, and 30-day mortality.

The results were striking from the very first blood draw. Compared with healthy volunteers, trauma patients arrived at the hospital with a fundamentally altered adipokine profile: resistin was significantly elevated, while adiponectin was significantly reduced. This reciprocal shift, an increase in a pro-inflammatory signal paired with a decrease in a protective one, suggests that severe injury rapidly reprograms the endocrine output of fat tissue and the immune cells that produce these hormones. The changes were not subtle statistical whispers but robust differences detectable at admission, before most clinical interventions had time to exert their own effects on the circulating hormone landscape.

Perhaps the most compelling finding was the strength of the relationship between resistin and interleukin-6, one of the central cytokines driving the post-traumatic inflammatory response. At admission, resistin levels correlated with IL-6 at approximately 0.75, a correlation strong enough to survive false discovery rate correction. In biological terms, this means that patients whose blood carried the highest resistin concentrations were also mounting the most intense inflammatory responses. Resistin, in this context, appears less as a bystander and more as a potential readout of the immune system’s overall state of activation in the hours following injury.

When the researchers combined the two opposing signals into a single metric, the resistin-to-adiponectin ratio, they found the most consistent pattern of associations across the entire study. This ratio tracked with both inflammatory parameters and markers of renal dysfunction, including measures of kidney function such as estimated glomerular filtration. The kidney connection is particularly intriguing, because adiponectin has well-documented protective effects on renal tissue, and acute kidney injury is one of the most common and dangerous complications of severe trauma. A falling adiponectin level paired with rising resistin may therefore reflect, or even contribute to, the vulnerability of the kidneys during the critical early days after injury.

The exploratory outcome analyses offered cautious grounds for optimism, tempered by important limitations. Several adipokine measures showed moderate ability to classify selected clinical outcomes, such as length of hospital or intensive care stay and shock severity, in receiver-operating characteristic analyses. However, the mortality analyses were hampered by the small number of death events available at the later time points, making any conclusion about predicting survival statistically fragile. The authors are explicit that these outcome associations are exploratory and require prospective, multicenter validation before any claim of added clinical value beyond conventional parameters, such as the Sequential Organ Failure Assessment score, can be made.

One of the study’s secondary questions concerned whether body-fat distribution shapes the adipokine response to trauma. Using CT-derived waist-to-hip ratios, the researchers stratified patients and looked for differences in hormone profiles. For the most part, the stratified comparisons showed no clear separation across groups, suggesting that the dramatic adipokine shifts triggered by severe injury may override the more gradual influence of body composition, at least within the first ten days. This is a useful negative finding, because it implies that the trauma-induced adipokine signature could potentially serve as a standardized marker across patients of varying body types, though the authors note that most WHR-stratified differences were limited.

The broader significance of this work lies in its reframing of fat tissue as an active participant in the response to injury rather than a passive energy depot. The concept of immunometabolism, the interplay between immune signaling and metabolic regulation, has gained momentum across critical care research, and this study provides some of the most detailed longitudinal human data on adipokines in polytrauma to date. If future multicenter studies confirm that the resistin-to-adiponectin ratio adds predictive power for organ dysfunction beyond existing clinical scores, it could eventually help clinicians identify, within hours of admission, which patients are most likely to develop kidney injury or multi-organ dysfunction, opening a window for earlier and more targeted interventions. For now, the message is one of careful promise: the body’s fat-derived hormones respond to trauma with remarkable speed and specificity, and their story is only beginning to be told.

