Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk.

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The risk factors for ACS development in detailed classified manner remain limited, and the management strategies to minimize risk are controversial. We conducted this meta-analysis to quantify ACS risk factors and evaluate the impact of treatment modalities on ACS incidence in tibial fractures. Methods We searched multiple literature scientific databases up to 17th of April 2025. Primary studies that investigated ACS risk factors in tibial fractures were included. We conducted random and fixed-effects meta-analyses, subgroup analyses, and meta-regression to estimate the risk factors and treatment effects. Study quality was assessed using the Newcastle-Ottawa Scale. Results Seventeen studies with total of 274,962 patients and 10,019 ACS cases met our inclusion criteria. Delayed fixation after 24 hours was associated with 67% reduced ACS risk (OR: 0.33, 95% CI: 0.19-0.58) compared to early fixation, with strongest effects in young males with plateau fractures. Proximal tibial fractures demonstrated significantly higher risk than shaft or distal fractures (OR: 2.02, 95% CI: 1.53-2.66). Male patients had higher risk with two to four folds across age groups. External fixation showed protective effects versus immediate internal fixation, especially for plateau fractures (OR: 0.46, 95% CI: 0.27-0.79). Meta-regression identified fracture type, injury mechanism, and patient demographics explaining 67% of treatment effect variance. Conclusion Our study results are going in an opposite direction to the standard approach of early fixation for tibial fractures, suggesting that delayed fixation or temporary spanning external fixation may significantly reduce ACS risk in high-risk patients. A patient tailored risk-stratified treatment algorithm considering fracture location, patient demographics, and injury mechanism could optimize management according to individual profile to reduce the risk of ACS development furtherly. 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F1000Research 2025, 14 :548 ( https://doi.org/10.12688/f1000research.165301.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Systematic Review Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] Yazan Jumah Alalwani 1 , Nihal Mushabb Alqahtani https://orcid.org/0009-0006-7919-2544 2 , Ahmed Khaled Almarri https://orcid.org/0009-0002-0576-1880 3 , [...] Khalid Abdullah Alkhalid 1 , Leen Albraik 4 , Abdurrahman Sami Seraj https://orcid.org/0009-0008-4720-236X 5 , Aseel Mustafa Andijany 5 , Layan Albraik 4 , Raghad Yaser Sonbul 1 , Ahmed Y Azzam https://orcid.org/0000-0002-4256-0159 6 , Suliman Mohammed Alshammari 3,7,8 Yazan Jumah Alalwani 1 , Nihal Mushabb Alqahtani https://orcid.org/0009-0006-7919-2544 2 , [...] Ahmed Khaled Almarri https://orcid.org/0009-0002-0576-1880 3 , Khalid Abdullah Alkhalid 1 , Leen Albraik 4 , Abdurrahman Sami Seraj https://orcid.org/0009-0008-4720-236X 5 , Aseel Mustafa Andijany 5 , Layan Albraik 4 , Raghad Yaser Sonbul 1 , Ahmed Y Azzam https://orcid.org/0000-0002-4256-0159 6 , Suliman Mohammed Alshammari 3,7,8 PUBLISHED 02 Jun 2025 Author details Author details 1 Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, Eastern Province, Saudi Arabia 2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Riyadh Province, Saudi Arabia 3 Department of Orthopedic Surgery, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, Eastern Province, Saudi Arabia 4 Alfaisal University College of Medicine, Riyadh, Riyadh Province, Saudi Arabia 5 Taibah University Faculty of Medicine, Medina, Al Madinah Province, Saudi Arabia 6 Director of Clinical Research and Clinical Artificial Intelligence, ASIDE Healthcare, Lewes, Delaware, USA 7 Department of Orthopedic Surgery, Mouwasat Hospital, Khobar, Eastern Province, Saudi Arabia 8 Department of Orthopedic Surgery, King Fahad University Hospital, Al Khobar, Eastern Province, Saudi Arabia Yazan Jumah Alalwani Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Nihal Mushabb Alqahtani Roles: Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ahmed Khaled Almarri Roles: Conceptualization, Data Curation, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Khalid Abdullah Alkhalid Roles: Investigation, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Leen Albraik Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdurrahman Sami Seraj Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aseel Mustafa Andijany Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Layan Albraik Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Raghad Yaser Sonbul Roles: Formal Analysis, Visualization, Writing – Review & Editing Ahmed Y Azzam Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Suliman Mohammed Alshammari Roles: Project Administration, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction Acute compartment syndrome (ACS) following tibial fractures can lead to permanent neuromuscular dysfunction and limb amputation if not rapidly diagnosed and treated a correct manner. The risk factors for ACS development in detailed classified manner remain limited, and the management strategies to minimize risk are controversial. We conducted this meta-analysis to quantify ACS risk factors and evaluate the impact of treatment modalities on ACS incidence in tibial fractures. Methods We searched multiple literature scientific databases up to 17 th of April 2025. Primary studies that investigated ACS risk factors in tibial fractures were included. We conducted random and fixed-effects meta-analyses, subgroup analyses, and meta-regression to estimate the risk factors and treatment effects. Study quality was assessed using the Newcastle-Ottawa Scale. Results Seventeen studies with total of 274,962 patients and 10,019 ACS cases met our inclusion criteria. Delayed fixation after 24 hours was associated with 67% reduced ACS risk (OR: 0.33, 95% CI: 0.19-0.58) compared to early fixation, with strongest effects in young males with plateau fractures. Proximal tibial fractures demonstrated significantly higher risk than shaft or distal fractures (OR: 2.02, 95% CI: 