Joint Diseases and Related Surgery (JDRS), the official journal of the Turkish Joint Diseases Foundation, is an international, peer-reviewed, immediate open access journal. All published articles in JDRS has been free for everyone, without embargo, since 1990.

Background/Objectives: Over the past 25 years, reconstructive techniques and patient management advancements have significantly improved outcomes in mangled lower extremity injuries. Functional results of limb salvage have been demonstrated to surpass those of primary amputations. Developments such as local fasciocutaneous flaps, vacuum-assisted closure, and hyperbaric oxygen therapy have enhanced the reconstructive ladder. Despite progress, the utility of the Mangled Extremity Severity Score (MESS) and Gustilo–Anderson classification remains debated, particularly in their prognostic value for limb salvage decisions. In the study, we aimed to evaluate the outcomes of optimizing mangled lower extremity reconstruction in 93 patients, focusing on their functional scores retrospectively. Methods: This retrospective study analyzed 93 patients treated for mangled lower extremities between January 2015 and October 2022. Patients were assessed for age, gender, injury location, MESSs, Gustilo–Anderson classifications, surgical methods, and functional outcomes using the Lower Extremity Functional Scale (LEFS). Surgical interventions included internal and external fixation, skin grafts, local flaps, muscle flaps, and free tissue transfer. LEFS scores were categorized into disability levels for functional evaluation. Correlations were drawn between LEFS and variables such as MESS, Gustilo–Anderson types, and nerve injuries. Results: Among the 93 patients, 16 had MESSs ≥ 7, and 77 had MESSs < 7. Reconstruction methods included local fasciocutaneous and muscle flaps (37 patients), free tissue transfer (29 patients), and skin grafting with vacuum-assisted closure (27 patients). Smoking was associated with delayed union and increased infection rates. LEFS scores were significantly lower in patients with MESSs ≥ 7, Gustilo grade 3C fractures, and tibial nerve injuries. Flap failures and a higher number of surgeries (>3) also correlated with poorer functional outcomes. The average soft tissue healing time was 18 days, and bone union time was 17 weeks. Conclusions: Lower extremity reconstruction demands precise surgical planning and execution, prioritizing functional restoration. MESSs and Gustilo–Anderson classifications provide practical frameworks but have limitations in predicting long-term functionality. Factors such as joint involvement, nerve injuries, and flap selection significantly influence outcomes. Smoking and delayed healing remain critical challenges. While free flaps are essential for complex defects, more straightforward methods yield better outcomes in suitable cases. LEFS emerged as a reliable tool.

Background: Rapid and accurate fracture detection is critical in emergency departments (EDs), where high patient volume and time pressure increase the risk of diagnostic error, particularly in radiographic interpretation. Multimodal large language models (LLMs) with image-recognition capability have recently emerged as general-purpose tools for clinical decision support, but their diagnostic performance within routine emergency department imaging workflows in orthopedic trauma remains unclear. Methods: In this retrospective diagnostic accuracy study, we included 1136 consecutive patients referred from the ED to orthopedics between 1 January and 1 June 2025 at a single tertiary center. Given the single-center, retrospective design, the findings should be interpreted as hypothesis-generating and may not be fully generalizable to other institutions. Emergency radiographs and clinical data were processed by a multimodal LLM (2025 version) via an official API using a standardized, deterministic prompt. The model’s outputs (“Fracture present”, “No fracture”, or “Uncertain”) were compared with final diagnoses established by blinded orthopedic specialists, which served as the reference standard. Diagnostic agreement was analyzed using Cohen’s kappa (κ), sensitivity, specificity, accuracy, and 95% confidence intervals (CIs). False-negative (FN) cases were defined as instances where the LLM reported “no acute fracture” but the specialist identified a fracture. The evaluated system is a general-purpose multimodal LLM and was not trained specifically on orthopedic radiographs. Results: Overall, the LLM showed good diagnostic agreement with orthopedic specialists, with concordant results in 808 of 1136 patients (71.1%; κ = 0.634; 95% CI: 68.4–73.7). The model achieved balanced performance with sensitivity of 76.9% and specificity of 66.8%. The highest agreement was observed in knee trauma (91.7%), followed by wrist (78.8%) and hand (69.6%). False-negative cases accounted for 184 patients (16.2% of the total cohort), representing 32.4% of all LLM-negative assessments. Most FN fractures were non-displaced (82.6%), and 17.4% of FN cases required surgical treatment. Ankle and foot regions showed the highest FN rates (30.4% and 17.4%, respectively), reflecting the anatomical and radiographic complexity of these areas. Positive predictive value (PPV) and negative predictive value (NPV) were 69.4% and 74.5%, respectively, with likelihood ratios indicating moderate shifts in post-test probability. Conclusions: In an emergency department-to-orthopedics consultation cohort reflecting routine clinical workflow, a multimodal LLM demonstrated moderate-to-good diagnostic agreement with orthopedic specialists, broadly within the range reported in prior fracture-detection AI studies; however, these comparisons are indirect because model architectures, training strategies, datasets, and endpoints differ across studies. However, its limited ability to detect non-displaced fractures—especially in anatomically complex regions like the ankle and foot—carries direct patient safety implications and confirms that specialist review remains indispensable. At present, such models may be explored as hypothesis-generating triage or decision-support tools, with mandatory specialist confirmation, rather than as standalone diagnostic systems. Prospective, multi-center studies using high-resolution imaging and anatomically optimized algorithms are needed before routine clinical adoption in emergency care.

This study aims to describe a retrospective study using prospectively gathered data to compare mini-open and extended open release techniques for moderate to severe carpal tunnel syndrome (CTS). The data of 198 consecutive patients (139 males, 59 females; mean age 57.0±4.5 years; range, 44 to 75 years) treated for CPS were used. For matching, age, gender and severity of the compression, the Greathouse Ernst Halle Schaffer neurophysiological classification system was used. After matching, 63 observations in each group (group 1: mini-open and group 2: extended open) were used for analysis. A Jamar hydraulic hand dynamometer was used to measure pre- and postoperative third month grip strengths. The key pinch test was performed also at third month. Patients completed the Boston Carpal Tunnel Questionnaire at the last follow-up. Symptom severity and functional status were improved up to half fold in both groups at final follow-up; however, there was no statistically significant clinical difference between the groups (p>0.05). There were totally six patients with paresthesia symptoms (three in each group; 4.7%), which improved in three months. Eight patients (6.3%, one in group 1 and seven in group 2, p=0.032) had dysesthesia and pillar pain. Mini-open and extended open carpal tunnel release have similar clinical outcomes without any major complications.