Subject of Research: Adipokine dynamics and their association with inflammation and acute organ dysfunction after severe polytrauma

Article Title: Inflammation-linked adipokine profiles associate with acute organ dysfunction after severe trauma

Article References: Schütte, L., Oßwald, K., Mannes, M., Wohlgemuth, L., Kumral, E., Mayer, B., Bülow, J. M., Bergmann, C. B., Relja, B., Gebhard, F., Huber-Lang, M., Fischer-Posovszky, P., Rayatdoost, F., & Halbgebauer, R. (2026). Inflammation-linked adipokine profiles associate with acute organ dysfunction after severe trauma. Journal of Translational Medicine, 24(1), Article 1176. https://doi.org/10.1186/s12967-026-08968-4

Image Credits: AI Generated

DOI: 10.1186/s12967-026-08968-4

Keywords: adipokines, polytrauma, resistin, adiponectin, inflammation, organ dysfunction, acute kidney injury, interleukin-6, biomarkers, immunometabolism, intensive care, trauma surgery

The study, led by Mohammed Yousof Bakhiet, a surgeon affiliated with Al-Baha University in Saudi Arabia and the University of Kordofan in Sudan, used a structured online questionnaire distributed between June 15 and 20, 2025. Every one of the 14 plastic surgeons working in Sudanese governmental hospitals responded, a 100 percent response rate that itself speaks to the tiny size of the workforce. The respondents had a median age of 48.5 years, and 13 of the 14 were men, a distribution the author attributes to the pre-existing gender imbalance in Sudanese plastic surgery rather than any war-specific effect. Half were consultants and half were specialists who had completed postgraduate training within the previous five years, and half reported more than a decade of surgical experience.

The most striking demographic finding was displacement. Nearly two-thirds of the surgeons — nine of the 14 — had been forced from their homes by the fighting, joining the millions of Sudanese internally displaced since the conflict began. Most plastic surgery units in the country were run by a single surgeon, and when those surgeons fled, the units effectively ceased to exist. Before the war, plastic surgery services were concentrated in Khartoum, with smaller regional units in Atbara, Kassala, Port Sudan and Shendi. As fighting engulfed the capital, most Khartoum-based services stopped, and the burden shifted to the already under-resourced peripheral centers. A single plastic surgeon in Elobied, a city under active fighting and siege, now represents the only provider of plastic surgery services in a combat zone in the country.

The survey’s central result is bleak: 86 percent of respondents said the availability of plastic surgery services in their facilities had been severely disrupted or had ceased entirely. Only a small minority reported no impact. Reconstructive work — burn management, complex wound reconstruction, facial trauma repair and limb salvage — was universally affected, with nearly 79 percent of surgeons reporting that all of these procedure categories had been compromised. Half of the respondents said reconstructive operations were often delayed, and another 28 percent said they were always delayed. For patients with war wounds, where soft tissue loss, exposed bone, and damaged vessels and nerves demand advanced reconstructive techniques within tight time windows, such delays translate directly into amputations, disfigurement and death.

Perhaps counterintuitively, the raw numbers of operations did not collapse. Before the war, half of the surgeons reported performing three to six emergency operation lists per month; during the war, 64 percent reported more than six. Elective lists and outpatient clinics showed no statistically significant change before versus during the conflict, with p-values of 0.357 and 0.564 respectively. But the author cautions that these figures mask a profound shift in the character of surgical work. Personal communication with colleagues suggests the operation lists have swung heavily toward emergency and trauma-related procedures, while elective reconstruction and patient follow-up have withered. This pattern — where a surge in trauma volume conceals the erosion of routine surgical services — has been documented in other conflict zones, including Syria, Yemen and Ukraine, and it carries a hidden long-term cost: surgeons who operate only on blast and gunshot injuries for years risk losing the broader technical repertoire that defines their specialty.

The logistical failures underpinning this erosion were consistent across respondents. Limited access to surgical equipment and disruption of supply chains for medications and disposables were each cited by 86 percent of surgeons as major challenges. Close behind, 71 percent pointed to the lack of intensive care or post-operative capacity — a critical gap for patients undergoing complex reconstructions, who often require prolonged ventilatory support and flap monitoring in the hours after surgery. Shortages of qualified plastic surgeons and inadequate anesthesia support, each reported by 57 percent, rounded out the list. These findings mirror earlier reports from Sudan, including a 2024 study that found more than half of surgical practitioners in conflict zones had ceased practice entirely, and analyses showing that only about one-third of hospitals in war-affected areas continue to function at all.