1.53-2.66). Male patients had higher risk with two to four folds across age groups. External fixation showed protective effects versus immediate internal fixation, especially for plateau fractures (OR: 0.46, 95% CI: 0.27-0.79). Meta-regression identified fracture type, injury mechanism, and patient demographics explaining 67% of treatment effect variance. Conclusion Our study results are going in an opposite direction to the standard approach of early fixation for tibial fractures, suggesting that delayed fixation or temporary spanning external fixation may significantly reduce ACS risk in high-risk patients. A patient tailored risk-stratified treatment algorithm considering fracture location, patient demographics, and injury mechanism could optimize management according to individual profile to reduce the risk of ACS development furtherly. READ ALL READ LESS Keywords Acute Compartment Syndrome; Tibial Fractures; External Fixation; Delayed Fixation; Early Fixation Corresponding Author(s) Ahmed Y Azzam ( [email protected] ) Close Corresponding author: Ahmed Y Azzam Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Alalwani YJ et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Alalwani YJ, Alqahtani NM, Almarri AK et al. Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :548 ( https://doi.org/10.12688/f1000research.165301.1 ) First published: 02 Jun 2025, 14 :548 ( https://doi.org/10.12688/f1000research.165301.1 ) Latest published: 02 Jun 2025, 14 :548 ( https://doi.org/10.12688/f1000research.165301.1 ) 1. Introduction Acute compartment syndrome (ACS) is a limb threatening emergency condition that is associated with orthopedic emergencies, characterized by increased pressure within a closed muscle compartment that leads to impaired circulation, muscle and nerve ischemia, and could lead to irreversible tissue damage. 1 If left untreated, ACS can result in severe complications including muscle necrosis, contractures, neurological deficits, and even limb amputation. Among orthopedic emergencies, ACS represents one of the most time-sensitive conditions, requiring rapid diagnosis and surgical intervention to prevent long-term disability. 1 Tibial fractures are susceptible to ACS risk due to the anatomical configuration of the lower leg, with its well-defined fascial compartments and limited space for tissue expansion following trauma. 2 The incidence of ACS following tibial fractures varies widely in the literature, with reported rates ranging from 2% to 9% depending on fracture type, location, and severity. Tibial plateau and high-energy diaphyseal fractures appear to carry higher risk, however the precise risk remains incompletely estimate. 2 The present variability creates significant challenges for practice decision, as physicians should balance the need for emergent monitoring and prophylactic interventions against the risks of unnecessary procedures. Several factors have been proposed as contributing predictors of ACS development in patients with tibial fractures. Patient demographics such as age and gender, injury characteristics including fracture topology, and mechanism of trauma, and treatment variables like timing of fixation and choice of surgical approach have all been introduced in the ACS risk. 3 , 4 However, the published literature demonstrates multiple heterogeneity points in both methodology and findings. Individual studies often report conflicting results, which are limited by small sample sizes, or focus on specific limited sub-populations, making it difficult to make definitive conclusions. Previous studies have attempted to synthesize the evidence about ACS, but most have provided only qualitative assessments without focused and detailed quantitative analysis. 4 The lack of consensus regarding ACS risk factors has significant considerations. Without clear risk stratification and evaluations, we may adopt inappropriate management or useless strategies that may interfere the with best desired outcomes that shall be achieved. This uncertainty is causing a burden given the severe consequences of delayed diagnosis and the narrow therapeutic window for proper intervention in ACS. 5 Previous meta-analyses have focused on comparing proportions between ACS and non-ACS groups, without precisely quantifying the strength of association between specific risk factors and ACS development. Such approaches do not account for the possible confounders and are susceptible to higher risk of bias when pooling heterogeneous data. 6 Therefore, given these limitations we aim to these limitations we aim to evaluate and assess the associations between specific risk factors and ACS in patients with tibial fractures. By synthesizing data from multiple studies using multiple approached methodologies, we look to: (1) identify patient demographics that modify ACS risk; (2) determine the impact of fracture characteristics and injury mechanisms on ACS development; (3) evaluate the impact of treatment modalities, especially fixation timing and technique, on ACS incidence; and (4) develop a risk-stratified approach to guide better patient management. Our findings could have a significant positive impact on practice by facilitating early identification of high-risk patients, informing tailored monitoring protocols, and guiding surgical timing and technique to minimize ACS risk as much as possible. 2. Methods 2.1 Search strategy and information sources We performed a literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. 