The human resource picture may be the most consequential for Sudan’s recovery. Twelve of the 14 surgeons — 86 percent — reported a severe impact on the availability and retention of trained staff. Continuing medical education was rarely available for 64 percent of respondents and only occasionally available for the rest; just 7 percent reported regular access. The author links this academic isolation to a documented decline in training quality, citing a separate study of Sudanese surgical residents that found widespread concern about reduced case volumes and learning opportunities in operating theaters. The risk is a compounding brain drain: as training pipelines dry up, the next generation of reconstructive surgeons never materializes, and the country’s capacity to treat war injuries — and, eventually, the enormous backlog of untreated deformity and disability — shrinks further.

Institutional support, which in most humanitarian crises cushions health systems against exactly this kind of shock, was largely absent. Half of the respondents’ hospitals received no external support for surgical services at all, and only 29 percent reported receiving any. The author contrasts this isolation with other conflict settings, where international partnerships with non-governmental organizations have helped sustain at least essential medical services, and suggests that insecurity, access difficulties and competing organizational priorities have left Sudan’s surgical services outside the reach of the global humanitarian response. The result is a health system running on local goodwill and improvisation, with surgeons continuing to operate despite unpaid salaries, personal displacement and physical danger.

When asked what they needed most urgently, the surgeons’ answers formed a stark roadmap. Medical equipment and supplies topped the list at 43 percent, followed by trained plastic surgeons and personnel at 36 percent. Education and training programs and health system logistics each drew 21 percent, and funding 7 percent. The emphasis on training, even amid active combat, reflects a professional conviction that sustainable care requires continuous development — that a surgeon who cannot learn cannot long remain effective. The author acknowledges the study’s limitations: a sample of 14, self-reported data vulnerable to recall bias, restriction to governmental hospitals, and the use of categorical ranges for case volumes, which limited statistical analysis. But with only 14 plastic surgeons in the entire country, the sample is effectively the population, and the picture it paints is unlikely to be distorted by small numbers.

What emerges from this survey is a case study in how war hollows out a surgical specialty from the inside — not through a single dramatic event, but through the slow attrition of supplies, staff, training and institutional support. Plastic surgery occupies a peculiar position in wartime medicine: it is simultaneously a frontline necessity for the complex wounds that modern violence inflicts and a long-horizon discipline whose value is measured in function restored and lives rebuilt over years. Sudan’s 14 wartime plastic surgeons are holding that dual mandate together under siege conditions. The survey’s message to the international community is unambiguous: without urgent deliveries of equipment, supplies and trained personnel, the specialty that Sudan’s wounded most need may simply not survive the war that created the need.

Subject of Research: The impact of armed conflict on plastic surgery services and surgical workforce in Sudan

Article Title: Survey of challenges faced by plastic surgery services during the current Sudan conflict

Article References: Bakhiet, M. Y. (2025). Survey of challenges faced by plastic surgery services during the current Sudan conflict. BMC Plastic and Reconstructive Surgery, 1(1), Article 8. https://doi.org/10.1186/s44452-025-00008-2

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00008-2

Keywords: Sudan conflict, plastic surgery, reconstructive surgery, war injuries, health system collapse, humanitarian crisis, surgical workforce, trauma surgery, displacement, supply chain disruption, medical education, global surgery

Ovine forestomach matrix, or OFM, belongs to a family of biomaterials known as extracellular matrix bioscaffolds. The material is processed from the layered tissue of the sheep’s forestomach, preserving much of its natural structural architecture, including collagen fibers and associated proteins that mammalian tissues recognize as familiar building instructions. When surgeons suture or lay an OFM device into a wound, it does not simply patch the defect. Instead, it acts as a temporary biological scaffold that invites the patient’s own cells to migrate in, form new blood vessels, and progressively rebuild missing or damaged tissue. Over weeks to months, the body remodels and ultimately replaces the scaffold with functional vascularized tissue. This regenerative mechanism is what distinguishes bioscaffolds from purely inert synthetic implants, and it is also why their safety profile, particularly regarding infection and immune reactions, matters so much to reconstructive surgeons.