7 We have searched in five major electronic databases: PubMed, EMBASE, Sopcus, the Cochrane Library, and Web of Science from inception up to date of 17 th of April, 2025. Our search strategy included a combination of controlled vocabulary terms (Medical Subject Headings [MeSH] in PubMed, Emtree terms in EMBASE) and free-text keywords. For tibial fractures, we used terms such as “tibial fracture*,” “tibia fracture*,” “tibial plateau fracture*,” “tibial shaft fracture*,” “tibial plafond fracture*,” and “tibial pilon fracture*.” For acute compartment syndrome, we included “compartment syndrome*,” “compartmental syndrome*,” “muscle compartment syndrome*,” and “fascial compartment syndrome*.” For risk factors, we used terms including “risk factor*,” “predict*,” “prognos*,” “caus*,” “associat*,” “correlat*,” “determinant*,” and “epidemiolog*.” These terms were combined using Boolean operators: (tibial fracture-related terms) AND (compartment syndrome-related terms) AND (risk factor-related terms). We applied no language restrictions during the initial search to maximize sensitivity, though non-English publications were later excluded during screening. We supplemented our electronic database search by manually reviewing the reference lists of all included studies and relevant review articles, and also we looked manually on Google Scholar later to double check if there are any records missed. 2.2 Eligibility criteria and study selection We determined our inclusion and exclusion criteria prior to our literature search. Studies were sorted as eligible if they: (1) include patients with tibial fractures, (2) have investigated risk factors associated with ACS in this population, and (3) reported sufficient extractable data points to conduct our analyses. We excluded: (1) non-original research articles (including abstracts, letters, comments, reviews, and case reports), (2) studies with duplicate data or overlapping populations, (3) studies that failed to report outcomes related to ACS or its risk factors, (4) non-English publications, and (5) conference proceedings and unpublished studies. We initially screened the titles and abstracts to identify the relevant articles. Then after that full texts of the selected articles were retrieved and evaluated against our eligibility criteria. 2.3 Data extraction From each eligible study, we extracted the following information: (1) study characteristics (author, publication year, country, study design), (2) patient demographics (sample size, age distribution, sex ratio, fracture site studied), and (3) risk factors for ACS with their corresponding events and estimates. 2.4 Quality assessment We assessed the methodological quality of all included studies using the Newcastle-Ottawa Scale (NOS), which is designed for non-randomized studies including cohort studies. The NOS evaluates studies across three domains: selection of study groups (0-4 stars), comparability of cohorts (0-2 stars), and assessment of outcomes (0-3 stars), with a maximum total score of nine stars. Two independent reviewers conducted the quality assessment, with discrepancies resolved through discussion. We classified studies as having low risk of bias (NOS score 7-9), moderate risk of bias (NOS score 5-6), or high risk of bias (NOS score ≤4). The quality assessment results were included into our analysis to evaluate the confidence of our findings and to inform sensitivity analyses based on study quality. 2.5 Statistical analysis We conducted our meta-analysis using RStudio with R version 4.4.2. For each risk factor, we calculated pooled odds ratios (OR) with 95% confidence intervals using both random-effects and fixed-effects models. Our selection between these models was based on the degree of heterogeneity, as assessed using the I 2 statistic. When I 2 was below 50%, we applied a fixed-effects model; otherwise, we used a random-effects model to account for between-study variability. Heterogeneity was assessed through visual inspection of forest plots and by calculating the Cochran’s Q statistic, with P-value <0.10 indicating significant heterogeneity. To explore the possible contributing sources of heterogeneity, we conducted subgroup analyses based on fracture type, patient age groups, and injury mechanisms. We also performed meta-regression analyses to look how study-level factors (publication year, sample size, methodological quality) and clinical characteristics affected effect estimates. Sensitivity analyses were conducted to assess the significance of our findings by excluding studies with high risk of bias, including only studies with similar fracture types, and using alternative statistical methods. Publication bias was evaluated through visual inspection of funnel plots and, where applicable, Egger’s regression test and the trim-and-fill method. All statistical tests were two-sided, and P-values less than 0.05 were considered statistically significant unless otherwise specified. 3. Results 3.1 Study characteristics Our search resulted at first with a total of 2,124 articles, that were finally filtered into 17 retrospective studies 2 , 8 – 23 which met our inclusion criteria and were included in our study ( Figure 1 ). The included studies were published between 2013 and 2024, with the most of studies originating from the United States (seven studies). Other countries represented included China (three studies), Switzerland (three studies), the United Kingdom (two studies), and Austria (one study). The pooled dataset included 274,962 patients, including 10,019 cases of ACS. Most of the studies (12 studies from 17) focused on adult populations, while two studies have focused on pediatric patients. The most frequently reported fracture sites were tibial plateau fractures (five studies), diaphyseal fractures (three studies), and shaft fractures (one study), with the remaining studies investigating mixed or various fracture types ( Table 1 ). Figure 1. PRISMA flowchart inclusion process and pipeline. Table 1. Characteristics of included studies. Study Country Study design Sample size (ACS/non-ACS) Age Fracture classification/site Wier J et al., 2024 USA Retrospective 87/3098 ≥18 Tibial plateau fractures Wang T et al., 2024 China Retrospective 127/127 ≥18 Not reported Strain R et al., 2024 UK Retrospective 58/1089 ≥18 Diaphyseal fractures (AO/OTA type 42) Milner JD et al., 2024 USA Retrospective 296/50670 10-18 Tibial Tubercle & Tibial Shaft An M et al., 2024 China Retrospective 86/619 ACS: 32.5 (24.8–53.0), non-ACS: 43.0 (30.0–56.0) Diaphyseal tibial fractures Ahmed N et al., 2023 USA Retrospective 49/4443 <18 Various tibial fracture types including open, proximal, and articular fractures Smolle MA et al., 2022 Austria Retrospective 23/230 50.7 (18.0–85.0) Tibial plateau fractures Gamulin A et al., 2022 Switzerland Retrospective 67/658 >16 Intra- or extra-articular proximal tibia fracture (AO/OTA codes 41A2, 41A3, 41B, 41C), tibial shaft fracture (AO/OTA 42), or distal tibia fracture (AO/OTA 43) Bouklouch Y et al., 2022 USA Retrospective 8748/194752 Male: 40.2 ± 18.1, Female: 49.2 ± 20.7 Proximal tibial fractures: 38%, midshaft fractures: 30%, distal fractures: 32% Deng X et al., 2021 China Retrospective 35/1084 18-80 Tibial plateau fractures Wuarin L et al., 2020 Switzerland Retrospective 31/239 >16 Tibial shaft fractures Beebe MJ et al., 2017 USA Retrospective 136/2749 42.9 ± 18.0 Fractures of proximal, middle, and distal tibia segments (OTA/AO classification) Gamulin A et al., 2017 Switzerland Retrospective 28/2749 >16 Tibial plateau fractures Haller JM et al., 2016 USA Retrospective 14/145 ≥18 High-energy tibial plateau and plafond fractures Allmon C et al., 2016 USA Retrospective 56/922 ≥18 Plateau, shaft or pilon fractures McQueen MM et al., 2015 UK Retrospective 160/1228 12-98 Tibial diaphyseal fractures Ziran BH et al., 2013 USA Retrospective 18/141 CS: 42 ± 11.6, non-CS: 48 ± 15.5 Plateau fractures 3.2 Treatment timing and ACS risk Our findings about the treatment timing revealed a protective effect of delayed fixation when delayed over 24 hours against ACS development ( Table 2 ). The pooled OR for delayed versus early fixation was 0.33 (95% CI: 0.19-0.58, P-value <0.01), indicating a 67% reduction in ACS risk when definitive fixation was delayed beyond 24 hours. This protective effect was evident in both tibial plateau fractures and tibial plafond fractures; however, the statistical significance was only reached for plateau fractures. Wier et al. study has found that early external fixation within the first 24 hours has significantly increased ACS risk (OR: 3.22, 95% CI: 1.31-7.94, P-value = 0.01), further supporting the benefit of delayed intervention. When investigating as a continuous variable, Wuarin et al. reported that each hour of surgical delay slightly reduced ACS risk (OR: 0.99 per hour, 95% CI: 0.98-1.00, P-value = 0.08), however this was not statistically significant. Table 2. Effect of treatment timing on acute compartment syndrome risk in tibial fractures. Study Fracture type Timing comparison Odds ratio 95% CI P-value Interpretation Haller JM et al. 2016 Tibial Pilon Delayed (>24h) vs early (24h) vs early (<24h) external fixation 0.31 0.13-0.74 0.01 Temporary external fixation preferred Wier J et al. 2024 Tibial Plateau Early (<24h) external fixation vs. other treatment approaches 3.22 1.31-7.94 0.01 Delay fixation in high-risk patients Wuarin L et al. 2020 Tibial Shaft Time to surgery (per hour increase) 0.99 0.98-1.00 0.08 No significant difference Pooled Effect Combined Delayed (>24h) vs. Early (<24h) External Fixation 0.33 0.19-0.58 <0.01 Choose delayed over early fixation 3.3 Fixation modality, fracture characteristics, and patient demographics Our findings about multiple risk factors revealed significant associations across fixation modalities, fracture characteristics, and patient demographics ( Table 3 ). External fixation showed a protective effect compared to internal fixation (pooled OR: 0.65, 95% CI: 0.39-1.10), with the strongest benefit observed for plateau fractures (OR: 0.46, 95% CI: 0.27-0.79, P-value = 0.005). Regarding the fracture classification, proximal tibial fractures demonstrated significantly higher ACS risk compared to tibial shaft fractures (pooled OR: 2.02, 95% CI: 1.53-2.66, P-value <0.01). The lowest risk was observed in pilon fractures compared to plateau fractures (OR: 0.16, 95% CI: 0.07-0.37, P-value <0.001) and diaphyseal fractures compared to plateau fractures (OR: 0.23, 95% CI: 0.11-0.48, P-value <0.001). Patient demographic factors showed that males have increased ACS risk in both of adults (OR: 2.21, 95% CI: 1.63-3.01) and pediatric populations (OR: 4.02, 95% CI: 2.57-6.29). Age demonstrated divergent effects: in adults, younger age increased risk (estimated at 2% per year younger), while in pediatric populations, older children had higher risk (estimated at 16% per year older). High-energy trauma has majored as a significant risk factor across multiple studies. Table 3. Risk factors for acute compartment syndrome in tibial fractures. Risk factor category Specific factor/comparison Odds ratio 95% CI P-value Interpretation Fixation Modality External fixation vs. other methods (plateau/plafond) 0.62 0.31-1.27 0.19 External fixation preferred External fixation vs. ORIF (mixed fracture types) 0.56 0.29-1.08 0.08 External fixation preferred Temporary external fixation vs. immediate ORIF 0.47 0.22-1.02 0.06 Temporary external fixation preferred External fixation vs. intramedullary nailing 0.84 0.36-1.97 0.69 No significant difference Pooled effect: External vs. internal fixation 0.65 0.39-1.10 0.05 Choose external over internal fixation Fracture Characteristics Proximal tibia vs. tibial shaft 2.02 1.53-2.66 <0.01 Shaft fractures safer than proximal Plateau vs. diaphyseal fractures 4.35 2.08-9.09 0.001 Diaphyseal fractures safer than plateau Plateau vs. pilon fractures 6.25 2.70-14.29 0.001 Pilon fractures safer than plateau OTA/AO 41 (proximal) vs. 42 (middle) 2.13 1.47-3.09 0.001 Middle segment safer than proximal OTA/AO 43 (distal) vs. 42 (middle) 0.78 0.50-1.22 0.28 No significant difference Patient & Treatment Interactions Male sex with high-energy trauma 3.12 2.25-4.33 0.001 Requires extra ACS monitoring Male sex with early fixation (<24h) 2.84 1.46-5.53 0.002 Delay fixation in male patients Age <40 with external fixation 2.57 1.68-3.94 0.001 Young patients need closer monitoring High-energy trauma with early fixation 5.14 2.36-11.19 0.001 Delay fixation after high-energy trauma 3.4 Subgroup and sensitivity analyses Subgroup analyses revealed significant effect modification by patient characteristics and fracture types ( Table 4 ). The protective effect of delayed fixation was significantly stronger in specific population subgroups: younger adults which are younger than 30 year-old had greater benefit from delayed fixation (OR: 0.29, 95% CI: 0.17-0.49) compared to older adults (OR: 0.63, 95% CI: 0.42-0.94), with a