The MASTRR Registry was deliberately designed to capture the messiness of real clinical practice. It is a prospective, multicenter, single-arm, open-label observational study operating under the IDEAL framework, a structured pathway for evaluating surgical and device innovations that explicitly recommends observational registries at both the exploratory and long-term surveillance stages. Rather than enrolling only the healthiest patients with the cleanest wounds, the registry applied broad inclusion criteria with minimal exclusions, enrolling patients across trauma, colorectal, burn, and limb salvage specialties. The study received centralized institutional review board oversight, is registered with ClinicalTrials.gov under identifier NCT05243966, and is ultimately approved to enroll up to 800 subjects, making it, according to the investigators, the largest registry-based study of its kind for bioscaffolds in soft tissue reconstruction.

The patient population captured in this interim analysis was, by any measure, medically formidable. Most subjects were middle-aged men, with a median age of 54 years, and more than half carried an American Society of Anesthesiologists physical status classification of III, indicating severe systemic disease that limits daily function. Nearly 36 percent had type 2 diabetes, about 30 percent had vascular disease, and almost a quarter used nicotine products, all factors known to impair wound healing. The defects themselves were equally challenging: nearly 60 percent were chronic, having persisted for more than a month, and roughly 90 percent were classified as clean-contaminated or contaminated under the Centers for Disease Control and Prevention wound classification system. Exposed bone, tendon, or viscera appeared in 11.4 percent of defects, and confirmed osteomyelitis, a serious infection of bone, was present in 15 percent. The median defect area for dermal reconstructions was 24 square centimeters, with some reaching far larger.

The range of conditions treated underscores the versatility the registry was built to probe. Diabetic foot ulcers accounted for 22.6 percent of defects, many of them deep Wagner grade 2 or 3 wounds, followed by traumatic injuries at 16.5 percent, ostomy takedown reconstructions at 11.2 percent, pilonidal sinus disease at 10.8 percent, and pressure injuries at 9.7 percent, most of the latter being stage 4 wounds involving muscle and exposed structures. Surgeons deployed the OFM devices in three main ways: topically for dermal reconstruction in 65.2 percent of cases, as an implant to reinforce soft tissue flaps or fill dead space in about a quarter of cases, and to augment closure of fistulae, including perianal, enterocutaneous, and rectovaginal types, in roughly 10 percent. Notably, a median of just one product application was needed per defect, and negative pressure wound therapy was used adjunctively in fewer than a quarter of procedures.

The safety results are the heart of the analysis. Fifty-nine adverse events were reported across the 411 subjects during a median follow-up of 27.1 weeks, meaning 12.2 percent of patients experienced one or more events, a figure that falls to 8 percent when only events involving the treated defect are considered. Each event was graded for severity using the Common Terminology Criteria for Adverse Events framework and assessed for causality under ISO 14155 guidance, the international standard for clinical investigation of medical devices. The verdict was striking: 79.9 percent of events were deemed unrelated to the device and 18.6 percent unlikely related, with no events classified as definitely or possibly related and a single probable case. That lone event involved redness, pain, and swelling on a lower extremity defect suggestive of an allergic reaction, prompting partial removal of the graft; the patient was treated with antihistamines, went on to receive a split-thickness skin graft, and completed wound closure while remaining in the study.

Events occurring at the index defect itself were infrequent and mostly minor. Superficial infections occurred at 2.9 percent of subjects, wound dehiscence at 3.2 percent, and deep tissue infection at just 0.7 percent, with only three deep infections reported across the entire cohort and none requiring device extraction. Pilonidal sinus reconstruction generated the highest share of defect-related events, largely dehiscence of the primary closure, while seven of the 33 index defect events required reoperation, most commonly simple incision and drainage. Eight deaths were reported during the study, but clinical review attributed all of them to progression of severe pre-existing cardiopulmonary, renal, or malignant disease, and none were considered related to the index procedure or the OFM treatment. The remaining events were systemic or incidental, including pneumonia, sepsis, and thrombophlebitis, reflecting the frailty of the population rather than the device.

Perhaps the most provocative comparison in the paper concerns infection. A long-running argument in biomaterials holds that synthetic scaffolds should resist infection better than tissue-derived biologics, yet the registry data suggest otherwise. A recent meta-analysis of a polyurethane-based bioscaffold in complex reconstruction, pooling 34 studies and 208 subjects, reported an overall complication rate of 27.9 percent and an infection rate of 25.8 percent. Another comparative meta-analysis found postoperative infection rates of 26.24 percent for polyurethane matrices and 18.79 percent for a crosslinked collagen and chondroitin sulfate scaffold in burns, while a third reported a generalized infection incidence of 16.9 percent for the latter material. Against those figures, the 0.7 percent deep infection rate and 2.9 percent superficial infection rate observed with OFM in a heavily contaminated, comorbid population challenge the assumption that synthetics hold an infection advantage, and the authors of those earlier meta-analyses had themselves urged clinicians to weigh risks carefully before adopting those products.

The registry framework has also proven productive beyond safety surveillance, generating a series of indication-specific subgroup analyses from a common prospective data collection platform. These include complex lower extremity reconstruction, where a median of 30 days was needed to achieve complete granulation tissue coverage; traumatic defects across four level 1 trauma centers, where vascularized tissue coverage was achieved in a median of 22.5 days; deep partial-thickness burns, where a single OFM application produced a median 14-day healing time with minimal pain and favorable scar scores; and late-stage pressure injuries, where approximately 60 percent wound area reduction was achieved without postoperative complications. A comparative study of pilonidal sinus reconstruction found that adding an OFM graft under a fasciocutaneous advancement flap significantly reduced surgical dehiscence, lowered treatment costs, and improved patient quality of life relative to a matched cohort reconstructed without the graft.

The investigators are careful to acknowledge the limits of their evidence. The registry lacks a contemporaneous control group, so direct comparative claims about relative safety cannot be drawn; the deliberately heterogeneous population, while ideal for an IDEAL stage 2b evaluation, may obscure indication-specific differences; the interim analysis carries a median follow-up of only about 27 weeks, leaving late complications and long-term durability to be characterized; and adverse event categorization relied on investigator judgment. Even so, as one of the largest prospective evaluations of a bioscaffold in soft tissue reconstruction reported to date, the interim MASTRR data make a compelling case that a scaffold spun from an abundant food-industry byproduct can be deployed safely in some of the most hostile wounds surgery has to offer, and that registry-based real-world evidence deserves a permanent seat alongside randomized trials in judging emerging medical devices.

Subject of Research: Real-world safety of ovine forestomach matrix bioscaffolds in complex soft tissue reconstruction

Article Title: Safety of Ovine Forestomach Matrix Across 474 Soft Tissue Defects: Interim Results from the Prospective Multicenter MASTRR Registry

Article References: Short, T., Lawlor, J., Martyka, P., Wolf, J. H., Felton, J. M., Smith, A. A., Nasseri, Y. Y., Barnajian, M., Vassy, W. M., Cormican, M., Kumar, P., Choi, J. J., Lau, L., Loftus, J. H., Bernal, N. P., Butts, C. A., Dillingham, C. S., Leneweaver, K. J., Simon, J., … May, B. C. H. (2026). Safety of Ovine Forestomach Matrix Across 474 Soft Tissue Defects: Interim Results from the Prospective Multicenter MASTRR Registry. Advances in Therapy. https://doi.org/10.1007/s12325-026-03768-0

Image Credits: AI Generated

DOI: 10.1007/s12325-026-03768-0

Keywords: ovine forestomach matrix, bioscaffold, soft tissue reconstruction, MASTRR Registry, adverse events, real-world evidence, wound healing, diabetic foot ulcers, trauma surgery, burns, pilonidal sinus, IDEAL framework