significant between-group difference. Similarly, predominantly male populations showed greater protective effects from the delayed fixation (OR: 0.34, 95% CI: 0.19-0.60) compared to mixed populations (OR: 0.67, 95% CI: 0.46-0.98, P-value = 0.026). High-energy trauma cases were observed to have the strongest benefit from delayed fixation (OR: 0.31, 95% CI: 0.18-0.53) compared to either of mixed or low-energy cases (OR: 0.70, 95% CI: 0.48-1.02), with this difference being highly significant. Table 4. Subgroup and sensitivity analyses for risk factors. Analysis type Factor Subgroup/Analysis Effect measure Heterogeneity (I 2 ) P-value Interpretation Demographic Subgroup Sex Male vs. Female (Adults) OR: 2.21 (1.63-3.01) 70% <0.001 Males consistently at higher risk across all studies Male vs. Female (Pediatric) OR: 4.02 (2.57-6.29) 32% 30 years OR: 2.57 (1.87-3.54) 42% <0.001 Young adults (18-30) at higher risk Age Per year younger in adults OR: 0.98* (0.96-0.99) 86% 0.008 Each year younger increases risk by ~2% Pediatric 15-18 years vs. <15 years OR: 1.16* (1.03-1.30) 22% 0.01 Adolescents at higher risk than younger children Treatment Interaction Males with early fixation OR: 2.84 (1.46-5.53) N/A 0.002 Early fixation particularly risky in males Young males (<30) with external fixation OR: 3.86 (2.48-6.01) N/A 0.001 Young males need monitoring even with external fixation High-energy trauma with early fixation OR: 5.14 (2.36-11.19) N/A 0.001 Highest-risk combination identified Sensitivity Analysis Treatment Timing High-quality studies only (NOS ≥7) OR: 0.51 (0.28-0.93) 38% 0.03 Delayed fixation protective across study quality strata Most recent studies only (2022-2024) OR: 0.37 (0.21-0.65) 12% 0.001 Stronger effect in more recent studies Excluding small studies (n<50 ACS cases) OR: 0.39 (0.22-0.69) 15% 0.001 Consistent effect with larger studies Fixation Modality High-quality studies only (NOS ≥7) OR: 0.58 (0.36-0.94) 25% 0.03 External fixation protective in high-quality studies Moderate-quality studies only (NOS 5-6) OR: 0.72 (0.38-1.37) 48% 0.32 Effect attenuated in moderate-quality studies Plateau fractures only OR: 0.46 (0.27-0.79) 18% 0.005 External fixation mostly beneficial for plateau fractures Between-Group Difference Fracture Type Plateau vs. Shaft/Diaphyseal (Subgroup difference) OR ratio: 0.48 N/A 0.009 Significantly greater benefit in plateau fractures Between-Group Difference Trauma Energy High-Energy vs. Mixed/Low-Energy (Subgroup difference) OR ratio: 0.44 N/A 0.005 Significantly greater benefit after high-energy trauma 3.5 Meta-Regression Study-level characteristics explained a significant proportion of effect size heterogeneity, with large study size (R 2 = 80.0%) and high study quality (R 2 = 61.3%) being the strongest moderators. Study quality impacted reported effect sizes, with higher-quality studies (NOS ≥7) showing more conservative treatment benefits (OR: 0.51, 95% CI: 0.28-0.93) compared to moderate-quality studies (OR: 0.35, 95% CI: 0.18-0.67). Fracture type significantly affected treatment efficacy, with plateau fractures showing better benefits from delayed fixation (OR: 0.36, 95% CI: 0.21-0.62) compared to the shaft or diaphyseal fractures (OR: 0.75, 95% CI: 0.48-1.17), and the results formed a significant between-group difference (P-value = 0.009). Our multivariate model explained 67% of the variance in treatment effects across studies, with fracture type, injury mechanism, and patient age appeared as the strongest predictors of treatment efficacy (refer to extended data: Supplementary Table 1 ). 3.6 Risk of bias assessment Quality assessment using the NOS revealed that four studies (23.5%) had low risk of bias (NOS score 7-9), 12 studies (70.6%) had moderate risk of bias (NOS score 5-6), and only one study (5.9%) had high risk of bias (NOS score ≤4) (refer to extended data: Supplementary Table 2 ). The highest-quality studies were Bouklouch et al., Milner et al., Gamulin et al., and Allmon et al., each demonstrating better quality in their methodological approaches. Selection criteria were generally well-addressed across studies, while the comparability domain showed more limitations. Few studies adequately controlled for all important confounding factors, and several studies had limitations in outcome assessment, especially regarding follow-up adequacy. Sensitivity analyses according to study quality confirmed that our main findings remained significant across quality subgroups, however the effect sizes were slightly attenuated in higher-quality studies, as we observed slight asymmetry through visual inspection of funnel plot of publication bias ( Figure 2 ). Figure 2. Funnel plot of asymmetry for publication bias assessment and correction estimates. 4. Discussion ACS is a one of the most serious complications of tibial fractures that may lead to permanent neuromuscular dysfunction, contractures, and even limb amputation if not rapidly diagnosed and managed correctly. Despite being a demarcated complication, the incidence of ACS following tibial fractures varies, with reported rates ranging from 2% to 9% that creates significant uncertainty in the risk assessment. 24 The time-sensitive nature of ACS diagnosis and management stress for the need of precise, focused and detailed evidence-based risk stratification. The typical signs of ACS including pain disproportionate to injury, paresthesia, paralysis, pallor, and pulselessness which often manifest lately in course when irreversible tissue damage may have already occurred. Given that, the importance of estimating precise and accurate predictors that can guide vigilance, monitoring intensity, and preventive interventions in high-risk patients. 25 We found that delayed fixation after 24 hours was associated with a 67% reduction in ACS risk compared to early fixation, which goes against the current trauma principles of early definitive fixation instead of delayed treatment. 26 This protective effect was mostly observed in specific high-risk populations which are, young adults, males, and patients with high-energy injuries. Regarding fracture characteristics, proximal tibial fractures, especially plateau fractures was observed to have higher ACS risk compared to shaft fractures and distal fractures that exceeds the double. External fixation showed a protective effect compared to immediate definitive internal fixation, especially for tibial plateau fractures. Male patients were observed to have two to four times higher ACS risk than female patients. We also found that age as a factor has demonstrated divergent effects as younger adults had progressively increasing risk with decreasing age, while in pediatric populations, older children showed higher risk than younger ones. Our meta-regression identified that 67% of the variance in treatment effects across studies could be explained by fracture type, injury mechanism, and patient demographics. Our finding that delayed fixation significantly reduces ACS risk represents an important concern to discuss here. Compared to the gold standard principles which recommend early definitive fixation to improve outcomes and reduce complications, 26 our results suggest that this approach may actually increase ACS risk in certain patients. This contradiction can be linked and explained by considering the pathophysiology of ACS: immediate post-trauma tissue edema may peak at 24-48 hours, and early aggressive manipulation during definitive fixation could exacerbate compartment pressures during this vulnerable period. 27 Some of the previous studies have concluded with similar timing effects recommending starting with close monitoring and observation within the first 24 hours before performing external fixation to reduce the risk of ACS development in high risk patients, especially in tibial plateau fractures. 4 , 6 , 8 , 24 , 28 The significance variations in ACS risk according to fracture location provides important considerations to keep in mind about the impact of anatomy and location. The higher risk associated with proximal tibial fractures, especially plateau fractures, likely reflects both the extensive soft tissue disruption typical of these injuries and the proximity to the anterior compartment, which is most frequently affected in ACS. 28 The relatively lower risk in pilon fractures and shaft fractures contradicts some previous assumptions but may reflect differences in compartment anatomy and soft tissue envelopes. 8 The meta-regression showed that fracture location was one of the strongest predictors of treatment effect, suggesting that anatomically specific protocols may optimize outcomes after further evaluation and validation in further focused studies. Our study clarifies the role of non-modifiable patient factors in ACS risk. The consistently higher risk in males with more than the double risk fold across studies likely due to both of the anatomical differences such as greater muscle mass within fixed fascial compartments, and the possible factors from higher-energy injury mechanisms in male patients. 29 In adults, we have observed a higher risk in younger patients, especially who are younger than 30-year old, this could be correlated and reflected due to the greater muscle mass and more active inflammatory responses in such individuals. However, in pediatric populations, the increasing risk with age, may relate to the rapid muscle growth during puberty outpacing fascial expansion during this developmental and growth life period. 30 – 33 One of the most important points to consider in our study is the identification of significant interaction effects between risk factors. The highest risk populations, young males with plateau fractures from high-energy mechanisms, demonstrated a five times higher increased ACS risk compared to lower-risk groups. This interactive effect explains why previous single-factor analyses often had inconsistent results as the true risk is formed from the combination of factors at the same time rather than looking into one factor only. We have summarized and concluded our findings about the management according to risk in Figure 3 . Figure 3. ACS risk stratification algorithm for tibial fracture patients. In the highly dynamic, advancing and growing literature within the field of orthopedic trauma, our study coincides with a recent meta-analysis by Cong and Zhang 2025, 6 in which they have investigated ACS risk factors in tibial fractures. Such methodological parallels are inherent and unavoidable in systematic reviews and meta-analyses addressing similar points of interest and investigating common questions, as both necessarily adhere to PRISMA guidelines and utilize high quality structured assessment tools. However, our study represents a novel and peculiar scientific contribution in several important considerations. While Cong and Zhang study has primarily investigated demographic and injury mechanism factors, 6 our study looked to investigate specifically the timing and modality of surgical fixation. Also, our finding that delayed fixation beyond 24 hours reduces ACS risk by 67% directly challenges the current gold standard approach of early fixation, representing a novel finding and new output discovery that was not studied nor investigated in the later study as they had different aims and goals from their work. We shall mention that our meta-regression modelling has explained 67% of treatment effect variance across studies, which have significant highlights and takeaways into how patient factors modify treatment efficacy. We have also formulated, proposed and developed a risk-stratification algorithm that helps in providing an applicable assisting clinical decision tool for individualized patient management. These significant differences in scope, methodology, findings, and applications clearly demarcate and differentiate our work as an original and independent study that is different from Cong and Zhang 2025 6 study aims, goals and their outcomes findings despite sharing similar concepts and considerations regarding investigated population of interest, inclusion criteria and exclusion criteria of eligible studies to include in both of our studies, as both of our studies deliver two important considerations and takeaways that are different and unique by their own. Despite the strengths and multiple statistical methods utilized in our study, we have several limitations warrant consideration. All of the included studies were retrospective in design, introducing a risk selection and recall biases. The absence of randomized controlled trials reflects the ethical challenges of experimentally studying ACS risk factors and morally unacceptable practices. Second, significant heterogeneity was present in ACS definitions, diagnostic criteria, and monitoring protocols across studies. This variability may have affected reported incidence rates and risk associations, especially when considering patient with open fractures and deep wounds who are at higher risk for more aggressive risks. Despite that, we tried to account for this through random-effects models and meta-regression, some residual heterogeneity remains unsolved. Also, as most of the included studies were from high-income countries, this may limit the generalizability to resource-constrained settings with different fracture management settings. We shall mention that our analysis was limited by the variables reported in the original studies. Important other underlying risk factors such as patient comorbidities, medication use, specific surgical techniques, as well as surgeon experience were inconsistently reported and could not be adequately analyzed which could play a role in the outcomes. Our findings call for multiple recommendations and directions to consider from our findings. We need to have further prospective studies with standardized ACS definitions, monitoring protocols, and outcome measures are needed to validate our risk model. Multicenter studies with subgroup analyses would help confirm the interaction effects we found. Also, our treatment timing findings warrant prospective evaluation and investigation through comparative effectiveness studies comparing between delayed versus early fixation in high-risk populations, with standardized monitoring protocols and clearly defined endpoints. From a clinical point of view, we recommend implementation and prospective evaluation of our risk-stratified treatment algorithm, with modification based on local resources and expertise. Particular attention should be given to standardizing monitoring protocols based on risk category, with high-risk patients receiving more intensive surveillance. Finally, we need to validate and assess further for the comparative safety and efficacy of delayed versus early treatment and the other factors that may play a role in treatment timing optimization for patients to ensure whether delayed external fixation is truly beneficial or not, and which cohort of patients will most likely benefit from it compared to the standard of care that recommends early surgical intervention. 5. Conclusion Our study findings warn that performing early definitive fixation for tibial fractures may increase ACS risk in certain high-risk patients. Our findings reveal that delayed fixation after 24 hours reduces ACS risk by 67%, with this protective effect was mostly significant in young adult males with plateau fractures from high-energy mechanisms. We identified a clear risk stratification pattern where proximal tibial fractures carry higher risk than shaft or distal fractures, and male patients demonstrate two to four times higher risk than females. The interactive effect between these factors explains why previous single-factor based studies had inconsistent results and stress the need for a multifactorial and multidisciplinary management to risk assessment. Our results suggest considering a risk-stratified treatment protocol where high-risk patients, as young males with plateau fractures from high-energy mechanisms, would benefit more from delayed definitive fixation or temporary spanning external fixation to allow for soft tissue recovery during peak edema within 24 to 48 hours. Optimized compartment monitoring should be prioritized for these patients, with careful monitoring proportionate to calculated risk. While our findings challenge the gold standard trauma principles advocating early fixation, they have a common sense with the possible ACS pathophysiology. Future prospective studies are needed to validate our findings confidently. Declarations Human ethics and consent to participate declarations Not applicable. Consent for publication Not applicable. Data availability All data underlying the results of this meta-analysis are available in a public repository under a CC BY 4.0 license. The complete dataset, including extracted values from all included studies, odds ratios, confidence intervals, statistical measures, and values used to generate all figures, is accessible at Figshare (Azzam, Ahmed (2025). DATA REPOSITORY FOR: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. figshare. Dataset. https://doi.org/10.6084/m9.figshare.29087453.v1 34 ). Extended data, including the detailed search strategy, quality assessment forms, supplementary tables, and the PRISMA checklist and flowchart used in this study, are available at Figshare (Azzam, Ahmed (2025). 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Ahmed N, Kuo Y-HJTS, Open AC: Factors associated with compartment syndrome after a tibial fracture in children.2023; 8 (1): e001158. 32. Lin JS, Samora JB: Pediatric acute compartment syndrome: A systematic review and meta-analysis. J. Pediatr. Orthop. B. 2020; 29 (1): 90–96. PubMed Abstract | Publisher Full Text 33. Shahrestani J, et al. : Compartment Syndrome in the Pediatric Patient. American Academy of Pediatrics; 2024. 34. Azzam A: DATA REPOSITORY FOR: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. figshare. 2025. 35. Azzam A: EXTENDED DATA FOR: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. figshare. 2025. Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 02 Jun 2025 ADD YOUR COMMENT Comment Author details Author details 1 Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, Eastern Province, Saudi Arabia 2 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Riyadh Province, Saudi Arabia 3 Department of Orthopedic Surgery, Imam Abdulrahman Bin Faisal University College of Medicine, Dammam, Eastern Province, Saudi Arabia 4 Alfaisal University College of Medicine, Riyadh, Riyadh Province, Saudi Arabia 5 Taibah University Faculty of Medicine, Medina, Al Madinah Province, Saudi Arabia 6 Director of Clinical Research and Clinical Artificial Intelligence, ASIDE Healthcare, Lewes, Delaware, USA 7 Department of Orthopedic Surgery, Mouwasat Hospital, Khobar, Eastern Province, Saudi Arabia 8 Department of Orthopedic Surgery, King Fahad University Hospital, Al Khobar, Eastern Province, Saudi Arabia Yazan Jumah Alalwani Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Nihal Mushabb Alqahtani Roles: Formal Analysis, Investigation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Ahmed Khaled Almarri Roles: Conceptualization, Data Curation, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Khalid Abdullah Alkhalid Roles: Investigation, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Leen Albraik Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Abdurrahman Sami Seraj Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Aseel Mustafa Andijany Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Layan Albraik Roles: Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Raghad Yaser Sonbul Roles: Formal Analysis, Visualization, Writing – Review & Editing Ahmed Y Azzam Roles: Project Administration, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Suliman Mohammed Alshammari Roles: Project Administration, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 02 Jun 2025, 14:548 https://doi.org/10.12688/f1000research.165301.1 Copyright © 2025 Alalwani YJ et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Alalwani YJ, Alqahtani NM, Almarri AK et al. Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :548 ( https://doi.org/10.12688/f1000research.165301.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 02 Jun 2025 Views 0 Cite How to cite this report: Inam M. Reviewer Report For: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :548 ( https://doi.org/10.5256/f1000research.181916.r407521 ) The direct URL for this report is: https://f1000research.com/articles/14-548/v1#referee-response-407521 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Sep 2025 Mohammad Inam , Abdul Wali Khan University, Mardan, Pakistan Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.181916.r407521 This manuscript requires major revision before consideration for indexing. The clinical implications are potentially significant but require: Independent statistical verification Comprehensive language editing More balanced discussion of limitations Emphasis on ... Continue reading READ ALL This manuscript requires major revision before consideration for indexing. The clinical implications are potentially significant but require: Independent statistical verification Comprehensive language editing More balanced discussion of limitations Emphasis on need for prospective validation Consideration of delayed fixation complications The findings, if validated, could impact trauma surgery protocols significantly. However, the current presentation has sufficient flaws that publication in this form could potentially harm patient care if the conclusions are implemented without proper validation. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? No Are the conclusions drawn adequately supported by the results presented in the review? No If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) No Competing Interests: No competing interests were disclosed. Reviewer Expertise: chemical and biological science, zoology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Inam M. Reviewer Report For: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :548 ( https://doi.org/10.5256/f1000research.181916.r407521 ) The direct URL for this report is: https://f1000research.com/articles/14-548/v1#referee-response-407521 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 02 Jun 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 02 Jun 25 read Mohammad Inam , Abdul Wali Khan University, Mardan, Pakistan Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Inam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 05 Sep 2025 | for Version 1 Mohammad Inam , Abdul Wali Khan University, Mardan, Pakistan 0 Views copyright © 2025 Inam M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This manuscript requires major revision before consideration for indexing. The clinical implications are potentially significant but require: Independent statistical verification Comprehensive language editing More balanced discussion of limitations Emphasis on need for prospective validation Consideration of delayed fixation complications The findings, if validated, could impact trauma surgery protocols significantly. However, the current presentation has sufficient flaws that publication in this form could potentially harm patient care if the conclusions are implemented without proper validation. Are the rationale for, and objectives of, the Systematic Review clearly stated? Partly Are sufficient details of the methods and analysis provided to allow replication by others? Partly Is the statistical analysis and its interpretation appropriate? No Are the conclusions drawn adequately supported by the results presented in the review? No If this is a Living Systematic Review, is the ‘living’ method appropriate and is the search schedule clearly defined and justified? (‘Living Systematic Review’ or a variation of this term should be included in the title.) No Competing Interests No competing interests were disclosed. Reviewer Expertise chemical and biological science, zoology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Inam M. Peer Review Report For: Optimizing Treatment Strategies and Risk Stratification in Tibial Fractures: A Meta-Analysis of Fixation Timing, Modality, and Fracture Classification on Acute Compartment Syndrome Risk. [version 1; peer review: 1 approved with reservations] . F1000Research 2025, 14 :548 ( https://doi.org/10.5256/f1000research.181916.r407521) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-548/v1#referee-response-407521 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });