Basic Science Focus Forum BSFF Podium #1
Harnessing the Power of Nature: mRNA-Activated Biomimetic Hematoma Scaffold for Volumetric Muscle Loss Regeneration
Vaida Glatt, PhD; Joshua Choe, MD; William Murphy, PhD
Purpose: Volumetric muscle loss (VML) causes permanent disability following severe extremity injuries from trauma or surgical resection. Current treatments often result in impaired mobility or amputation. Hematoma formation is a crucial early step in tissue repair, significantly influencing both muscle and bone regeneration. This understanding led to the development of the biomimetic hematoma (BH) scaffold, designed to replicate the native fracture hematoma and serve as a growth factor delivery system. Preclinical studies have demonstrated that BH delivering rhBMP-2 effectively regenerates large defects without complications. Recognizing the shared role of hematoma in muscle and bone repair, we investigated the potential of BH to deliver mRNA encoding RSPO-2, a myogenic growth factor, to enhance functional regeneration of VML.
Methods: A 30% full-thickness tibialis anterior defect was created in male Fischer-344 rats. Rats were assigned to three groups (n = 6/group): (1) empty defect (ED), (2) biomimetic hematoma (BH)-alone, and (3) 25µg RSPO-2+mRNA+BH. The uninjured limb served as a control. Autologous blood was combined with calcium and thrombin to generate the BH scaffold, with or without RSPO-2. Muscles were harvested at 5, 10, 21, and 28 days after injury to evaluate revascularization (MicroCT) and tissue morphology (histology).
Results: At 5 days, few vessels formed in the BH and mRNA+BH groups, while none was observed in the ED group. By 10 days, vessel numbers increased in both treatment groups but remained lower in the ED group. By 21 and 28 days, revascularization in the treatment groups resembled the uninjured limb. However, the mRNA+BH group showed more fibroblasts, whereas BH-alone closely mirrored uninjured tissue morphology. In contrast, the ED group had fewer vessels and was dominated by fibrous tissue.
Conclusion: These preliminary findings demonstrate that the autologous BH scaffold, with or without RSPO-2 mRNA, successfully promoted VML regeneration within 4 weeks. The BH-alone group exhibited normal muscle morphology, similar to the uninjured limb, while the ED group showed only fibrotic tissue, indicating failed regeneration. These findings highlight the potential of the BH scaffold as a novel, autologous approach for functional muscle repair, laying the groundwork for future clinical applications.
Basic Science Focus Forum BSFF Podium #2
Co-Delivery of Mesenchymal Stem Cells and Disordered Peptides Attenuates the Inflammatory Response and Improves Fracture Healing in Polytrauma
Augustine Mark Saiz, MD; Mechanistic Polytrauma Working Group
Purpose: Our objective was to test a hyaluronic acid–based hydrogel (Hyd) containing osteogenic intrinsically disordered peptide 2 (P2) with mesenchymal stem cells (MSC) on fracture healing in a polytrauma murine model.
Methods: We evaluated the osteogenesis and biocompatibility of our Hyd and hydrogel+P2 (Hyd+P2) groups in vitro for a period of 21 days using viability, alkaline phosphatase, PicoGreen, calcium ions, and secretome array assays. In a polytrauma model (femur osteotomy, 4 mm defect size, plus chest trauma), we studied the inflammatory response and bone formation after 3 weeks of healing in three treatment groups including Hyd, Hyd+P2, and Hyd+P2+MSCs.
Results: In vitro data confirmed the biocompatibility and osteogenic capacity of the biomaterial. Our µCT and histologic staining of mineralized versus nonmineralized tissues exhibited that although adding P2 enhanced the bone mineralization at the fracture site, the Hyd+P2+MSCs group stimulated significantly higher and more uniform bone formation than other groups (see figure).
Conclusion: This study demonstrates the Hyd+P2+MSCs system as a potential biomaterial for attenuating the inflammatory response and enhancing bone formation in the polytrauma environment.
OTA Grant
Basic Science Focus Forum BSFF Podium #3
Injury-Associated Anemia Attenuates Fracture Healing
Victoria Duke, BS; Cynthia Alcazar, BS; Natasha S McKibben, MD; Zachary Mark Working, MD; Nick J Willett, Ph.D.; Karina Nakayama, PHD
Purpose: Lower extremity orthopaedic trauma induces injury-associated anemia in 95% of patients; however, anemia’s impact on fracture healing is poorly understood. The objective of this study was to determine the impact of anemia on fracture healing using a murine model of injury-associated anemia.
Methods: To establish anemia, female C57BL/6 mice were preconditioned on an iron-deficient diet for 7 weeks, and 20% of total blood volume was drawn immediately before injury. Control mice consumed an iron-replete diet. All mice underwent a 1-mm transverse femur osteotomy stabilized with an intramedullary pin. Weekly blood samples assessed hematologic parameters and inflammatory serum cytokines. Flow cytometry quantified immune cell composition of callus tissue 3 days post-injury (n = 5/group). Bone volume was determined via microCT 4 weeks post-injury (n = 4/group).
Results: Anemic mice experienced a 4.2 g/dL drop in hemoglobin after fracture, with anemia (hemoglobin <12 g/dL) persisting throughout healing (Figure 1A). Compared to controls, anemic mice demonstrated 40% less new bone volume 4 weeks post-injury (p = 0.031) (Figure 1B-D). Injury-associated anemia elevated serum IL-6 (week 1: p = 0.0016) and IFN-γ (weeks 1–3: p<0.0001; week 4: p = 0.045) (Figure 1E-F). Three days post-injury, fracture calli of anemic mice consisted of increased M1 macrophages and pro-inflammatory monocytes as well as fewer anti-inflammatory monocytes (Figure 1G).
Conclusion: These findings suggest injury-associated anemia disrupts the inflammatory response and attenuates fracture healing, therefore establishing a critical investigatory target in orthopaedic trauma.
OTA Grant
Basic Science Focus Forum BSFF Podium #4
The Role of Human Hematoma and Soft Callus in Fracture Healing
Ting Zheng, PhD; Schimizzi Gregory, MD, PHD; Robert Bilodeau, BS; Ruge Chen, BS; Kathryn A Barth, MD; Heather Haeberle, MD ; Alona Katzir, MD; Klinger E Craig, MPH; William M Ricci, MD; Baohong Zhao, PHD
Purpose: Fracture healing is complex, requiring coordinated interaction of cells and cytokines. In early stages, fracture hematoma/soft callus plays a vital role by creating an environment conducive to cell recruitment, inflammation resolution, and tissue remodeling. However, these tissues are often surgically removed. Animal studies suggest this practice may reduce bone healing potential, underscoring the importance of exploring strategies to preserve or restore fracture hematoma/soft callus. The purpose of this study is to better understand the role of these tissues in bone healing to improve fracture management, particularly for cases at risk of nonunion.
Methods: In this IRB-approved prospective study, hematoma/soft callus tissue was collected from 35 patients age 25 to 50 years undergoing surgery for distal fibula fractures within 15 days of injury. Tissue cells were analyzed using flow cytometry to identify immune and skeletal stem/progenitor cell profiles. These cells were also differentiated into osteoblasts, and mineral deposition was measured using alkaline phosphatase (ALP) activity, alizarin red staining, and quantitative-polymerase chain reaction (PCR) for osteoblastic genes.
Results: Hematoma-derived cells exhibited osteogenic potential, with cells from samples older than 6 days demonstrating significantly enhanced osteoblast formation capacity. Flow cytometry analysis revealed a significant increase in skeletal stem/progenitor cells, rising from 0.01% to 0.131% in samples collected 6 days post-injury versus earlier stages. In contrast, early-stage samples contained higher inflammatory immune cells. These findings were supported by significantly increased osteoblast differentiation, (1.9-fold higher ALP activity and 2.3-fold stronger alizarin red staining). Osteoblastic gene expression analysis confirmed significantly higher ALP levels (2.1-fold) and IBSP (1.4-fold) in later stage hematoma-derived cells. A significant positive Pearson correlation was found between time post-injury and osteogenic potential of hematoma/soft callus (r = 0.5357; p = 0.0396).
Conclusion: Human fracture hematoma exhibits significant increased osteogenic potential in samples from 6 days post-injury, with its evolving molecular and cellular environment playing a crucial role in modulating bone repair. Deeper understanding of these mechanisms could enhance our knowledge of fracture healing and pave the way for developing targeted therapeutic strategies to improve fracture recovery, particularly in cases at risk of nonunion.
Basic Science Focus Forum BSFF Podium #5
Inhibition of CAMKK2 Signaling and ROS Mitigates PTOA After Acute Cartilage Injury
Julian Emerson Dilley, M.D.; Aaron Nanavaty, B.A.; Keegan Riggs, B.S.; Nyssa Qiao, B.S.; Abhijit Seetharam, M.D.; Hessam Noori-Dokht, Ph.D.; Diane Wagner, Ph.D.; Roman M Natoli, MD, PHD; Todd O McKinley, MD; Uma Sankar, Ph.D.
Purpose: Posttraumatic osteoarthritis (PTOA) is a leading cause of morbidity worldwide. PTOA can be initiated by a single traumatic event such as a high-impact trauma on articular cartilage. There are no effective treatments in the prevention of PTOA. The goal of this study was to evaluate the therapeutic potential of Ca2+/Calmodulin-Dependent Protein Kinase Kinase 2 (CaMKK2) inhibition via STO-609 and mitigation of mitochondrial reactive oxygen species (ROS) generation via amobarbital (AMO) in attenuating PTOA after acute cartilage injury in New Zealand White (NZW) rabbits.
Methods: Eight-month-old male NZW rabbits underwent acute medial femoral condyle (MFC) cartilage injury on right knees via a previously described impact model. In the early treatment groups, subjects were treated with either subcutaneous injections of saline (control) or STO-609 (0.033 mg/kg) three times weekly, intra-articular administration of AMO (110 µmol) given once directly after impact, or a combination of STO-609 and AMO (N = 15/group). A separate cohort of N = 15/group received the same treatment 2 weeks after surgery. Rabbits underwent euthanasia 16 weeks post-impact, their impacted and contralateral knees were harvested. Knees underwent formalin-fixation followed by micro-computed tomography scanning of subchondral bone. The knees were then plastic embedded, sectioned, and histologically stained. Safranin O Fast Green-stained sections were evaluated for cartilage degradation and hematoxylin and eosin (H&E)-stained sections for synovial inflammation. Micro-CT was used to quantify osteophyte volume. Group comparisons were performed using one-way analysis of variance (ANOVA), followed by Tukey’s Honestly Significant Difference (HSD) post-hoc test with alpha P<0.05.
Results: Early treatments with STO-609 and/or AMO significantly reduced osteophyte formation and cartilage and synovial pathologies in the impacted MFC (p<0.001) compared to saline-treated samples. There was no effect of injury or treatment in unimpacted compartments. All delayed treatments reduced osteophyte formation (p<0.001), and STO-609 decreased synovial inflammation and cartilage degradation in the impacted MFC (p<0.05), compared to saline treatment.
Conclusion: Inhibition of CaMKK2 signaling and/or ROS after acute cartilage trauma at the time of injury mitigates PTOA. CaMKK2 inhibition at the time of injury has stronger effects on reducing synovial inflammation with a similar decrease in osteophyte formation and cartilage degradation when compared to delayed treatment.
Basic Science Focus Forum BSFF Podium #6
IGF1-Integrated Muscle Void Fillers for Interim Support in Volumetric Muscle Loss
Andrew Clark, PhD; Claudia Hernandez, N/A; Chun-Hui Su, PhD; Roman Natoli, MD, PhD; Todd O McKinley, MD; Christopher Dearth, PhD; Stephen Goldman, PhD
Purpose: Volumetric muscle loss (VML) treatments often require extensive resources, limiting their use in military settings. We previously developed a muscle void filler (MVF) to stabilize VML injuries for delayed treatment. Here, we incorporated insulin-like growth factor 1 (IGF1), an anabolic agent, into the MVF to assess its impact on muscle regeneration. We hypothesized that IGF1-releasing MVFs would enhance muscle strength over time.
Methods: Male Lewis rats (~350 g) underwent a 6-mm VML injury to the tibialis anterior muscle, followed by application of a polyethylene glycol (PEG) hydrogel with varying doses of IGF1 (0, 28, or 280 µg) in different forms. Four weeks later, neuromuscular strength and histologic changes were assessed and analyzed statistically using multivariate analysis of variance (MANOVA) and Holm-Šídák post hoc testing.
Results: After 4 weeks of implantation in a VML defect, the MVF was visibly present within the VML defect region. There were no differences in neuromuscular strength for groups with MVFs incorporating IGF1 (P = 0.19). However, there was an increase in muscle mass for the combined tibialis anterior + extensor digitorum longus of the 280 μg IGF1 in the poly(lactic-co-glycolic) acid (PLGA) group compared to no IGF1 (+277.2 mg, P = 0.04). None of the groups was different from the no-IGF1 group in either myofiber count or median size. There were no differences in collagen content among any of the groups.
Conclusion: This study showed that a PEG biomaterial can fill a muscle defect after VML injury. Although IGF1 did not improve strength, high-dose IGF1 in PLGA increased muscle mass, suggesting hypertrophy, consistent with previous findings that IGF1 increases fiber size but not force production, highlighting the need for further optimization. Disclaimer: The views expressed in this document are solely those of the authors and do not necessarily reflect the official policy or positions of the Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences, Defense Health Agency, Department of Defense, or the U.S. Government.
Basic Science Focus Forum BSFF Podium #7
Collagen X Longitudinal Fracture Biomarker Expression Demonstrates Similar Endochondral Activity in Intra and Extra-articular Fractures
Caellagh D Catley, MD; Catherine E T Hutchison, MD; Natasha S McKibben, MD; Talia Trapalis, BS; Colby Curtis, BS; Dane Brodke, MD; Graham John DeKeyser, MD; Darin Friess, MD; Chelsea S Bahney, PHD; Zachary Mark Working, MD
Purpose: A biologic method to quantify fracture healing remains elusive. Growing evidence supports Collagen X as an experimental yet validated marker of endochondral ossification in fracture healing through a cartilaginous intermediate (assay: “CXM”). We hypothesized that CXM would demonstrate increased expression in intra-articular fractures against extra-articular fractures given the hypothesized contribution of cartilage damage to circulating CXM levels.
Methods: Patients presenting to a single Level I trauma center from 2019 to 2023 within 14 days of isolated fractures were consented and observed; patients received standard of care treatments. Blood was collected at all clinical encounters and analyzed for CXM. Maximum CXM expression (peak) and time to peak (days from injury to peak) were compared among pelvic ring and acetabular fractures, femoral shaft and distal femur fractures, and tibial shaft and pilon and plateau fractures. A pooled analysis of all intra-articular fractures was compared against extra-articular fractures using t tests.
Results: In total, 113 patients were enrolled who sustained fractures of the pelvis (15 acetabulum/8 pelvic ring), femur (14 femoral shaft/3 distal femur), and tibia (28 tibial shaft/9 pilon/36 tibial plateau). The average age was 43.4 years (range: 18–82 years). Most patients were male (57%) with a high-energy mechanism (71%) with similar proportions present in both intra- and extra-articular groups. An average of 4.6 samples per patient were collected. Peak CXM and time to peak CXM did not significantly differ among any of the comparison groups (p>0.1 in all groups). Pooled comparison of all intra-articular and extra-articular fractures similarly did not demonstrate a difference in expression (p>0.1). Critical subanalyses showed that patients older than age 65 years demonstrated higher peak CMX compared with younger patients (1536 ± 700 pg/mL vs 1085.1 ± 527 pg/mL, p = 0.024) without difference in time to peak expression (73 ± 117 days vs 35 ± 35 days, p = 0.2). Patient sex did not demonstrate effect on expression (p>0.1)
Conclusion: Endochondral ossification did not differ significantly between fractures sparing adjacent joint surfaces and those that were intra-articular with cartilage injury. This is an important translational stepping stone, allowing for inclusion of intra-articular injuries in future fracture biomarker studies investigating endochondral fracture healing.
Basic Science Focus Forum BSFF Podium #8
Raman Spectroscopy: Investigating the Predictive Value for Fracture
Andrew John Rodenhouse, MD; Kyle Jerreld, BS; Anthony Yosick, BS; Sashank Lekkala, MS; Andrew Berger, PhD; Hani Awad, PhD; Constantinos Ketonis, MD, PhD
Purpose: Raman spectroscopy is a molecular fingerprinting technique using nonionizing radiation to yield a chemical fingerprint of bone. We aimed to classify femoral neck explants as normal, osteopenic, or osteoporotic using Raman spectroscopy.
Methods: 58 femoral neck specimens were obtained from patients undergoing elective total hip arthroplasty. Samples were excited using a near-infrared, multiple spatial mode, semiconductor laser excitation source 830nm, 150mW laser; scattered light was collected. A custom MATLAB code calculated Raman outcomes. Osteoporosis status of samples was determined from bending moment diagram (BMD) calculations from DXA scans. Raman was correlated with osteoporosis status (WHO classification) using descriptive statistics, linear and multiple regressions, receiver-operating characteristic (ROC) curves, and area under the ROC curves (AUC). Sensitivity, specificity, odds ratio, and accuracy were determined.
Results: A composite analysis of all Raman components demonstrated a modest correlation with BMD (R2 = 0.29 [male]; R2 = 0.27 [female]). However, when the outcome was simplified to a categorical determination of osteoporosis, a notable improvement was demonstrated to distinguish and predict osteoporotic classifications (female classification: normal AUC = 0.88, osteoporotic AUC = 0.83; male classification: normal AUC = 0.76; osteoporotic AUC = 0.88). Normal and osteoporosis classifications performed well using sensitivity, specificity, odds ratio, and accuracy metrics (Table 1).
Conclusion: The determination of osteoporosis illustrated supports clinical applications for Raman spectroscopy as a nonionizing, efficient imaging modality capable of screening for osteoporosis compared to existing techniques such as DXA.
Basic Science Focus Forum BSFF Podium #9
Systemic Longitudinal Immune Profiling to Noninvasively Predict Fracture Nonunion
Kelly Leguineche, MS; Jena Robinson, BS, CCRP; Lauren Hill, BS, CCRC; Danielle Olson, BS; Raj Karia, MPH; Samantha Nino, MD; Auveen Hajarizadeh, BS; Kimberly Jones, PhD; Roman Natoli, MD, PhD; Philipp Leucht, MD; Todd O McKinley, MD; Robert Guldberg, PhD
Purpose: Diagnosis of fracture nonunion is challenging and typically delayed, resulting in prolonged disability. Early detection would revolutionize fracture care by eliminating intervention delays. Our preclinical studies implicated systemic immune dysfunction, specifically elevated immunosuppressive cell populations, in impaired bone healing. To translate these findings, we embarked on the multicentered, prospective, "Precision Nonunion" study, investigating cell-based immunologic signatures in patients who sustained Gustilo-Anderson Type I-IIIA tibia fractures.
Methods: We collected blood (1) preoperatively, (2) prior-to-discharge, (3) 2 to 4 weeks, and (4) 6 to 8 weeks postoperatively from 25 patients. We identified 16 cell types via spectral flow cytometry and biobanked plasma and debridement tissues for proteomic analysis (1500 analytes).
Results: Myeloid cells were acutely elevated compared to 2 to 4 and 6 to 8 weeks after injury (Figure 1, top row) whereas T- and B-lymphocytes were elevated by 2 to 4 (T Cells) and 6 to 8 (T and B Cells) weeks. These patterns are novel observations in patients with open fracture and match the expected sequence of innate and adaptive immune responses observed in our preclinical studies. We also observed high interpatient variation in acute levels of immunosuppressive cells, including regulatory T-cells, myeloid-derived suppressor cells (MDSCs), and nonclassical monocytes (Figure 1, bottom row).
Conclusion: Systemic immune profiling captured the innate and adaptive immune responses and revealed high divergence in immunosuppressive cell populations, highlighting their potential role in fracture nonunion.
Basic Science Focus Forum BSFF Podium #10
Distinct Immunologic Mediators Are Associated with Venous Thromboembolism in Polytrauma Patients
Prism Schneider, MD, PHD, FRCSC; Peter Quinn, BSc; Renan Castillo, MS; Greg Gaski, MD; Katherine Frey, PhD; Seth Schobel, PhD; Felipe A. Lisboa, MD; Henry Robertson, PhD; Timothey Billiar, MD; Eric Elster, MD; Laurence B Kempton, MD; Reza Firoozabadi, MD; Joshua Layne Gary, MD; Stephen Warner, MD, PHD; William T Obremskey, MD, MPH, FIOTA; Robert O’Toole, MD; Arun Aneja, MD, PhD; Eric Gann, PhD; Simon Tallowin, PhD; Todd O McKinley, MD; Major Extremity Trauma Research Consortium (METRC)
Purpose: Venous thromboembolism (VTE) risk remains high in polytrauma patients, despite thromboprophylaxis. Increasing evidence supports the interplay between hypercoagulability and inflammation during clot formation, as certain circulating cytokines can promote either thrombus formation (interleukin [IL]-6, IL-9, IL-17A) or resolution (IL-4, IL-8, IL-10). This study aimed to describe the relationship between immunologic mediators and VTE risk in polytrauma patients with major orthopaedic injuries.
Methods: This is an a priori planned secondary analysis of a multicenter prospective observational study of polytrauma patients (age 18–55 years) with pelvis, acetabulum, femur, and/or diaphyseal tibia fractures. The primary outcome was image-confirmed VTE during the index admission. Sequential serum immunologic mediator analysis for 33 mediators (Luminex) was completed until 24 hours post-admission. Multivariable logistic regression adjusting for demographics, body mass index (BMI), and injury severity score (ISS) identified cytokines independently associated with VTE.
Results: A total of 322 patients were included in this analysis (mean age: 36.2 ± 11.1 years; 72% male). There were 293 patients without VTE and 29 with VTE events (9.0%) between 24 hours post-admission and hospital discharge. There were no demographic differences, including ISS, between those with and without VTE (ISS = 24.6 ± 12.4 VTE, 27.4 ± 13.4 no VTE; p = 0.3]). In univariate models, IL-17A (p = 0.047), IL-9 (p = 0.038), and sIL-2Ra (p = 0.002) were elevated in patients in whom VTE developed. In the multivariate model, IL-10 (p = 0.017), IL-13 (p<0.001), and sIL-2Ra (p<0.001) remained independent predictors of VTE. The final model had an area under the curve (AUC) of 0.71.
Conclusion: Prothrombotic immune activation appears to contribute to VTE risk in polytrauma patients. This model suggests that immune resolution mediators (IL-10, IL-13, and sIL-2Ra) may play a role in thrombogenesis. These findings are potentially clinically important, as this suggests that distinct inflammatory pathways are influencing VTE risk, which highlights potential novel therapeutic targets for risk stratification and prevention.
Basic Science Focus Forum BSFF Podium #11
The Effect of Retrograde Nail Tip Location on Proximal Femur Fracture: A Finite Element Study With Validation
Gregory R Roytman, DC, MS; Sarah Elizabeth Rizzo, MD; Jay Moran, MD; Brad J Yoo, MD; Steven M Tommasini, PhD; Daniel H Wiznia, MD; Brianna R Fram, MD
Purpose: Our objective was to study associations between the retrograde intramedullary nail (rIMN) termination level and the extent and type of osteoporotic femur fractures.
Methods: Finite element (FE) modeling and biomechanical testing (BIOM) were performed. We obtained real and virtual models of standardized osteoporotic femurs—eight rIMNs each with a 9-mm diameter and tip termination distances of 170 mm, 130 mm, 90 mm, 70 mm, 50 mm, 30 mm, and 10 mm below the lesser trochanter and 10 mm above the lesser trochanter. In FE, we created eight models, simulating each rIMN implanted in a femur. For BIOM, we performed n = 5 trials per rIMN in synthetic femurs. Single leg stance (SLS) was tested as a baseline where femoral heads were loaded with body weight (784 N from 80 kg) and femoral condyles were fixed. In lateral impact fall (LIF), the femoral head was fixed and the lateral greater trochanter displaced at 150 mm/sec. For FE, maximum stress was recorded for SLS and elements with stresses greater than 76 MPa were considered fractured and were taken as a percentage of the total number of elements in the femur for LIF. For BIOM, fracture type was determined based on AO classification, and a Poisson regression model determined association between rIMN termination level and fracture type.
Results: No significant association was found between rIMN tip termination and fracture types in BIOM. In FE of SLS, there were no notable changes in maximum stress from 170 mm to 70 mm below the lesser trochanter, but decreased from 70 mm below the lesser trochanter to 10 mm above the lesser trochanter. For FE of LIF, all rIMN scenarios experienced fracture with a nearly threefold increase in percentage of failed elements from rIMN tip distance 50 mm below the lesser trochanter to 10 mm above the lesser trochanter. There was no significant difference between FE and synthetic femur models (p = 0.081).
Conclusion: There was no significant difference between rIMN termination level and fracture type. However, when rIMNs terminated near the lesser trochanter, the area of predicted failure increased.
Basic Science Focus Forum BSFF Podium #12
Risk of Nonunion and Revision Surgery With Early Bisphosphonate Use in Proximal Femoral Fractures
Mehul Mittal, B.S.; Aruni Areti, B.S.; Aaron Singh, B.S.; Daniel Enrique Pereira, M.D.; Pooya Hosseinzadeh, MD; Mahshid Mohseni, M.D.
Purpose: This study aims to assess the impact of immediate versus delayed bisphosphonate therapy on nonunion and revision surgery rates after surgical repair of proximal femoral fractures.
Methods: Data were obtained from the TriNetX Research network. Patients age 50 and older who underwent surgical repair for proximal femoral fractures between January 2002 and August 2023 were included. Two cohorts were compared: those who were receiving bisphosphonates within 6 weeks post-fracture (+Bisphos) and those who were not (–Bisphos). The primary outcome of interest was nonunion and revision surgery within a 1-year follow up. Propensity score matching ensured balanced cohorts, and hazard/risk ratios (HR/RR) with 95% confidence intervals were calculated. P<0.05 was considered significant.
Results: Among 109,838 patients, 7215 were in the +Bisphos cohort and 102,623 in the –Bisphos cohort. After matching, each cohort included 7215 patients. Initiating bisphosphonate therapy within 6 weeks was linked to a significantly higher risk of revision surgery (HR: 1.242, p< 0.05) and nonunion (HR: 1.585, p<0.05) compared to patients without bisphosphonate use. Delaying therapy to between 3 and 6 months postoperatively reduced the relative risk of revision surgery (RR: 1.156, p = 0.47). Furthermore, postponing bisphosphonate therapy from 6 months postoperatively to 6 to 12 months did not increase the likelihood of vertebral fractures (RR: 0.866, p = 0.35) or other osteoporotic fractures (RR: 0.966, p = 0.71).
Conclusion: Initiating bisphosphonate therapy within 6 weeks after fracture significantly increases the risk of revision surgery. Delaying therapy until 6 months postoperatively may reduce this risk without a concurrent increase in the likelihood of other osteoporotic fractures, suggesting that a delay in therapy may be advantageous.
Basic Science Focus Forum BSFF Podium #13
Increased Platelet Activity Follows Hip Fracture Surgery Compared to Elective Total Hip Arthroplasty
Daniyya Chaudhry, PhD Candidate; Golpira Elmi Assadzadeh, PhD; Souvik Maiti, BSc; Jessica Duong, PhD; Robert Korley, MDCM; Paul Duffy, MD; Prism Schneider, MD, PHD, FRCSC
Purpose: Aspirin (ASA) is an antiplatelet medication commonly used as a thromboprophylaxis agent for the prevention of venous thromboembolism (VTE) following elective total hip arthroplasty (THA). However, this practice has not been as widely adopted in the hip fracture surgery (HFS) population. Thrombelastography (TEG) is a point-of-care tool that evaluates individual coagulation profiles, with the maximal amplitude (MA) parameter indicating clot strength and increased VTE risk. Prior research supports that patients undergoing HFS are more hypercoagulable in the early postoperative period and experience a coinciding higher incidence of VTE compared to patients undergoing elective THA. TEG-based Platelet Mapping (TEG-PLM) analysis quantifies platelet activity and can be used to evaluate antiplatelet efficacy. This study aimed to compare platelet hyperactivity and platelet inhibition in patients undergoing elective THA and urgent HFS.
Methods: This is a comparison of prospective cohort studies with patients who underwent elective THA or urgent HFS, excluding those with known VTE risk factors. Serial whole blood samples were collected preoperatively and until 12 weeks postoperatively for TEG-PLM analysis (TEG6s). Thromboprophylaxis included ASA 81 mg daily for 28 days following THA, while most HFS patients received low-molecular-weight heparin (LMWH) for 35 days. Mann-Whitney U tests compared mean platelet hyperactivity-MA and platelet inhibition values at each timepoint.
Results: The study included 37 THA patients (age: 68.4 ± 9.0 years, female: 51%) and 169 HFS patients (age: 77.5 ± 11.0 years, p<0.001; female: 63%, p = 0.29). The HFS group exhibited significantly higher platelet hyperactivity and lower platelet inhibition at most postoperative timepoints. VTE events occurred in nine HFS patients (5.3), primarily during the early postoperative period when platelet hyperactivity was highest.
Conclusion: This study found higher platelet hyperactivity and lower platelet inhibition in HFS patients compared to elective THA patients, suggesting that the higher incidence of VTE in the HFS group may be related to the platelet contribution to clot formation that is not targeted by LMWH. These findings support ASA as a potential thromboprophylaxis agent after HFS. The VTE events in THA may reflect ASA resistance, highlighting the importance of a personalized approach for VTE prevention.
Basic Science Focus Forum BSFF Podium #14
Implantable Strain Sensors Revealed Higher Strain Thresholds for Robust Fracture Healing
Kylie Elizabeth Williams, PhD; Farhan Muhib, BSc; Jeffrey A Weiss, PhD; Robert E Guldberg, PhD; Ghee Ong, PhD
Purpose: Perren’s strain theory posits that 2% to 10% strain creates the ideal secondary fracture healing environment. Modern fracture fixation devices lack objective strain feedback. We present an implantable sensor to quantify real-time fixation plate strains to test this theory using a rat femur fracture model.
Methods: Wistar rat femurs were osteotomized in vivo before stabilization with internal fixation plates. Wireless sensors quantified real-time fixation plate strains (Fig1A). Rats were randomized to high- or low-intensity rehabilitation protocols (high- or low-friction running wheels). MicroCT and strain data informed subject-specific finite-element models of the fracture region.
Results: Rats in the high-intensity group experienced higher mean fixation plate strain (2665 ± 811 µstrain) than those in the low-intensity group (1498 ± 475 µstrain, Fig1B). High-intensity rats demonstrated fracture strains of 0.98% to 17.8% compared to 0.22% to 8.9% strains in low-intensity rats (Fig1D). High-intensity rats exhibited robust union with earlier callus formation and higher mean regenerated bone volume than low-intensity rats (21.29 ± 4.2 mm3 vs 14.43 ± 5.1 mm3, Fig1C). High-intensity rats achieved full functional restoration, with endpoint maximum failure torque matching intact levels (Fig1C).
Conclusion: An in vivo femur fracture model revealed strain is dynamic throughout healing, with strains beyond Perren’s proposed 10% limit conducive to robust healing. The implantable strain sensor’s ability to monitor intra- and postoperative strains may have major ramifications for research and personalized clinical care.
Basic Science Focus Forum BSFF Podium #15
Infill Architecture Influences Bone Growth in 3D Printed PCL Scaffolds
Hisham Omar, MS; Paulina Bargallo Gonzalez Lugo, BS; Rachel Bonfini, BS; Matthew Fainor, BS; Sarah Gullbrand, PhD; Michael Hast, PhD
Purpose: Bone defects can be filled with porous bone scaffolds, but it is unknown how 3D printing parameters influence the healing response. This in vitro study evaluated polycaprolactone (PCL) scaffolds with varying infill architectures (gyroid and honeycomb) and density (40% and 60%). We hypothesized that gyroid designs would enhance bone regeneration.
Methods: In total, 72 cylindrical test samples were 3D printed. Scaffolds underwent sterilization and were filled with juvenile bovine bone marrow. Constructs were cultured under standard conditions. AlamarBlue™ assays measured metabolic activity, and Von Kossa staining at 4 weeks assessed calcium deposition (see figure). Micro-CT quantified calcium content at 4 weeks and compression tests were also performed.
Results: AlamarBlue assays showed that all constructs maintained a high level of cell viability. Von Kossa staining showed G40 exhibited greater mineralization (49.60 ± 8.57) compared to H40 (68.42 ± 7.90, p = 0.015). Micro-CT analysis showed significantly higher bone volume in gyroid groups (G40: 58.5 ± 5.0 mm³; G60: 58.1 ± 5.4 mm³) versus honeycomb groups (H40: 26.9 ± 2.9 mm³; H60: 26.3 ± 7.4 mm³, p<0.0001). Honeycomb samples had higher stiffness and yield force during compression testing compared to gyroid samples. All samples exhibited increased mechanical properties because of bone tissue growth.
Conclusion: Gyroid scaffolds led to improved bone formation; however, honeycomb scaffolds provided superior mechanical strength. This result signifies a tradeoff in selection of scaffold architecture, which is dependent on application requirements.
Basic Science Focus Forum BSFF Podium #16
Right Femur Fractures: Establishing a Timeline for Returning to Drive Using a Braking Simulator Device
Daniel Scott Horwitz, MD; Claire E Hayes, BS; Daniel Hayes, BS; Ahmed Nageeb Mahmoud, MD, PhD; Zane David Patterson, BS; Joseph Patrick Carrey, BS; Eric A. Kennedy, PhD
Purpose: Although limited literature exists on the time to return to driving after lower limb fractures, specific guidelines for each bone are lacking. This study uses a braking simulator (BS) to assess postoperative brake reaction time and force in patients with right femoral fractures to determine a timeline for safe return to driving.
Methods: A total of 45 licensed driver patients with right femoral fractures was tested using a BS during their postoperative visits. Patients performed three driving-to-emergency stop trials, measuring brake reaction time and force, and the averaged data were analyzed in a MATLAB script and Excel. The referenced thresholds included a minimum accelerator-to-braking reaction time of 1 second (s) and a maximum generated-braking-force exceeding 350 newtons (N). Accordingly, patient outcome data were classified into four categories according to patients' fulfillment of the thresholds: Category 1: Met both thresholds for time and force; Category 2: Fast, but not powerful; Category 3: Powerful, but not fast; Category 4: Did not meet either threshold (Slow and not powerful).
Results: Within the first 25 days postoperatively, only 6% of the tested patients met both thresholds (Figure 1, 2). Reaction time was primarily affected from 26 to 125 days postoperatively, while the maximum brake force range remained similar. At 125+ days postoperatively, 63%, 13%, 21%, and 4% fell into categories I, II, III and IV, respectively.
Conclusion: Right femoral fracture patients should not be permitted to drive within 25 days postoperatively. Physicians should consider full weightbearing, drug intake, and, ideally, a BS test when determining patient driving readiness from 26+ days postoperatively.
Basic Science Focus Forum BSFF Podium #17
Fixation of B3 Sacral Fractures Utilizing a Novel Compressive Bolt: A Biomechanical Comparison
Devin Froerer, MD; Sebastion Jensen, -; Colin Gregersen, MS; Justin Haller, MD
Purpose: An FDA-approved device that allows for pelvis fracture fixation using a compression sleeve and screw allowing for bilateral compression has recently been developed. Our hypothesis is that this newly invented device (the Bone Bolt) will have superior fixation when compared to transsacral screws for stabilizing B3 pelvis fractures.
Methods: A biomechanical analysis was conducted using Sawbones pelvic fracture models (complete zone 2 sacral osteotomy with superior and inferior ramus osteotomies) to compare these two fixation methods (n = 6 per group). Each pelvis was fixed with either a transsacral 7.0-mm Bone Bolt (BB) or 7.0-mm cannulated screw (CS) at S1 and S2. Each pelvis was mounted to a materials testing machine and cyclically loaded to 250 N in single leg stance for 10,000 cycles while infrared (IR) light-emitting markers fixed to each side of the fracture allowed for 3D measurement of relative motions between bodies
Results: At cycle completion, the CS group experienced 3.49 mm of sacral gap widening after fixation, whereas the BB group experienced 0.6 mm of widening (= 0.008, Figure 1). The BB group had significantly less displacement in angulation in the sagittal (= 0.002) and coronal planes (= 0.018). Two pelvises from the CS group lost fixation during testing.
Conclusion: The Bone Bolt device improved fixation for sacral fractures over the standard of care in this biomechanical model.
Basic Science Focus Forum BSFF Podium #18
Dynamic Interfragmentary Compression Through a Tibial Intramedullary Nail Compared to Backslapping Alone: A Biomechanical Analysis
Brittany Haws, MD; Daniel Thompson, MS; Jonathan Yawman, MD; Jana Davis, MD; Nina Suh, MD; James Alan Blair, MD, FACS
Purpose: Our objective was to investigate the amount of interfragmentary compression that can be obtained in a transverse tibia fracture model with backslapping alone (BS) versus the intramedullary nail’s dynamic internal compression (IC) mechanism and whether that compression is maintained after loading. The hypothesis is that IC will achieve and maintain greater compression of a transverse tibial fracture compared to BS.
Methods: A biomechanical transverse diaphyseal tibia fracture model was used. A Smith & Nephew (S+N) Trigen or Stryker T2 Alpha (T2A) nail was inserted. Tibias were divided into two groups (n = 10/group). Fracture compression was obtained either by BS or use of the nail’s IC device. Specimens were loaded for 135,000 cycles of 700N at 3Hz to simulate 3 months of weightbearing. Interfragmentary pressure measurements were recorded at procedure completion (precycling) and after loading (postcycling). Compression at each stage was compared between BS and IC groups, as well as changes in compression after loading. A subanalysis was performed to compare outcomes between the T2A and S+N nails.
Results: Significantly greater compression was generated precycling in the IC group compared to the BS group (394.4N vs 94.7N, p<0.001) and maintained postcycling (331.6N vs 67.5N, p<0.001). Both groups experienced statistically significant loss of compression during the cycling process (BS: 28.7% loss; IC: 15.9% loss; p<0.05 each). On subanalysis, IC of the T2A nail demonstrated no significant loss of compression after cycling (5.7%, p = 0.148) and also exhibited greater postcycling compression than that obtained by IC of the S+N nail (416.6N vs 246.6N, p = 0.032). However, the S+N BS group generated and maintained significantly more compression than the T2A BS group (precycling: 168.3 N vs 21.1 N, p = 0.001; postcycling: 120.2N vs 14.9N, p = 0.004).
Conclusion: Our test results suggest that intramedullary IC devices generate and maintain greater interfragmentary fracture compression than traditional BS techniques alone. However, some compressive force is lost after loading regardless of compression technique used. Differences in compressive force were observed between nail manufacturers with both techniques, which suggests that nail geometry may contribute to maintaining interfragmentary fracture compression.
Basic Science Focus Forum BSFF Podium #19
Nerve to Artery Coaptation for Neuroma Prevention: A Pilot Study
Tyler Daniel Ragsdale, MD; Benjamin Nwadike, M.D. ; J Tracy Watson, MD
Purpose: Neuroma formation is a significant complication that can occur following amputation. Newer techniques are proving to be successful in preventing neuroma formation by providing the proximal nerve segment with an end organ to help with organized growth. Redirecting arterial blood flow to the nerve ending may be an effective mechanism of preventing neuroma formation. The aim of this study is to demonstrate that by coapting the proximal end of a transected nerve with a functional artery as a vascular end organ, neuroma formation can be prevented.
Methods: Six Sprague-Dawley rats were used for the control and experimental groups. Subjects underwent hind limb dissection to identify the femoral neurovascular bundle. The control group underwent an in situ neurectomy of the femoral nerve, and the experimental group had the addition of a femoral artery arteriotomy and an end-to-side coaptation of the proximal nerve segment into the functional artery. The rats were euthanized after 90 days and histologic analysis was performed using S100 stains.
Results: For the control group, the average number of axons was found to be 13 (3–33). For the experimental group, the average number of axons was 4.6 (1–12). The average diameter of the axons was 109.75 µm (range: 74–230 µm) and 157.37 µm (range: 100–278 µm) for the control and experimental groups, respectively. The average area of neural tissue was 16,707.76 µm2 (range: 4470–59,642 µm2) and 24,709.46 µm2 (range: 8222–64,529 µm2) for the control and experimental groups, respectively. No statistically significant difference was found between the control and experimental groups for mean number, diameter, or area of axons.
Conclusion: The nerve-artery coaptation may be able to reliably prevent neuroma formation in acutely transected nerves. Histopathologic analysis showed that the experimental group had more organized growth. Future studies should be performed to see how this technique could be translated to human patients.
Basic Science Focus Forum BSFF Podium #20
Halicin Increases Rifampicin Potency and Prevents Resistance Against S aureus Biofilms
Allison Wintring, MD; Joash Suryavanshi, MD; Akira Morita, MD, PhD; Roman Natoli, MD, PhD; Edward Greenfield, PhD
Purpose: Biofilms shield bacteria from antibiotics in fracture-related infections (FRI). Our lab found that halicin, recently repurposed as an antimicrobial treatment, effectively eradicates Staphylococcus aureus biofilms in vitro on orthopaedically relevant substrates, including titanium alloy (Ti6Al4V). Although rifampicin also has strong antibiofilm activity, monotherapy is contraindicated because of the rapid emergence of resistance. We hypothesized that the combination of halicin and rifampicin would synergize, increasing effectiveness against biofilm-residing S aureus and helping prevent resistance.
Methods: S aureus-Xen36 biofilms were grown on titanium alloy disks for 24 hours (less mature) or 7 days (more mature) and treated with halicin and/or rifampicin. Biofilm colony-forming units (CFU) were counted to assess antibacterial effects and determine minimum biofilm eradication concentrations (MBEC) for each antibiotic. Antibiotic resistance was evaluated by comparing the minimum inhibitory concentrations (MIC) of rifampicin and halicin in S aureus isolated from biofilms to naïve S aureus. Biofilm eradication data was analyzed using generalized estimation equations (GEE).
Results: Rifampicin monotherapy (up to 1500 uM) did not affect biofilm CFUs. In contrast, the combination of rifampicin (15 uM) and halicin (250 uM, ¼ of its MBEC) eradicated both less-mature and more-mature biofilms (p<0.0001). CFUs were undetectable (<10) in biofilms treated with halicin/rifampicin combination therapy, while 107 CFUs were found in untreated control biofilms and biofilms treated with rifampicin or halicin monotherapy (250 uM). Highlighting translatability of these findings, 15 uM rifampicin is clinically achievable both in serum and bone. In our resistance assay, rifampicin monotherapy (15 uM) induced resistance as expected, while combination therapy with halicin (250 uM) prevented rifampicin resistance. Halicin did not induce resistance to itself, alone, or in combination with rifampicin.
Conclusion: Halicin and rifampicin synergize against S aureus biofilms, increasing rifampicin potency by more than 100-fold and preventing the emergence of rifampicin resistance. Ongoing studies are testing this combination in murine FRI models.
OTA Grant
Basic Science Focus Forum BSFF Podium #21
Temporal Effects on Intraoperative Bacterial Contamination of Surgical Gloves in Non-Infection Orthopaedic Trauma Cases
Arya Amirhekmat, MD; Julie Shimabukuro, BS; Cassiana Bittencourt, MD; James Robert Learned, MD, BA; John Alan Scolaro, MD, MA; Philip Lim, MD
Purpose: Surgical site infections are a significant issue in orthopaedic trauma surgery resulting in patient morbidity and placing a sizable financial burden on healthcare systems. Although multifactorial in origin, intraoperative inoculation is a potential contributing source, including “sterile” surgical gloves. The purpose of this study is to determine if there is bacterial contamination on surgical gloves throughout various points during a surgical case and if duration of glove wear has any effect on the incidence of contamination.
Methods: Institutional review board (IRB) approval was obtained to collect intraoperative surgeon glove cultures from 115 noninfected orthopaedic trauma surgical cases. Samples were obtained by imprinting gloved fingertips onto sheep blood agar plates that were then incubated for 14 days. Colony-forming units were counted and speciated by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry. Imprints were obtained at four intraoperative action points: before draping (control), after standard extremity surgical prepping and draping, after placement of implants, and after open fracture debridement (if applicable). Duration of glove wear was recorded. SPSS was used to perform statistical analysis of cultures that yielded positive bacterial growth.
Results: In total, 360 intraoperative glove cultures were obtained. Of these 0% (0) of the control samples, 14% (2) of post–open-fracture debridement samples, 19.5% (23) of the post-draping samples, and 33.6% (39) of the post-implant placement samples had positive bacterial growth. χ2 analysis demonstrates that the previously listed groups were significantly distinct populations (p<0.05). Cases that yielded positive cultures at time of implant placement had longer time of glove wear than negative culture samples (83.9 min vs 68.2 min, p<0.05). No significant difference was observed when comparing upper versus lower extremity samples or who provided the sample (attending surgeon or operating room staff/surgical resident).
Conclusion: This study demonstrably confirms the presence of bacterial contamination on surgical gloves at various timepoints during a case. Surgical gloves are relatively inexpensive. Therefore, changing surgical gloves at predetermined action or timepoints during a surgical case may be a cost-effective strategy to potentially reduce the risk of surgical site infections.
Basic Science Focus Forum BSFF Podium #22
Plasma Metabolomics Discriminates Patients With Fracture-Related Infection From Uninfected Controls
Priyanka Ghosh, MD; Lauren Hill, BS; Makenzie Barger, MS; Sarah Malek, DVM, PhD; Roman M Natoli, MD, PHD
Purpose: Insufficient diagnostic biomarkers exist for fracture-related infections (FRIs). We hypothesized that the peripheral blood plasma metabolome would differ between patients with confirmed FRI and uninfected matched controls.
Methods: A prospective case-control study was conducted at a Level I trauma center. 27 adults ages 18 to 85 years who were surgically treated for fracture with a retained orthopaedic implant and who met FRI consensus definition confirmatory criteria were matched to 27 control patients based on age (± 15 years), time after surgery (±2 weeks), and fracture region. Control patients were infection-free for a minimum of 6 months after enrollment. Peripheral blood plasma was obtained on the day of FRI diagnosis for patients in the first group and during routine clinical follow up for control patients. Untargeted metabolomic profiling using ultrahigh performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) (Metabolon, Morrisville, NC) was performed. Random forest analysis (RFA) was used to classify groups and identify candidate biomarkers.
Results: The RFA (Figure 1) had a predictive accuracy of 79.7% (95% CI: 66.5–89.4%), sensitivity of 77.8% (95% CI: 57.7–91.4), and specificity of 81.5% (95% CI: 61.9–93.7%). Lipids, amino acids, and xenobiotics (ie, substances not expected to be present within the organism) were common among the top 30 predictive metabolites, of which 26 had Q-values of <0.05 (controlling for false discovery when multiple comparisons are performed).
Conclusion: Unbiased, supervised classification of the plasma metabolome via RFA may be useful in FRI diagnosis.
Basic Science Focus Forum BSFF Podium #23
Impact of Preoperative Antibiotic Administration on Culture Positivity in Musculoskeletal Infections: A Preclinical Investigation
Lauren Luther, MD; Brittney D. Gimza, PhD; Kara Eichelberger, PhD; Stephanie N Moore-Lotridge, PhD; Michael Quacinella, DO, MPH; Jonathan G Schoenecker, MD Ph.D.; James E. Cassat, MD, PhD; William T Obremskey, MD, MPH, FIOTA
Purpose: The decision to initiate antibiotics for suspected mature musculoskeletal infection (MSKI) must balance two fundamental management tenets: halting infection progression and identifying the causative pathogen to guide treatment. Despite the importance of this trade-off, there is a key knowledge gap regarding the duration of antibiotics required to negatively impact culture yield. The purpose of this study was to determine the impact of antibiotic treatment prior to culture collection using an established murine model of mature MSKI.
Methods: A mature infection was established in C57BL/6J mice using a validated preclinical model of MSKI. The mice were infected with a USA300 lineage strain of Staphylococcus aureus and then divided into two cohorts: the first group was treated with vancomycin and the second with cefazolin. Each cohort was further divided into subgroups by duration of antibiotics prior to culture collection: normal saline control, 30 minutes (m), 24 hours (h). Upon sacrifice, surface swabs and tissue culture were analyzed to quantify colony-forming units (CFU). To compare the impact of antibiotics in mature infection versus acute inoculation, a second set of experiments was performed with initiation of vancomycin at 0m, 3h, 6h, 12h, or 24h after bacteria introduction and culture collection at 7 days post-inoculation. Two-way ANOVA testing with multiple comparisons correction was used to compare mean CFU among subgroups, significance was set at p<0.05.
Results: We observed no statistically significant difference in bacterial burdens for mice with a mature MSKI receiving 30m or 24h of vancomycin or cefazolin prior to culture collection. Vancomycin therapy initiated within 3 hours of inoculation significantly reduced CFU, but initiation at later time points did not differ from control groups.
Conclusion: Less than 24 hours of antibiotics or a one-time preoperative dose is unlikely to negatively impact culture yield in the setting of mature S aureus MSKI. Our preclinical data suggest a limited window after inoculation or contamination in which a short course of antibiotics alone can effectively reduce bacterial burden and prevent pathogen identification on culture.
OTA Grant
Basic Science Focus Forum BSFF Podium #24
Bactericidal Efficacy of Bacterial Load Reduction Techniques Against Biofilm
Peter Mittwede, MD, PhD; Chelsey E Smith, MD; Patrick F Bergin, MD; Dillon Christopher O'Neill, MD
Purpose: Postoperative infections in orthopaedic surgery remain a significant problem that can be detrimental to patients and difficult to eradicate. Biofilms are the main culprit for these infections, and their natural defenses, including their impenetrable glycocalyx, aid in hardware attachment and bolster antibiotic resistance. Although biofilm research has traditionally focused on arthroplasty, fracture-related infections present unique challenges because of early biofilm formation in contaminated wounds, which can occur shortly after injury. This study evaluated bactericidal efficacy of bacterial load reduction techniques including mechanical debridement, antibiotic loaded bone cement (ALBC), and bactericidal washes on models using titanium coupons and cortical bone.
Methods: Titanium coupons were inoculated with Staphylococcus aureus and incubated to establish mature biofilms. The coupons were then exposed to one of the following: untreated control, mechanical debridement, ALBC, vancomycin soak, Betadine® 10% soak, Bactisure® soak, or XPerience® soak. The coupons underwent daily media exchanges, and bacterial burden was quantified by colony-forming unit (CFU) counts at 24 hours, 3 days, 7 days, and 10 days. Additional trials were also conducted with bovine cortical reaming.
Results: Mechanical debridement alone provided only modest bacterial load reduction and did not prevent regrowth over time. ALBC significantly halted biofilm propagation throughout the study duration. Notably, XPerience demonstrated complete bacterial inhibition at 24 hours, even in the absence of mechanical debridement, suggesting its ability to disrupt the mature biofilm structure. However, these findings were limited by resumed bacterial growth on day 3. Bactisure also significantly reduced bacterial burden temporarily but did not achieve the same level of inhibition as XPerience. The bone model also showed a modest and brief reduction after mechanical debridement.
Conclusion: In this study using a titanium coupon as a model of fracture-related infection involving an implant, treatment with ALBC was most successful at eradicating infection. Mechanical debridement was modestly effective in the short term, while XPerience was the most effective antibacterial soak, although its effects were also temporary. These findings may guide future strategies for orthopaedic fracture-related infections and open fracture management. Future studies will be needed to optimize treatment protocols and evaluate in-vivo efficacy.
Basic Science Focus Forum BSFF Podium #25
Deficient Epithelial and Adaptive Immunologic Mediators Predict Organ Dysfunction in Patients Treated With Early Total Care (ETC)
Greg Gaski, MD; Prism Schneider, MD, PHD, FRCSC; Katherine Frey, PhD; Timothy R Billiar, MD; Renan Castillo, MS; Robert V O'Toole, MD; Reza Firoozabadi, MD; William T Obremskey, MD, MPH, FIOTA; Laurence B Kempton, MD; Stephen Warner, MD, PHD; Arun Aneja, MD, PhD; Todd O. McKinley, md; METRC
Purpose: Optimizing timing for orthopaedic interventions in patients with polytrauma improves outcomes. This study quantified differences in immunologic mediators in patients who were physiologically stable and treated with early total care (ETC) (definitive fixation <36 hours post-injury) in whom organ dysfunction did or did not develop.
Methods: This is a secondary analysis of 322 prospectively enrolled patients with polytrauma with surgical fractures of the pelvis, acetabulum, femur, or tibia. Injury severity scores (ISS), maximum lactate, and transfusion volumes were quantified on injury day 1 (D1). Daily organ dysfunction was quantified using Marshall Organ Dysfunction Scores (MODS). Patients with an average MODS of 3 or greater from post-injury D2 to D5 (aMODSD2-D5) had greater ventilation days and complications; therefore, they were defined as having high-magnitude organ dysfunction, while aMODSD2-D5 of 2.75 or less indicated low-magnitude organ dysfunction. In total, 33 immunologically active mediators were quantified at five timepoints from admission to 48-hours post-admission. We identified 122 of 322 patients who met criteria for ETC (ISS < 24, maximum lactate < 3.9, transfusion volume < 3000 mL, GCS > 8) of whom 77 had ETC. We compared temporal changes in immunologic mediator concentrations between patients treated with ETC in whom high-magnitude (aMODSD2-D5 > 3; n = 7) developed versus low-magnitude organ dysfunction (aMODSD2-D5 < 2.75; n = 70).
Results: Hierarchical clustering delineated three mediator clusters in the entire population (n = 322), including an inflammation-, adaptive-, and epithelial-based cluster. Inflammatory mediators demonstrated minimal differences between the low- and high-magnitude organ dysfunction groups. In contrast, the epithelial mediators interleukin (IL)-9 and IL-21 were 2.5 to 3 times lower at all timepoints (p<0.001) in patients with high-magnitude organ dysfunction, with 2.0 to 3.0 times decreases in other epithelial cytokines (IL-23, IL-33) at 24- and 48-hours post-injury (p<0.01). Adaptive mediators (IL-7, IL-1β, IL-2, interferon gamma and interferon alpha) were decreased beginning 12 hours post-injury (p<0.01) in patients with high-magnitude organ dysfunction.
Conclusion: Deficient epithelial and adaptive mediators were associated with risk of organ dysfunction development in patients who met criteria for ETC, while excessive inflammatory mediators were not observed. This finding needs further investigation to identify patients at risk for organ dysfunction after ETC.
Basic Science Focus Forum BSFF Podium #26
Metabolomics After Polytrauma: A Biobank Analysis of 97 Patients Over the Time Course of 10 Days
Felix Klingebiel, MD; Christian T Hübner, MD; Yannik Kalbas, MD; Sascha Halvachizadeh, MD, PhD; Michel Paul Johan Teuben, MD/PhD; Bergita Ganse, MD; Paolo Cinelli, PhD; Hans-Christoph Pape, MD, FACS, FAAOS, FOA, FIOTA; Roman Pfeifer, MD
Purpose: Severe injury is known to have systemic effects at multiple levels, with the inflammatory response being a major focus of research in recent years. However, little is known about the perturbation of metabolic pathways after polytrauma. Therefore, we performed a metabolomic analysis of patients from our in-hospital polytrauma biobank, which contains up to 10 days of samples from each patient.
Methods: Patients from the in-hospital polytrauma biobank with signed ethical consent were used. Sample time points were baseline (hospital admission), 8 hours, 24 hours, 48 hours, 5 days, and 10 days post trauma. Untargeted mass spectrometry was performed, while metabolites reliably identified using the KEGG/HMDB databases were subset-analyzed in a semitargeted approach. Cluster analyses were performed and metabolite dynamics over time were assessed to investigate the metabolic response between musculoskeletal trauma and hemorrhagic shock.
Results: The study included 97 severely injured patients (79.4% male). The median injury severity score (ISS) of this cohort was 29 (IQR = 19). The semitargeted analysis reliably identified 46 metabolites. The immediate response (0–8 hours) shows increased activation of hemostasis and inflammation along with excessive corticosteroid production. In the 8 to 24 hour period, there is an excessive catabolic state with energy mobilization from fatty and amino acids. At 24 to 48 hours, detoxification, immune regulation, and metabolic adjustments are primarily active. In the 5 to 10 day period, energy requirements are still elevated but reduced compared to the previous time points. An elevation of acetylcarnitines in patients with hemorrhagic shock was observed over multiple timepoints from admission to the trauma bay.
Conclusion: Severe trauma causes a major disruption in metabolism. Immediately after trauma, the body activates lifesaving pathways and begins to mobilize excessive energy resources by breaking down fats and amino acids for adenosine triphosphate (ATP) production. Initial treatment and intensive care should take this excessive energy demand into account and assess the extent to which organ-protective treatment (eg, liver) may be beneficial to the patient. Acetylcarnitines, which are indicative of mitochondrial dysfunction, have been identified as a promising marker for understanding the underlying mechanisms of traumatic ischemia.
International Trauma Care Forum ITCF Podium #1
Fracture Related Infection After Internal Fixation of Pelvic and Acetabular Fractures: A Population-Based Analysis of Risk Factors and Economic Costs
Daniel Axelrod, M.D, FRCSC; Andrew foster, MD, PHD; Jacelle warren, PHD; Kevin Tetsworth, MD, FRACS, FIOTA; Andrej trampuz, MD, PHD; Michael Schuetz, MD
Purpose: Fracture-related infection (FRI) is a relatively common and severe complication following surgically managed fractures. Patients with pelvic and acetabular fractures (PAFs) are a high-risk patient group, who represent high injury severity and are often polytraumatized. The purpose of this study is to characterize a population-based cohort of patients with PAF complicated by FRI, to identify factors associated with the development of FRI, and estimate the health economic burden.
Methods: A retrospective analysis of a 10-year, population-based, person-linked dataset including all PAF patients who underwent internal fixation within Queensland, Australia, was performed. Demographic and clinical variables were collected and included into a multivariate logistic regression. Health economic variables were compared between infected and uninfected PAF patients
Results: There were 842 patients who sustained a PAF and underwent surgical stabilization. Of these, 52 (6.4%) patients had FRI complications. Open fractures, increased length of stay, and rural residence were all independently associated with the development of FRI. Direct inpatient costs for managing FRI were higher at $69,088 versus $40,904 for uninfected PAF management.
Conclusion: The health economic impact of fracture-related infection is significant, with infected patients staying in the hospital 2.5-times longer and costing 1.7-times more in direct inpatient costs compared to uninfected patients.
International Trauma Care Forum ITCF Podium #2
Microbe Profile and Antimicrobial Sensitivity Pattern for Fracture-Related Infections: A Hospital-Based Cross-Sectional Study
Alazar Menbere Haile, MD; Binyam Dagnaw; Adonias Ager; Hamid Mohammed; Biruk Lambisso, MD
Purpose: Understanding the local microbe profile is essential for selecting appropriate prophylactic antibiotics and preventing drug resistance. In many resource-limited settings, ceftriaxone is often chosen as a stand-alone agent because of its broad-spectrum coverage and cheaper cost. A study conducted in our institution two decades ago showed low resistance to ceftriaxone, which led to its adoption as the prophylactic agent to be used for open fractures. However, more recent studies done outside the orthopaedics department, have shown a 62.5% resistance rate to ceftriaxone. This paper aims to analyze the current microbiological profile of infected long-bone fractures and their antimicrobial sensitivity pattern.
Methods: A 5-year cross-sectional study was conducted at **, a hospital in a low-income country as defined by the World Bank. Following ethical approval, we analyzed cases of infected long-bone fractures that required surgical debridement and had culture samples sent for sensitivity studies, excluding non–long-bone injuries. Demographic data, anatomic location, injury mechanism, Gustilo-Anderson grade, stabilization methods, microorganisms, and their antimicrobial sensitivity tests were analyzed. Multidrug resistance (MDR) was defined as resistance to at least one agent in three or more antimicrobial classes. Clinical and Laboratory Standards Institute (CLSI) protocol was followed for sensitivity testing. Data were analyzed using the R package vcd.
Results: A total of 59 cases was reviewed. Most fractures were classified as type 3A or higher per the Gustilo-Anderson classification. Most bacterial isolates were gram-negative (78.9%), with no growth observed in 29%. The most common organisms were Staphylococcus aureus and Escherichia coli. Of the isolates, 57.9% were resistant to three or more antibiotic classes. Notably, 92.6% of the isolates were resistant to ceftriaxone.
Conclusion: Our findings reveal a higher percentage of gram-negative bacteria than previous studies at our institution. Additionally, we had more cases of no growth, slightly above the 21% reported in other regional studies. The resistance rate for ceftriaxone was alarmingly high. We stress the need for further studies to explore the link between drug resistance and the prolonged use of empirical antibiotics in contaminated open fractures.
International Trauma Care Forum ITCF Podium #3
Role of Frozen Section Studies in FRI
Viju Daniel Varghese, MS(Orth); Moses D Rohithson, MS(Orth)
Purpose: Our objective was to determine the use of frozen sections in patients with fracture-related infections (FRI) undergoing staged management to prognosticate outcomes and guide management. This study was aimed at assessing the sensitivity, specificity, and positive predictive value of frozen sections in predicting reinfection and planning the management of FRI.
Methods: This study was conducted in the Department of Orthopedics Unit 3 at Christian Medical College, Vellore, India. It included all patients who presented with FRI or suspected FRI, infected nonunion, and those undergoing elective second-stage definitive management from January 2018 to December 2024. Patients were assessed with laboratory investigations including complete blood counts, serum inflammatory markers (ESR, CRP, and preoperative imaging). Definitive surgery, which could be internal or external fixation, was then planned. The decision for either was based on the FRI criterion, and the frozen section. During surgery, tissue from the surgical site was sent for frozen section (histopathological examination for neutrophil count). If the frozen section was positive, repeat debridement and spacer, and/or definitive treatment with external fixation was then planned. If the frozen section was negative, patients were taken for definitive internal fixation. Patients were then followed up for clinical outcomes, union, and recurrence of infection.
Results: The frozen section as assessed in this study was 71.43% sensitivity, 85.29% specificity, and 66.67% positive predictive value. There was 94.5% concordance between the frozen section and biopsy neutrophil count. These results are better than studies regarding periprosthetic joint infection where the sensitivity of the frozen section histology was 53.6% and the specificity was 95.2%.
Conclusion: There was good correlation of the frozen section with postoperative positive cultures and infection scores. Hence, internal fixation is best deferred if frozen sections are positive. This study helps to develop an algorithm and treatment protocol for managing fracture-related infections using FRI criteria (preoperative inflammatory markers and perioperative findings), especially in patients undergoing staged treatment where another internal fixation is planned.
International Trauma Care Forum ITCF Podium #4
The Modified Balanced Cable Transport System: A Novel and Innovative Technique for Treating Critical Bone Defects
Abbas See, MBBChir; Neel Badhe, BA; Caroline Kirk, RCN; Bethan Pincher, FRCS; Andrew Taylor, MD; Simon Craxford, FRCS; Benjamin Ollivere, FRCS (ORTHO), MBBS, MD
Purpose: Within the advent of the balanced cable transport system, cable transport has become increasingly popular for treatment of bone defects, but there are issues with complexity of the technique, risk of cable weave fracture, and the need for simultaneous frame removal and intramedullary (IM) nailing. We propose a novel technique in the modified balanced cable transport system using an endosteal plate to stabilize the transport segment and allow delayed intramedullary nail fixation. This reduces overall time in the frame and allows early weightbearing while the regenerate consolidates. We present our case series of patients treated with this technique.
Methods: We retrospectively reviewed our limb reconstruction database, patient notes, and radiographs. All patients who were treated with a modified balanced cable transport for a tibial diaphyseal defect were included. Demographic data, surgical details, time to radiologic union, and length of bone transport, including any obstacles encountered, were collected.
Results: In total, 13 patients were identified (mean age: 40 years; range: 20–58 years). A defect secondary to debridement following an open fracture was present in 54% of patients. The remaining patients had bone defects as a complication of previous treatment. All patients completed transport within an average timespan of 140 days (range: 41–350 days). The average transport length was 52 mm (range: 28–133 mm). Union over a mean time of 22 months occurred in eight patients, two required further procedures for nonunion, and three patients are being monitored for progressive signs of union. Of the 13 patients, 11 had an IM nail after a pin-site holiday, with the exception of one patient. The remaining two patients showed sufficient union to not require further internal fixation. Only one patient had snapping of the transport cables; this led to conversion to pin transport.
Conclusion: Our modified balanced cable transport technique allows for successful bone transport for significant defects in the tibia. The internal cable system allowed all patients to complete their planned transport, and use of an endosteal plate allows staged IM nailing without risk of recoil.
International Trauma Care Forum ITCF Podium #5
One-Stage Limb Lengthening of the Femur Using Intramedullary Nailing: A Retrospective Analysis of 22 Cases With a Mean Follow-Up of 3 Years
Lionel Llano, MD; Guido Carabelli, MD; Gonzalo Guillermo García Barreiro, MD; Carlos Sancineto, MD; Danilo Taype Zamboni, MD; Jorge Barla, MD
Purpose: Lower limb deformities, often because of congenital conditions or fracture sequelae (nonunions or infections), are commonly treated with external fixators. However, external fixators require prolonged use and are associated with complications like axial deformity and joint stiffness. This study evaluates the effectiveness of one-stage femoral lengthening using intramedullary nailing, with a focus on calcification of the distraction site and factors influencing healing.
Methods: This retrospective study included patients treated between January 2010 and January 2024, excluding those with neurologic disorders or age older than 65 years. All patients underwent femoral osteotomy, one-stage distraction, and intramedullary nailing fixation. For infected cases, cemented antibiotic-coated nails were used. Immediate weightbearing was permitted in all cases. Limb length discrepancy, lengthening achieved, and residual discrepancy were measured in millimeters (mm). Autologous bone grafting was performed at the surgeon's discretion. Patients were followed monthly until radiologic calcification of the distraction site, measured in weeks.
Results: A total of 22 patients underwent one-stage femoral lengthening between January 2010 and January 2024. The causes of the original deformities included malunion (8), nonunion (11), and infectious nonunion (3). The mean follow up was 58.7 months. The mean preoperative limb length discrepancy was 26 mm (range: 15–45 mm), the mean lengthening achieved was 22.1 mm (range: 10–38 mm), and the mean residual discrepancy was 4 mm (range: 0–9 mm). Autologous bone grafting was used in nine patients (40.9%). The mean time to radiologic calcification of the distraction site was 42 weeks (range: 9–81 weeks). Statistical analysis using a nonparametric ANOVA test revealed no significant influence of preoperative discrepancy (p = 0.42), lengthening (p = 0.39), or residual discrepancy (p = 0.62) on bone healing. However, a t-test showed that the use of autologous bone graft significantly accelerated calcification (p = 0.008).
Conclusion: One-stage femoral lengthening using intramedullary nailing is a valid surgical technique for correcting limb discrepancies of up to 45 mm. The use of autologous bone grafting enhances the rate of calcification in the distraction area, potentially improving clinical outcomes.
International Trauma Care Forum ITCF Podium #6
Comparative Study of the Sural Flap in 78 Patients With a Minimum Follow-Up of 1 Year: Does Pedicle Length Matter?
Guido Carabelli, MD; Lionel Llano, MD; Gonzalo Guillermo García Barreiro, MD; Danilo Taype Zamboni, MD; Carlos Sancineto, MD; Jorge Barla, MD
Purpose: The sural flap is widely recognized as an effective method for soft-tissue coverage in severe lower limb trauma or sequelae. This retrospective cohort study investigates the impact of vascular pedicle length in reverse sural fasciocutaneous flaps on vascular complications, specifically whether longer pedicles are associated with increased complications.
Methods: We included patients with distal third leg and foot soft-tissue defects, treated between March 2008 and March 2021, with a minimum follow up of 1 year. The cohort was divided into two groups based on the location of the flap: those with flaps above the ankle joint (short pedicle) and those below (long pedicle). Patient demographics, comorbidities (eg, diabetes, peripheral vascular disease, smoking), and the causes of defects (including fractures, ulcers, and degloving injuries) were assessed. The occurrence of complications, including epidermolysis, partial necrosis, and total necrosis, were compared between groups using bivariate linear regression.
Results: A total of 44 patients received flaps above the ankle joint, while 34 had flaps below the ankle joint. Overall, 35% of patients experienced complications: 5% epidermolysis, 20% partial necrosis, and 10% total necrosis. In the short-pedicle group (flaps above the ankle), 13 complications were observed: three cases of epidermolysis, five of partial necrosis, and five of total necrosis. In the long-pedicle group (flaps below the ankle), 15 complications occurred: one case of epidermolysis, 11 of partial necrosis, and three of total necrosis. Although complication rates were similar between the two groups, a trend toward a higher incidence of partial necrosis was observed in the longer pedicle group. Statistical analysis using bivariate linear regression found no significant difference in complication rates based on pedicle length (p = 0.407). For individual complications, there were no statistically significant differences: epidermolysis (p = 0.504), total necrosis (p = 0.808), and partial necrosis (p = 0.098).
Conclusion: Flap rotation points positioned 5 to 6 cm above the lateral malleolus, with a wide, short pedicle, may reduce vascular complications. For defects beyond the ankle joint, careful surgical planning is crucial to minimize the risk of partial necrosis and other complications.
International Trauma Care Forum ITCF Podium #7
Modified Tightrope Technique for the Fracture of Ulnar Coronoid Process in the Treatment for the Terrible Triad of the Elbow
Zhe Song, MD; Kun Zhang, MD; Na Yang, Dr.
Purpose: The goal of reconstruction of terrible triad injuries is to restore sufficient elbow stability to allow early mobilization within a stable elbow arc of motion. The purpose of this study is to investigate the surgical strategies of the modified tightrope technique for an ulnar coronoid process fracture, its application value, and clinical curative effect in the terrible triad of the elbow joint.
Methods: A retrospective study was conducted on 63 patients treated for terrible triad of the elbow joint injuries from January 2015 to January 2020. The study included 27 males and 36 females, age 26 to 68 years (mean, 38.6 years). All patients underwent surgical treatment to repair fracture of the ulnar coronoid process, the radial head, and the lateral collateral ligamentous complex from the deep layer to the superficial layer. All fractures of the ulnar coronoid process were treated with a loop-plate technique, fractures of the radial head with a tiny-plate, anatomic plate, and hollow screws or replaced with a prosthesis, and the lateral collateral ligamentous complex was reconstructed with a suture anchor without surgical repair of the medial collateral ligamentous complex.
Results: 63 patients were followed up for 18 to 24 months (mean, 20.2 months). Bony and ligamentous structures healed in all patients. The Mayo Elbow Performance Score (MEPS) at the last follow up was approximately 55 to 100 with an average of 85.8. Elbow function was excellent in 47 patients, good in eight, fair in five, and poor in three, resulting in an excellent to good rate of 87.3%. Elbow stiffness occurred in three patients, heterotopic ossification in four, and superficial infection in four. Anti-infection treatment and wound care resolved the infections.
Conclusion: Restoration of the ulnar coronoid process is the key factor. The loop-plate technique for fracture of the ulnar coronoid process in treatment of the terrible triad of the elbow can result in excellent fixation of the coronoid process, restore the elbow joint stability, allow early functional exercise, and provide satisfactory clinical effects.
International Trauma Care Forum ITCF Podium #8
The A.L.P.S.® Proximal Humerus Plating System Study: A Prospective Multicentric Evaluation of 135 Patients Treated With Open Reduction and Plate Fixation
Rudy Reindl, MD; Gregory K Berry, MD; Mitchell Bernstein, MD; Jung You Kim, MD; Suk Haw Jang, MD; David Duckworth, MD; Woong Kyo Jeong, MD; Frederic Vauclair, MD
Purpose: Open reduction and plate fixation is considered a successful technique for the treatment of proximal humerus fracture despite high complication rates. The objective of this prospective multicentric study was to systematically document the clinical outcome and complications of the ALPS plating system in a cohort of 135 patients. The plating system is designed to increase fixation stability while minimizing the likelihood of screw perforation and the occurrence of subacromial impingement. Our hypothesis was that the ALPS system will provide a good clinical outcome and low complication rates for proximal humerus fracture fixation.
Methods: After ethic approval was received at each site, 135 consecutive patients were enrolled in the study at seven study sites. Patients were clinically and radiologically assessed preoperatively, at 6 weeks, and at 3, 6, 12, and 24 months (optional) postoperatively. Functional and subjective scores were obtained (EQ-5D, American Shoulder and Elbow Surgeons [ASES], Subjective Shoulder Value [SSV]).
Results: Of the 135 patients, 81 (62.3%) were female. Average age was 60.7 years (range 20–86 years). The most common injury mechanisms were a simple fall (69.2%), sports injury (13.1%), fall from a height (6.9%), and a motor vehicle or motorcycle accident (5.4%). AO/OTA type A fracture occurred in 32.5% of patients, type B in 18.1%, and type C in 49.3%. At 1 year (n=87), active external rotation was 54.8° ± 19.5°, and forward elevation was 144.2° ± 27.3°. Complete fracture healing occurred in 93.3%, ongoing healing in 4.5% (n = 4), and nonunion in 2.2% (n = 2). The SSV was 86.1 ± 11.2 (n = 87) at 1 year and 91.5 ± 6.5 (n = 19) at 2 years. Through 1-year follow up, 12.0% of patients underwent device removal after uneventful fracture healing through routine care. There have been 27 shoulder-related adverse events that occurred in nine patients: screw/peg perforation (cut out) in 6.92% (n = 9), avascular necrosis in 2.31% (n = 3), and malunion in 2.31% (n = 3).
Conclusion: The ALPS plating system showed satisfactory clinical outcomes and low complication rates and is effective for the management of proximal humerus fractures.
International Trauma Care Forum ITCF Podium #9
MIPO Humeral Shaft Fracture Study: Multi-Centre Retrospective Review of the Australian Experience
Nicholas Boyd Jorgensen, FRACS, FAOrthA; Roger Bingham, MD; Kevin Tetsworth, MD, FRACS, FIOTA; George Banic, FRACS
Purpose: The goal of this study was to evaluate the risk of major complications following anterior minimally invasive plate osteosynthesis (MIPO) of displaced humeral shaft fractures in adults.
Methods: This was a retrospective review of the medical records and radiographs at three hospitals in Australia, two of which are tertiary referral trauma centers. Adults who sustained humeral shaft fractures that were managed with anterior MIPO between 2012 and 2024 and had a minimum follow up of 1 year were included. Patients younger than age 16 years and those with inadequate follow up were excluded. Primary outcome measures were relative risk of nonunion, infection, unplanned reoperation, and iatrogenic nerve injury.
Results: In total, 108 adults with acute fractures of the humeral shaft who underwent MIPO stabilization were identified. An overall complication rate of 8.3% was observed in the study cohort (6.6% in closed fractures). There were two infections, both in open fractures, that were later successfully revised to open reduction and internal fixation (ORIF) in a staged fashion. Repeated falls resulted in loss of fixation in three patients; these required revision MIPO, with ethyl alcohol (EtOH) a contributing factor. There was one nonunion, in a comminuted proximal shaft fracture at the level of the pectoralis major and deltoid insertions. There were three iatrogenic nerve injuries, two involving the radial nerve and one in the musculocutaneous nerve; all of these responded to nonoperative management, and all patients subsequently recovered completely.
Conclusion: Anterior MIPO represents a safe and effective technique to manage displaced humeral shaft fractures in adults, although caution should be exercised in open fractures and patients with alcoholism. The risk of major postoperative complications in closed fractures is favorable when compared to published results using either ORIF or intramedullary (IM) nails. In our opinion, this method should be considered another attractive option for those adults who may benefit from surgical stabilization of a traumatic humeral shaft fracture. Level of Evidence: Level IV
International Trauma Care Forum ITCF Podium #10
Discovering the Biological Basis of Frailty in Hip Fracture: mRNA Expression in Muscle Tissue and Implications for Surgical Recovery
Adeel Ikram, PhD MRCS; Joanne Mallinson, PhD; Scott Cooper, PhD; Liz Simpson, PhD; Paul Greenhaff, PhD; Benjamin Ollivere, FRCS (ORTHO), MBBS, MD
Purpose: The biological basis of frailty in relation to muscle metabolism has not previously been investigated in patients with fragility hip fracture. The aim of this study is to quantify the expression of mRNA, representing a range of cellular functions relevant to muscle homeostasis in the nonfractured and fractured hip, to ascertain the impact of frailty on muscle gene expression.
Methods: In a prospective observational cohort study in a Level I major trauma center, patients were recruited from the FEMUR study (NCT:04764617). Vastus lateralis muscle biopsies were obtained at the time of surgery from both the fractured and nonfractured hip through open and modified Bergström techniques. mRNA expression was completed via TaqMan® microfluidic gene cards and quantitative real time polymerase chain reaction (PCR) in 80 patients. mRNA abundance was analyzed using Ingenuity Pathway Analysis (IPA) to predict inhibition or activation of cellular processes and gene expression. Statistical analysis included paired t-test, Z-score calculations, and -log of the P value.
Results: Complete gene expression analysis was undertaken in 76 samples in the fractured hip and 77 in the nonfractured (control) hip. In the fractured hip, 35 genes were differentially expressed when compared to the nonfractured hip. In the nonfractured hip, there was no differential gene expression when stratifying for frailty score. In the fractured hip, there was a statistically significant differential gene expression when stratified for frailty, increasing with increasing frailty scores. IPA predicted a decreasing inhibition of apoptosis, inflammation, and cell death of muscle cells as frailty increased with specific genes being identified.
Conclusion: This is the first study investigating mRNA muscle gene expression in frail patients with hip fracture. This study identifies the loss of inhibition of apoptosis, cell death of muscle cells, and inflammation with increasing frailty. These are potential causes of sarcopenia, poor performance, and poor outcomes following surgery. These processes can potentially be targeted to devise treatments to improve frailty outcomes and potentially prevent or slow physical frailty.
International Trauma Care Forum ITCF Podium #11
Femoral Shortening in Pertrochanteric Fractures: Impact of Dynamically vs Statically Locked Cephalomedullary Nails. A Prospective Quasi-Experimental Study
Gonzalo Guillermo García Barreiro, MD; Lucero Nicolas, MD; Fernando Vega, MD; Lionel Llano, MD; Carlos F Sancineto, MD; Guido Carabelli, MD; Danilo Taype Zamboni, MD; Jorge Barla, MD
Purpose: Cephalomedullary nails have proven reliability in the treatment of intertrochanteric fractures. However, femoral shortening remains a problem associated with this treatment, potentially hurting patients' functionality. The aim of this study was to compare the femoral shortening up to consolidation in patients treated for intertrochanteric fractures using cephalomedullary nails (TFNA-DePuy Synthes) with proximal locking (screw/blade) in static versus dynamic mode. Secondly, functional outcomes and surgical failures were compared between these two groups.
Methods: A prospective quasi-experimental study was performed on patients with pertrochanteric hip fractures treated with dynamically versus statically locked cephalomedullary nails. Inclusion criteria were patients older than 65 years, low-energy mechanism of injury, being treated with TFNA, and radiographic follow up until healing or failure (minimum of 3 months). Quantification of fracture shortening was determined using the lateral screw protuberance method, femoral offset, tip-apex distance (TAD), and neck-shaft angle. An adjustment of femoral shortening was made according to reduction quality based on Chang's criteria. Fracture shortening measurements were calculated from immediate postoperative films up to fracture healing. Functional outcomes were assessed using the Parker Mobility Score.
Results: A total of 206 patients met the inclusion criteria (109 using TFNA with static locking and 97 with dynamic locking). When comparing the final screw protuberance (2.10 mm vs 4.55 mm), reduction of femoral offset (1.75 mm vs 3.72 mm), and the change in the neck-shaft angle (0.47° vs 2.21°), the femoral shortening of the TFNA static group was significantly less than that of the dynamic group (p<0.01). Adjusting the final screw protuberance based on reduction quality, femoral shortening was 2 mm (static) versus 4 mm (dynamic) for excellent reduction and 1.5 mm versus 5 mm for good reduction (p<0.01). Regarding functionality between the two groups, no significant differences were detected (p = 0.35).
Conclusion: Static locking showed half the femoral shortening compared to dynamic locking, with no clinical implications for patient functionality. Further studies are needed to evaluate the impact of femoral shortening on gait analysis between these two groups.
International Trauma Care Forum ITCF Podium #12
A New AI-Assisted Technique for Distal Interlocking of Long Cephalomedullary Nails: A Mixed Method Study
Sandro M. Heining, MD; Tobias Bayer, MD; Lutz Mahlke, MD; Hans-Christoph Pape, MD, FACS, FAAOS, FOA, FIOTA
Purpose: Distal interlocking techniques evolved from freehand methods through navigated approaches. For most techniques, repeated imaging continues to be necessary. Most recently, the AI-Assisted Surgery System (AIAS), an AI-assisted technique, has been developed. In a cadaver study, we tested the AI-assisted surgery approach to facilitate distal locking of long cephalomedullary nails. We now present the first clinical cases.
Methods: The markerless system is wired to a standard C-arm and automatically recognizes and processes each newly acquired 2D C-arm image. From standard projections, a 3D reconstruction is computed using a statistical femur model. From a single oblique lateral image, the relative 3D position between a drill bit and a nail implanted in the distal femur is calculated. This static 3D navigation is used to direct a power tool. When connected to an augmented reality device (head mounted display [HMD]: Magic Leap 2, optional), there is also real-time feedback to direct the power tool to aim at the locking hole. We tested 42 drillings with the system in 32 fresh-frozen cadaveric specimens and 10 first clinical cases. End point was the accuracy of drilling using the guidance provided by the AIAS system with or without additional HMD guidance. All tests were recorded by video (including the drilling sound) and all C-arm images were documented (intraoperative, postoperative, and postoperative 3D-measurement). All surgeries were performed using long cephalomedullary nails with standard surgical tools.
Results: A total of 42 distal locking screw drillings was performed by five experienced surgeons and with additional augmented reality (AR)-Information via HMD in 17 of 42 procedures. There was a 100% success rate in the first attempt, eg, no misses in any of the 42 drillings. Moreover, the system was successful in predicting the length of the interlocking screws with a median error of <1.5 mm.
Conclusion: The presented AIAS demonstrated a high degree of precision in a cadaver study for distal interlocking of long cephalomedullary nails. Moreover, the screw length was predicted reliably, thus saving a surgical step by avoiding manual length measurement. First clinical experiences show high accuracy and provide recommendations for the intraoperative setup.
International Trauma Care Forum ITCF Podium #13
Post-Operative Management Following Hip Fracture Fixation in Latin America
Verena Oberlohr, BS; Theodore Miclau, MD, FIOTA; Madeline C. MacKechnie, PhD; Dino Aguilar, MD; David Escalante, MD; Igor Escalante, MD; Luis Padilla, MD; Jose E Quintero, MD, FIOTA; Marcelo W Rio, MD, FIOTA; Julio Segovia, MD; Aleksandar Munjin, MD; Ivan Salce, MD; Alvaro Andrés Cordero, MD; Mauricio Eugenin, MD; Mario Garuz, MD; Horacio Tabares, MD; Edwin Martinez Dominguez, MD; Rita Maria Tobia, MD; José Arturo Xicará Rodríguez, MD; Vincenzo Giordano, MD PhD FBCS
Purpose: Variability exists in the postoperative treatment of hip fractures. This study seeks to determine how experienced orthopaedic surgeons in Latin America manage patients postoperatively following hip fracture fixation and factors that influence this decision-making process.
Methods: A survey was developed and distributed through REDCap using a snowball sampling method. A surgeon-leader was identified from the Latin American countries active in the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR) network. Each leader identified up to 10 national surgeons experienced in treating hip fractures. The survey presented 10 patient scenarios with pre- and postoperative radiographs that described patient characteristics (gender, age, hip fracture type), fixation techniques (extra- or intramedullary technique), and quality of reduction (anatomic/satisfactory or nonanatomic/unsatisfactory). Participants responded to associated questions using a 5-point Likert scale that ranked items between 1–“strongly agree” and 5–“strongly disagree.” Statistical significance and feature importance were evaluated using Random Forest plots and Pearson’s χ2 tests.
Results: The survey was completed by 130 respondents representing 16 Latin American countries. Averaged responses for the 10 scenarios demonstrated that early weightbearing was favored by half the respondents. Patient age was found to be a significant determinant of early weightbearing following femoral neck fixation (p = 0.004), as respondents were 1.4 times as likely to recommend early weightbearing for patients older than age 65 years. Age was less likely to influence early weightbearing following intertrochanteric fixation (p = 1.49). Most respondents (69%) were satisfied with the postoperative quality of reduction and the implant selections presented. Patient age older than 65 years also was determined to have a strong influence on implant prediction. Overall, 80% of respondents did not support revision osteosynthesis for any of the presented cases, with most surgeons (63%) reporting a general preference for delayed weightbearing in place of revision osteosynthesis.
Conclusion: An understanding of postoperative hip fracture management is fundamental to developing best practices and optimizing patient outcomes. This study provides insights into factors that influence surgeons’ postfixation hip fracture management in Latin America and can provide the foundation for how treatment strategies are determined in differently resourced countries.
International Trauma Care Forum ITCF Podium #14
Fixation Strategies for Periprosthetic Femur Fractures Around Knee Replacements: A Comprehensive Single-Center Analysis of 103 Consecutive Cases
Josep Nomdedeu-Sancho, 1147301; José-Vicente Andrés-Peiró, 1147301; Jordi Tomas-Hernandez, 1147301; Diego Gonzalez-Morgado, 1147301; Jordi Teixidor-Serra, 1147301
Purpose: Our objective was to analyze the outcomes of periprosthetic femur knee fractures (PFKF) treated by fixation in a single-center and to look for new strategies to improve the outcomes.
Methods: This is a retrospective cohorts study at a public and university hospital. In total, 149 patients who sustained a PFKF from 2010 to 2023 with a minimum follow up of 1 year were included in the study. Of these, 103 patients treated with different fixation strategies were finally analyzed.
Results: At 1 year, mortality was 16.67%; the mean hospitalization rate was 22.74 days. Patients waited nearly 8 days until they underwent surgery. Of the patients who lived in their home before the fracture, only 26.5% were able to return home after discharge. Local complications occurred in 37.3% of patients. At the end of follow up, 92.2% of the patients presented with impaired ambulatory status. Older patients, scoring worse in age-adjusted Charlson, American Society of Anesthesiologists (ASA) scale, or with affected ambulation prior to PFKF, have higher mortality at 1 year (p<0.01, p = 0.02, p = 0.02, p = 0.04). We observed no differences in outcomes when using different types of fixation to treat PFKF.
Conclusion: Patients with PFKF have high mortality and comorbidity rates, and frail patients have worse outcomes. Patients with PFKF have long hospitalization rates and most of them are not able to return home.
International Trauma Care Forum ITCF Podium #15
Femoral Peri-Implant Fracture Management: Which Surgical Strategies Have Better Outcomes? Validation of the PISCO Recommendations in 438 Patients From the PIPPAS Study.
Hector Jose Aguado, PhD Prof; Pablo Castillón-Bernal, MD PhD; Josep Muñoz-Vives, MD PhD; Montsant Jornet-Gibert, PhD; Jordi Teixidor, MD PhD; Pilar Camacho, MD PhD; Adela Pereda-Manso, SC; Yaiza Sánchez-García, PhD; Cristina Ojeda-Thies, MD PhD; Pablo García-Portabella, MD PhD; David Noriega, MD PhD; The PIPPAS Study Group, SG
Purpose: Do the surgical recommendations proposed by the Peri-Implant Spanish Consensus (PISCO) improve 1-year mortality, surgical and medical complications, gait function, and independent living in patients with femoral peri-implant fractures (FPIF)?
Methods: The PISCO investigators outlined four key principles for FPIF surgical management, aiming to reduce complications and mortality while preserving mobility and independence. The principles are (#1) use of closed or minimally invasive reduction techniques with fixation protecting the entire bone; (#2) gaps between two implants should be avoided; (#3) previous implants should be retained whenever possible; and (#4) femoral neck protection must be maintained.
Results: This multicenter prospective study included 438 consecutive patients with FPIF (median age: 87 years [range: 81–92], female: 82.4%) between January 2021 and December 2023. Patient outcomes were analyzed based on adherence to the key principles during the first-year post-surgery. FPIF occurred around a plate in 21.4% (n = 94) and around a nail in 78.6% (n = 344). There was no significant difference in 1-year mortality between patients who adhered to all four principles and those who followed none. However, failure to follow Principle #1 was associated with a higher risk of surgical complications (OR: 1.6, 95% CI: 1.04–2.52, p = 0.032). Patients in whom gaps between implants were avoided (Principle #2) experienced less mobility decline at 6 months, although no differences were observed at 1 year. Retaining previous implants (Principle #3) was associated with reduced weightbearing restrictions (OR: 0.47, 95% CI: 0.30–0.74, p<0.01). Adherence to all four principles correlated with lower mobility decline at 6 and 12 months.
Conclusion: Less aggressive surgical approaches for FPIF management reduce first-year surgical complications. While adherence to PISCO recommendations does not significantly impact functional outcomes, it helps prevent future inter-implant and femoral neck fractures, supporting their use in clinical practice.
International Trauma Care Forum ITCF Podium #16
Evidence-Based Clinical Guidelines for Fracture Care in Low-Resource Settings: A Collaborative Initiative. The ACTIONS (African Consensus Trauma in Orthopaedics National Standards) Development Group
The ACTIONS Guidelines Development Group; Joseph Wilbert Mwanga, MBChB/MMed Ortho; Lekina Florent Anicet, MD; Lapido Adewoile, MD; William Harrison, MD; Tim Chesser, FRCS, FIOTA; Claude Jr. Martin, MD, FRCSC
Purpose: Musculoskeletal injuries account for a significant portion of the global burden of disease, with a disproportionate impact on low and middle income countries (LMIC), where most fractures occur, resources for optimal treatment are limited, and access to care is challenging. There has been a notable lack of context-appropriate, standardized guidelines for fracture care in low-resource settings, leading to variability in treatment approaches. The aim of the project was to develop standards and care pathways for high-morbidity injuries where evidence-based consensus exists, focusing on cost-effective interventions suitable for low-income settings.
Methods: The development process involved stakeholders from national societies in sub-Saharan Africa, the College of Surgeons of East, Central and Southern Africa (COSECSA), and the West African College of Surgeons (WACS), achieving multi-country agreement. Injuries were given priority by the lead surgeons of more than 20 LMIC Sub-Saharan countries combining their extensive practical experience with evidence-based methodology. The guidelines were developed through a rigorous, structured multi-phase process that emphasized both evidence-based methodology and practical expertise.
Results: The initiative has resulted in the development of five comprehensive, context-appropriate guidelines that are being implemented across multiple countries in sub-Saharan Africa. Key achievements include the following: 1) creation of standardized protocols for closed femoral fractures, open tibial fractures, proximal femoral fractures, ankle fractures, wrist fractures, and supracondylar fractures in children; 2) evidence-based, culturally appropriate, and economically viable treatment standards; 3) incorporation of audit and governance tools to enable the introduction of governance into hospitals, including establishment of quality indicators for monitoring outcomes; 4) implementation of cost-control measures through standardized implant selection; and 5) integration of guidelines into training programs (COSECSA and WACS).
Conclusion: The ACTIONS clinical guidelines initiative demonstrates the feasibility and importance of developing context-appropriate standards for fracture care in low-resource settings. Through collaboration with regional surgical colleges and key opinion leaders, this project has created practical, continental evidence-based guidelines that address the specific challenges of providing fracture care in low-resource settings. Continued monitoring and evaluation will be essential to assess the long-term impact on patient outcomes and resource utilization.
International Trauma Care Forum ITCF Podium #17
Assessing Barriers to Musculoskeletal Trauma Care in a Large East African Country: A Technical Priorities Survey of Providers
Samhita Kadiyala, BA; Cameron Almeida, BA; Mengistu G Mengesha, MD; Ephrem Gebrehana, MD; James Berwin, MD; Alpha seifu Ali, MD; Samuel Hailu, MD; Kiran Jay Agarwal-Harding, MD
Purpose: As the first study of its kind in East Africa, we sought to define evidence-based, expert-informed technical priorities for national trauma and orthopaedic capacity building.
Methods: A scoping review of 80 peer-reviewed publications guided the development of essential goals and challenges to orthopaedic trauma care delivery nationwide. This list was refined through in-depth interviews with local orthopaedic surgeons, and a survey was distributed to providers and public health workers nationally through professional networks.
Results: Of 128 respondents, primarily orthopaedic surgeons (n = 110) from eight of 14 regions, most treated more than one patient weekly with tibial/fibular fracture (92%), femoral shaft fracture (89%), and chronic bone infections (74.4%). Most reported inadequate diagnosis (77%), treatment (83%), and rehabilitation (90%) of musculoskeletal pathology, with no significant variation by the respondent’s geographic region (p>0.05). In the prehospital setting, inadequate first aid (99%) and untimely triage and referral (96%) were the most commonly reported barriers. At primary and secondary hospitals, more than 70% reported inadequate triage and referral. At primary hospitals, access to slings and plaster was inadequate (79.8%); surgical implants/instruments (88.9%) and blood products (67.4%) were most frequently reported lacking at secondary hospitals. At tertiary centers more than 70% reported appropriate and safe surgical care, although inadequate implants/instruments (75.7%), fluoroscopy (68.9%), and tools for managing bone (67%) and soft-tissue defects (50.5%) were common barriers. Negative pressure wound therapy was most often absent at secondary (80.5%) and tertiary (78%) hospitals. Insufficient trauma training was reported at primary (90.9%), secondary (78.3%), and tertiary hospitals (53.3%).
Conclusion: Our study identified key targets for musculoskeletal trauma care capacity improvement at every level. Inadequate diagnosis, treatment, and rehabilitation were reported by most survey respondents. Training in trauma care was a key area for improvement, particularly in triage and referral in prehospital settings and primary hospitals, and definitive orthopaedic trauma management at secondary hospitals. At tertiary centers, improving availability of surgical supplies is essential. These evidence-based, expert-guided insights should guide policy priorities and actionable strategies.
International Trauma Care Forum ITCF Podium #18
Impact of Implant Donation on Time to Surgery in Spine Trauma at a High-Volume Trauma Center in Tanzania
East Africa Spine Trauma Network; Charlotte Wahle, BA
Purpose: The cost of spine surgery in lower middle-income countries (LMIC) often leads to major delays in surgery, threatening clinical outcomes. Spinal implants account for most surgical expenses. Prior research has indicated that implant donation programs may help alleviate this financial burden. However, the impact of this intervention has not been examined in the spine trauma setting. The objective of this study was to investigate the impact of spine implant donation on time to surgery as compared to historical controls.
Methods: All spine trauma patients presenting to a single high-volume institution in an LMIC over a 6-month period between July 2024 and January 2025 were included. All uninsured patients with surgical injuries were offered donated implants. Demographic information, injury characteristics, and the clinical course were recorded.
Results: In total, 76 patients presented with spine trauma over a 6-month period, for which surgery involving instrumentation was indicated for 54 (71%) patients. Most patients were uninsured (42 patients, 81%). Of the 42 uninsured patients who underwent instrumentation, 30 (71%) received donated implants. The overall mean time to surgery from admission was 10.6 ± 7.6 days. This is a significant improvement when compared to historical controls at the same institution prior to implant donation, where the mean time to surgery was 27.4 ± 17.8 days (p<0.001). Additionally, following initiation of the implant program, there were no significant differences in time to surgery based on insurance status (p = 0.10). Of note, the timing of surgery was still considered “delayed” in 46 of 54 patients. The most common reason for delayed surgery was the patients' inability to pay (34 delays, 74%), which included other fees of operation.
Conclusion: In the first 6 months of implant donation, we report a significant reduction in time to surgery as compared to historical controls. Additionally, there were no differences in time to surgery between insured and uninsured patients, suggesting that implant donation helped alleviate previous insurance-based disparities. Although there are still a number of remaining financial barriers, the implant donation program has demonstrated promising potential in providing broader access to critical, time-sensitive interventions, thus promoting improved clinical outcomes.
International Trauma Care Forum ITCF Podium #19
The Persistent Preference for Traditional Bonesetting in a Large East African Country: Risk Factors and Missed Opportunities
Mengistu Mengesha, MD; Morgan Askew, MD; Abdoulie Ousman Njai, MD MPH; Ephrem G Adem, MD; Mario Keko, DrPH, MPH; Sintayehu Bussa, MD; Yisihak Zerihun, MD; Matiyas Seid, MD; Mahamed Areis, MD; Birlew Teshome Alemayehu, MD; Bekalu Wubshet, MD; Moa C Jira, MD; Habtamu B. Gula, MD; Eyueal Ambaye, MD; Claude Martin, MD, MBA; William J Harrison, MD; Kiran Jay Agarwal-Harding, MD
Purpose: Traditional bone setting (TBS) remains a common choice of patients for musculoskeletal injury management in many African countries, despite known complications. For patients who received TBS, we sought to identify risk factors for TBS preference at the time of injury and for future injuries.
Methods: Over 15 months, we prospectively enrolled all patients who presented to eight tertiary hospitals in a low-income country in East Africa after receiving TBS for an injury. Patients/families were surveyed regarding TBS preferences. For initial and future TBS preference, we used multivariable regression to evaluate associations with 22 covariates, including demographics, injury characteristics, TBS preferences, treatments, and outcomes.
Results: We enrolled 1243 patients (male: 68%; age younger than 18 years: 37%; mean age: 27 years). Elbow injuries (307, 24.7%) and leg/ankle/foot injuries (245, 19.7%) were most common. Most were closed fractures/dislocations (978, 78.7%). TBS was the first choice for 808 (65%) patients, although 298 (24%) reportedly visited health facilities before TBS. Initial TBS preference was lower for patients with secondary education or higher (OR: 0.41, 95% CI: 0.27–0.62, p<0.001) and open fractures (OR: 0.37, 95% CI: 0.20–0.70, p = 0.003). TBS involved rigid immobilization (481, 39%) and topical organic/inorganic materials (771, 62%). On presentation, 1003 (80.7%) patients had complications, most commonly joint stiffness/contracture (671, 54%) and malunion (346, 27.8%). For future injuries, 455 (36.6%) patients/guardians still reported preferring TBS. Odds of future TBS preference were higher for patients living in poverty (OR: 1.67, 95% CI: 1.11–2.50, p = 0.013), who had initial TBS preference (OR: 54.08, 95% CI: 28.38–103.08, p<0.001), and who visited a health facility initially before TBS patronage (OR: 2.11, 95% CI: 1.38–3.21, p<0.001). Neither prolonged hospitalization (p = 0.804) nor amputation (p = 0.881) affected the odds of future TBS preference.
Conclusion: More than one-third of patients in our diverse cohort preferred TBS despite its risks. Those in poverty, with less education, and an initial TBS preference should be key targets for outreach to enhance formal healthcare utilization. Initial health facility visits before TBS increased future TBS preference, highlighting possible missed opportunities to integrate patients into the formal health system and the need to strengthen primary care capacity.
International Trauma Care Forum ITCF Podium #20
Risk Factors for Femoral Intramedullary Nail Breakage: Analysis of 279 Broken SIGN Nails
Shravya Kakulamarri, BA; Charlotte Wahle, BA; Koreyne Tucker, BS; David Shearer, MD, MPH; Saam Morshed, MD, PhD
Purpose: Femoral shaft fractures are devastating orthopaedic injuries that often require surgical stabilization with intramedullary nails (IMN). Although intramedullary nailing is widely accepted as effective, there are rare complications, such as nail breakage, that can result in negative outcomes for the patient, such as nonunion, malunion, and the need for revision surgery.
Methods: This is a retrospective analysis of data collected by SIGN Fracture Care International on all adults treated with the solid, hand-reamed, SIGN nail for femoral fractures. The database includes patient demographics, fracture characteristics, surgical details, and clinical and radiographic follow up. Given the rarity of nail breakage, we conducted a nested case-control study with a 2:1 random match, with replacement, on age, gender, person-time of follow up, and Gustilo-Anderson open fracture type. Conditional logistic regression analysis was used to determine risk factors for nail breakage.
Results: Of 130,060 femoral shaft fractures, 279 cases (incidence = 0.2%) of broken SIGN nails with accurate clinical and radiographic data were successfully matched. A multivariable conditional regression showed more than a 2-fold increase in the odds of nail breakage when surgery was performed for established nonunion (adjusted OR: 2.31, 95% CI: 1.54–3.47, p<0.001) and every additional 30 days between injury and surgery resulting in a 1.44% increase in odds of nail breakage (adjusted OR: 1.014, 95% CI: 1.002–1.027, p = 0.023). The use of a nail with a diameter greater than or equal to 10 mm was associated with a 59% decrease in the odds of nail breakage (adjusted OR: 0.41, 95% CI: 0.29–0.59, p<0.001). Nail length and reaming method showed no association with nail breakage.
Conclusion: This study leverages the scale of the global SIGN network for the purposes of identifying risk factors for femoral nail breakage. Increasing nail diameter was identified as a strongly protective surgeon-controlled factor. Identified correlates such as surgery for nonunion and time to surgery suggest that health systems improvements, such as access to care, may mitigate the risk of catastrophic nail failure.
International Trauma Care Forum ITCF Podium #21
Determinants of Union and Complications in Femoral Shaft Fractures Treated With Retrograde Intramedullary SIGN Nails
Marcella Ryan-Coker, MBChB, ChM Trauma & Ortho; Hilary Kubai, MBChB, MMed Ortho; Martha Y E Forde, MBChB, MWACS; Melvin Edwards, MBChB; Sara Abu-Noah, MBChB; Nadia Yilla, MBChB; Juan Carlos Perdomo, M.D; Marco Necchi, M.D; Kebba Sunjatta Marenah, FRCS
Purpose: Intramedullary nailing stands as the gold standard treatment for femoral shaft fractures (FSF), offering the advantage of preserving soft tissue and favorable postoperative functional outcomes. In resource-limited settings, the Surgical Implant Generation Network (SIGN) intramedullary nail is of significant interest. This study evaluates bone union rates and complication incidences in FSFs treated with retrograde SIGN nails and identifies factors that influence union in Sierra Leone.
Methods: A retrospective patient data analysis from the SIGN online database focused on cases of FSF in Sierra Leone treated with retrograde SIGN nails from January 2013 to September 2023. Exclusion criteria included individuals younger than age 16 years, those treated with antegrade methods, or those with insufficient follow-up data. Primary outcomes were bone union assessed radiographically by mRUST scores and clinically with the Squat and Smile Test. Complication rates, time to surgery, follow-up duration, and factors influencing outcomes were also analyzed.
Results: A cohort of 219 patients, predominantly male (70.8%), with an average age of 35.7 years, was analyzed. Most fractures (55.4%) resulted from road traffic accidents. Bone union was observed in 90.1% of patients, with an overall complication rate of 10.8%. Notable complications were screw loosening (29.2%), nail loosening (16.7%), and the necessity for repeat surgery (20.8%). A comparison of standard versus Fin SIGN nails revealed no substantial difference in bone union or complication rates, although standard nails exhibited a slightly higher complication rate (7.9%). Delayed surgery (median 6 days, 0–21 days) was associated with poorer outcomes, and 31.6 of patients were lost to follow up. Factors significantly associated with improved union included closed fractures (p = 0.021), closed reduction (p = 0.024), primary wound closure (p = 0.027), and shorter time from injury to surgery (p<0.001).
Conclusion: This research contributes to understanding the effectiveness and challenges of using retrograde intramedullary SIGN nails for FSFs in resource-limited settings. It highlights how understanding factors affecting union and complications can greatly improve patient results, especially in resource-limited areas. Further studies addressing follow-up challenges are recommended to refine treatment approaches.
International Trauma Care Forum ITCF Podium #22
The Accuracy of 3 D-Image of Statistical Shape Model (SSM) for Measuring Femoral Rotational Alignment: Validation Study at Pediatric and Adult Population
Joon-Woo Kim, MD, PhD, FIOTA; Chang-Wug Oh, MD,PhD; Sangroc Han, M.D.
Purpose: Femoral rotational alignment significantly influences the functional outcome after fracture fixation. CT scans have been widely used to measure and compare it postoperatively, while it burdens radiation exposure and cost. Recently, mobile application based on the statistical shape model (SSM) was developed from the data of a certain disease and age population. This study aimed to evaluate the validity and reliability of the SSM-based mobile application for measuring femoral rotation in the general pediatric and adult population, compared to CT-based measurements.
Methods: Medical records of 50 children before skeletal maturity and 50 adults older than age 20 years were reviewed. All patients could walk independently before the time of measurement. Standard anteroposterior (AP) and lateral (LAT) radiographs and CT scans were analyzed on the non-injured or non-operated femur. To measure femoral anteversion, 3D femoral images were reconstructed from a mobile application (Femora® Mobile Application, Didim) and CT scan. Three researchers measured femoral anteversion independently. Reliability was measured with use of the intraclass correlation coefficient (ICC). Pearson’s correlation analysis was conducted to evaluate the correlation between the measurements obtained from the mobile application and the CT scan.
Results: Femoral anteversion measurements using the mobile application and CT demonstrated excellent reliability, with slight differences between pediatric and adult groups. The correlation with CT was stronger in the pediatric group (ICC: 0.939, p<0.001) compared to the adult group (ICC: 0.819, p<0.001), with an overall ICC of 0.909 (p<0.001).
Conclusion: The mobile application from SSM demonstrated accuracy comparable to CT in measuring femoral anteversion in children and adults, suggesting its clinical usability as an intraoperative alternative in the general population. Because its accuracy was undervalued in adults, further refinement of SSM-based programs may be needed in order to measure femoral rotation alignment precisely.
International Trauma Care Forum ITCF Podium #23
Predictors of Short-Term Outcomes After Post-Operative Periprosthetic Femoral Fracture
Omar Musbahi, MBBS(MD); Mohammad Aryaie, PhD; Toby Smith, PhD; Alex Bottle, PhD
Purpose: Postoperative periprosthetic femoral fracture (POPFF) is a common complication following total hip replacement. Unlike for primary hip fractures, research on predicting outcomes after POPFF is limited. This limits the clinician’s ability to properly inform patients about the sequelae of this injury. This study aims to address this gap.
Methods: We analyzed England’s administrative hospital admissions database, Hospital Episode Statistics (HES), linked at hospital level to National Hip Fracture Database (NHFD) data. We included patients age 18 years and older with a primary diagnosis of POPFF between 2016 and 2022. Patient-level predictors included demographics, comorbidities, prior fracture of the femoral neck, admission source, missed outpatient appointments, emergency admissions within 12 months prior to POPFF, and treatment type (fixation, revision, or neither). Hospital-level predictors, such as admission to a specialist ward and prompt surgery, were NHFD key performance indicators. Outcomes were in-hospital death, 30-day total mortality, 30-day emergency readmission, and length of stay (LOS) dichotomized at the upper quartile.
Results: The study included 33,728 admissions (median age 82 years; 65.9% female). Of these, 41.8% of POPFF cases were treated with fixation and 19.9% with revision. Within 30 days, 1510 deaths occurred. Age was associated with increased mortality and LOS. Males had higher odds of mortality and readmission. Several comorbidities (arrhythmias, congestive heart failure, liver disease, cancer, diabetes, and renal failure) were associated with all outcomes. Fixation (OR: 0.79, 95% CI: 0.68–0.92) and revision (OR 0.72, 95% CI: 0.64–0.81) were associated with lower 30-day mortality compared with no surgical intervention. Revision was associated with lower readmission (OR 0.81, 95% CI: 0.75–0.88), while fixation was associated with longer LOS (OR: 2.46) compared with revision (OR: 1.71). We also found significant associations among the other patient factors: prior hip fracture, care home residence, prior emergency admissions, and missed outpatient appointments. No hospital-level factors were associated with any outcome. Area under the curve (AUC) values for in-hospital death, 30-day mortality, 30-day readmission, and LOS were 0.81, 0.78, 0.62, and 0.72, respectively.
Conclusion: Various patient-level factors were significant predictors of short-term outcomes after POPFF but not of hospital-level factors. These findings can be helpful in counseling patients and risk stratification.
International Trauma Care Forum ITCF Podium #24
Clinical and Functional Outcomes of Patients With Femoral Neck Fractures Treated Non-Operatively at a Rural District Hospital in a Low-Income Country
Elijah Mlinde, BSc; James Ricks, BA; Vincent Lewis Mkochi, MBBS, FCS; Nohakhelha Nyamulani, MBBS; Edward Kenneth Rodriguez, MD, PhD; Kiran Jay Agarwal-Harding, MD
Purpose: Surgical management of femoral neck fractures (FNF, OTA 31B) is widely accepted. However, in low-income countries (LIC), where FNF incidence is rising, limited surgical capacity can necessitate definitive treatment with skin traction, despite unclear outcomes. We therefore evaluated clinical and functional outcomes of nonoperatively managed FNFs in a rural LIC hospital.
Methods: We retrospectively reviewed records of all adults with FNF treated at a rural LIC district hospital from January 2019 to December 2021. Study staff conducted follow-up clinical/functional assessments in patients’ home communities, and patients were referred for radiographs. Two high-income country- and two LIC-based orthopaedic surgeons independently interpreted radiographs for malunion/nonunion.
Results: In total, 108 patients (50% male, mean age 68.9 ± 13.7 years) were treated for FNFs; 79 (73%) were from ground level falls and 20 (19%) from road traffic collisions. All were definitively treated with skin traction. Mean hospitalization/immobilization lasted 6.2 ± 2.3 weeks. During hospitalization, five patients died, skin blisters/cellulitis from skin traction developed in 20 (19%), and one patient had a deep vein thrombosis. At a mean of 3.7 ± 1.4 years post-injury, 29 (27%) patients had died. Of 74 (69%) patients available for follow up, mean Short Musculoskeletal Function Assessment (SMFA) functional index was 60.6 ± 20.5, the SMFA Bothersome Index was 76.0 ± 19.7, Health-related Quality of Life (HRQOL) as measured by EQ-5D utility score was 0.57 ± 0.10. Ten (14%) patients were nonambulatory/bedridden, 19 of 70 (27%) had Visual Analogue Scale (VAS) pain greater than 5/10, and 50 (68%) had Timed Up and Go (TUG) tests greater than 30 seconds. Age older than 65 years was significantly associated with worse outcomes (nonambulatory, pain >5/10, TUG test >30 seconds, SMFA, with p<0.001 for each). For 28 patients (28 of 74, 39%) with follow-up radiographs, functional outcomes paralleled the larger cohort (mean EQ-5D 0.58 ± 0.11, 71% with TUG test >30 seconds); nonunion (18, 64%) or malunion (9, 32%) developed in all but one patient.
Conclusion: Non-operative treatment of FNFs led to a 27% mortality rate at 3.7 years. Survivors had high rates of malunion/nonunion and experienced severe functional impairment, likely exacerbating the burden on economically vulnerable communities. These findings highlight the urgent need to expand access to hip fracture surgery in resource-limited settings.
International Trauma Care Forum ITCF Podium #25
Percutaneous Pelvic Fixation Model: Our Experience With a Low-Cost and Realistic Simulator for Pelvic Trauma Training
Massimiliano Carrozzo, MD; Marco Smaldino, MD; Stefano Rizzo, MD; Michele Grasso, MD; Giuseppe Solarino, MD
Purpose: Pelvic ring and acetabular fractures are serious orthopaedic injuries with high morbidity and mortality. Minimally invasive percutaneous surgical stabilization has become more common because of advancements in surgical techniques and imaging tools. This study aimed to assess the educational effectiveness and practical applicability of a pelvic fixation simulator developed by NJ Tucker and C Mauffrey for specialized training of physicians.
Methods: In the study, five orthopaedic trauma surgeons in training and one senior surgeon were tasked with placing percutaneous wires on a model, targeting the anterior column (retrograde) and iliosacral corridors (S1, S2). The evaluation criteria included wire length within the bone corridor, cortical violations, redirections, radiation exposure (in mGy), and the time taken to position the wire. Each operator repeated the exercise 15 times for both bone channels.
Results: Between the first and 15th attempts, there was a statistically significant reduction in the average surgical simulation time, the number of X-ray exposures (expressed in mGy), the number of redirections, and the number of cortical violations.
Conclusion: Although traditional open surgery is fundamental for understanding pelvic trauma, minimally invasive percutaneous fixation is now an important tool with many advantages, despite its technical challenges and learning curve. The study shows that the pelvic fixation simulator effectively helps operators familiarize themselves with the technique and boosts their confidence. It offers a low-cost, reproducible way to shorten the learning curve for orthopaedic surgeons and is a valuable educational resource for medical trainees in pelvic trauma surgery.
International Trauma Care Forum ITCF Podium #26
Multimodal Neuroelectrophysiological Monitoring Combined With Robot-Assisted Placement of Transiliac–Transsacral Screw for the Treatment of Transforaminal Sacral Fractures
Pengfei Wang, MD; Kun Zhang, MD; Jian Xing, MD; Shuang Han, MD; ZhiQiang Fan, MD; Hongquan Wen, MD
Purpose: This study aimed to evaluate the safety and efficacy of fixation of transforaminal sacral fractures using TiRobot-assisted transiliac-transsacral screws (TITS) under multimodal neuroelectrophysiologic monitoring (MNM).
Methods: We retrospectively evaluated 22 patients (17 males) with transforaminal sacral fractures who were treated with closed reduction and placement of TiRobot-assisted TITS screws under MNM. Patients' average age was 43.32 ± 11.40 (19–63) years. Patients received MNM, including somatosensory-evoked potentials (SEP), motor-evoked potentials (MEP), and free electromyographic monitoring (EMG) prior to the beginning of surgery, during closed reduction, placement of a guide wire and TITS screw, and at the end of surgery. The operation was adjusted according to the MNM results.
Results: Overall, 22 TITS screws were inserted in 22 patients, including five TITS screws in the S1 body and 17 TITS screws in the S2 body. The average time of screw placement was 27.95 ± 6.84 minutes, and the average frequency of X-ray fluoroscopy was 31.00 ± 5.56 times for each patient. Anterior ring fixation was performed in four patients using an external fixator, in five patients using cannulated screws, and in 13 patients using reconstruction plates. The mean follow-up time was 14.46 ± 2.46 (12–20) months. According to the Tornetta and Matta radiographic grades, 10 cases were excellent and nine cases were good (86.36%), two cases were fair, and one case was poor. At the final follow up, the Mejeed score was 82.18 ± 14.52; nine cases were excellent and nine cases were good (81.81%), one case was fair, and three cases were poor. Preoperatively, in nine patients, the amplitude of SEP potential on the injured side was lower than that on the contralateral side before reduction (>50%). In this study, no screw was mistakenly inserted into the sacral canal, and no surgical site infection occurred.
Conclusion: MNM combined with TiRobot assistance can safely implant TITS screws and can effectively identify the neurologic function of patients under anesthesia as well as reduce iatrogenic nerve injury.
International Trauma Care Forum ITCF Podium #27
A Retrospective Cohort Study to Evaluate if Surgical Approach Affects Quality of Life and Sexual Function Following an Acetabulum Fracture
Sophia M Wakefield, MBBCh; Nikolaos K Kanakaris, MD, PhD; Peter V Giannoudis, MD, FACS, FRCS
Purpose: Acetabulum fractures pose challenges to surgeons because of their complexity and requirement for direct anatomic access. There is currently a paucity of research exploring the use of Patient-Reported Outcome Measures (PROM) after acetabulum fracture, notably with specific reference to surgical approach outcomes. This retrospective cohort study primarily aimed to evaluate the impact of three surgical approaches (ilioinguinal [IL], modified Stoppa, Kocher-Langenbeck [KL]) on overall patient quality of life (QoL). The secondary objective explored additional QoL measures, including sexual and urinary function and baseline demographics, to provide a rationale for observed differences.
Methods: Patients (age: 18–65 years), without pre-injury ambulatory or urogenital pathology, were recruited from a single Level I major trauma center from June 2004 to December 2022. All patients were at least 12-months postoperative. Data from original admission, including fracture-type, were collected. Five QoL questionnaires were administered: EuroQol–Visual Analogue Scale (EQ-VAS), International Index of Erectile Function, Female Sexual Function Index, Core Lower Urinary Tract Symptom Score, Return to Sport After Serious Injury Questionnaire, and VAS for pain; p≤0.05 denoted statistical significance.
Results: In total, 70 patients (male: 60; mean age: 42.21 ± 14.25 years) were recruited. Three surgical approaches were assessed: IL (n = 21), Stoppa (n = 16), and KL (n = 33). Road traffic accident (RTA) was the primary mechanism of injury (51.4%), and 70.0% of patients had associated fractures. The mean follow-up time was 72.9 ± 54.8 months (range: 15–240 months). Compared to IL, there was strong evidence (p = 0.031) that a Stoppa approach increased EQ-VAS by 12.26 points (95% CI: 1.33–23.18). Secondary analysis showed that the KL approach was associated with significantly worse overall male sexual function satisfaction when compared to the IL approach (p = 0.027); no other significant findings were observed among the surgical approaches.
Conclusion: This study is novel as it evaluates QoL outcomes and sexual function using validated measures with respect to three well-established surgical approaches and directly addresses PROMs associated with the relatively newer Stoppa approach. It demonstrated that surgical approach did impact overall QoL and male sexual function satisfaction after acetabulum fracture. The differences in QoL noted among surgical approaches require further investigation. Future research should address a wider range of PROM domains with larger patient cohorts.
International Trauma Care Forum ITCF Podium #28
Biomechanical News: Advances in Pelvic Fracture Techniques
Fabian Kress, Arzt; Florian T Gebhard, MD PhD; Konrad Schuetze, Dr.
Purpose: Recent biomechanical research has focused on improving the stability of fixation techniques for fragility fractures of the pelvis (FFP), particularly Type IIc fractures. These injuries are increasingly common because of demographic changes. The study sought to evaluate the effectiveness of different anterior pelvic ring fixation methods combined with posterior stabilization.
Methods: A study conducted at the AO Research Institute in Davos examined 12 female cadaveric pelvises (mean age 86.9 years). A simulated FFP Type IIc fracture was treated with trans-iliosacral–transsacral (TITS) screw fixation for the posterior ring. The anterior ring was stabilized using four methods: no fixation, external fixator, 4.5-mm retrograde screw, or 7.3-mm antegrade screw. Biomechanical testing simulated single-leg stance conditions under cyclic loading until failure, measuring displacement and implant stability.
Results: Initial construct stiffness showed no significant differences across groups. Screw fixation techniques demonstrated superior performance in reducing displacement and increasing cycles to failure. At 5000 cycles, the retrograde screw group exhibited the least displacement at the anterior sacrum fracture point, followed by the antegrade screw group. The control group showed significantly higher displacement.
Conclusion: The study highlights that antegrade and retrograde screw fixation techniques provide enhanced stability for anterior pelvic ring fractures compared to external fixation or no fixation. Additionally, stabilizing the anterior ring improved posterior ring stability, emphasizing the importance of comprehensive fracture management.
International Trauma Care Forum ITCF Podium #29
AI assisted diagnosis using DEANet to improve correct diagnosis of iliac wing fracture and ischial spine fracture
Chun-Hao Tsai, MD,PHD; Shang-Lin Hsieh, MD; Tsung-Li Lin, MD; Yuan-Shun Lo, MD; Chun-Yen Chen, MD; Hao Wei Chang, Attending Physician; Hsien-Te Chen, MD,PHD; Yi-Chin Fong, MD,PHD
Purpose: This study aims to develop and evaluate the DEANet model for classifying iliac wing and ischial spine fractures using X-rays. By integrating image enhancement, edge detection, and attention mechanisms, it seeks to improve diagnosis accuracy, reduce reliance on costly imaging, and streamline clinical workflows.
Methods: Data were collected from the Chinese University of Medical Sciences (CUMS) and consisted of 100 pelvic X-ray images. During preprocessing, images were resized to 224 × 512 pixels, and enhancement techniques (CLAHE and HE) were applied to highlight the fractures. Segmentation was evaluated using accuracy, precision, recall, F1-score, and IoU. CLAHE showed the best results. Augmentation included applied random rotation and luminance contrast adjustments for better model robustness. Prewitt edge detection was tested, and the fusion of edge features with original images improved ischial spine classification. In model training, DEANet used attention mechanisms for effective feature extraction and classification. Compared with existing models, analysis showed better fracture classification performance using X-rays alone.
Results: The results show that DEANet performs well in classifying iliac wing and ischial spine fractures. In segmentation, CLAHE-enhanced images yielded the best results with 0.96 accuracy, 0.95 F1-score, and 0.91 IoU. In image augmentation, random rotation achieved 0.97 accuracy, 0.97 F1-score, and 0.94 IoU, while random scaling performed poorly (IoU = 0.75). Prewitt edge detection did not improve iliac wing fracture classification but helped ischial spine classification, boosting accuracy to 0.94 and recall to 0.89 when fused with original images.
Conclusion: DEANet accurately classifies iliac wing and ischial spine fractures using X-rays, improving diagnostic speed and efficiency. It reduces reliance on costly imaging, offering a cost-effective solution for clinical practice.
International Trauma Care Forum ITCF Podium #30
Better Reduction of Acetabular Fractures Using Intra Operative 3D Fluoroscopy
Colin Christiaans, BSC; Erik Hermans, MD; Vincent Stirler, MD PhD; Michael Edwards, Prof. MD
Purpose: Treatment of acetabular fractures remains a challenge for orthopaedic/trauma surgeons. Surgical treatment with anatomic reconstruction of the articular site is necessary to optimize the clinical outcome and prevent secondary osteoarthritis. However, reduction is often done without direct visualization. Intraoperative 3D imaging could improve the reduction quality in acetabular fracture surgery.
Methods: A retrospective cohort study of prospectively collected data at two Level I trauma centers in the Netherlands was conducted. All adult patients (18 years and older) with an acetabular fracture treated with an open reduction and internal fixation (ORIF) between March 2016 and December 2022 were included. The quality of the reduction was the primary endpoint. Secondary endpoints were number of intraoperative corrections after 3D fluoroscopy, radiation exposure, duration of surgery, perioperative blood loss and complications, postoperative complications (within 30 days), the number of revision surgeries within 6 weeks, total hip arthroplasty conversion rate, and mortality.
Results: Preliminary results: In total, 400 patients were included in the initial analysis, 150 with intraoperative 3D fluoroscopy (intervention group) and 250 with only the postoperative CT according to protocol at the treating hospital (control group). The step-off was significantly higher in the control group when compared to the intervention group (3.6 mm vs 1.2 mm). The gap after surgery was not significantly different in both groups (2.1 mm vs 1.9 mm). Postoperative complications and the number of revision surgeries did not differ significantly in both groups. Conversion to THA rate is currently under analysis.
Conclusion: The use of intraoperative 3D fluoroscopy results in better reduction for acetabular fractures. These results may help surgeons opt for implementing perioperative 3D fluoroscopy in the management of acetabular fractures.
International Trauma Care Forum ITCF Podium #31
Does the Implementation of a Certified Geriatric Trauma Center Have Any Effect on the Number and Severity of Complications: A Retrospective Analysis After 798 Patients
Alexander Maximilian Eickhoff, MD; Raffael Cintean, MD; Konrad Schuetze, Dr.; Carlos Pankratz, M.D.; Florian T Gebhard, MD PhD; Alexander Böhringer, MD
Purpose: A certified geriatric trauma center was established in a Level I trauma center in 2019 to address the specific needs of geriatric patients in trauma surgery. This study was intended to demonstrate the impact on the occurrence and severity of surgical and nonsurgical complications.
Methods: The retrospective analysis included 798 patients older than age 70 years who were diagnosed with a proximal humerus fracture, pelvic fracture, vertebral fracture, or a proximal femur fracture. All patients received a geriatric cotreatment in accordance with the standards of a certified geriatric trauma center. A control group with 954 patients of the same age with the same diagnoses was formed. The data were evaluated in regard to the complications that occurred and their influencing factors.
Results: In the cohort that received a geriatric cotreatment, time to surgery was reduced. The number of surgical complications was reduced in this group as well (10.3% vs 5.9%, P = 0.032), whereas the rate of nonsurgical complications was higher (22.7% vs 35.6%, P = 0.001). In particular, urinary tract infections, pneumonia, and cardiovascular events were observed more frequently in the group with a geriatric cotreatment.
Conclusion: The establishment of a certified geriatric trauma center has clearly heightened awareness of timely surgical care, which should subsequently lead to reduced mortality. The occurrence of surgical complications decreased; however, nonsurgical complications were observed more frequently. The causes of this need further analysis. In this context, the trained eye of the geriatrician, along with the initiation of appropriate diagnostics, could play a central role.
International Trauma Care Forum ITCF Podium #32
The Effect of Regional Anaesthesia on the Diagnosis of Compartment Syndrome in Diaphyseal Tibial Fractures
Peter Cay, MA (Oxon), MB BChir; Mayur Nayak, FRCS; Enis Guryel, FRCS
Purpose: The objective of this study was to assess whether the use of regional anesthetic blocks had any impact on the diagnosis of compartment syndrome in diaphyseal tibial fractures.
Methods: We retrospectively identified all patients older than age 16 years who were referred to our major trauma center with a diaphyseal tibial fracture between January 2021 and August 2023. We recorded patient demographics, mechanism of injury, fracture details, surgical details, type of anesthetic, cases of compartment syndrome, including how it was diagnosed, the timing of compartment syndrome diagnosis, and any further operations required.
Results: There were 97 tibial fractures in 96 patients (average age: 47 years [range: 17–94 years]), including 20 patients (21%) older than age 65 years. These were isolated injuries in 66 patients (68%). Overall, there were 37 open fractures (38%). We had 23 patients (24%) who transferred to our center from local trauma units. There were 56 patients (58%) who were operated on with a general anesthetic and regional local anesthetic block, 17 patients (18%) with neuraxial blocks, and six patients (6%) with a regional and a neuraxial block. We had 13 cases (13%) of compartment syndrome in this cohort overall, with 12 (92%) diagnosed either on admission or prior to definitive fracture surgery. Compartment syndrome developed on postoperative day 1 in one patient who had received a regional block. This was diagnosed promptly and decompressed on the same day with no long-term complications. In eight cases (62%), the diagnosis was made with clinical examination alongside intracompartment pressure monitoring, while five cases were diagnosed on clinical examination alone.
Conclusion: Our study has shown that nearly all cases of compartment syndrome in diaphyseal tibial fractures were diagnosed either on admission in the emergency department or prior to definitive tibial fixation. This finding suggests that the restriction on the use of regional anesthetic for tibial fractures to avoid masking clinical symptoms of compartment syndrome is unnecessary.
International Trauma Care Forum ITCF Podium #33
Is MRI Feasible in Polytrauma Patients? Results From a Large Animal Model
Christian T Hübner, MD; Christian T Stoeck, PhD; Felix Klingebiel, MD; John T Ricklin, MD; Miriam Weisskopf, MD; Yannik Kalbas, MD; Roman Pfeifer, MD; Hans-Christoph Pape, MD, FACS, FAAOS, FOA, FIOTA
Purpose: In polytrauma patients, fast and safe imaging is necessary to detect potential life-threatening injuries and conduct emergency treatment. Although whole-body CT scan has been established as gold standard, these images are associated with radiation exposure and resuscitation is typically paused during scanning time. In vulnerable patients (for example, children and pregnant women), the indication might be challenging. As part of a large animal model study, we performed this feasibility study to discuss whole-body MRI as an alternative imaging in polytrauma patients.
Methods: In this study, six landrace pigs (70 kg ± 5 kg) were used; three pigs in the polytrauma group received a blunt chest injury and bilateral femur fractures, and three pigs without injuries were used as control. MRI was performed immediately after induction of trauma. A whole-body T2-weighted MRI-protocol was designed to detect relevant traumatic sequelae. Time was measured from the beginning of transport until the completion of imaging. Afterward, a whole-body CT was performed. Both the MRI and CT suites were adjacent to the operating room.
Results: Our MRI protocol resulted in a total scan-time of 14:30 minutes. Mean time from transport to diagnosis was 21:18 minutes, including transport and repositioning on the gurney. Duration of whole-body CT imaging was 16:27 minutes from transport to diagnosis, including a 11:05 minute average scanning time. MRI and CT were both effective in detecting the induced injuries (femoral fractures, rip fractures, and pneumothorax); however, for effective detection of pneumothoraces, specialized MRI sequences were customized. During MRI, resuscitative measures could be continued. Tissue injuries (lung contusions and intra-muscular hematomas) were more clearly visible in MRI, while bony injuries and pneumothoraces were easier to detect in CT.
Conclusion: This study shows the feasibility of MRI in polytrauma patients with only slightly longer diagnostic time and superior detection of tissue trauma. This might be useful to detect lung contusions, intraabdominal lesions as well as intracerebral bleeding and sheering injuries. Furthermore, MRI might offer the possibility to continue resuscitative measures in-suite without exposing personnel to radiation. However, the use of MRI in practice is still limited by the existing infrastructure (availability, distances, and personnel requirements).
International Trauma Care Forum ITCF Podium #34
Outcomes of Prolonged Tourniquet Application on the Battlefield
Alona Katzir, MD; Jonathan Krispel, medicine; Mahmoud Jammal, MD. / MSc.; Rami Mosheiff, MD; Meir Liebergall, MD, FIOTA; Yoram A Weil, MD, FIOTA
Purpose: The objective of this study is to provide insights into the implications of prolonged tourniquet use in battlefield injuries, ultimately contributing to the optimization of clinical practices in military healthcare settings.
Methods: This was a retrospective study that took place at two academic Level I trauma centers. Patient selection criteria included adults who sustained high-energy battlefield injuries to the limbs and were treated with prolonged tourniquet application (>4 hours). Patients who underwent immediate limb amputation upon arrival at the hospital were excluded. The outcome measures and comparisons of this study involved clinical outcomes, including hemodynamic status, vascular repairs, rhabdomyolysis, renal injury, infection, nerve injury, amputation, and functional outcomes.
Results: The study included 18 patients (100% male) with 21 high-energy limb injuries with prolonged tourniquet application; nine (42.9%) were upper limb injuries, and 12 (57.1%) were lower limb injuries. The mean age of the cohort was 24 years (SD 8.9, range 19–50). The mean tourniquet time was 5.8 hours (SD 1.2, range 4–9 hours). All of the patients (100%) underwent urgent fasciotomies upon arrival. Vascular repair was required in five patients (27.8%); temporary renal injury developed in seven patients (38.9%), and hemodialysis was required in two patients (11.1%). Infections developed in eight patients (44.4%), which required additional surgical interventions. Infection control was achieved with limb salvage in six patients (33.3%), and limb amputation was performed for the remaining two patients (11.1%). The mean number of surgical procedures per person was 4.8 (SD 2.3, range 2–12). 16 patients (88.9%) sustained debilitating nerve injuries. The average upper extremity functional index (UEFI) score was 40.6 (SD 14.9 range 30–57), and the average lower extremity functional index (LEFI) was 42.3 (SD 20.1, range 14–68).
Conclusion: Limb ischemia after prolonged tourniquet application is extremely challenging to treat. This study offers a comprehensive analysis of tourniquet-related outcomes and aims to optimize clinical practices in military healthcare settings.
International Trauma Care Forum ITCF Podium #35
Analyzing Orthopaedic Trauma Patterns in Gaza During Armed Conflicts: Addressing Disaster Care Challenges Through the FAJR Methodology
Abdullah Ghali, MD; Elias Nasser, BS; Mohammed Taher, FRCS; Ali Hussein Elaydi, MD; Ahmad Hasan, MD; Bilal Irfan, BS; FAJR Scientific Research Collaborative; Khaled Saleh, MD, FAAOS
Purpose: Amid ongoing armed hostilities, the Gaza Strip has faced an unprecedented rise in orthopaedic trauma, posing significant challenges to local and visiting surgeons. According to the United Nations, more than 100,000 Palestinians have been injured during the ongoing military incursion, and more than 23,000 have sustained life-altering injuries. This study presents the challenges in the delivery of orthopaedic trauma care in resource-constrained conflict zones by presenting injuries documented by volunteer surgeons in Gaza.
Methods: Beginning in April 2024, FAJR Scientific, a US-based nonprofit organization, has deployed five volunteer surgical teams to Gaza. A retrospective analysis was performed on 370 patients receiving acute orthopaedic trauma care from four medical centers in Gaza. Local FAJR research associates were paired with a visiting orthopaedic surgeon to document the presenting diagnosis, mechanism of injury, and surgical management. However, limited staff availability, poor access to the local medical records, and laboratory closures prevented thorough documentation of postoperative patient outcomes.
Results: Explosive and gunshot injuries accounted for most cases, with tibial fractures, nerve injuries, and soft-tissue trauma predominating. Explosive trauma was found to make up 51.9% of injuries, with 8.4% resulting from gunshot wounds. Adults between the ages of 20 and 40 comprised nearly 50% of patients (males, 82%). Adaptive surgical strategies, such as external fixation and staged debridement, were employed despite significant constraints in resources, infrastructure, and follow-up care.
Conclusion: This study underscores the critical role of structured, adaptive methodologies in managing large-scale orthopaedic trauma in conflict zones. The challenges outlined in this study highlight the need for immediate interventions by global stakeholders and sustained humanitarian support from nonprofit organizations to mitigate the long-term medical and psychosocial impact of such crises.
International Trauma Care Forum ITCF Podium #36
Timing of Definitive Fracture Fixation in Patients With Concomitant Intracranial Injuries: A Systematic Review and Meta-Analysis of the Literature by the IMPACT Group
Felix Klingebiel, MD; Christian T Hübner, MD; Markus F Oertel, MD; Yannik Kalbas, MD; Zsolt J Balogh, MD, PhD, FIOTA; Frank J P Beeres, MD; Raul Coimbra, MD, PhD; Christian Fang, FRCS; Peter V Giannoudis, MD, FACS, FRCS; Falco Hietbrink, MD, Phd; Frank Hildebrand, MD; Hayato Kurihara, MD; Thomas Lustenberger, MD; Ingo Marzi, MD; Ruben Peralta, MD; Shanmuganathan Rajasekaran, MD; Emil H Schemitsch, MD, FIOTA; Heather A Vallier, MD, FIOTA; Boris A Zelle, MD; Hans-Christoph Pape, MD, FACS, FAAOS, FOA, FIOTA; Roman Pfeifer, MD; IMPACT Group
Purpose: The timing of definitive fracture care in polytrauma patients remains a complex topic especially in the presence of concomitant intracranial injuries, which often dictate the surgical sequencing. Therefore, in 2024, the IMPACT Group proposed recommendations on the timing of surgical interventions in patients with concomitant injuries. The aim of this study was an in-depth analysis of the available literature comparing early versus late definitive fracture care in patients with traumatic brain injuries (TBI) using a systematic review.
Methods: A systematic review on PubMed and EMBASE was performed including original articles from 2000 to 2024 that compare the outcome of early versus late definitive fracture fixation in polytrauma patients with TBI. Patient demographics, overall and intracranial injury severity, surgical details, time thresholds, complications/outcomes, and timing recommendations were assessed and compared in a qualitative approach.
Results: In total, 9782 studies were identified in the databases. After application of the inclusion and exclusion criteria, seven studies were included. Overall, a relevant heterogeneity in selection criteria was observed, with some studies focusing primarily on severe TBI and others on mild TBI as classified by the Abbreviated Injury Scale (AIS) and Glasgow Coma Scale (GCS). Femoral shaft fracture management in patients with concomitant intracranial injury was of particular interest in the included studies. Overall, three publications support early fracture treatment, two are neutral, and two prefer late surgical treatment.
Conclusion: Early fracture treatment in patients with concomitant injuries appears to be feasible in a selected cohort of patients. Overall, the evidence on the timing of fracture fixation in patients with concomitant intracranial injury is limited and restricted by the individual inclusion criteria of the publications, the varying severity of TBI, and the primary focus on long bone care. In the absence of higher-level evidence, the expert recommendations of the IMPACT group should be considered.
Annual Meeting Podium AM Podium #1
Reducing AKI Rates in Hip Fractures: Individualized Fluid Resuscitation Protocol Utilizing Noninvasive Plethysmography and Hemoglobin
Michael J DeRogatis, MD; Ryan A Deleon, MD; Robert J Gomez, MD; Anna J Ng Pellegrino, MD; Deborah J Bubba, MD; Aldo J Carmona, MD; Douglas W Lundy, MD, FIOTA; Robert William Gomez, MD
Purpose: The purpose of this study is to evaluate the noninvasive Plethysmography Variability index (PVi) and total hemoglobin's utility in reducing acute kidney injury (AKI) and mortality rates in patients with hip fracture.
Methods: A prospective cohort study of 100 patients with isolated hip fractures was conducted from February 2023 to June 2024 at an academic Level I trauma center (see figure). Patients were divided into two groups: one without a preoperative fluid resuscitation protocol and the other with an individualized fluid resuscitation protocol guided by noninvasive PVi and continuous hemoglobin (SpHb) monitoring. Outcomes analyzed included postoperative AKI incidence, ICU admissions, length of stay, and 90-day mortality.
Results: The PVi group showed lower AKI rates (6% vs 20%; p = 0.037), reduced ICU transfers (0 vs 14%; p = 0.006), and shorter hospital stays (5.1 vs 6.5 days; p = 0.008) compared to the control group. However, there was no significant difference in 90-day mortality (4% vs 10%; p = 0.24).
Conclusion: Individualized fluid resuscitation using PVi and SpHb monitoring significantly reduced AKI incidence and ICU transfers in elderly patients with hip fracture but did not impact 90-day mortality. These findings underscore the importance of precision fluid management to improve surgical outcomes.
Annual Meeting Podium AM Podium #2
Biologic Age and Age Acceleration as Predictors of One-Year Mortality After Geriatric Hip Fracture
Zachary Randall, MD, MPHS; Helena F Barber, MD; Katherine E Buesser, MD; Abdelzaher Abdurrahman , MD; Mitchel R Obey, MD; Jenna-Leigh Wilson, MD; Christopher M McAndrew, MD; Marschall Brantling Berkes, MD
Purpose: Geriatric hip fractures are a significant cause of morbidity and mortality, with 1-year mortality rates as high as 30%. Incorporating biologic age and age acceleration into traditional assessments may improve outcome predictions and guide interventions.
Methods: This prospective cohort study included patients aged ≥50 years with low-energy hip fractures. Demographic data, chronologic age, and nine laboratory values—albumin, creatinine, glucose, C-reactive protein, lymphocyte percentage, mean corpuscular volume, red cell distribution width, alkaline phosphatase, and white blood cell count—were collected within 24 hours preoperatively. Biologic age was calculated using Levine et al's method (2018), and age acceleration (biologic age minus chronologic age) was derived. Patients were dichotomized into two age acceleration groups (–15 to 20 years, 20+ years) for survival analysis and stratified into four subgroups (–15 to 5, 5–20, 20–30, 30+ years) to compare mortality rates.
Results: Among 81 patients (35.1% male, 64.9% female; mean age 77.0 ± 8.7 years), the 1-year mortality rate was 23.5%, with a mean time to death of 3.3 ± 2.6 months. Chronologic age did not differ significantly between survivors (76.7 ± 7.9 years) and non-survivors (77.9 ± 11.0 years, P = 0.49). However, biologic age (100.9 ± 12.5 vs 87.9 ± 14.3 years, P = 0.001) and age acceleration (23.0 ± 13.8 vs 11.2 ± 12.0 years, P = 0.001) were significantly higher in non-survivors. Mortality rates increased with age acceleration: 8% (–15 to 5 years), 16.7% (5–20 years), 43.8% (20–30 years), and 50% (30+ years; P = 0.008). Patients with age acceleration >20 years had lower survival probabilities (log-rank P = 0.0007) and a 4.41-fold higher mortality risk (95% CI: 1.73–11.21, P = 0.002) compared to those with –15 to 20 years of age acceleration.
Conclusion: Biologic age and age acceleration were strongly associated with 1-year mortality, outperforming chronologic age. These findings support the use of biologic aging measures in risk stratification and personalized care for geriatric patients with hip fracture.
Annual Meeting Podium AM Podium #3
Periprosthetic Femur Fractures in Hemiarthroplasty Are Correlated With Stem Type: An Analysis From the American Joint Replacement Registry
Michael J DeRogatis, MD; Margaret Judith Higgins, MD; Isabella Zaniletti, PhD, MA; Paul S Issack, MD; Antonia Chen, MD, MBA; Douglas W Lundy, MD, FIOTA
Purpose: This study evaluates the rate of revision arthroplasty and open reduction and internal fixation (ORIF) for periprosthetic femur fractures in hip hemiarthroplasty (HA) using four stem designs: cemented taper slip, cemented composite beam, uncemented fit-and-fill, and uncemented tapered wedge stems.
Methods: Data from the American Joint Replacement Registry (2012 to 2021) on patients aged 70+ years undergoing hip HA were analyzed, with outcomes tracked through December 2023 with a 2-year minimum follow up. We assessed patient demographics, comorbidities, and reoperation rates for periprosthetic femur fractures. Stem types included cemented composite beam (18,070), cemented taper slip (499), uncemented fit-and-fill (15,589), and uncemented tapered wedge (13,831), with 47%, 0%, 22%, and 27% of these featuring a collar, respectively. Statistical analyses included Hochberg method, χ2, t-tests, and Cox models to evaluate hazard ratios (HR) for periprosthetic femur fracture risk.
Results: Cemented composite beam stems with a collar showed the lowest risk of periprosthetic femur fractures, significantly outperforming tapered wedge stems without a collar (HR 4.2, 95% CI 2.7–6.6) and fit-and-fill stems without a collar (HR 3.6, 95% CI 2.3–5.7, p<0.001). Fit-and-fill stems with a collar had a threefold higher risk compared to cemented composite beam stems with or without a collar (p<0.003). Tapered wedge stems without a collar had a fourfold higher risk compared to collarless cemented composite beam stems (p<0.001). Cemented taper slip stems showed no significant difference. The presence of a collar reduced fracture risk across all stem types. Risk of fractures declined over time (HR 0.9, 95% CI 0.85–0.97, p = 0.005).
Conclusion: Cemented composite beam stems with a collar are associated with the lowest risk of periprosthetic femur fractures in patients age 70+ years. Surgeons should prioritize these stems for hip HA fixation.
Annual Meeting Podium AM Podium #4
The Effect of Fully Threaded Screws on Valgus Collapse in Garden One and Two Femoral Neck Fractures
Colin Keith Cantrell, MD; Clayton Robert Welsh, MD; Joseph Tanenbaum, MD; Michael Murphy, MD; Bennet Arthur Butler, MD; Michael D Stover, MD
Purpose: Nondisplaced and valgus impacted femoral neck fractures are often treated in situ with partially threaded cannulated screws. Excessive valgus collapse is a common cause of failure with this treatment modality, and complication rates are estimated to exceed 20%. Screw type (fully versus partially threaded) has been proposed as a possible driver of excessive valgus collapse in these fractures, yet it is currently unknown whether and to what extent screw type is associated with risk of failure. This study addresses this gap in the literature by quantifying the amount of postoperative valgus collapse in Garden 1 and 2 femoral neck fractures treated with all partially threaded screw (PTS) configurations versus configurations with one or more fully threaded screws (FTS).
Methods: Patients who sustained a Garden 1 or 2 femoral neck fracture treated with cannulated screw fixation and with a minimum of 6 months of follow up were included. Valgus collapse, femoral head offset, height, and femoral neck length at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively were measured and compared among screw configurations (PTS versus FTS).
Results: From 2000 to 2021, 144 patients met inclusion criteria. Of these, 16% were treated with FTS configurations compared to 84% treated with PTS configurations. PTS configurations demonstrated significantly more offset and height collapse at 3-, 6-, and 12-month follow up when compared to FTS configurations (p<0.05). Femoral neck length collapse was increased at 12-month follow up in PTS patients (p = 0.01). PTS patients also had a higher rate of substantial (> 5 mm) offset and femoral neck length collapse at all time periods (p<0.05). The reoperation rate for PTS configurations was 28% versus 17% in FTS configurations (p = 0.42).
Conclusion: FTS configurations decrease offset collapse at all time periods and reduce the incidence of substantial offset and femoral neck length collapse when compared to PTS configurations in the treatment of Garden 1 and 2 femoral neck fractures.
Annual Meeting Podium AM Podium #5
Association Between Hyperosmolar Dehydration and Short-Term to Medium-Term Mortality in Elderly Patients With Hip Fractures
Huanyi Zhu, MD; Xiangxu Chen, PhD; Yunfeng Rui, PhD
Purpose: Hyperosmolar dehydration (HD) is a prevalent electrolyte disorder among elderly patients, particularly those with hip fractures. Previous studies have indicated that up to 50% of such patients exhibit signs of dehydration before and after surgery. HD is considered a modifiable in-hospital complication that may influence readmission rates and functional outcomes in elderly patients. However, evidence for dehydration screening recommendations in elderly patients with hip fracture is insufficient, and the relationship between dehydration and complications or mortality remains unclear.
Methods: This study included 851 elderly patients who sustained unilateral hip fractures from low-energy injuries and underwent surgical treatment after hospital admission from January 2018 to December 2022. During hospitalization, the patients were managed by a multidisciplinary team (MDT), with a follow-up period of 1year. According to the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines, serum osmolality was calculated using the Khajuria and Krahn equation: Osmolality = 1.86 × (Na⁺ + K⁺) + 1.15 × glucose + urea + 14 (unit: mmol/L), and HD was diagnosed when serum osmolality exceeded 295 mmol/L.
Results: The incidence of HD was 39.95%. Compared with non-HD patients, there was a higher proportion of female HD patients (70.31% [HD group] vs 63.34% [non-HD group]; p = 0.05), more frequent polypharmacy (66.25% [HD group] vs 49.78% [non-HD group]; p<0.05), and a higher prevalence of diabetes (33.44% [HD group] vs 18.48% [non-HD group]; p<0.01). Additionally, the incidence of pneumonia (p = 0.02), electrolyte imbalances (p = 0.03), and worsening heart failure (p<0.01) was higher in HD patients. HD was an independent predictor of short-term (1-month) mortality (OR = 2.78, 95% CI: 1.45–5.33, p<0.001) and medium-term (3-month) mortality (OR = 1.66, 95% CI: 1.04–2.64, p = 0.03), but not significantly associated with long-term (12-month) mortality (OR = 2.32, 95% CI: 0.89–6.05, p = 0.09).
Conclusion: Elderly patients with hip fracture, especially females with diabetes and polypharmacy, are prone to HD. HD is associated with higher risks of pneumonia, electrolyte imbalances, and worsening heart failure. It is an independent predictor of short- to medium-term mortality. Systematic dehydration screening and individualized hydration management for high-risk patients are recommended to improve HD rates.
Annual Meeting Podium AM Podium #6
Computed Tomography Overestimates Posterior Tilt in Geriatric Garden I/II Femoral Neck Fractures
Neil Jain, MD; Samantha Nicole Weiss, MD; Douglas W Lundy, MD, FIOTA; Dustin Greenhill, MD, FAOA
Purpose: In 2019, data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial concluded that surgeons should consider primary arthroplasty for elderly patients with a Garden I or II femoral neck fracture (FNF) when posterior tilt is ≥20°. After widespread adoption of this treatment recommendation, clinicians are now measuring posterior tilt on CT when available. However, the FAITH trial only measured plain film hip radiographs. The correspondence of posterior tilt measured on radiograph versus CT is unknown.
Methods: In five trauma centers, a retrospective review of surgically managed patients ≥65 years-old with Garden I or II FNFs in whom both preoperative hip radiographs and CT of the affected hip were available took place between January 2018 and August 2024. Patients with an unacceptable lateral radiograph were excluded. Posterior tilt was measured on X-ray (PT-XR) and CT (PT-CT).
Results: After review of 1208 records, a total of 100 patients average age 82 ± 8 years met inclusion criteria: 29 hemiarthroplasty, 71 internal fixation (IF). Mean measurements of PT-XR and PT-CT were 9° and 14°, respectively. Radiographs identified two patients (2%) with a posterior tilt ≥20° while CT identified 17 (17%). For the additional 15 patients in whom arthroplasty may be indicated only by CT, the mean difference between PT-XR and PT-CT was 25° ± 15°. Among patients receiving a hemiarthroplasty, PT-XR and PT-CT accurately predicted treatment in 6.9% and 41.4% of cases, respectively.
Conclusion: Plain radiograph underestimates posterior tilt for nondisplaced FNFs. With CT, an additional 15% of patients are identified with a posterior tilt ≥20°. Advanced imaging of Garden I or II FNFs increases accuracy, but its use as an indication for primary arthroplasty is not yet evidence based.
Annual Meeting Podium AM Podium #7
Homelessness and The Outcomes of Hip Fracture Surgical Management: A Nationwide Study in the US
Amir Human Hoveidaei, MD, MSc; Fatemeh Kanaani Nejad, MD; Kasra Pirahesh, MD candidate; Amirhossein Ghaseminejad-Raeini, MD; Basilia O Nwankwo, MD; Janet Donohue Conway, MD
Purpose: The purpose of this study was to determine whether people experiencing homelessness (PEH) have higher rates of postoperative complications following hemiarthroplasty, total hip arthroplasty (THA), hip open reduction and internal fixation (ORIF), and percutaneous skeletal fixation surgeries following hip fracture in the United States.
Methods: Those who received hemiarthroplasty, THA, ORIF, and percutaneous skeletal fixation operations following a hip fracture between 2010 and 2022 were included in a retrospective nationwide analysis in the United States using the PearlDiver Patient Records Database. The CPT codes corresponding to surgeries were searched. The housing status was then extracted using the ICD codes for homelessness.Baseline patient characteristics and comorbidities were obtained using ICD and CPT codes. After matching, the postoperative 30-day and 90-day rates of acute renal failure (ARF), myocardial infarction (MI), respiratory failure, sepsis, venous thromboembolism (VTE), pneumonia, urinary tract infection (UTI), surgical site infection (SSI), and readmission were compared between PEH and housed patients using two models: A χ2 test and a multivariate logistic regression with comorbidities control.
Results: In total, 692,933 housed and 2795 PEH patients were assessed. After matching the housed patients to PEH for age, sex, and year of surgery at a 1:3 ratio, a total of 8382 housed patients were chosen for the postoperative complication analysis, compared to 2795 PEH. In the χ2 analysis, it was observed that rates of postoperative 90-day ARF (1.36 [1.18–1.56]), sepsis (1.70 [1.44–1.99]), respiratory failure (1.33 [1.16–1.52]), UTI (1.37 [1.19–1.58]), pneumonia (1.49 [1.28–1.74]), SSI (2.03 [1.62–2.54]), and readmission (1.60 [1.45–1.77]) were significantly higher among PEH (P<0.001). The regression model revealed that homelessness was an independent predictor of 90-day SSI (1.47 [1.1–3-1.91], P = 0.004) and UTI (1.21 [1.03–1.43], P = 0.022) following surgical management of hip fracture.
Conclusion: Homelessness was identified as an independent risk factor for postoperative SSIs and UTIs within 90 days. Additionally, homelessness was associated with higher comorbidity rates, which were linked to increased complications and readmissions.
Annual Meeting Podium AM Podium #8
Proximal Femur Cut-Out Management, Re-Fixation or Arthroplasty, Which Yields Better Outcomes? Insights From 145 Patients From the PIPPAS Study.
Hector Jose Aguado, PhD Prof; Pablo Castillón-Bernal, MD PhD; Josep Muñoz-Vives, MD PhD; Jordi Teixidor, MD PhD; Montsant Jornet, PhD; Pilar Camacho, MD PhD; Adela Pereda-Manso, SC; Yaiza García-Sánchez, PhD; Pablo García-Portabella, MD PhD; Cristina Ojeda-Thies, MD PhD; David Noriega, MD PhD; The PIPPAS Study Group, SG
Purpose: Proximal femur cut-out injuries are traditionally managed with arthroplasty. Recently, re-fixation with a nail has emerged as an alternative approach. However, it remains unclear which strategy—re-fixation or arthroplasty—leads to better outcomes regarding 1-year mortality, surgical and medical complications, gait function, and independent living.
Methods: This multicenter prospective cohort study included 145 consecutive patients with a proximal femur cut-out injury between January 2021 and December 2023. Patients were divided into two groups: those treated with revision fixation using a nail (n = 23) and those managed with arthroplasty (n = 122). Additionally, 16 patients underwent screw removal with or without nail removal.
Results: The mean age of patients was 85.4 years (SD 6.00) in the re-fixation group and 84.8 years (SD 7.75) in the arthroplasty group (p = 0.72). Most patients were female (81.8% in the re-fixation group and 82.6% in the arthroplasty group). In the re-fixation group, 68.2% of patients were able to walk outdoors compared to 53.3% in the arthroplasty group (p>0.05). More patients in the arthroplasty group were living independently in the community (76.7% vs 54.6%, p = 0.04). There were no differences in cognitive impairment or comorbidities. In all cut-out cases, a nail was the implant involved. The 1-year mortality rate was significantly lower in the re-fixation group (4.5% vs 23.1%, p = 0.047). Medical (54.5% vs 72.7%, p = 0.08) and surgical complications (40.9% vs 55.8%, p = 0.19) were more frequent in the arthroplasty group. Postoperative and 30-day weightbearing restrictions were higher in the re-fixation group (63.6% vs 22.5%, p<0.01 and 50.0% vs 18.6%, p<0.01). No significant differences were observed in mobility decline at 1-year follow up (p = 0.52, p = 1). More arthroplasty patients required nursing home placement at 30 days (p = 0.072), but no differences were found at 1 year (p = 0.503).
Conclusion: Re-fixation with a nail is a viable alternative for managing proximal femur cut-out injuries, demonstrating lower 1-year mortality rates compared to arthroplasty while maintaining comparable functional outcomes.
Annual Meeting Podium AM Podium #9
Local Osteo-Enhancement Procedure Significantly Increases Bone Mineral Density in the Proximal Femur of Postmenopausal Women With Osteoporosis at High Risk of Hip Fracture
Jo De Schepper, MD; Koen Bulterys, Mr.; Bryan Huber, Dr.
Purpose: Our objective was to assess procedural safety and long-term clinical performance of the AGN1 local osteo-enhancement procedure (LOEP).
Methods: A prospective, single-arm, clinical study was conducted in Belgium and the Netherlands. Ethics committee approval was obtained, and participants provided written consent. The main eligibility criteria were postmenopausal female, intact hip without previous surgery or fracture, osteoporosis as per DXA, a femoral neck T-score of ≤ –2.5, and an ASA score ≤2. Participants had one or two hips treated. LOEP involves preparing and filling a site in the femoral neck and intertrochanteric area with a triphasic, resorbable, calcium-based implant material (AGN1). The study concluded at 1 year, and participants were invited to consent for an extension study to 5 years post-LOEP. Ethics committee approval was obtained. This abstract includes interim data for participants through 2 years post-LOEP. Proximal femur bone mineral density (BMD) and resorption were evaluated by an independent core laboratory. Both studies were registered on ClinicalTrials.gov (NCT02916953, NCT04511364).
Results: Between March 2017 and April 2021, 60 participants (73 hips) were treated. Participants were age 69.3 ± 11.7 years and had a baseline mean femoral neck BMD of 0.62 ± 0.07 g/cm². The mean preoperative Fracture Risk Assessment Tool (FRAX) score for 10-year risk of hip fracture was 12.8 ± 10.6%. The mean skin-to-skin surgical time was 15.2 ± 3.9 minutes. The mean volume of AGN1 injection was 16.2 ± 3.4 mL. Adverse events at least possibly related to the procedure were noted in 53% (32 of 60 participants). Most events were mild, expected, and without sequelae. One event was serious (cardiac arrest) and resulted in death. Consent for the extension study was given to 50 participants (59 hips). At 2 years, femoral neck BMD had increased 36.7 ± 37.7% (P<0.001). X-ray evaluation showed AGN1 resorption and bone formation. No hip fragility fractures were reported in LOEP-treated hips.
Conclusion: These data support the use of AGN1 LOEP for osteoporosis-related bone loss in the proximal femur. BMD increased significantly, which is expected to reduce hip fracture risk. Additional study of LOEP's impact on hip fracture risk is warranted and ongoing in a randomized, controlled trial (NCT04796350).
Annual Meeting Podium AM Podium #10
Outcomes after Blood Transfusion in Geriatric Hip Fractures: A Risk-Adjusted ACS-NSQIP Analysis
Rachit Saggar, MBBS; Joseph Mullen, BS; Warren Austin, BS; Abdulganeey Olawin, BS; Emily Nicole Lau, MD; Gele Moloney, MD; George V Russell, MD
Purpose: Blood transfusion is a key component of perioperative management in geriatric patients with hip fractures, yet its impact on outcomes remains controversial, particularly across different anemia-severity groups. This study evaluates the independent association between perioperative transfusion and adverse outcomes to potentially guide transfusion protocols.
Methods: We analyzed geriatric patients with hip fractures, age 65 years or older, in the ACS-NSQIP database merged with the targeted hip fracture dataset (2016–2023) who underwent internal fixation. Fracture types included femoral neck (40.0%), intertrochanteric (53.0%), and subtrochanteric (5.3%). The primary exposure was perioperative transfusion (within 72 hours), with outcomes including major and minor complications, 30-day readmissions, return to the operating room, and mortality. Major complications included cardiac arrest, myocardial infarction, stroke, prolonged ventilation, acute renal failure, sepsis, pneumonia, pulmonary embolism, and reintubation. Minor complications included wound dehiscence, delirium, deep vein thrombosis (DVT), superficial surgical site infections (SSI), urinary tract infections (UTI), and organ-space infections. Preoperative anemia was stratified as severe (<30% hematocrit), moderate (30%–33%), or mild/no anemia (>33%). Multivariable logistic regression adjusted for age, ASA score, hematocrit, comorbidities, and surgical timing.
Results: The cohort included 83,461 patients (mean age: 82.2 ± 7.3 years, body mass index [BMI]: 25.0 ± 5.6, female: 69.6%). Transfusions were given to 18,970 (22.7%), with rates varying by anemia severity: severe (55.6%), moderate (29.9%), and mild/no anemia (10.8%). Transfusion odds were significantly lower in femoral neck (OR: 0.178, 95% CI: 0.166–0.191) and intertrochanteric fractures (OR: 0.528, 95% CI: 0.495–0.563) compared to subtrochanteric fractures (p<0.001). After risk adjustment, transfusion was associated with increased hospital length of stay (LOS) (+0.78 days, p<0.001), major complications (12.4% vs 8.2%, OR: 1.49, 95% CI: 1.41–1.57, p<0.001), minor complications (12.8% vs 11.1%, OR: 1.08, 95% CI: 1.02–1.13, p = 0.004), readmissions (9.4% vs 7.2%, OR: 1.28, 95% CI: 1.21–1.36, p<0.001), return to the operating room (2.5% vs 2.0%, OR: 1.29, 95% CI: 1.15–1.44, p<0.001), and mortality (7.2% vs 5.5%, OR: 1.13, 95% CI: 1.06–1.21, p<0.001).
Conclusion: Transfusion in geriatric patients with hip fractures was independently associated with increased complications and mortality, even after adjusting for anemia severity and comorbidities. These findings challenge routine transfusion practices and suggest more restrictive protocols, particularly for patients with mild anemia.
Annual Meeting Podium AM Podium #11
Hip Fracture Surgery Delayed by Operating Room Capacity is an Independent Risk Factor for 120-Day Mortality
Sam King, BMBCh; Sophia Wakefield, MBBCh; Vasilis Giannoudis, MBChB, MRes; Jeya Palan, PhD, FRCS; Paul Rodham, Mres, FRCS; Peter V Giannoudis, MD, FRCS
Purpose: Delay in surgical management of hip fracture is a modifiable risk factor for mortality. Multiple national guidelines recommend target times to the operating room (OR). However, the literature is limited by small sample sizes and/or nondiscrimination between patients delayed to OR for medical optimization and those delayed because of surgical capacity. The latter is a confounding factor as medically unfit patients are likely to experience perioperative complications. Additionally, male gender, advanced age, medical comorbidity, preoperative confusion, and residing in a care facility are nonmodifiable risk factors for mortality following hip fracture. This study aims to assess the effects of delay to surgical management while controlling for nonmodifiable risk factors for mortality.
Methods: Across a 4.5-year period, data were prospectively collected for all elderly patients presenting with a proximal femoral fracture at our Level I trauma center. Exclusion criteria included pathologic fractures, age younger than 65 years, periprosthetic fractures, nonoperatively managed fractures, and delay of more than 36 hours because of a requirement for medical optimization. Binary logistic regression modeling analyzed the effects of time to operation on 120-day mortality, controlling for age, ASA grade, gender, preoperative confusion, preoperative mobility, preoperative care requirements, and time to review by an elder care physician.
Results: In total, 2364 patients were eligible for inclusion (female: 73.1%, median [IQR] age: 84.6 years [78.2–90.0]), time from the emergency department (ED) to the OR was 38.6 hours (22.8–53.9). Surgical procedures included cannulated screws (n = 12), dynamic hip screw (n = 603), intramedullary nailing (n = 452), cemented hemiarthroplasty (n = 1182), and total hip arthroplasty (n = 115). Overall mortality at 120 days was 14.2%. Increasing time from the ED to the OR increased the mortality rate (p = 0.002), with a time to the OR of more than 36 hours associated with an odds ratio (95% confidence interval) of 120-day mortality of 1.495 (1.134–1.977).
Conclusion: In this large single-center cohort study, delaying surgical management of patients with hip fractures because of surgical capacity substantially increases mortality rates. This is key evidence for prompt surgical management and support for an increase in surgical capacity to prepare for increased demands due to a global aging population.
Annual Meeting Podium AM Podium #12
Delayed Surgery for Anticoagulated Patients With Hip Fractures is Associated With Increased Coagulopathy and Complications
Prism Schneider, MD, PHD, FRCSC; Golpira Elmi Assadzadeh, PhD; Casandra Tan, RN; Souvik Maiti, BSc; Jessica Duong, PhD; Ahmed Negm, PhD; Andrew Dodd, MD; Paul Duffy, MD; Herman Singh Johal, MD MPH; Ryan Martin, MD; Robert Korley, MD
Purpose: The incidence of elderly patients receiving oral anticoagulation (OAC) therapy at the time of a hip fracture is increasing. This can result in delayed time-to-surgery (TTS) despite evidence supporting timely surgery for anticoagulated patients with normal renal function. This study aimed to compare coagulopathy, complications, and mortality among patients with hip fracture who are anticoagulated with those who are not.
Methods: This is an a priori planned secondary analysis of a single-center prospective cohort of patients with hip fracture who were either receiving pre-injury OAC or not. Complications, including venous thromboembolism (VTE) events, cardiovascular events, pulmonary events, infectious complications, and 90-day mortality were captured. All patients underwent thrombelastography (TEG6s) analysis preoperatively. χ2, Mann-Whitney U, and independent samples t-tests were used to compare between groups.
Results: In total, 338 patients with hip fracture were included, with 52 receiving pre-injury OAC (15.4%). Those who were receiving pre-injury OAC were significantly older compared to those who were not (84.9 ± 8.5 years vs 77.0 ± 11.2 years; p<0.001). TTS was significantly delayed for the OAC group compared to those not receiving OAC (median: 44.2 hours [IQR: 24–48 hours] vs median: 24.5 hours [IQR: 18.8–36.3 hours]; p<0.001). The OAC group had significantly more cardiovascular and infectious-related complications (p = 0.002 and p<0.001, respectively), and they were significantly more hypercoagulable based on decreased k-time (p = 0.001), increased alpha-angle (p = 0.001), and increased maximal amplitude (p = 0.027) on preoperative TEG analysis. There was no difference in VTE between those receiving OAC and those not (3.8% vs 3.5%; p<0.05) or transfusion rate in those receiving OAC and in those not (15.7% vs 17.5%; p = 1.0). The 90-day mortality rate in the OAC group was higher (7.7% vs 2.1%), but was not statistically significant (p = 0.055).
Conclusion: Safe and timely surgery for anticoagulated patients with hip fracture is a global health priority. This study found that patients receiving pre-injury OAC had delayed TTS, contributing to increased coagulopathy, cardiovascular-, and infectious-related complications. Therefore, early TTS for anticoagulated patients with hip fracture remains an important benchmark to reduce morbidity and mortality.
OTA Grant
Annual Meeting Podium AM Podium #13
Do Thromboembolic Events Differ by Prophylaxis Type in Patients With Orthopaedic Trauma Based on Patient Setting?
Lucas S Marchand, MD; Thomas F Higgins, MD; Anthony R. Carlini, MS; William T Obremskey, MD, MPH, FIOTA; Reza Firoozabadi, MD; Joshua Layne Gary, MD; Michael J Bosse, MD, FIOTA; Patrick F Bergin, MD; Renan Castillo, MS; Robert V O'Toole, MD; Brook Martin, PhD; METRC
Purpose: The PREVENT CLOT study demonstrated that thromboprophylaxis with aspirin (ASA) was noninferior to low-molecular-weight heparin (LMWH) in preventing death and pulmonary embolism (PE) in patients with extremity or pelvic trauma. However, the timing of venous thromboembolic events (VTE) (combined deep venous thrombosis [DVT] and PE) during and after hospitalization were not reported. Given that the compliance of ASA and LMWH is conceivably different in the inpatient versus outpatient setting, investigation of differential VTE rates between treatment types and settings is warranted.
Methods: We compared VTE rates from 12,211 patients with fracture in the PREVENT CLOT trial. A time-to-event survival model with all-cause mortality as a competing risk was used to compare VTE through 90-days postdischarge based on randomized treatment and stratified by inpatient versus outpatient setting.
Results: A total of 379 VTEs and 90 deaths occurred within 90 days of admission, including 180 PEs (1.5%) and 254 DVTs (2.1%). Of the 379 VTEs, 155 (40.9%) occurred during the initial hospital stay. The per-day risk of VTE was greater during hospitalization. LMWH had a lower, but nonsignificant risk of VTE relative to ASA in both the inpatient (HR: 0.83, 95% CI: 0.63–1.08, p = 0.163) and postdischarge (HR: 0.88, 95% CI: 0.59–1.332, p = 0.551) settings. Overall, the risk of VTE was significantly greater in the inpatient setting than in the postdischarge setting (HR: 6.3, 95% CI: 3.88–10.2, p<0.001). There were an equal number of PEs per group and the risk was not modified by setting. However, the previously reported increased risk of DVT in the ASA group was the result of distal DVTs while hospitalized (HR: 1.77, 95% CI: 1.12–2.79, p = 0.01).
Conclusion: Interestingly, the previously reported difference in DVT rates between ASA and LMWH appears to occur solely while the patients are hospitalized. This appears driven strictly by a differential in distal clots. In contrast, death and PE rates did not differ between groups based on setting. These data suggest no change in previously reported noninferiority of ASA versus LMWH based on setting, but demonstrate that the improved performance of LMWH in distal DVTs appears to occur solely during hospitalization.
Annual Meeting Podium AM Podium #14
Aspirin is a Safe Alternative for VTE Prophylaxis After Total Hip Arthroplasty for Femoral Neck Fracture
Elshaday Belay, MD; Nicholas Reid Kiritsis, BS; Paul M Werth, PhD
Purpose: Venous thromboembolism (VTE) is a well-known complication of lower extremity surgery. However, there remains a lack of consensus on the preferred agent for VTE prophylaxis following total hip arthroplasty (THA) for hip fracture. We aim to compare the bleeding risk and rate of VTE within 90 days postoperative for patients prescribed aspirin, enoxaparin, or the direct oral anticoagulants (DOACs) apixaban and rivaroxaban following THA.
Methods: The Epic Cosmos database was queried for 13,846 patients who underwent THA (CPT 27130) for femoral neck fractures (ICD-10 S72.0) from October 2015 to March 2023. Patients were divided based on their postoperative anticoagulation regimen. The primary outcome included 90-day postoperative complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), anemia, periprosthetic joint infection (PJI), and transfusion.
Results: Patients prescribed enoxaparin and DOACs saw an increased rate of postoperative transfusions compared to those receiving aspirin (9.6% and 10.0% vs 6.0%; p<0.001). The DOAC cohort experienced greater rates of DVT compared to the aspirin and enoxaparin cohorts (1.0% vs <0.2% and <0.4%; p<0.001). Patients taking DOACs had higher rates of PE compared to the aspirin and enoxaparin groups (0.9% vs 0% and <0.4%; p<0.001). Enoxaparin and DOACs were associated with increased odds of postoperative transfusion (OR: 1.507, p<0.001 and OR: 1.276, p = 0.038). There were no significant differences in the rates of postoperative anemia and PJI.
Conclusion: VTE prophylaxis with aspirin after THA for hip fracture is associated with a lower incidence of transfusion compared with enoxaparin or DOACs. Aspirin had an equivalent rate of DVT or PE compared to enoxaparin. Aspirin may be a safe alternative prophylaxis for VTE after THA for hip fracture.
Annual Meeting Podium AM Podium #15
Aspirin is an Effective Method of Prophylaxis in Lower Extremity Fracture Patients With a History of VTE
Jens Verhey, MD; Connor Park, BS; Adam Michael Ross, MD; Brian Miller, MD
Purpose: Although aspirin has become the prophylactic agent of choice for venous thromboembolism (VTE) prevention in low VTE-risk patients undergoing surgical fixation of lower extremity fractures, there remains a paucity of data in the literature on the efficacy of aspirin as a mode of chemoprophylaxis in patients who have previously experienced a VTE episode. The purpose of this study was to determine the efficacy of aspirin versus other anticoagulant medications in patients undergoing surgical intervention for lower extremity fractures who have a documented history of a prior thromboembolic event.
Methods: This study used a national database to identify patients who underwent surgical intervention for lower extremity fractures between 2010 and 2021. Only patients with a documented history of a VTE event were included. Using demographic data, medical comorbidities, and preoperative anticoagulation use, patients with a history of VTE who received non-aspirin medications for thromboprophylaxis were propensity-score matched on a 3:1 basis with those who received aspirin. Patients with either an active or previous history of cancer were excluded. The odds of developing 90-day medical and surgical complications were assessed and compared among patients receiving aspirin only versus other types of chemoprophylaxis.
Results: In total, 3789 matched patients with lower extremity fractures who underwent surgical fixation were included in the analysis. Patients in the aspirin group had significantly lower odds of development of deep vein thrombosis (DVT) (OR: 0.49; 95% CI: 0.38–0.63) and pulmonary embolism (PE) (OR: 0.35; 95% CI: 0.22– 0.57). Similarly, those in the aspirin group were also at lower odds for returning to the emergency department and were less likely to experience gastrointestinal bleeding and blood loss anemia in the 90-day postoperative period (p<0.05).
Conclusion: We found that patients with a history of VTE who received aspirin thromboprophylaxis after surgical fixation of lower extremity fractures had significantly lower odds of DVT and PE developing, when compared to those receiving non-aspirin medications. Based on these findings, it appears that aspirin may be a suitable method of VTE prophylaxis in patients with a prior thromboembolic episode.
Annual Meeting Podium AM Podium #16
Determining Venous Thromboembolic and Pulmonary Embolism Risk in Orthopaedic Trauma Patients
Lucas S Marchand, MD; Thomas F Higgins, MD; Robert V O'Toole, MD; William T Obremskey, MD, MPH, FIOTA; Reza Firoozabadi, MD; Joshua Layne Gary, MD; christina bolton, MD; Greg Gaski, MD; brook martin, PhD; Anthony R. Carlini, MS; Renan Castillo, MS; METRC
Purpose: Patients with orthopaedic trauma are at an elevated risk of venous thromboembolic events (VTE) because of immobility, surgery, and comorbidities. Accurate risk prediction is crucial for guiding prophylaxis. Accurate prediction of VTE and pulmonary embolism (PE) risk is crucial for guiding prophylactic interventions. The purpose of this study was to assess the ability of the Caprini score and a novel pulmonary risk (PR) score to risk stratify patients with skeletal trauma.
Methods: Data from 12,211 patients in the PREVENT CLOT Study were included. Existing demographic data were used to calculate Caprini and PR scores. The Caprini score was used to risk stratify VTEs while the PR score was used for PE risk. Multivariable logistic regression models were generated. Caprini scores stratified VTE risk as low: 0–4, moderate: 5–7, high: 8–10, or severe: 11+. PR scores stratified PE risk as low: ≤38, medium: 39–45, or high: >45. Discriminative ability was assessed using area under the receiver operating characteristic curve (AUC).
Results: We analyzed 2923 low, 4829 moderate, 2571 high, and 1887 severe Caprini risk patients. The risk of VTE increased incrementally for the low (OR: 1.0), moderate (OR: 1.9, 95% CI: 1.4–2.7), high (OR: 3.1, 95% CI: 2.2–4.3), and severe-risk cohorts (OR: 5.2, 95% CI: 3.8–7.3; p<0.001 for all OR). For the PR score, the three categories demonstrated progressive increase in PE rates: low-risk (n = 5115, PE rate: 0.65%, 95% CI: 0.43–0.87), medium-risk (n = 3516, PE rate: 1.59%, 95% CI: 1.18–2.01), and high-risk (n = 3508, PE rate: 2.57%, 95% CI: 2.04–3.09). The AUC for the Caprini score was 0.65, and for the PR score it was 0.68.
Conclusion: The Caprini and PR scores effectively stratified patients into risk categories, demonstrating a progressive increase in VTE and PE rates. Although AUCs were less than 0.70, risk stratification remains valuable when it leads to clinically meaningful differences in event rates, as demonstrated here. These tools can aid in decision-making when used alongside clinical judgment. Further external validation is needed to refine these models and assess their broader applicability in orthopaedic trauma populations.
Annual Meeting Podium AM Podium #17
Assessing the Impact of Site VTE Practice Variation on a Multicenter RCT Comparing Aspirin and LMWH for Mortality Prevention: A Secondary Analysis of PREVENT CLOT Study
Anthony R. Carlini, MS; Lucas S Marchand, MD; Thomas F Higgins, MD; Brook Martin, PhD MPH; William T Obremskey, MD, MPH, FIOTA; Reza Firoozabadi, MD; John Wesley Munz, MD; Michael J Bosse, MD, FIOTA; Patrick F Bergin, MD; Robert V O'Toole, MD; Renan Castillo, PhD; METRC
Purpose: PREVENT CLOT, a large, pragmatic, multicenter randomized controlled trial (RCT), evaluated non-inferiority of aspirin versus low molecular weight heparin (LMWH) for preventing all-cause mortality. A concern in pragmatic trials is whether site practice variation biases result. We assessed whether site variations observed in this trial impacted the trial’s primary conclusions using three advanced statistical approaches.
Methods: We re-analyzed all-cause mortality in 12,211 patients randomized to aspirin (n = 6079) or LMWH (n = 6096). To test the robustness of results against site-level venous thromboembolism (VTE) differences, we applied three statistical approaches: a hierarchical mixed-effects model with site-specific random intercepts, inverse probability weighting (IPW) to adjust for equipoise differences, and instrumental variable (IV) analysis using site aspirin preference as an instrument for treatment assignment.
Results: Site VTE practices with substantial variance included patients being discharged without prophylaxis (0%–22%), deep vein thrombosis (DVT) imaging rates per 100 patient-days (0.00–6.40), and pulmonary embolism (PE) imaging rates (0.00–1.47) per 100 patient-days. The high range relative to the mean (range >4 × mean) and a moderately high coefficient of variation (CV = 0.88) confirm significant variability in site practices. The hierarchical model found no significant difference in mortality between aspirin and LMWH (OR: 0.96, p = 0.83) and minimal variation across sites. IPW-adjusted regression also showed no effect (OR: 0.77, p = 0.24), suggesting site practice differences did not influence outcomes. The IV approach was invalid (p = 0.46) as site aspirin preference did not predict treatment. All methods confirmed the trial’s original finding of non-inferiority.
Conclusion: Site-level variation in VTE prophylaxis practices did not affect trial results, which were robust after testing with three advanced statistical approaches. These findings reinforce the validity of the trial’s conclusions and suggest site level practice variation does not have to be a major impediment to the conduct of large, pragmatic, comparative effectiveness trials.
Annual Meeting Podium AM Podium #18
Impact of Continuous Perioperative Anticoagulation on DVT/PE Events in Trauma Patients
Armarion Stegall, BS; J Tracy Watson, MD; Heidi Israel, PhD
Purpose: Historically at our institution, if patients with orthopaedic trauma went directly to the operating room (OR) from the emergency department (ED), no preoperative prophylaxis was given. Postoperatively, the agents were held for 24 hours, then started. On review, unacceptable rates of deep vein thrombosis/pulmonary embolism (DVT/PE) based on Trauma Quality Improvement Program (TQIP) standards were noted. We then instituted a prospective protocol operating directly through prophylaxis and not stopping preoperatively or postoperatively, regardless of circumstances. Enoxaparin is now used throughout the perioperative and entire postoperative periods. The purpose of this study was to determine if reduction in DVT/PE followed, compared to our initial prophylaxis scheme. Secondary measures were assessed to determine if an increase in adverse complications or outcomes occurred.
Methods: A matched cohort of patients based on mechanism of injury from our retrospective review was compared to our new study cohort evaluating DVT/PE rates in patients following the procedural change over a 5-year time period, using our trauma and Epic database(s) with 3 years of new protocol data. Clinical data recorded time to surgery, type of injury/surgery, anticoagulant prior to surgery, and if anticoagulation agents were held. DVT and/or PE occurrence, mortality, and cause of death were noted. Closed head and spinal injuries were excluded. Transfusions, wound issues, and other complications were documented. Categorical variables were summarized for significance using Pearson χ2 and likelihood ratios. Linear-by-linear association assessed differences in DVT/PE rates and secondary outcomes between the pre- and post-policy groups.
Results: More than 400 patients were analyzed. A significant difference in DVT/PE rates between the pre- and post-policy groups was 9% versus 0.7% (p = 0.016). DVT/PE was 14.553 times (p = 0.002) more likely when anticoagulation agents were held prior to surgery. Secondary analysis for blunt trauma revealed no difference in transfusion or mortality related to DVT/PE.
Conclusion: This study demonstrates the effectiveness of continuous anticoagulation in reducing the incidence of thromboembolic events in patients with orthopaedic trauma. These findings suggest that DVT/PE rates have significantly decreased without an increase in complications. Continuous anticoagulation was shown to be successful in this interim analysis. We continue to evaluate our prospective study with no protocol change.
Annual Meeting Podium AM Podium #19
Timing of Venous Thromboembolic Events and Mortality Following Orthopaedic Trauma
Lucas S Marchand, MD; Thomas F Higgins, MD; Anthony R. Carlini, MS; Robert V O'Toole, MD; William T Obremskey, MD, MPH, FIOTA; Reza Firoozabadi, MD; Joshua Layne Gary, MD; Christina Bolton, MD; Greg Gaski, MD; Brook Martin, PhD; METRC
Purpose: Venous thromboembolic events (VTE) can lead to significant morbidity and mortality following skeletal trauma. Yet the duration of elevated risk after injury and ideal duration of prophylaxis are not clearly understood. Understanding the precise timing of VTEs and mortality will aid in setting appropriate duration of thromboprophylaxis. The purpose of this study is to describe the timing of VTEs and mortality in patients with orthopaedic trauma.
Methods: We performed a secondary analysis of the PREVENT CLOT data in which trauma patients were randomly assigned 81 mg of aspirin (ASA) or 30 mg of low molecular weight heparin (LMWH) twice daily. Thromboprophylaxis could end at hospital discharge or continue with the assigned treatment per hospital protocols. VTEs (combined pulmonary embolism [PE] and deep venous thrombosis [DVT]) were identified and recorded. The timing of the VTEs relative to hospital admission was then calculated and a time-to-event analysis was performed using mortality as a competing risk factor.
Results: In total, 12,211 patients were included in the analysis. A total of 379 VTEs and 90 deaths occurred within 90 days of admission, including 180 PEs (1.5%) and 254 DVTs (2.1%). The average time to VTE was 21 days (SD: 21.6) with a median of 13 days. Nearly half (41%) of VTEs were diagnosed during index hospitalization. Most VTEs (90%) occurred within 57 days of discharge. Within 14 days of admission, 55% of clots were diagnosed; within 4 weeks, 74%; within 6 weeks, 83%; within 8 weeks, 90%; and within 10 weeks, 95%. Mortalities occurred within 2 weeks of admission in 23%; within 4 weeks, 41%; within 6 weeks, 60%; within 8 weeks, 70%; and within 10 weeks, 78%. The average number of days to VTE onset was fewer in the ASA group compared to the LMWH group (18.9 vs 24.5, p<0.05).
Conclusion: This investigation provides valuable insights into the timing of VTEs following skeletal trauma. While the ideal duration of VTE prophylaxis for trauma patients remains controversial, a better understanding of the timing of VTEs can help providers tailor prophylactic strategies to reduce the incidence of these potential life-threatening events.
Annual Meeting Podium AM Podium #20
The Impact of Topical Tranexamic Acid on Perioperative Blood Loss in Isolated Operative Posterior Wall Acetabular Fractures: A Randomized, Double-Blinded, Placebo-Controlled Trial
Sarah Kurkowski, MD; Michael T Archdeacon, MD, FIOTA; Amanda J Schroeder, MD; Henry Kuechly, BS; Frank R Avilucea, MD; Michael J Beltran, MD; H Claude Sagi, MD
Purpose: The purpose of this trial was to evaluate the use of topical tranexamic acid (TXA) compared to placebo on blood loss and rate of venous thromboembolic events in the perioperative period in patients undergoing surgical repair of isolated posterior wall acetabular fractures.
Methods: A randomized, double-blind, placebo-controlled trial was held at a Level I trauma center. Patient selection criteria included skeletally mature patients aged 18 years and older with an isolated posterior wall acetabulum fracture managed surgically within 7 days of injury. Patient consent was necessary to participate. Outcome measures and comparisons included postoperative blood transfusion (number and quantity of transfusions), calculated blood loss, estimated blood loss, postoperative hematocrit, and 30-day venous thromboembolic events between patients randomized to topical TXA and those randomized to placebo.
Results: Ninety-one patients were prospectively enrolled and randomized to either topical TXA or placebo between October 2017 and January 2024. Of these patients, 45 received topical TXA and 46 received placebo. No differences were found between the groups in terms of patient characteristics (gender distribution, age, height, weight, medical comorbidities, mechanism of injury, injury severity score, and other injuries). Surgery time was similar between groups (p = 0.106). No differences were found between the placebo and topical TXA groups in estimated blood loss (p = 0.303), calculated blood loss (p = 0.805), preoperative hematocrit (p = 0.284), postoperative hematocrit (p = 0.429), volume of blood transfused (p = 0.509), number of transfusions received (p = 0.644), or incidence of 30-day venous thromboembolic events (p = 0.714).
Conclusion: No difference in postoperative blood loss, blood transfusions, or venous thromboembolic events was demonstrated between patients randomized to topical TXA versus placebo. Topical TXA does not reduce blood loss or increase blood clotting complications in patients with an isolated posterior wall acetabular fracture.
Annual Meeting Podium AM Podium #21
The Anterior Approach Does Not Improve Recovery After Hemi-Arthroplasty for Femoral Neck Fracture: A Randomized Controlled Trial
Taylor Woolnough, MD; Isabel Horton, BASc; Simon Garceau, MD FRCSC; Paul E Beaule, MD FRCSC; Robert J Feibel, MD FRCSC; Wade T Gofton, MD FRCSC; Stephane Poitras, PT PhD; Paul Kim, MD FRCSC; Georgios Grammatopoulos, DPhil (Oxon) FRCSC
Purpose: Evidence supporting the anterior approach (AA) over the lateral approach (LA) in patients undergoing hemiarthroplasty for intracapsular hip fracture, although promising, is inconsistent and largely retrospective. The purpose of this study was to compare the AA to the LA for early function, time to discharge, pain, and complications in patients undergoing hemiarthroplasty for hip fracture.
Methods: A multi-surgeon, single-center, randomized-controlled trial (RCT) was performed. 102 patients undergoing hemiarthroplasty for acute femoral neck fractures were randomized to AA (n = 50) or LA (n = 52). All procedures were performed by fellowship-trained arthroplasty surgeons using cemented (92 of 102) or uncemented (10 of 102) stems. Patients were followed at regular intervals, and outcomes were assessed at 2, 6, 12, and 26 weeks. Age (mean: 81 ± 7.6 years), body mass index (BMI), preoperative mobility, ASA grade, and stem fixation were similar between groups (p>0.05). The primary outcome was patient function assessed using the Barthel-20 Index at 6 weeks. Secondary outcomes included pain (Visual Analogue Scale [VAS] Pain), EQ-5D global health assessment, length of stay, and complications.
Results: The Barthel-20 Index score did not differ between groups at 6 weeks (AA: 15.8 ± 5.3; LA: 15.8 ± 5.2, p = 0.976) or at any other time. EQ-5D and VAS pain were not different. Mean length of hospital stay (AA: 11.1 ± 7.7 days; LA: 9.4 ± 6.7 days, p = 0.226) and time from surgery to rehabilitation discharge (AA: 31.3 ± 18.6 days; LA: 30.4 ± 28 days, p = 0.867) were not different. There was no difference in readmission/ED visit within 90 days (p = 0.858) or 90-day mortality (AA: 2 of 50; LA: 2 of 52, 4%, p = 0.916). There was no difference in re-operations (AA: 2 of 50; LA, 1 of 52, p = 0.535) or medical (AA: 14 of 50; LA: 21 of 52, p = 0.365) complications.
Conclusion: The AA is not associated with superior recovery or early-term outcomes in patients with hip fracture. At present, without proven benefit, widespread adoption of the AA in this population is not recommended, particularly considering the learning curve and specialized equipment requirements.
Annual Meeting Podium AM Podium #22
The Effect of Preoperative Tranexamic Acid on Blood Transfusions in Geriatric Hip Fracture Surgery: A Randomized Controlled Trial
Megan C Sullivan, DO; Lindsey L Perea, DO; Eric H Bradburn, DO, FACS; Kimberly Guglielmo, MS; Kellie Bresz, MS; Michael A Horst, PhD; Barbara Martin, PhD; Colin Heinle, MD; Gregory Tocks, DO
Purpose: Hip fractures in the geriatric population are associated with high morbidity and mortality, often necessitating surgical intervention. Blood loss during surgery and the subsequent need for transfusions increase the risk of cardiac and renal complications, further complicating management. Tranexamic acid (TXA) has demonstrated efficacy in reducing blood loss and transfusion requirements in elective arthroplasty surgeries. However, its role in emergent surgeries, such as hip fractures, remains uncertain. To our knowledge, this is the largest randomized controlled trial (RCT) to date studying TXA in geriatric patients with hip fracture. We hypothesize that preoperative administration of TXA will reduce the need for postoperative transfusions without increasing complications. Secondary objectives include assessing its effects on hospital length of stay (HLOS), 30-day readmission rates, complications within 90 days, and 90-day mortality.
Methods: A prospective, double-blinded RCT was conducted at a single center from June 2019 to June 2022, involving 284 patients age ≥65 years with hip fractures undergoing surgical intervention. One patient was enrolled in the study but not randomized into a treatment group. Participants were randomized 1:1 to receive either TXA (1 g) or placebo prior to incision. The trial was stopped early after a planned interim analysis revealed that futility criteria were met. Statistical analyses were performed using odds ratios and two-sample proportion tests with an alpha level adjusted for interim and final analyses.
Results: Of the 283 participants, 229 (80.9%) had no postoperative transfusion, including 111 (81%) in the control group and 118 (80.8%) in the treatment group. At least one postoperative transfusion was required in 54 (19.1%) patients, with 26 (19%) in the control group and 28 (19.2%) in the treatment group. No significant differences were found in HLOS, readmission rates, complications or mortality between groups. As part of an exploratory analysis, subgroup analysis indicated higher transfusion rates in patients undergoing internal fixation compared to those undergoing hip replacement.
Conclusion: Preoperative TXA did not significantly reduce the need for postoperative transfusions, nor did it affect secondary outcomes such as HLOS, complications, or mortality. Further research is needed to evaluate the potential risks and benefits of TXA in this high-risk population.
Annual Meeting Podium AM Podium #23
A Multicenter Randomized Trial Evaluating the Effect of Tobramycin Powder for Reducing Surgical Site Infection After Fracture Surgery (TOBRA)
Robert V O'Toole, MD; METRC
Purpose: The VANCO trial showed vancomycin powder reduced gram-positive infections, but it had no effect on gram-negative infections after fracture surgery. Our hypothesis was that there would be a reduced proportion of deep surgical site infections (SSI) within 6 months of fracture fixation with the addition of tobramycin, a topical antibiotic aimed at gram-negative bacteria, in patients with tibial pilon and plateau fractures at high risk of infection.
Methods: This study was a phase III, prospective, randomized, clinical trial. The study population consisted of patients age 18 to 80 years with high-risk tibial plateau or pilon (tibial plafond) fractures definitively treated with plate and screw fixation. Fractures were either open (Gustilo Anderson Types I, II, or IIIA) or treated initially with external fixation because of swelling. Participants were centrally block randomized in a 1:1 ratio to either treatment (1200 mg of local tobramycin powder and 1000 mg of local vancomycin powder, placed immediately before wound closure) or control (1000 mg of local vancomycin powder). The primary outcome measure was deep SSI treated surgically within 6 months of surgery. The primary analysis followed the intent-to-treat paradigm and assessed treatment effects using Bayesian methods.
Results: The study randomized and enrolled 1574 patients at 40 Level I trauma centers to either treatment (n = 780) or control (n = 794). The study sample was largely male (60%) and non-Hispanic white (61%) with a mean age of 47.0 years (SD: 14.4). Most fractures (80%) were closed. More than 80% of all expected follow up has been completed. Of enrolled patients, 96% received the study treatment per the protocol. Results of the final analysis will be presented at the OTA Annual Meeting.
Conclusion: The results of one of the largest prospective randomized multicenter trials conducted to date within orthopaedic trauma should provide a definitive answer as to whether the combination of tobramycin and vancomycin powders can help reduce the burden of SSI in these high-risk patients.
Annual Meeting Podium AM Podium #24
Permissive Weight Bearing Versus Restrictive Weight Bearing in Surgically Treated Trauma Patients With Displaced Intra-Articular Calcaneal Fractures: The PIONEER Study
Coen Verstappen, MD; Mitchell L.S Driessen, PhD; Pishtiwan Kalmet, PhD; Michael Edwards, PhD; Erik Hermans, PhD; Martijn Poeze, PhD
Purpose: Displaced intra-articular calcaneal fractures (DIACF) require an extensive rehabilitation protocol that influences functional recovery and socioeconomic outcomes. Current postoperative guidelines often recommend restrictive weightbearing (RWB), yet evidence suggests that permissive weightbearing (PWB) could be equally effective while promoting faster recovery. The PIONEER study aims to compare PWB and RWB in surgically treated DIACF patients to assess functional outcomes, health-related quality of life (HRQoL), radiographic parameters, cost-effectiveness, and complication rates.
Methods: This prospective, multicenter, randomized controlled trial (RCT) will include 115 patients age 18 to 67 years with unilateral DIACFs treated surgically using an extended lateral, sinus tarsi, or percutaneous approach. Participants will be randomized (1:1) to either a PWB or RWB rehabilitation protocol. The primary outcome will be functional recovery measured by the American Orthopaedic Foot and Ankle Society (AOFAS) score at 6 months. The secondary outcomes will include Maryland Foot Score (MFS), EQ-5D for HRQoL, radiographic assessment (Böhler’s angle and posterior facet alignment), cost-effectiveness analysis, and complication rates. Follow-up assessments will be conducted at 2, 6, and 12 weeks and 6 months postoperatively.
Results: By assessing functional recovery, cost-effectiveness, and safety of PWB compared to RWB, this study seeks to determine whether early weightbearing is a viable alternative to current restrictive protocols. Existing literature suggests that PWB may result in earlier mobilization without increasing complications, but high-quality RCT data are lacking.
Conclusion: This is the first RCT designed to provide definitive evidence on the optimal weightbearing protocol for DIACFs. If PWB proves non-inferior to RWB in functional and radiographic outcomes, it could challenge existing conservative rehabilitation protocols and lead to a paradigm shift in postoperative care.
OTA Grant
Annual Meeting Podium AM Podium #25
A Prospective Randomized Trial to Assess Early Versus Delayed Weight Bearing Following Operatively Treated Ankle Fractures in the United States
METRC; William T Obremskey, MD, MPH, FIOTA
Purpose: The primary aim of this study was to determine the safety of early versus delayed weightbearing and the effectiveness for improving return-to-work outcomes following ankle fracture surgery. We hypothesized that the 12-month complications rate in the early weightbearing group would be noninferior to that of the delayed weightbearing group and that early weightbearing would promote an earlier return to work.
Methods: This prospective multicenter randomized trial assigned adult patients undergoing surgery for ankle fracture (OTA 44 A, B, or C) to early (2 weeks postoperatively) or delayed (6 weeks postoperatively) weightbearing. Open Type IIIB or IIIC injuries and syndesmotic injuries were excluded. Patients in both groups received standardized instructions and home exercises tailored to weightbearing assignment. Patients received weekly calls from a physical therapist and text message reminders to reinforce compliance. The coprimary outcomes were 12-month reoperation for hardware failure, non-union, loss of reduction, infection, or fusion and return to work, which was collected by surveying patients at 6 weeks and 3 , 6, and 12 months post injury.
Results: The study enrolled and randomized 435 patients across 19 centers from January 2020 to October 2023. The modified intent-to-treat sample included 417 patients (213 early, 204 delayed). Average age was 45 years (SD:15), 45% were male, and 68% were White. Most fractures were OTA 44B (72%) and closed (94%). 96% of individuals had at least 365 days of follow up for the reoperation outcome. Return-to-work status was ascertained in 80% of the 285 patients who were working prior to their injury. Results of the final analysis will be presented at the OTA Annual Meeting.
Conclusion: This well-powered multicenter randomized controlled study directly addresses the safety of early weightbearing after ankle fractures, a key concern for both clinicians and patients. We also will determine if return to work is sooner in patients who are allowed early weightbearing.
Annual Meeting Podium AM Podium #26
Nine months of Fluoxetine Aids in the Reduction of Negative Psychiatric Symptomology Following a Traumatic Musculoskeletal Injury
Marissa N Pazik, MS, ATC; Terrie Vasilopoulos, PhD; Diana V Rijo, BS; MaryBeth Horodyski, EdD, ATC; Carol Mathews, MD; Ludmila Barbosa De Faria , MD; Jennifer Elizabeth Hagen, MD, MS
Purpose: Negative psychiatric symptomology develops post-injury in close to 50% of individuals who sustain a traumatic musculoskeletal injury. We evaluated the efficacy of immediate fluoxetine therapy versus calcium treatment in improving mental health scores in the post-injury period for patients with musculoskeletal trauma.
Methods: This prospective study randomized patients to 9 months of fluoxetine or calcium following a high-energy traumatic musculoskeletal injury. Post-traumatic stress symptomology was assessed using the PTSD Symptom Scale Self-Report Version (PSS-SR) with higher scores indicating worsened symptoms.
Results: We enrolled 68 subjects (males: 38; females: 30) in the study; 33 subjects were randomized to fluoxetine and 35 to calcium. Median PSS-SR scores at 6 weeks (n = 45), 6 months (n = 33), and 1 year (n = 27) were 9, 4, and 3 for the fluoxetine group and 8, 11.8, and 8 for the calcium group (see figure). The Hodges-Lehmann median difference between the groups (fluoxetine and calcium) was 0 (95%CI: –6,5) at 6 weeks; –5 (95%CI: –1,3) at 6 months, and –3 (95%CI: –18,3) at 1 year.
Conclusion: While the fluoxetine group showed a 66% decrease in PSS-SR scores from 6 weeks to 1 year, the calcium group showed no improvement. Taking fluoxetine for 9 months post injury may clinically decrease the negative psychiatric symptomology that is common following a traumatic musculoskeletal injury.
Annual Meeting Podium AM Podium #27
The Operative Rib Fixation (ORiF) Study
Benjamin Ollivere, FRCS (ORTHO), MBBS, MD; Katie Elisabeth Rollins, MBBS; Matthew Costa, FRCS (Tr&Orth), PhD, FIOTA
Purpose: Management of patients with chest wall injuries represents a major financial and social burden to the National Health Service (NHS). Patients managed in ICUs require specialist nursing and ventilatory support, and rehabilitation can be long. The Operative Rib Fixation (ORiF) Study aims to establish if operative rib fixation, when given in addition to supportive management, reduces mortality and/or increases quality of life in patients who experience chest wall trauma.
Methods: We conducted a prospective blinded randomized controlled trial of operative rib fixation versus standard care in 16 Level I centers in the United Kingdom to assess differences in all-cause mortality between the intervention and control groups at 12 months. The primary outcome was all-cause mortality. Secondary outcome measures were to quantify and draw inferences from observed differences in quality of life over 12 months following surgery. Health economic and cost utility data were collected with the EQ-5D-5L index with direct trial collection of primary outcome data.
Results: Overall, 467 patients were recruited and randomized to one or the other treatment. Full trial results and outcomes will be presented at the OTA Annual Meeting as the first presentation of the ORiF trial results. Results are not yet available because of data lock, and the abstract will be updated prior to presentation.
Conclusion: See the information stated above.
Annual Meeting Podium AM Podium #28
Is Postoperative Ketorolac Administration Associated With Nonunion and Malunion After Proximal Humerus Open Reduction and Internal Fixation? A Retrospective Cohort Study
Anthony Baumann, DPT; Robert J. Trager, DC; Shahab Yazdanpanah, M.S.; Tyler Sanda, MD; Michael Makowski, MD
Purpose: Although ketorolac's association with poor bone healing remains debated, no study has examined the impact of ketorolac administration in adults with proximal humerus fracture (PHF) after open reduction and internal fixation (ORIF), limiting surgeon decision-making. Therefore, this study sought to examine the association between short-term ketorolac administration within the first 3 days after ORIF for PHF and incidence and risk of nonunion and/or malunion through 1 year.
Methods: This preregistered retrospective propensity-matched cohort study used a large U.S. health-records–based database (TriNetX, LLC) and included adult patients undergoing first-time proximal humerus ORIF who received either short-term (≤3 days) postoperative ketorolac (ketorolac cohort) or acetaminophen (control cohort). The primary outcome was the risk ratio (RR) of a composite of nonunion and/or malunion through 1 year of postoperative follow up. More than 15 risk factors identified in the literature associated with bone union were controlled via propensity matching.
Results: There were 2081 patients per cohort (n = 4162 total patients) with a mean age of 60 years with a median follow up of 1 year. Comparing the ketorolac cohort to the control cohort, there was a significant increase in risk of nonunion and/or malunion (p = 0.037; RR: 1.37 [1.02, 1.83]; 4.9% vs 3.6%). Individual outcomes demonstrated a significant increased risk of nonunion (p = 0.031; RR: 1.49; 3.4% vs 2.3%), and no significant difference in risk of malunion (p = 0.560; RR: 1.14; 1.9% vs 1.7%), revision ORIF (p = 0.676), total shoulder arthroplasty (TSA) (p = 1.000), oral opioid prescription (p = 0.139), or acute kidney injury (AKI) (p = 0.754). Among patients prescribed oral opioids, there was no significant difference in mean opioid prescription count between cohorts (p = 0.169).
Conclusion: Short-term postoperative ketorolac is associated with a significant increase in risk of nonunion (RR: 1.489; 1.1% absolute risk difference) after proximal humerus ORIF. However, there was no significant increase in risk of malunion, revision ORIF, reoperation via TSA, AKI, or oral opioid prescription. Surgeons should apply this data cautiously on a case-by-case basis, given each patient’s unique risk profile for adverse outcomes.
Annual Meeting Podium AM Podium #29
Long-Term (10–15 year) Functional Outcome in Adults After an Elbow Dislocation (Elbow-LTF): Follow-Up of a Multicenter RCT and Prospective Case Series
Niels Plaisier, BSc; Esther van Lieshout, PhD, MSc; Gijs Iordens, MD, PhD; Michael Verhofstad, MD, PhD, FIOTA; Dennis Den Hartog, MD, PHD; FuncSiE Trial Investigators; Dutch Elbow Collaborative
Purpose: Two previous studies demonstrated that early active mobilization is safe and effective for both simple and complex elbow dislocations, with a hinged external fixator applied for persistent instability in the latter. Both studies showed excellent functional outcomes at 1-year follow up, with faster recovery in simple elbow dislocations than in plaster immobilization. Whether these results persist in the long term remains unknown. This long-term follow-up study of a multicenter randomized controlled trial (RCT) on simple elbow dislocations and a prospective case series on complex elbow dislocations was performed to assess functional outcome scores, range of motion (ROM), and complications or complaints at least 10 years after trauma.
Methods: Patients were invited to complete a questionnaire comprising the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH), the Oxford Elbow Score (OES), the pain level for both elbows on the Visual Analog Scale (VAS), and questions regarding complaints and additional treatments. Afterward, patients were invited to attend an online video appointment to conduct the Mayo Elbow Performance Index (MEPI) and measure the elbow ROM.
Results: A total of 60 patients was included. The mean duration of follow up was between 12.5 years (SD 0.8) in the early mobilization group and 13.6 years (SD 0.5) in the external fixator group. The median Quick-DASH score was 2.3 (P25–P75 0.0–11.4) in the early mobilization group, 4.5 (P25–P75 0.0–11.4) in the plaster immobilization group, and 8.0 (P25–P75 2.8–38.6) in the external fixator group. The median losses of flexion–extension were 5⁰ (P25–P75 3⁰–9⁰), 1⁰ (P25–P75 -1⁰–6⁰) and 24⁰ (P25–P75 6⁰–48⁰), respectively. At the long-term follow up, 15 (25%) patients reported complaints of the elbow.
Conclusion: Good to excellent patient-reported and functional outcomes after a simple or complex elbow dislocation were preserved in the very long term. Slight improvements were found in the Quick-DASH, OES, MEPI, pain level, and range of motion. Complaints occurred in 25% of the patients, although this was not reflected in the functional outcome scores.
Annual Meeting Podium AM Podium #30
Nonunion and Post-Operative Complications Associated With Intramedullary Nailing Versus Plate Fixation of Humeral Shaft Fractures
William Marmor, MD; David A. Momtaz, MD; Jad Jack Lawand, MS; Eric Kholodovsky, BS; Francisco José Fuster, MD
Purpose: Humeral shaft fractures are typically managed surgically with open reduction and internal fixation (ORIF) or intramedullary nailing (IMN). Understanding the potential complications and their rate of occurrence is important in identifying the optimal treatment strategy for patients. This study aims to identify the outcomes following the use of ORIF with plate fixation versus IMN in humeral shaft fractures.
Methods: A retrospective cohort study was conducted using electronic medical records from January 2005 to March 2023. Pathologic fractures and revision cases were excluded. To minimize bias, a propensity score match was performed based on demographic variables, including age, sex, and body mass index (BMI), as well as comorbidities such as diabetes and heart disease, and concomitant upper extremity injuries. The primary outcome measured was nonunion. Secondary outcomes included malunion, radial nerve palsy, surgical site infections (SSI), wound dehiscence, and reoperation rates.
Results: Following propensity matching, the study analyzed 6592 patients equally distributed between the ORIF and IMN cohorts (n = 3296 each). The risk of nonunion was significantly higher in the ORIF cohort (3.46%) compared to the IMN cohort (2.03%), with a risk ratio (RR) of 1.70 (95% CI, 1.52–1.91; p<0.001). Radial nerve palsy was more common in the ORIF group (9.92%) compared to the IMN group (4.19%), resulting in an RR of 2.37 (95% CI, 2.22–2.53; p<0.001). Deep infections were also more frequent with ORIF, observed in 2.94% versus 1.88% for IMN, RR = 1.56 (95% CI, 1.38–1.78; p = 0.006). No significant differences were observed for malunion (p = 0.742), SSI (p = 0.841), or reoperation (p = 0.216). Wound dehiscence was greater in the plate group (RR = 1.54, 95% CI, 1.34–1.76; p = 0.014).
Conclusion: The findings indicate that IMN is associated with a lower risk of nonunion and radial nerve palsy compared to ORIF with plate fixation in the treatment of humeral shaft fractures. These insights can guide clinicians in making informed decisions regarding surgical intervention, highlighting the importance of individualized treatment planning to mitigate complication risks.
Annual Meeting Podium AM Podium #31
Healing the Humeral Shaft Nonunion: Prior Surgery, not Initial Operative Management, Confers Increased Risk of Recalcitrant Nonunion
Erika Roddy, MD; Reza Firoozabadi, MD; Daphne Beingessner, MD; David P Barei, MD, FRCSC
Purpose: Our objective was to determine the rate of successful nonunion repair for patients in whom initial attempted nonunion repair failed to unite after initial nonoperative treatment of a humeral shaft fracture compared to patients with initial surgical treatment of a humeral shaft fracture complicated by nonunion.
Methods: This was a retrospective cohort study at a Level I academic trauma center including all skeletally mature patients undergoing nonunion repair of a humeral shaft fracture between 2005 and 2023. The primary outcome was successful radiographic bony union after nonunion repair.
Results: The final cohort included 159 patients. Of the 79 patients who underwent primary nonunion repair after initial nonoperative treatment, a recalcitrant nonunion developed in two patients (3%). For patients with any prior surgical treatment (prior acute surgical fixation or prior nonunion repair after failed nonoperative management), a recalcitrant nonunion developed in 17 (21%, p<0.001). No demographic factors were associated with development of a recalcitrant nonunion. Among injury factors, atrophic or oligotrophic nonunion was associated with increased risk of recalcitrant nonunion (p = 0.044). The number of prior operations on the arm was significantly associated with a risk of recalcitrant nonunion (p = 0.004). The amount of fracture comminution, initial implant choice (plate versus nail), and type of and use of autograft or allograft were not associated with a risk of recalcitrant union. Among patients with a history of prior surgical treatment, initial treatment method (operative vs nonoperative) was not associated with risk of recalcitrant union (22% vs 17%).
Conclusion: The first attempt at nonunion repair after failed nonoperative treatment of a humeral shaft fracture has a high (97%) rate of success. However, subsequent nonunion repair for recalcitrant nonunion has a 17% failure rate, similar to the failure rate of nonunion repair after failed initial surgical management (22%). Thus, patients undergoing nonunion repair after any prior surgical treatment of a humeral shaft fracture have a one in five rate of recalcitrant nonunion. Patients with hypertrophic nonunion may be at decreased risk of recalcitrant nonunion compared to those with atrophic or oligotrophic nonunion.
Annual Meeting Podium AM Podium #32
Comparison of Bracing With Coaptation Splinting for the Initial Treatment of Acute Humeral Shaft Fractures: The COBRAS Trial
Jack Gagne, MD; Matthew T Kingery, MD; Nirmal C Tejwani, MD, FRCS; Kenneth A Egol, MD
Purpose: The optimal method for initial immobilization of acute humeral shaft fractures remains undefined. This study aimed to compare the efficacy of coaptation splinting versus Sarmiento bracing in optimizing patient comfort, pain control, and functional recovery during the first 2 weeks of nonoperative management. We hypothesized that immediate functional bracing would result in lower pain scores and improved early patient-reported outcomes compared to coaptation splinting.
Methods: A multicenter randomized controlled trial was conducted within one academic institution. Patients with isolated humeral shaft fractures (OTA 12-B) were randomized to either closed reduction and coaptation splinting or immediate Sarmiento bracing in the emergency department. Daily visual analogue scale (VAS) pain scores were collected by phone from day 1 to 10 post-injury, and again on day 14. Secondary outcomes included narcotic pain medication intake, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, degree of angulation on radiographs, and a final patient satisfaction rating on a scale from 0 to 10. Statistical comparisons between groups were performed using t-tests for continuous variables and χ2 tests for categorical variables.
Results: In total, 46 patients were enrolled, 23 in each group. Pain scores did not differ significantly between groups at any post-injury timepoint (p>0.05). PROMIS scores were also similar, with pre-injury values of 89.4 (splint) and 97.1 (brace) and no significant differences at day 7 (51.1 vs 54.8) or day 14 (55.6 vs 58.8; p>0.05). Narcotic pain medication requirements were comparable between groups (p>0.05). There were no significant differences in the change in coronal angulation (12.79° ± 14.79° vs 11.72° ± 9.21°; p = 0.830) or sagittal angulation (7.32° ± 6.76° vs 4.67° ± 3.25°; p = 0.237) from the initial postreduction radiograph to the 1-week post-injury radiograph, indicating comparable maintenance of reduction between groups. Final patient satisfaction rating was 5.6 ± 2.8 in the splint group and 5.9 ± 3.0 in the brace group (p = 0.795).
Conclusion: Both immobilization protocols provided equivalent pain control, early functional outcomes, maintenance of reduction, and patient satisfaction within the first 2 weeks following acute humeral shaft fracture.
Annual Meeting Podium AM Podium #33
Hemiarthroplasty Versus Nonoperative Treatment of Comminuted Proximal Humeral Fractures: Results of the ProCon Multicenter Randomized Controlled Trial
Dennis Den Hartog, MD, PHD; Leendert HT Nugteren, BSc; Kiran C Mahabier, MD PhD; Aron JM de Zwart, Bsc; Stella CM Heemskerk, PhD; Stefaan J Nijs, MD PhD; Michael Verhofstad, MD, PhD, FIOTA; Niels WL Schep, MD PhD; Esther MM Van Lieshout, PhD MSc; ProCon trial investigators
Purpose: The best treatment of comminuted proximal humeral fractures in the elderly population is an unresolved clinical problem. This study aimed to compare the outcome and costs of hemiarthroplasty (HA) and nonoperative treatment in elderly patients with a comminuted proximal humeral fracture.
Methods: From October 2009 to April 2017, 57 elderly patients with a comminuted proximal humeral fracture were enrolled in the multicenter randomized controlled trial (RCT). Patients were randomized to HA or nonoperative treatment. Outcome measures were the Constant-Murley score (primary outcome), Disabilities of the Arm, Shoulder, and Hand (DASH), pain (Visual Analog Scale), quality of life (Short Form-36 and EuroQoL-5D-3L), complications, revision operations, healthcare consumption, and costs. Patients were followed for 2 years.
Results: Of the 57 patients included, 30 underwent treatment with HA and 27 were treated nonoperatively (median age: 77 years, female: 89%). According to the Hertel classification, most fractures were type 7 (47%) or type 12 (42%). The median Constant-Murley score increased from 23 (95% CI: 17–29) at 6 weeks to 48 (95% CI: 41–53) at 24 months in the HA group and from 24 (95% CI: 17–31) at 6 weeks to 59 (95% CI: 52–65) at 24 months in the nonoperative group. Throughout follow up, scores were similar in both groups. The DASH score consistently decreased over time in both groups. At 24 months, median DASH scores were 24.0 (95% CI: 17.4–30.8) in the HA group and 23.4 (95% CI: 16.5–30.4) in the nonoperative group. Pain levels, SF-36, and EQ-5D were similar in both groups throughout follow up. One or more complications developed in 11 patients, seven in the HA group; six patients required surgical interventions. Total costs were €20,000 higher for HA, although not statistically significant. Costs for primary treatment and follow up were €1,300 and €1,422 in the nonoperative group respectively, and €11,062 and €1,367 in the HA group.
Conclusion: Based on results of this RCT, primary hemiarthroplasty cannot be considered superior to nonoperative treatment for comminuted proximal humeral fractures in the elderly population.
Annual Meeting Podium AM Podium #34
Immediate Mobilization Following Volar Locked Plating for Distal Radius Fractures is Safe and Effective
Jadie E De Tolla, MD; Samara Moll, BA; Janos Barrera, MD; Utkarsh Anil, MD; Louis W Catalano, MD; Philipp Leucht, MD; Kenneth A Egol, MD; Jacques Hacquebord, MD
Purpose: This study evaluates whether immediate mobilization with a home therapy program leads to improved early functional outcomes compared to immobilization with formal therapy following volar locked plating (VLP) for distal radius fractures (DRF).
Methods: In total, 240 patients were enrolled in this prospective, randomized cohort study. Patients older than age 18 years with isolated displaced DRFs requiring surgical fixation were included. Patients with open fractures, ipsilateral injuries, and supplemental fixation were excluded. All fractures were classified based on the AO/OTA system. Participants were randomized to immediate mobilization (no splint) with a home therapy program or immobilization (splint) with formal therapy prior to surgery. Outcomes included VAS pain, QuickDASH, grip strength, range of motion (ROM), and complication rates at multiple follow ups (2 weeks, 6 weeks, 3 months, and 6 months). Analysis included Wilcoxon rank sum and Fisher’s exact tests. Multivariable regression identified independent predictors of patient reported outcome measures (PROM).
Results: In all, 185 patients completed all follow ups and had complete data for analysis; 87 patients were randomized to the no-splint group and 98 patients were randomized to the splint group. There were no significant differences in demographics between the two groups (mean age: 54 years [no-splint group]; 57 years [splint group]). The no-splint group had better QuickDASH scores (35 vs 42, p = 0.02) and grip strength (16.6 vs 9.6 kg, p = 0.002) at 6 weeks. Wrist ROM was initially better in the immediate mobilization group but showed no significant differences at final follow up (p>0.05). No significant differences in loss of fixation or reduction were observed at any time point between the groups. Multivariable regression identified increased AO/OTA fracture severity (p = 0.02) and ulnar styloid base fracture (p = 0.02) as predictors of poorer functional outcomes. Splinting was associated with higher VAS pain scores at 6 months (p = 0.018).
Conclusion: Early mobilization without formal therapy after VLP does not increase the risk of fixation loss or fracture misalignment and improves early and midterm functional outcomes. These findings suggest that immediate mobilization is a safe and effective option for patients seeking a quicker return to activity.
Annual Meeting Podium AM Podium #35
Bier Block Regional Anesthesia Versus Hematoma Block for Closed Distal Radius Reduction: A Randomized Controlled Trial
Lucas S Marchand, MD; Megan Leigh Campbell, MD; Allan Metz, MD; Kayla Gates, MD; Thomas F Higgins, MD; David L Rothberg, MD; Justin Haller, MD
Purpose: Intravenous regional anesthesia (Bier block [BB]) is a frequently used method of emergency department analgesia but has elicited some concerns over potential significant complications, largely related to the fear of systemic reactions of lidocaine, including neurologic and cardiac toxicity. For this reason, local injection of analgesic into the fracture site (hematoma block [HB]) is often performed but may not provide satisfactory pain control during fracture manipulation. The objective of this study was to evaluate the effectiveness of HB compared to BB during closed reduction of distal radius fractures.
Methods: This was a prospective randomized controlled trial comparing HB to BB in parallel treatment arms executed over a 2-year treatment period (2022–2024). Skeletally mature patients with closed distal radius fractures in the emergency department were included in the study. The primary outcome of interest was Visual Analog Scores (VAS) for pain prior to fracture manipulation, during fracture manipulation, and 30 minutes following manipulation. Secondary outcomes of interest included safety profile and reduction quality. A preplanned interim analysis occurred at 50% enrollment.
Results: In total, 58 patients were enrolled in the study at the time of interim analysis with 31 BB and 27 HB patients. There were more smokers in the BB cohort (p = 0.001), but otherwise demographic and injury data were similar between groups. The two groups had similar initial average VAS pain scores (HB: 5.6 vs BB: 6.6, p = 0.35). The BB group demonstrated less average pain during fracture manipulation compared to the HB group (BB: 1.4 vs HB: 5.1, p<0.001) as well as post-procedure (BB: 2.4 vs HB: 3.8, p<0.001). There were two minor and no major complications noted in each cohort.
Conclusion: This study demonstrated that BB anesthesia is a safe means of providing emergency department analgesia when performing manual closed reduction of distal radius fractures. BB resulted in less pain both during and after fracture manipulation. This trial was stopped early based on the results of the planned interim analysis showing clear superiority and safety of the BB.
Annual Meeting Podium AM Podium #36
Internal vs External Fixation of the Anterior Ring in Unstable Pelvic Fractures Was Associated With Discharge to Home
Joseph Thomas Patterson, MD; Ian G Hasegawa, MD FAAOS; Brandan Sakka, MD; Andrew P Collins, MD; Soroush Shabani, BS; Andrew M Duong, BS; Li Ding, MD MPH; Monica D Wong, MS; Reza Firoozabadi, MD MS FAAOS; Joshua L Gary, MD FAAOS
Purpose: The purpose of this study was to determine if anterior internal fixation versus external fixation combined with posterior internal fixation of unstable pelvic fractures is associated with frequency of discharge to home.
Methods: A retrospective cohort study was conducted at two Level I trauma centers and one academic tertiary referral center. Patients aged ≥16 years with unstable OTA/AO 61B/C pelvic fractures were treated with surgical fixation of the anterior and posterior pelvic ring by three fellowship-trained orthopaedic trauma surgeons from October 2020 to November 2022. The primary outcome was the adjusted odds of discharge to home assessed by multivariable logistic regression analysis with AIC optimization considering age, BMI, sex, public insurance, polytrauma (ISS>15), severe head injury (AIS head ≥4), volume-expanding pelvic ring injury, upper and lower extremity weightbearing status, medical comorbidities, and days from injury to surgery. Secondary outcomes included ICU days, ventilator days, hospital length of stay, and hospital charges.
Results: The study included 122 patients of which 39% were female with a mean age of 45.7 ± 18.8 years and a mean ISS of 26.4 ± 12.8. Seventy-nine patients (65%) treated with internal fixation presented with higher Glasgow Coma Scale scores (13.5 ± 3.6 vs 10.5 ± 5.4, p<0.01) and lower prevalence of severe head injury (5.6% vs 2.43%, p<0.01) than patients treated with external fixation, but were otherwise similar. On multivariable analysis, patients treated with internal fixation more frequently discharged to home (53.2% vs 27.9%, odds ratio 3.39, 95% confidence interval 1.25–9.84, p = 0.0193). Patients treated with anterior internal fixation also experienced fewer mean ICU days (6.0 ± 8.8 vs 9.8 ± 16.3, p = 0.0213), ventilator days (3.5 ± 8.2 vs 6.9 ± 15.9, p<0.0081), and hospital days (18.7 ± 16.2 vs 31.2 ± 26.7, p<0.01); and incurred fewer hospital charges ($278,563.29 ± $261,602.35 vs $580,625.98 ± $503,067.98, p<0.01).
Conclusion: Patients who received anterior and posterior internal fixation of their unstable pelvic fractures were more likely to discharge to home than patients treated with anterior external fixation and posterior internal fixation. Anterior internal fixation was also associated with fewer ICU, ventilator, and hospital days, as well as fewer hospital charges.
Annual Meeting Podium AM Podium #37
Is There a Gold Standard for Addressing the Anterior Ring in Surgical Fixation of Young-Burgess Lateral Compression Type 1 (LC1; AO/OTA 61-B1/B2) Pelvic Ring Injuries?
Wayne Hoskins, PhD, FRACS; Charles Gusho, MD; Daniel Allen Bravin, MD; Brett Duane Crist, MD; Joshua Neill Milby, DO; Gregory J Della Rocca, MD, PhD; Kyle Schweser, MD; James P Stannard, MD; Jaime Lyn Bellamy, DO; Rown Parola, MD; Douglas Haase, MD
Purpose: The purpose of this study was to determine if there is a difference in the rate of pelvic ring deformity greater than 1 cm (1) with anterior ring fixation, (2) between indirect (external-fixator or InFix) or internal fixation, and (3) between long and short percutaneous screws in patients receiving surgical fixation of LC1 pelvic ring injuries with posterior ring stabilization.
Methods: Data from two Level I trauma centers identified all LC1 pelvic ring injuries managed surgically from January 2019 through January 2024. Indications for surgical management were radiographic instability or a failed trial of mobilization. Exclusion criteria were nonacute presentations, pathologic fractures, nonunions, and surgical cases without posterior ring fixation. Follow up until confirmation of radiographic healing was required. Medical records, radiographs, and operative reports were reviewed. Information recorded included if anterior ring fixation was applied, whether fixation was indirect (external fixator or InFix) or internal (percutaneous screws or plates applied through open reduction). For percutaneous screws, it was noted if they were applied antegrade or retrograde, and lengths were defined as long (bicortical or juxtacortical finishing) or short (all other screws). The primary outcome measure was the presence of pelvic ring deformity greater than 1 cm from immediate postoperative radiographs to final radiographs showing fracture healing. Fixation type cohorts were compared using χ2 tests.
Results: In total, 120 LC1 injuries were included. Most patients were female (n = 69; 58%) and mean age was 63.9 ± 18.6 years. Despite increased fracture comminution (48% vs 26%, p =0.034) and unstable longitudinal fracture patterns (p = 0.034), anterior ring fixation correlated with lower rates of pelvic ring deformity compared with no fixation (20% vs 41%, p = 0.016). Anterior ring indirect fixation had a higher rate of deformity relative to internal fixation (53% vs 13%, p<0.001). Long percutaneous screws were most often applied antegrade (p = 0.014), and associated with a decreased deformity rate compared with short percutaneous screws (4% vs 32%, p = 0.004).
Conclusion: Anterior ring fixation with long percutaneous screws decreases the risk of postoperative displacement in LC1 pelvic ring injuries with posterior fixation.
Annual Meeting Podium AM Podium #38
A Comparison of Anterior Ring Fixation Constructs in Young-Burgess Lateral Compression Type 2 and 3 (LC2, LC3; AO/OTA 61-B2/B3) Pelvic Ring Injuries: Does Fixation Matter?
Wayne Hoskins, PhD, FRACS; Charles Gusho, MD; Douglas Haase, MD; Joshua Neill Milby, DO; Brett Duane Crist, MD; Gregory J Della Rocca, MD, PhD; Kyle Schweser, MD; James P Stannard, MD; Rown Parola, MD; Daniel Allen Bravin, MD
Purpose: The purpose of this review was to compare outcomes of lateral compression (LC) LC2 and LC3 (AO/OTA 61-B2/B3) pelvic ring injuries when posterior ring fixation is applied and different anterior ring constructs are used.
Methods: All LC2 and LC3 (AO/OTA 61-B2/B3) pelvic ring injuries treated surgically from January 2019 through January 2024 at two academic Level I trauma centers were retrospectively reviewed. Comparisons of anterior ring constructs were made, including no fixation versus fixation, indirect fixation (external fixators and InFix) versus internal fixation, and long versus short percutaneous screws. Long percutaneous screws were defined as either bicortical bypassing all 3 Nakatani zones or bypassing the fracture by 2 Nakatani zones with intramedullary juxtacortical or bicortical finishing. A short screw was defined as all other screws, regardless of direction. Primary outcome measure was greater than 1 cm of pelvic ring displacement from postoperative to final radiographs showing fracture healing with sufficient callus. Secondary outcomes were unplanned major reoperation, removal of implants or nonunion repair, and other surgical complications.
Results: 67 patients were included for analysis. Most were female (n = 35, 52%), mean age was 48.3 ± 21.7 years, and most injuries were LC3 (n = 39, 58%). All cases had posterior ring fixation. Relative to the 55 patients (82%) with anterior ring fixation, the 12 (18%) with no anterior ring fixation had significantly higher rates of pelvic ring deformity develop (58% vs 16%, p = 0.005). Indirect fixation (n = 12, 18%) had a significantly higher rate of deformity compared with internal fixation (n = 43, 64%; 50% vs 7%, p = 0.002). There was a significantly higher rate of deformity when a short percutaneous screw (n = 6, 9%) rather than a long screw was used (n = 26, 39%; 50% vs 0%, p = 0.004).
Conclusion: Routine anterior ring fixation in conjunction with posterior ring fixation is strongly encouraged for LC2 and LC3 injuries. A long percutaneously applied anterior screw provides optimal stability to maintain reduction and prevent deformity.
Annual Meeting Podium AM Podium #39
Postoperative Radiation Does Not Decrease Risk of Heterotopic Ossification After Acetabulum Fracture Fixation
Jeremy Michael Adelstein, MD; Andrew J Moyal, MD; Robert J Burkhart, MD; Logan M Good, MD; Nicholas M Romeo, DO; Joshua K Napora, MD
Purpose: This study aims to evaluate the effectiveness of postoperative radiation for heterotopic ossification (HO) prophylaxis after acetabular fracture fixation.
Methods: A retrospective analysis was performed using TriNetX, an aggregated, de-identified database. Patients who underwent open reduction and internal fixation (ORIF) for acetabulum fractures were identified via CPT codes. Cohorts were then created for those patients with radiation within 72 hours postoperatively and those without. Subgroups were created based on ORIF CPT codes 27226 (wall), 27227 (one column/transverse), and 27228 (associated). Patients with neoplasms and those who received indomethacin were excluded from analysis. Each radiation subgroup was propensity matched (1:1) to their nonradiation counterpart based on demographic and medical comorbidity factors. Rates of HO formation were then assessed, as well as wound dehiscence, surgical site infection (SSI), hip instability, and conversion to total hip arthroplasty (THA) at 90 days, 2 years, and 5 years.
Results: In total, 11,872 patients were identified for inclusion, 1719 with radiation and 10,153 without. Mean age at index surgery for all acetabulum fractures was 38.5 ± 14.2 years. After a propensity match, there were no differences in demographic or medical comorbidities (p>0.05). For associated and wall fractures, the radiation group had a higher risk of HO formation at 90 days, 2 years, and 5 years (p<0.05). For one column/transverse fractures, there was no significant difference in HO formation at any time point (p>0.05). For the associated cohort, the radiation group was found to have a significantly higher risk of hip instability at 90 days (4.83% vs 1.98%, p = 0.017), 2 years (6.17% vs 1.98%, p = 0.001), and 5 years (6.70% vs 1.98%, p = 0.0004). Additionally, conversion to THA at 5 years was higher in those in the associated cohort who underwent radiation compared to their nonradiation counterparts (7.23% vs 4.40%, p = 0.023). No differences were found in the other secondary outcomes (p>0.05).
Conclusion: This study suggests that postoperative radiation for HO prophylaxis does not correlate with lower risk of HO formation. In fact, it may be associated with adverse outcomes such as hip instability and conversion to THA in associated acetabulum fractures. Future prospective studies are required to confirm these results.
Annual Meeting Podium AM Podium #40
Do the Odds of Developing Deformity in Lateral Compression Type 1 (LC1; AO/OTA 61-B1/B2) Pelvic Ring Injuries Differ With Operative Versus Non-Operative Management When Accounting for Stability and Fixation Strategy?
Wayne Hoskins, PhD, FRACS; Rown Parola, MD; Daniel Allen Bravin, MD; Joshua Neill Milby, DO; Brett Duane Crist, MD; Gregory J Della Rocca, MD, PhD; Kyle Schweser, MD; Charles Gusho, MD; Jaime Lyn Bellamy, DO; James P Stannard, MD; Douglas Haase, MD
Purpose: Outcomes for Young-Burgess lateral compression type 1 (LC1) pelvic ring injuries (AO/OTA 61–B1/B2) may differ based on fracture patterns, stability, and the surgical fixation methods. This study assessed correlates of developing fracture displacement after controlling for displacement risk score in operative and nonoperative management with sub-analysis of surgical constructs.
Methods: Data from two Level I trauma centers identified all acute LC1 injuries presenting within 3 weeks of injury from January 2019 to January 2024 with follow up until radiographic healing. The previously determined displacement risk score based on fracture pattern was calculated for each. Included LC1 injuries were divided into operative and nonoperative management and then stratified by postoperative displacement, and by treatment cohort: nonoperative, non–gold standard operative and gold standard operative. Gold standard operative management was defined as posterior ring fixation with a percutaneous anterior long screw that had either bicortical finishing or juxtacortical finishing if bypassing the fracture by 2 Nakatani zones. All other constructs with posterior ring fixation were considered non–gold standard. Logistic regression identified correlates of deformity development.
Results: The study included 333 LC1 injuries, with 214 (64.3%) managed nonoperatively and 119 (32.7%) operatively. Among surgical cases, 50 (42.0%) had gold standard fixation and 69 (58.0%) had non–gold standard consisting of posterior fixation with no anterior fixation (n = 33), short percutaneous screw (n = 21), INFIX (n = 13) or external fixation (n = 2). Of the 333 cases, deformity developed in 108 (32.4%). Bivariate regression demonstrated correlation between deformity development and risk score (OR = 1.67, 95% CI: 1.46–1.92, p<0.001). Multivariate regression controlling for risk score demonstrated continued correlation with risk score (OR = 2.03, 95% CI: 1.72–2.44, p<0.001) and 98% decreased displacement odds relative to nonoperative management with gold standard fixation (OR = 0.02, 95% CI: 0.00–0.06, p<0.001), but no significant correlation with non–gold standard fixation when evaluated as a combined group (OR = 0.67, 95% CI: 0.33–1.32, p = 0.259) or among individual construct strategy.
Conclusion: Posterior fixation of LC1 injuries with a long percutaneous anterior screw reduces fracture displacement odds relative to nonoperative management. All other fixation constructs do not reduce the odds of displacement.
Annual Meeting Podium AM Podium #41
How Important Is Fracture Stability in ‘Fix and Replace’ for Acute Acetabular Fractures? A Comparison of Outcomes in an International Multicenter Study
Wayne Hoskins, PhD, FRACS, MBBS (Hons); Charles Gusho, MD; Daniel Allen Bravin, MD; Brett Duane Crist, MD; Joshua Neill Milby, DO; Jaime Lyn Bellamy, DO; Kyle Schweser, MD; Lindsey Bravin, MD; Douglas Haase, MD; Gregory J Della Rocca, PhD, MBA; Rown Parola, MD; James P Stannard, MD; Mark Rickman, FRCS
Purpose: Combined fixation and total hip arthroplasty (THA)—"fix and replace"—for acute acetabular fracture is increasing, but failure rates can be considerable. This study compared outcomes when fracture stability is achieved with acetabular trauma fixation principles prior to THA versus when they are not.
Methods: Data from four tertiary centers identified all acute acetabular (OTA/AO 62A/B/C) fractures involving one or more columns, managed with THA within 3 weeks of injury and 1-year minimum follow up. Medical records, radiographs, and operative reports were reviewed to abstract patient demographics, fracture classification, reduction and fixation, implants used, and outcomes. It was noted if fractures were reduced and rigidly fixed using acetabular trauma fixation principles before THA versus when limited or no fixation was applied, with or without fracture reduction. The primary outcome measure was revision or reoperation procedure. Secondary outcomes were acetabular component loosening, migration, dislocation, and infection.
Results: 100 patients were identified, with 85 meeting inclusion criteria; 29 (34.1%) had acetabular trauma fixation principles applied and 56 (65.9%) did not. Groups were matched for patient ASA Score and body mass index, but the acetabular trauma fixation principles group had more males (72% vs 50%, p = 0.047), a mean younger age (standard [SD]) 66.4 ± 11.8 years vs 73.0 ± 11.5 years, p = 0.019), fewer fractures involving the anterior column (p = 0.002), and less follow up (mean 632 days versus 1478 days, p<0.001) than those without acetabular trauma fixation principles. There was a lower revision and reoperation rate in the group with acetabular trauma fixation principles (3.4% vs 23.2%, p = 0.028), less acetabular component loosening (0 vs 17.9%, p = 0.026) and migration (7.0% vs 32.1%, p = 0.011) compared to the group without acetabular fixation principles, with no difference in dislocation (p = 0.4) or infection (p = 0.3).
Conclusion: When appropriate acetabular column reduction and fixation is not performed using trauma fixation principles, there is an unacceptably high arthroplasty failure rate following a fix and replace strategy for acute acetabular fractures.
Annual Meeting Podium AM Podium #42
Revisiting Instability in Lateral Compression Pelvic Ring Injuries: Predictors for Surgical Fixation
Sarah Wegman, B.S. ; Hashim Shaikh, M.D. ; Sameer Jain, B.A. ; James David Brodell, M.D. ; John P Ketz, MD; Varun D. Puvanesarajah, M.D. ; Noah Michael Joseph, MD
Purpose: There has been significant controversy in the literature surrounding the significance of lumbar spine transverse process (LSTP) fractures in the context of concomitant injuries of the pelvic ring. We hypothesized that LSTP fractures are a harbinger of instability in patients with concomitant pelvic ring injuries.
Methods: This study was approved by our Institutional Review Board. Patients with pelvic ring injuries were identified using CPT codes. Inclusion criteria were patients age 18 years and older with pelvic ring injuries who had complete CT scans of the pelvis and lumbar spine. Demographic characteristics, Young-Burgess classification, and the status of all LSTPs were recorded. Exclusion criteria were patients with anomalous lumbosacral anatomy, pelvic ring–acetabulum combination injuries, and history of previous lumbosacral spine procedures. Unstable injuries included those with greater than 5 mm displacement of the sacroiliac joint or sacrum, complete comminuted sacral fractures, and indeterminate injuries that had a positive stress examination under anesthesia.
Results: In total, 406 patients were included, with 253 patients with unstable and 153 with stable pelvic ring injuries. Of these, 173 (42.6%) patients had LSTP fractures. There was a significant association with LSTP fractures and pelvic ring injury instability (p<0.001) and a significant association with increasing quantity of LSTP fractures and pelvic ring instability (p<0.001), a finding supported by univariate regression analysis (OR: 7.70, 95% CI: 4.66–12.75, p<0.001). When considering the subgroup of lateral compression (LC) type I injuries, there was a significant association with LSTP fractures and LC I injury instability, as well as a significant association with increasing quantity of LSTP fractures (p<0.001). Univariate regression analysis with the subgroup of patients with LC I injuries demonstrated a significant relationship between LSTP fracture quantity and instability (OR: 2.33, CI: 1.69–3.21, p<0.001).
Conclusion: A positive association was identified between LSTP fractures and pelvic ring instability, including when assessing a subgroup of LC I injury patterns. The presence of multiple transverse process fractures was a sign of pelvic ring instability. This study provides a radiographic marker of pelvic ring instability, even among patients with LC I pelvic ring injuries.
Annual Meeting Podium AM Podium #43
Outcomes of Operative Versus Nonoperative Treatment of Geriatric Pelvic Ring Injuries
Carol Lee, MD; Andy Liu, BS; Lauren Turner, BS; Carol Alice Lin, MA, MD
Purpose: The prevalence of low-energy geriatric pelvic ring injuries is increasing, but controversy exists regarding the indications for operative management. This study aims to assess outcomes between operative and nonoperative management of geriatric pelvic ring injuries.
Methods: A PearlDiver database review analyzed isolated pelvic ring injuries in patients older than age 60 years presenting to the hospital from 2016 to 2022. Exclusion criteria were patients with additional lower extremity injuries. Patients were grouped into three cohorts: early operative (E-O; surgery within 3 days), delayed operative (D-O; surgery between 3 days and 3 weeks), and nonoperative (N-O). Primary outcomes included length of stay (LOS), readmission rates, opiate prescriptions (within 1 month and after 1 month), total costs, and disposition to a skilled nursing facility (SNF).
Results: A total of 321,305 patients met the inclusion criteria. The E-O, D-O, and N-O cohorts comprised 716, 406, and 320,183 patients, respectively. D-O patients had the longest hospital stay (9.6 days), followed by E-O patients (8.4 days); N-O patients had the shortest stay (8.1 days). Readmission rates were significantly higher in the D-O group (23.2%) compared to the E-O (13.4%) and N-O (8.4%) groups (p<0.0001). There were no significant differences in opiate use within 1 month (p = 0.32) or after 1 month (p = 0.30) across cohorts. Total costs were highest in the D-O group ($23,413.80) compared to E-O ($16,884.99) and N-O ($11,213.90) groups (p = 0.0003 for E-O vs D-O; p<0.0001 for E-O vs N-O and D-O vs N-O). Discharge to an SNF occurred in 26.4% of D-O patients compared to 22.2% of E-O patients and 19.8% of N-O patients, but this difference was only significant when comparing D-O and N-O cohorts (p = 0.0009).
Conclusion: D-O patients experienced the longest hospital stays, highest readmission rates, greatest total costs, and highest discharge to SNFs, compared to both E-O and N-O patients. Interestingly, there were no significant differences in postoperative opiate use between operative and nonoperative groups. These findings suggest that delayed operative management may be associated with worse outcomes, but further clinical studies are needed to better understand the potential advantages of percutaneous fixation for pelvic ring injuries in elderly patients.
Annual Meeting Podium AM Podium #44
Complications Following Total Hip Arthroplasty in Patients with Acetabular Fracture versus Primary Osteoarthritis: A Retrospective Cohort Analysis
Alexander N Berk, MD; Cyrus F Eghtedari, BS; Logan M Good, MD; Robert J. Burkhart, MD; Samuel A Florentino, MD; Harkirat Jawanda, MD; George Ochenjele, MD; Robert Wetzel, MD; Joshua Kyle Napora, MD
Purpose: Total hip arthroplasty (THA) following acetabular fracture provides benefits including immediate weightbearing and accelerated rehabilitation; however, it involves a technically complex procedure with potentially high complication rates. This study aimed to evaluate the frequency of complications in patients undergoing THA after an acetabular fracture.
Methods: The TriNetX database was queried to identify patients age 18 and older who underwent THA between 2004 and 2024 following an acetabular fracture. The control cohort consisted of patients who underwent THA for primary osteoarthritis (OA). Complications were analyzed during both the immediate (7-day, 14-day, and 30-day) and intermediate (90-day, 180-day, 1-year, and 2-year) postoperative periods. A multivariate model, adjusted for age, sex, and comorbidities, was used to further evaluate the risk of prosthetic dislocation, periprosthetic fracture, and revision THA.
Results: A total of 62,611 patients met all inclusion criteria. Among these, 359 underwent THA for an indication of acetabular fracture, and 62,252 underwent THA for primary OA. Prior to risk-adjusted analysis, the acetabular fracture group was older, more likely to be male, and had a higher burden of comorbidities compared to the OA group (p<0.05). On bivariate analysis, patients in the acetabular fracture group demonstrated a higher risk of deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), stroke, pneumonia, acute kidney injury (AKI), hematoma, acute blood loss anemia, acute respiratory distress syndrome (ARDS), sepsis, deep infection/periprosthetic joint infection (PJI), rehospitalization, death, prosthetic hip dislocation, revision THA, and periprosthetic dislocation in the immediate and intermediate postoperative periods (p<0.05). Additionally, surgical site infections (SSI) and emergency department visits were more frequent in the intermediate period, while urinary tract infections (UTI) were more common in the immediate period (p<0.05). After multivariate analysis, the risk of prosthetic hip dislocation (HR, 95% CI: 6.15 [3.65–10.36], p<0.001), periprosthetic fracture (HR, 95% CI: 2.67 [1.19–6.00], p = 0.017), and revision THA (HR, 95% CI: 2.61 [1.44–4.75], p = 0.002) remained greater at 2 years among the acetabular fracture group.
Conclusion: Patients undergoing THA after an acetabular fracture experience higher rates of complications, including prosthetic hip dislocation, periprosthetic fracture, and revision THA, compared to those undergoing THA for primary OA.
Annual Meeting Podium AM Podium #45
Does the Sinus Tarsi Approach for Calcaneal Fractures Really Confer any Infection Protection?
Sarah Blumenthal, MD; Christina Stennett, PhD; Nathan O'Hara, PhD, MHA; Lisa Reider, PhD; Anthony R. Carlini, MS; Renan Castillo, MS; John Wesley Munz, MD; Robert V. O'Toole, MD; Joshua Layne Gary, MD; METRC
Purpose: The optimal surgical approach for calcaneal fracture fixation remains uncertain, particularly with regard to limiting complications. Our hypothesis was that the sinus tarsi approach has a lower infection rate than the extensile lateral approach for calcaneus fracture fixation after adjusting for known infection confounders.
Methods: This cohort study was a secondary analysis of prospective OXYGEN trial data collected from 29 United States trauma centers. We included adult patients with calcaneus fractures deemed at high risk for infection (fractures treated >3 days from injury or Gustilo-Anderson type I, II, and IIIA open fractures) and definitively treated with plates and screws using either the sinus tarsi or extensile lateral approach. The primary outcome was any surgical site infection within 365 days of definitive fixation. Secondary outcomes included deep infection requiring reoperation and superficial infection treated with antibiotics alone. The association of surgical approach with study outcomes was analyzed using logistic regression, adjusting for potential confounders including age, injury mechanism, injury severity score, and the number of days between injury and surgery.
Results: Of 214 included calcaneus fractures, 92 (43%) were treated using the sinus tarsi approach and 122 (57%) with the extensile lateral approach. Surgical site infections occurred in nine (10%) patients treated with the sinus tarsi approach and 15 (12%) patients treated with the extensile lateral approach (odds ratio [OR]: 1.04; 95% CI: 0.32–3.81; p = 0.94). Similarly, the surgical approach was not associated with the adjusted odds of deep infection (OR: 0.74; 95% CI: 0.18–2.59; p = 0.64) or superficial infection (OR: 1.95; 95% CI: 0.21–19.8; p = 0.54).
Conclusion: Surprisingly, this analysis of a prospectively collected cohort of high-risk calcaneal fractures treated with plate-and-screw constructs found that the odds of surgical site infection did not statistically differ with either the sinus tarsi or extensile lateral approach. This unexpected finding challenges current dogma and may be the result of higher quality prospective data and limiting selection bias with a more homogeneous group of patients with higher-risk fracture.
Annual Meeting Podium AM Podium #46
A Retrospective Review Comparing Unstable Ankle Fractures With (PMF) and Without (N-PMF) a Posterior Malleolus Fracture
Nicholas Roman Heinz, MBChB, MMedSci; Shawn Fredrick, Dr; Anish K Amin, Dr; Andrew David Duckworth, BSc, MSc, FRCSEd(Tr&Orth), PhD; Tim White, Dr
Purpose: The aim of this study was to evaluate the long-term clinical outcomes and complication rates of patients who had sustained an unstable ankle fracture with a posterior malleolus fracture (PMF) and those who had not (N-PMF).
Methods: Adult patients presenting to a single large academic trauma center from 2009 to 2012 with an unstable ankle fracture requiring surgery were identified. Data collected were patient demographics, fracture classification, and clinical outcomes. The primary outcome was any complication leading to further surgery as a result of infection, acute failure, or posttraumatic osteoarthritis (PTOA). A multivariate Cox Regression model was carried out in order to identify independent risk factors for development of PTOA.
Results: There were 675 patients in the study cohort (mean age: 48.5 years [range: 16–92 years]; female: 59% [n = 395/675]). Median follow up was 13 years (IQR: 12–14). Of the total cohort, 63.9% (n = 431/675) fractures had an associated PMF. Of those fractures with an associated PMF, 85% (n = 367/431) did not undergo fragment-specific fixation. There were no statistically significant differences between groups with regard to further surgery secondary to complication (N-PMF: 5.7% [n = 14/244] vs PMF: 7.5% [n = 32/431]; p = 0.403) or infection (N-PMF: 7.8% [n = 19/244] vs PMF: 8.4% [n = 36/431]; p = 0.796). PTOA was significantly more likely to develop in patients with a PMF (N-PMF: 27.0% [n = 66/244] vs PMF: 54.5% [n = 235/431]; p<0.001). However, only 1.2% (n = 3/244) of patients in the N-PMF group versus 3.0% (n = 13/431) in the PMF group required an ankle fusion (p = 0.190). Independent predictors for development of PTOA other than increasing age (p = 0.006) and Charlson Comorbidity Index (p = 0.016) were the presence of a medial malleolus fracture (p = 0.034) and complication requiring further surgery (p = 0.013).
Conclusion: In this large cohort of patients, a PMF did not increase the risk of further surgery secondary to a complication despite 85% of patients not undergoing fragment-specific fixation. Although patients with an associated PMF were twice as likely to acquire PTOA, this did not equate to an increased rate of late intervention in terms of ankle fusion, which was overall very low (3.0%).
Annual Meeting Podium AM Podium #47
Local Multimodal Injection vs. Regional Nerve Block for Rotational Ankle Fracture: A Randomized Clinical Trial
Justin Haller, MD; Makoa Mau, BS; Derek Keeney, BS; Morgan Dauk, BS; David L Rothberg, MD; Thomas F Higgins, MD; Lucas S Marchand, MD
Purpose: The purpose of this randomized clinical trial was to evaluate the effectiveness of controlling pain, limiting complications, and maintaining functional outcomes with local multimodal injection as compared to regional block in patients with rotational ankle fracture.
Methods: Patients with acute, isolated, closed rotational ankle fracture presenting to a Level I trauma center between 2021 and 2024 were prospectively enrolled. Patients were randomized 1:1 based on injury severity (single incision versus dual incision) to create equal distribution in treatment arms. Local multimodal injections included morphine (5 mg), epinephrine (500 mg), ketorolac (15 mg), and bupivacaine (20 mg). Regional blocks were performed postoperatively with standard single-shot anesthesia consisting of 0.25% bupivacaine with epinephrine. Automated REDCap queries obtained visual analog scales (VAS) scores preoperatively, postoperatively, and at 1, 2, 4, 8, and 24 hours postoperatively. Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), Foot and Ankle Ability Measure (FAAM), and postoperative complications were recorded during clinical follow up at 2, 6, 12, and 24 weeks. This study was designed as a non-inferiority trial, where the primary outcome was detecting a 1.5 point difference in VAS scores at 24 hours postoperatively between multimodal injection and regional block groups. To achieve 80% power and a = 0.05, 43 patients were needed per group.
Results: In total, 113 patients were randomized to the appropriate treatment (58 regional and 55 multimodal). There were no significant differences in patient demographics or fracture characteristics. There was no significant difference in VAS score between multimodal (4.0, 95% CI: 2.6–5.3) and regional block (3.3, 95% CI: 2.5–4.1) at 24 hours postoperatively (p = 0.4). There was no significant difference in VAS scores at any measured timepoint and no difference in narcotic usage. Regional block patients had significantly better PROMIS PF at 6 weeks (35 vs 29, p = 0.007) and 12 weeks (45 vs 41, p = 0.02) than multimodal injection patients. There was no difference in FAAM activities of daily living (ADL), FAAM sport, or complications between groups.
Conclusion: There was no significant difference in VAS scores for patients receiving local multimodal injection versus regional block for rotational ankle fracture. Regional block patients had improved PROMIS PF at 6 and 12 weeks, but this did not reach a clinically important difference. Local multimodal injections are a reasonable alternative to regional block for rotational ankle fractures.
Annual Meeting Podium AM Podium #48
Severe Frailty Predicts Four-Fold Increased Mortality After Ankle Fracture ORIF: Analysis of 14,400 Geriatric Patients
Rachit Saggar, MBBS; Warren Austin, BS; Joseph Mullen, BS; Abdulganeey Olawin, BS; Emily Nicole Lau, MD; Chukwudi Onyeukwu, MD; Gele Moloney, MD; MaCalus V. Hogan, MD, MBA; George V Russell, MD
Purpose: Our objective was to evaluate whether the Modified 5-Item Frailty Index (mFI-5) predicts adverse outcomes after open reduction and internal fixation (ORIF) in geriatric patients with ankle fractures and could guide operative versus nonoperative treatment decisions.
Methods: Using the ACS‑NSQIP database (2011–2023), we identified patients age 65 years and older who underwent ankle fracture ORIF (CPT codes 27766, 27769, 27792, 27814, 27822, 27823). Patients were stratified by mFI-5 (based on functional dependence, diabetes, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], hypertension) into non-frail (NF), mildly frail, moderately frail, and severely frail (SF) (see table). Multivariable logistic regression was used to analyze 30-day outcomes, adjusting for age, body mass index (BMI), sex, and ASA class.
Results: Of 60,625 ankle fractures, 14,400 geriatric patients met inclusion criteria: NF (28.7%), mildly frail (42.0%), moderately frail (23.6%), and SF (5.8%) (mean age: 73.7 ± 6.9 years; BMI: 30.15 ± 7.34 kg/m²; female: 72.3%). Overall complications increased from NF (4.0%) to SF (20.5%). Major complications rose from 0.5% (NF) to 3.9% (SF), readmissions from 1.7% (NF) to 9.8% (SF), and mortality from 0.3% (NF) to 4.1% (SF). Hospital length of stay (LOS) doubled (2.05 vs 4.61 days) and non‑home discharge quadrupled (8.3% vs 30.5%) in SF versus NF patients (all p<0.001).
Conclusion: mFI-5 effectively risk-stratifies geriatric ankle fractures, with severe frailty predicting significantly worse outcomes. Given the increase in complications and mortality, careful preoperative optimization and consideration of nonoperative management is warranted in SF patients.
Annual Meeting Podium AM Podium #49
Strain Manipulation: The Treatment of Fracture Nonunion Without the Use of Bone Graft
Alex Trompeter, Professor; Richard Navratil, MRCS; Saleem Jawaad, MRCS; Patrick Lancaster, MRCS
Purpose: Various noninvasive and biologic treatment modalities as well as bone graft have been suggested to manipulate the biologic environment of fracture nonunion. There is, however, no high-quality evidence that these additional interventions lead to higher union rates. A more recent concept, the bone healing and nonunion theory (BHN), puts strain and mechanical factors at the forefront of nonunion pathogenesis. We propose that bone graft is not required in the treatment of fracture nonunion unless a bone defect is present. We present a case series of 142 patients (the largest of its kind) treated for nonunion of various fracture sites with purely mechanical, strain environment modifying methods (strain manipulation), without the use of bone graft.
Methods: This was a retrospective review of cases in a Level I major trauma and tertiary referral center between 2014 and 2023. The primary objectives were pre- and postoperative radiographic union scale for tibia (RUST) score, union rate, and time to union.
Results: In this review, 221 cases were screened. After exclusions (loss to follow up, bone defects, insufficient data), 142 cases were identified and included. Most were long bone fracture nonunions—68 femurs, 49 tibias, and 11 humeri. Union was achieved in 129 patients after a single intervention, with a median postoperative RUST score of 11 (median preoperative RUST 6 at diagnosis) and median time to union of 6 months after intervention. More than one procedure was required in 12 patients (2 patients required more than two), and 11 patients did not achieve union (some died prior to union, others were lost to follow up). We achieved a union rate of 92% in an unselected case series of injuries that included major polytrauma, open fractures (25%), and infected nonunions (18%).
Conclusion: Our study demonstrates that high success rates of nonunion surgery can be achieved without the use of bone graft or any additional biologic treatments. This further supports the theory that the mechanical environment is critical for fracture union, and strain environment modifying interventions alone are sufficient to achieve union without the extra cost and potential morbidity of additional interventions.
Annual Meeting Podium AM Podium #50
Long Term Follow-up and Outcomes of a UK Trial of Osseointegrated Prosthesis for the Rehabilitation for Amputees: 1995–2025
Sophie Dupré, MD; Vijay Kolli, MD; Jonathan Lohn, MD; Alex Trompeter, MD
Purpose: Amputation of a limb impacts patients’ quality of life. ‘Osseointegrated’ prostheses are directly anchored to the skeleton and aim to avoid soft-tissue complications associated with conventional prostheses. We report on long-term outcome data for patients involved in the UK trial of the Osseointegrated Prosthesis for the Rehabilitation of Amputees (OPRA), previously published in 2018.
Methods: In total, 18 transfemoral amputees received unilateral implants between 1997 and 2008. Mean follow up of the group was 18.8 years (range 3–27.3 years).
Results: Seven implants have been removed and one more is awaiting removal, all for chronic deep infection (n = 8, 44%). In addition, one patient is awaiting implant removal, having reached the implant’s end of life because of frequent custom abutment changes. Superficial infections requiring antibiotics are common (n = 16, 89%), of which six patients have had more than 10 episodes. Sixteen patients have required surgery for abutment changes (89%); the mean number of changes is 4.3 (with a recorded maximum of 10 per patient). The Special Interest Group on Amputation Medicine (SIGAM) mobility grade has stayed the same or declined since preoperative assessment in 13 patients (n = 5, 28% and n = 8, 44%, respectively).
Conclusion: This longitudinal study demonstrates a significant burden of soft-tissue and implant complications in patients undergoing osseointegration for lower limb amputation. Ultimately, these complications limit implant survival and patients’ quality of life. The authors present a modern strategy for diagnosing implant-related infection, implant removal, and eradication of infection.
Annual Meeting Podium AM Podium #51
Incidence, Risk Factors, and Patient Reported Outcomes for Post-Traumatic Osteoarthritis in Non-Geriatric Distal Femur Fractures
Makoa Mau, BS; Tyler Thorne, MD; Ellie Sato, MD; Lucas S Marchand, MD; David L Rothberg, MD; Thomas F Higgins, MD; Justin Haller, MD
Purpose: Posttraumatic osteoarthritis (PTOA) is a debilitating condition with an undetermined incidence in non-geriatric distal femur fractures (DFF). The purpose of this paper is to describe the rate and risk factors of PTOA development in non-geriatric DFFs and to compare the clinical and patient-reported outcomes of patients with and without PTOA.
Methods: This is a retrospective review of patients age 60 years and younger with surgically treated DFF between January 2000 and January 2022 at a Level I academic trauma center. PTOA, demographics, osteoporosis or osteopenia diagnosis, concomitant lower limb fracture, mechanism of injury, open fracture, AO/OTA classification, preoperative functional status, postoperative articular step-off, Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF), pain interference (PI), and anxiety were recorded. Clinical and patient-reported outcomes were compared between patients with and without PTOA.
Results: In total, 118 patients were included (mean age: 42.0 years, [SD: 12.0]; median follow-up: 6.0 years [SD: 4.8]). PTOA developed in 51% (n = 60) of all DFF and in 57% of intra-articular fractures. Patients in whom PTOA developed had a significantly longer follow up (7.0 vs 4.9 years, p = 0.017), a greater average body mass index (BMI) (30.9 vs 27.3, p = 0.026), were more likely to have been injured during a vehicular accident (55.0% vs 27.6%, p = 0.011), and have an intraarticular fracture (68.7% vs 53.4%, p = 0.002). Patients with PTOA had significant differences between the implant used at index surgery (p = 0.013) and a significantly larger average articular step-off (0.82 mm vs 0.20 mm, p = 0.017). Conversion to total knee arthroplasty (TKA) occurred in 14.3% of patients with PTOA at an average of 4.6 years post injury.
Conclusion: PTOA develops in more than half of intraarticular distal femur fractures. Intraarticular extension and reduction of articular step-off are significant risk factors for development of PTOA. Many young patients with PTOA will not convert to TKA within 5 years of injury.
Annual Meeting Podium AM Podium #52
Muscle Pressure Trends in Patients With Extremity Fractures Indicate Compartment Syndrome Risk
Ross Kenneth Leighton, MD, FIOTA; Yasser Bouklouch, PharmD MPH; Justin Matta, Bsc MS; William T Obremskey, MD, MPH, FIOTA; Mitchell Bernstein, MD; Edward J Harvey, MD, FIOTA, FAAOS, FRCSC
Purpose: Acute compartment syndrome (ACS) is a serious condition resulting from increased intracompartmental pressure (ICP) within a closed muscle compartment. There is a lack of understanding of continuous pressure trends despite their being an accepted method for tracking disease. This study examined a prospective cohort of trauma patients with extremity fractures for which ICPs were tracked.
Methods: ICP pressures from 147 trauma patients with extremity fractures were gathered. Statistical and observational analyses were carried out to examine trends in patients with and without resultant ACS.
Results: Patients in whom ACS developed did not always have significantly higher absolute ICPs that exceed the theoretical critical 30 mmHg threshold for fasciotomy. Patients with ACS showed a consistent upward trend over time (average increase of 0.674 mmHg/hour). In contrast, non-ACS patients, even those who exceeded the previous postulated 30 mmHg threshold, exhibited a natural and gradual decline in ICP over time (average decline of 0.285 mmHg/hour) (see figure).
Conclusion: Continuous pressure data enable better clinical decision-making, reducing the risk of both unnecessary and delayed fasciotomies. This study emphasizes the need for integrating continuous pressure monitoring into standard practice to improve the management and outcomes of patients at risk for ACS.
Annual Meeting Podium AM Podium #53
Fracture Alignment and Union Affect PROMIS Scores following Tibial Shaft Fractures
Mir Ibrahim Sajid, MD; Stephen Doxey, DO; Urvi J. Patel, MD, MS; Melissa Holloway, MD; Lily Qian, BA, BSB; Noah Michael Joseph, MD; Brian Patrick Cunningham, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA
Purpose: PROM scores assess patients' perspectives on their functional status and well-being. This study aims to assess recovery in patients with tibial shaft fractures treated with intramedullary nailing (IMN) using NIH's Patient-Reported Outcome Measurement and Information System (PROMIS) scores and to evaluate any correlations with fracture alignment and union.
Methods: This is a multicenter retrospective review of prospectively collected data in patients with isolated tibial shaft fractures (OTA 41-3) treated with IMN at three Level I trauma centers between 2021 and 2023. PROMIS scores were collected at 6 weeks, 3 months, 6 months, and 1 year. Scores included global physical health (GPH), global mental health (GMH), physical function–computer-administered testing (PF-CAT), pain interference–computer-administered testing (PI-CAT), mobility-CAT, and depression-CAT. Patient and injury characteristics and quality of reduction (QoR) were collected. QoR was graded as anatomic, acceptable (<5° coronal and sagittal malalignment) or poor (>5° coronal and sagittal malalignment).
Results: In total, 767 patients were included (mean age: 45.8 years [range: 18–98 years]; 482 [62.8%] male). Diabetes was prevalent in 122 (15.9%) patients and hypertension in 291 (37.9%); 180 (23.5%) patients were active smokers. A closed injury occurred in 688 (89.7%) patients. Alignment was excellent in 635 (82.8%) patients and acceptable in 130 (17%) patients. Union was achieved in 718 (93.6%) patients. All PROMIS scores trended toward improvement over time: GPH (p<0.001), GMH (p = 0.611), PF-CAT (p<0.001), mobility-CAT (p<0.001), PI-CAT (p<0.001), and depression-CAT (p<0.05). Patients with anatomic alignment and fracture union had better PROMIS scores at each time point. Additionally, a floor effect was seen for the depression-CAT (not depressed) at all time points, and the PI-CAT (not painful) after 3 months.
Conclusion: PROMIS scores improve over time following tibial IMN. High depression-CAT at any time point and high PI-CAT after 3 months merit further evaluation. Anatomic alignment correlates with improved scores, indicating that reduction quality improves outcomes. Progression to union has higher scores at each time point, indicating that patients with worse PROMIS scores or decline should be closely evaluated for healing.
Annual Meeting Podium AM Podium #54
General Health Outcomes After Locked Plating Versus Retrograde Nailing for Periprosthetic Distal Femur Fractures
Aaron Nauth, MD; Rosa Park, MBBS, FRCSC; Michael D McKee, MD; Jeremy Alan Hall, FRCSC; Amir Khoshbin, MD, MSc, FRCSC; Milena Vicente, RN; Jennifer Hidy, BSc, CCRP; Matthew Raleigh, BSc; Ashmanie Brijmohan, Bsc; Emil H Schemitsch, MD, FIOTA; Canadian Orthopaedic Trauma Society (COTS); Periprosthetic Distal Femur Fracture Investigators
Purpose: Periprosthetic fractures of the distal femur (PPDF) above a total knee arthroplasty (TKA) are challenging to manage, and substantial controversy exists regarding the ideal treatment. There remains substantial debate regarding whether locked plating (LP) or retrograde intramedullary nailing (RIMN) leads to superior outcomes. We previously reported the results of a multicenter, randomized controlled trial of LP versus RIMN for the treatment of PPDFs and reported no significant differences with respect to mobility scores and knee-specific outcomes. The objective of this secondary analysis was to compare general health outcomes between the two treatment strategies.
Methods: In total, 94 patients with a PPDF above a TKA amenable to both treatment groups were randomized to either LP or RIMN at 13 centers in Canada, the United States, and Spain. Patients were followed for 2 years. For this secondary analysis, we compared general health outcomes (EQ-5D and SF-12 scores) at regular time intervals after surgery until 2 years postoperatively.
Results: In the trial, 53 patients were randomized to LP and 41 patients to RIMN. No significant differences were observed between groups in the EQ-5D Index or VAS Scores at any time point (with the exception of the EQ-5D VAS at 6 weeks, which was significantly higher in the LP group, p = 0.03). Similarly, there were no significant differences in SF-12 Physical Component Scores (PCS) or Mental Component Scores (MCS) between the two groups at any time point. Mortality rates were also similar in both groups at 1 year (13% LP group vs 14.3% RIMN group, p = 1.0).
Conclusion: This randomized controlled trial of LP versus RIMN for the treatment of PPDFs did not demonstrate any significant differences between the two fixation strategies with respect to general health outcomes. Taken together with the previously reported results that there were no significant differences with respect to mobility scores (Timed Up and Go Test) and knee-specific outcomes (Knee Society Scores), our findings suggest that both LP and RIMN are acceptable treatment options for the management of PPDF above a TKA.
OTA Grant
Annual Meeting Podium AM Podium #55
Intraoperative Fluorescence-Based Perfusion Imaging Predicts Early Re-Infection in Fracture Related Infection
Ida Leah Gitajn, MD; Yue Lea Tang, PhD; Nathan O'Hara, PhD, MHA; Jonathan Elliott, PhD; Xu Cao, PhD; Lillian Fisher, BA; Chelsey Recendez, MS; Gerard P Slobogean, MD, MPH, FRCSC; Shudong Jiang, PhD
Purpose: Fracture-related infection (FRI) remains a major clinical challenge with re-infection rates exceeding 30%. Successful treatment relies on surgical debridement of devitalized bone. However, this is highly subjective as devitalized bone cannot be reliably identified by visual inspection. Over-debridement increases reconstructive needs, while under-debridement increases treatment failure. To address this gap, indocyanine green (ICG)-based dynamic contrast-enhanced fluorescence imaging (DCE-FI) has been developed for intraoperative perfusion assessment. The aim of this study was to evaluate the association between post-debridement bone perfusion and early (<3 months) reinfection. We hypothesized that poor post-debridement perfusion metrics would correlate with early re-infection risk.
Methods: A multicenter prospective cohort trial was conducted, enrolling 106 patients with FRI. At 1-year follow up, 75 patients remained infection free, while 31 experienced recurrences (18 within 3 months, 13 thereafter). Following surgical debridement, patients received intravenous ICG and fluorescence imaging. Perfusion parameters, including blood flow (BF), maximum fluorescence intensity (Imax), and ingress slope (IS) were quantified in the exposed area. Differences were analyzed using Kaplan-Meier survival analysis, t-tests, and χ2 tests. A multivariable logistic model assessed early re-infection probability and prognostic performance.
Results: Patients with early re-infection had significantly lower BF (mean 4.4 mL/min/100g, SD 2.8 vs mean 7.2, SD 6.4, p = 0.006). Kaplan-Meier analysis revealed that patients with large low-perfusion areas (Imax <24 relative fluorescence units [RFU]) had a significantly higher early recurrence rate (p = 0.021), with 27% experiencing recurrence at 3 months, compared to 4% in those with small low-perfusion areas (p = 0.017). The prognostic model demonstrated strong predictive performance (area under the curve [AUC]: 0.78; 95% CI: 0.65–0.88). Patients meeting all three low perfusion criteria (median Imax <75 RFUs, median BF <8 mL/min/100g, and median IS <4 RFUs/sec) had a 24.1% (95% CI: 13.9%–24.3%, p<0.001) probability of early re-infection. This increased to 39.7% (95% CI: 16.5%–63%, p<0.001) in patients with high body mass index (BMI) and diabetes.
Conclusion: Low post-debridement bone perfusion is strongly associated with early re-infection. These findings support intraoperative ICG-based DCE-FI as a valuable tool for improving surgical decision-making regarding debridement margins. We believe real-time perfusion data will optimize debridement and reduce infection recurrence.
Annual Meeting Podium AM Podium #56
Do More Debridement Procedures Impact Risk of Infection in Open Fractures?
Logan Bateman, MS; Susana Diaz-Coto, PhD; Nathan O'Hara, PhD, MHA; Sofia Bzovsky, MSc; Robert D Zura, MD; Gerard P Slobogean, MD, MPH, FRCSC; Sheila Sprague, PhD; Anna N Miller, MD, FACS, FIOTA; PREP-IT Investigators; Ida Leah Gitajn, MD
Purpose: Early surgical debridement is the cornerstone of treatment for patients with open fracture to prevent infection. Modern strategies emphasize staged debridement, particularly in highly contaminated fractures. However, there is wide practice variability around the number of debridement procedures and time to definitive wound closure. Limited prior studies explored the relationship between the number of debridements and infection, but none controlled for wound contamination, a critical factor driving additional debridements. Therefore, this study seeks to evaluate the association between the number of debridements and infection, stratified by degree of wound contamination. We hypothesized a strong association between a larger number of debridements and reduced rate of infection in severely contaminated wounds.
Methods: This secondary analysis of prospectively collected data from the PREP-IT program involved 34 sites across North America and Spain. All patients with open fractures were included. The primary outcome measure was adjudicated surgical site infection. Independent variables were the number of debridement procedures and time from injury to definitive wound closure. Analyses were stratified by degree of contamination and multivariate analyses controlled for confounders.
Results: In this analysis, 3222 patients with open fracture were included; 2199 patients had no or minimal contamination, 970 had surface contamination, and 333 had embedded contamination. After controlling for patient-level characteristics, each additional debridement increased infection risk by 27% in the overall patient cohort (Odds Ratio [OR] 1.27 [95% CI 1.12–1.43] p<0.001) and 45% in the embedded contamination group (OR 1.45 [1.12–1.88], p = 0.004).
Conclusion: The results of this study indicate that an increased number of debridement procedures does not reduce the risk of infectious complications, even in the most highly contaminated patient cohort. In fact, patients with the highest degree of contamination demonstrated a significantly increased risk of infection with each additional debridement. These findings challenge the prevailing dogma that severe, high-energy, highly contaminated wounds require multiple debridements. Instead, it is possible that a single, aggressive, and thorough debridement may be more beneficial in reducing infection risk in this patient population.
Annual Meeting Podium AM Podium #57
Culture Positivity in Open Fractures Is an Indicator of Bacterial Bioburden
Ida Leah Gitajn, MD; Emily Ann McClure, PhD, MS; Roman M Natoli, MD, PHD; Benjamin Ross, PhD; Renan Castillo, PhD; Anthony R. Carlini, MS; Joseph C. Wenke, PhD; Robert V O'Toole, MD; Michael J Bosse, MD, FIOTA; METRC
Purpose: Infection following high-energy open fractures remains a major challenge. Open fractures yield positive cultures in 24% to 83% of cases, with culture-positive wounds at significantly higher risk for subsequent infection. Despite this, culture data are rarely used to guide clinical decision-making. Although culture positivity has been thought to reflect overall wound bioburden, this relationship has not been previously validated. The aim of this study was to evaluate the relationship between culture positivity and quantitative bioburden using next generation sequencing (NGS)-based approaches. We hypothesized that higher wound bioburden would be associated with culture positivity.
Methods: This is a secondary analysis of the BIOBURDEN Study, including patients age 18 to 74 years with Gustilo type III tibial fractures or traumatic transtibial amputations requiring delayed primary closure or flap coverage with NGS testing (n = 22). At definitive wound closure and follow up, standardized wound samples were collected for culture and banked for future NGS analysis. Patients were followed for 12 months for complications, including deep infection, nonunion, flap failure, amputation, or bone grafting. The primary independent variable was quantitative bioburden, as reflected by the bacteria to human sequencing read ratio by NGS, while culture positivity served as the dependent variable.
Results: At definitive wound closure, bioburden was significantly higher in culture-positive specimens compared to culture-negative specimens (mean 28.4 [SD 68.06] vs 0.13 [SD 0.34], p = 0.03). When baseline and follow-up time points were analyzed together, culture-positive wounds maintained a significantly higher bioburden (mean 17.7 (43.50) vs 0.16 (0.36), p = 0.02).
Conclusion: This is the first study to evaluate the relationship between culture positivity and wound bioburden using NGS-based analysis in open fractures. Our findings confirm that culture positivity reflects overall wound bioburden, highlighting its potential role in guiding open fracture management. NGS-based bioburden quantification may offer a more objective and precise method to guide treatment, including decisions regarding additional debridement or local antibiotic therapy. Future research is needed to build on these results and establish bioburden thresholds that predict infection risk, which could enhance clinical decision-making and improve patient outcomes.
Annual Meeting Podium AM Podium #58
Older Age Increases Risk of Infection in Orthopedic Trauma: A Secondary Analysis of Four Multicenter Studies Including 14,500 Patients
Lisa Reider, PhD; Anthony R. Carlini, MS; Jonathan Sayegh, BS; William T Obremskey, MD, MPH, FIOTA; Michael J Bosse, MD, FIOTA; Todd O. McKinley, MD; Reza Firoozabadi, MD; Sanjit Reddy Konda, MD; Michael Willey, MD; Robert V O'Toole, MD; Justin Haller, MD; Renan Castillo, PhD; METRC
Purpose: Although older age is a recognized risk factor for surgical site infection (SSI) following orthopaedic procedures in general, its relationship with infection risk in orthopaedic trauma is not well characterized. The goal of this study was to definitively describe the relationship between age and infection in the context of other risk factors.
Methods: This secondary analysis included a cohort of 12,200 orthopaedic trauma patients (PREVENT CLOT trial) to assess the shape of the age-infection relationship and a detailed cohort of 2546 patients from three trials: two of open and closed lower extremity trauma (VANCO and OXYGEN trials) and one of severe open lower extremity trauma (FIXIT trial). The primary outcome was reoperation for deep SSI. Logistic regression models were used to evaluate age effects, test for differences by injury severity, and determine whether age remained an independent predictor after adjusting for open fracture, severe soft-tissue injury, diabetes, body mass index (BMI), length of hospital stay (LOS), and pre-injury patient-reported health (VR-12).
Results: Age showed a nonlinear relationship with infection risk, with models that accounted for this pattern fitting significantly better than simple linear models (p<0.001). Infection risk was strongly influenced by injury severity, with open fractures and severe soft-tissue damage being the most significant predictors. However, even after adjusting for injury severity and other key risk factors, age remained independently associated, with each additional year increasing infection risk by 1% (OR = 1.01, 95% CI: 1.00–1.02, p<0.01) in individuals age 18 to 65 years. Beyond 65 years, limited data, along with the effects of severity and frailty, made the pattern less clear, suggesting a more complex association.
Conclusion: Clinicians should be aware that the risk of deep SSI changes with age in orthopaedic trauma. Although open fractures and severe soft-tissue injury remain the strongest immediate predictors of infection, age exerts a consistent and independent effect that is not explained by comorbidities or hospital-related factors. These findings may highlight a benefit of age-responsive infection prevention strategies.
Annual Meeting Podium AM Podium #59
A Novel Risk Prediction Model for Recurrent Fracture-Related Infections
Ida Leah Gitajn, MD; Anthony R. Carlini, MS; Roman M Natoli, MD, PHD; Renan Castillo, MS; Robert V O'Toole, MD; Saam Morshed, MD, PhD; Paul Tornetta, MD, PhD, FIOTA; Theodore Miclau, MD, FIOTA; Cyril Mauffrey, MD, FACS, FRCS; William T Obremskey, MD, MPH, FIOTA; METRC
Purpose: Fracture-related infections (FRI) present a major clinical challenge, with reinfection/treatment failure rates exceeding 30%. Despite this, limited data exist on early risk factor identification and patterns of treatment failure. This study aimed to develop a risk prediction model for recurrent infection and treatment failure using sociodemographic, injury-related, infection-related, and microbiome-associated variables.
Methods: This is a secondary analysis of the POvIV study, including patients ages 18 to 84 with culture-positive surgical site infection following internal fixation for fracture repair or arthrodesis. The primary outcome was adjudicated reinfection. Bivariate analyses identified an initial set of predictors, followed by multivariable logistic regression with backward selection to develop the final predictive model. A total of 233 patients with FRI was included.
Results: 73 patients (31.3%) experienced a re-infection in a mean of 152 (SD 192) days. An optimized risk prediction model was developed, achieving an area under the curve (AUC) of 0.73, indicating strong discriminatory ability. Key predictive factors of worse outcomes included poor social support, increased time from fixation to debridement, gram-negative infection, tobacco use, vacuum (VAC)-assisted wound closure, and number of debridements. A scoring system was created, achieving an AUC of 0.72, with low-, medium-, and high-risk categories having probabilities [95% CI] of reinfection ranging from low-risk: 19% [12%, 27%]; medium-risk: 41% [31%, 52%]; and high-risk: 54% [27%, 81%].
Conclusion: This study provides a validated risk prediction model for infection recurrence. The model demonstrated strong performance in distinguishing risk levels for infection recurrence, offering potential utility for patient prognosis and personalized treatment strategies. Identifying high-risk patient cohorts could inform targeted interventions to improve FRI management and reduce infection recurrence.
Annual Meeting Podium AM Podium #60
Utility of Sonication for Fracture-Related Infections
Austin Taylor Gregg, BS; Stephen C. Moye, BS; Christina Liu, MD; Alina Fischer, BA; Michael Akodu, BA; Paul T. Appleton, MD; Edward Kenneth Rodriguez, MD, PhD; John J Wixted, MD
Purpose: Fracture-related infections (FRI) are a significant complication after fracture fixation, with traditional tissue cultures serving as the primary diagnostic tool. However, tissue culture may fail to detect indolent infections. This study evaluates the diagnostic utility of sonication compared to tissue culture in detecting FRI.
Methods: A retrospective cohort study was conducted at a Level I trauma center, including patients who underwent reoperation for suspected infection, nonunion, or hardware failure between 2018 and 2023. Sonication was performed on explanted implants, with fluid cultures compared to traditional tissue cultures. The primary outcome was sonication positivity relative to tissue culture. Sensitivity, specificity, and predictive values were calculated. Secondary outcomes included factors associated with positive sonication in culture-negative cases and cost analysis.
Results: In total, 67 patients were included (mean age: 57 years [IQR: 43–72], female: 50%). Most fractures (85%) were in the lower extremity, and 73% were treated with plates. Tissue culture was positive in 18 patients (27%) and negative in 49 (73%). Sonication was positive in 27 patients (40%). Compared to tissue culture, sonication had higher sensitivity (80% vs 56%) and slightly lower specificity (92% vs 97%). The positive predictive value of sonication was 89%, and the negative predictive value was 85%. Patients with positive sonication were more likely to be male (p = 0.048), older (p = 0.045), and had longer hospital stays (p = 0.025). Sonication costs were $229 per patient, totaling $15,343 for the cohort.
Conclusion: Sonication demonstrated superior sensitivity in detecting FRI compared to traditional tissue culture, particularly in identifying indolent infections. Given its minimal additional cost and potential to prevent missed infections, sonication should be considered an adjunct diagnostic tool in reoperations for suspected orthopaedic infections, hardware failure, and nonunion of unclear etiology. Further studies should assess its cost-effectiveness and impact on early pathogen identification and treatment outcomes.
Annual Meeting Podium AM Podium #61
Implant Retention Versus Fixation Removal for the Treatment of Fracture-Related Infections (FRIs)
Timothy Murphy, MD; James Slaven, MS; Tara Taylor, MPH; Anthony R. Carlini, MS; Renan Castillo, MS; Ida Leah Gitajn, MD; J. Spence Reid, MD; Catherine Passaretti, MD; Paul Spencer Whiting, MD, FIOTA; Robert V O'Toole, MD; Paul Tornetta, MD, PhD, FIOTA; William T Obremskey, MD, MPH, FIOTA; Roman M Natoli, MD, PHD; Major Extremity Trauma Research Consortium
Purpose: Fracture-related infections (FRI) are surgically managed with debridement and one of two treatment strategies: implant retention or fixation removal. We hypothesized there would be no difference in the rate of treatment failure between these strategies.
Methods: This was a secondary analysis of the prospective randomized POvIV trial. Patients with unhealed fractures who enrolled within 90 days of initial fracture treatment were categorized as undergoing implant retention or fixation removal based on their index surgical management of FRI. We analyzed demographics, comorbidities, injury characteristics, initial surgical treatment, infection treatment, and time from initial fracture fixation to FRI debridement. To account for confounding variables, inverse probability weighting (IPW) using a propensity score model was applied to balance baseline characteristics. The primary outcome was treatment failure, defined as the occurrence of at least one of the following: wound complications requiring surgery, recurrent infection, radiographic loosening or hardware failure, joint erosion requiring arthrodesis or amputation, or new infection.
Results: In total, 103 patients were included (implant retention: n = 67; fixation removal: n = 36). Unadjusted treatment failure was higher in the implant retention group (49.3%) versus the fixation removal group (36.1%), but this difference was not statistically significant (p = 0.20). Patients undergoing implant retention had a significantly shorter time from fixation to debridement (26 vs 56 days, p<0.001) and lower rates of substance abuse (0% vs 8.3%, p = 0.04). After IPW adjustment, implant retention was significantly associated with higher treatment failure (OR: 2.02, 95% CI: 1.10–3.71, p = 0.023). Additionally, longer time from fixation to debridement (p = 0.003) and undergoing three or more debridements (p = 0.013) were significantly associated with increased treatment failure risk.
Conclusion: Implant retention was significantly associated with an increased risk of treatment failure compared to fixation removal, even after adjusting for many confounders. These findings suggest that fixation removal might be the more favorable surgical strategy for managing FRIs. Future well-powered, prospective randomized trials that control for other factors unable to be accounted for in the current analysis are needed to confirm these results and further inform clinical decision-making in FRI management.
Annual Meeting Podium AM Podium #62
PO vs IV Antibiotics for Fracture Related Infections: Bayesian Analysis
Nathaniel Elliot Schaffer, MD, PhD; Anthony R. Carlini, MS; Renan Castillo, MS PhD; Robert V O'Toole, MD; Brian H Mullis, MD, FIOTA; Paul Spencer Whiting, MD, FIOTA; Catherine Passaretti, MD; Clifford B Jones, MD, FACS, FIOTA; William T Obremskey, MD, MPH, FIOTA; Heather A Vallier, MD, FIOTA; Sanjit Reddy Konda, MD; Reza Firoozabadi, MD; METRC
Purpose: Treatment of fracture-related infections (FRIs) entails debridement and 6 weeks of intravenous (IV) antibiotics. A published randomized trial of FRI patients provided varied results regarding the noninferiority of oral (PO) and IV antibiotics (POvIV trial). The purpose of this study was to reevaluate these data using Bayesian statistical methods.
Methods: A randomized trial across 24 US centers enrolled 233 patients with FRIs treated with debridement and randomized to PO or IV antibiotics. Modified intention-to-treat (assigned PO versus assigned IV) and per-protocol (PP) (PO only versus any IV) effects for number of surgical interventions within 1 year and re-infection by 1 year were estimated using Bayesian methods. A zero-inflated Poisson model with an offset for follow-up time was used for the primary outcome and a nonparametric survival model accommodating right censoring was used for the secondary outcome. To account for potential confounding, inference for PP effects were weighted by the inverse probability of treatment received (PO only versus any IV) conditional on 15 pretreatment factors; Bayesian logistic regression was used in the computation of the weights.
Results: For modified intention-to-treat (mITT), the posterior difference in mean number of surgical interventions within 1 year for oral versus IV was 0.23 (95% Upper CI: 0.52). For PP, the posterior difference was 0.36 (95% Upper CI: 0.73). The posterior probability of noninferiority (defined as a difference in means less than 0.67) was 99.3% and 92.1% for mITT and PP, respectively. The posterior difference in the probability of reinfection by 1 year for oral versus IV was 2.8% (95% CI: –6.7%, 12.2%) and 8.9% (95%CI: –0.6%, 19.2%) for mITT and PP, respectively.
Conclusion: The Bayesian analysis allows precise statements about the probability of noninferiority, and our results show that both mITT and PP effects have high probabilities (ie, greater than 90%) of noninferiority of oral antibiotics for surgical interventions based on a threshold of 0.67. The mITT and PP effects for re-infection are different. Patients and providers can weigh their preference for oral antibiotics versus tolerance for additional surgical procedures and re-infection.
Annual Meeting Podium AM Podium #63
Which Organisms are Associated With Poorer Results in Septic Long Bone Nonunions?
Kathryn Barth, MD; Robert Bilodeau, BS; Heather Haeberle, MD ; Mark Megerian, MD; Craig E. Klinger, MPH; Gregory Vincent Schimizzi, MD PhD; William M Ricci, MD
Purpose: Management principles for septic long-bone nonunions (SLBNU) include eradication of existing infection through surgical debridement, fracture stabilization, and antibiotic treatment. This study assessed the association between cultured organism species and outcomes of septic long-bone nonunion treatment.
Methods: Adult patients who underwent SLBNU repair at a single institution from 2014 to 2023 were retrospectively reviewed. Septic nonunion was defined as having one or more positive intraoperative cultures at the study site during any nonunion repair operation. Patients with incomplete data, less than 6 months of follow up without achieving osseous union, or nonunion resulting from osteotomy, fusion, or pathologic fracture were excluded. Initial injury and patient characteristics, surgical and antibiotic treatments, cultured organisms, and outcomes were collected. The primary outcomes were osseous union and unplanned operations after index study-site nonunion repair to address infection or to promote union.
Results: In total, 102 patients (mean age: 52 years [range: 18–89], 73% male) were included. Average follow up from study-site definitive nonunion repair was 21 months (range: 1.4–92.5 months). At final follow up, 88 patients (86.3%) achieved radiographic union. Those with negative study-site cultures at the index procedure (n = 21, those who had positive cultures at secondary procedures) were more likely to have unplanned operations (57%) than those with positive cultures (30%) (p = 0.019). Patients with polymicrobial study-site cultures were associated with more than double the rate of needing unplanned operations compared to mono-colonized patients (43% vs 18%, p = 0.014). Patients with both gram-positive and gram-negative bacteria had higher rates of unplanned operations than those with multiple bacteria of the same gram classification (75% vs 28%, p = 0.007). Initial acute fracture treatment with external fixation was associated with development of polymicrobial infections (54.5% vs 25.4%, p = 0.013). No differences in final union rates across bacterial groups were observed (p>0.9).
Conclusion: Organisms cultured from septic long-bone nonunions play a significant role in the number of operations needed to achieve clinical resolution. Patients with polymicrobial infections may need more aggressive initial eradication efforts, as this group had a higher rate of unplanned operations to manage infection or to promote union.
Annual Meeting Podium AM Podium #64
Antibiotic Powder Associated With Delayed Presentation of Deep Surgical Site Infection for Pilon and Plateau Fractures: A Secondary Analysis of the VANCO and OXYGEN Studies
Mariel Rickert, MD ; Christina Stennett, PhD; Nathan O'Hara, PhD, MHA; Rachel Honig, MD; Anthony R. Carlini, MS; Renan Castillo, PhD; Madhav A Karunakar, MD; Stephen Warner, MD, PHD; Conor P. Kleweno, MD; Robert V O'Toole, MD; METRC
Purpose: Pilon and plateau fractures have high rates of deep surgical site infection (SSI), but factors associated with the timing of infection presentation remain poorly understood. We hypothesized that predictors of delayed infection could be identified in this population.
Methods: We conducted a cohort study using data from VANCO and OXYGEN, two randomized controlled trials of patients with pilon or plateau fractures. The primary outcome was days from definitive fracture fixation to deep SSI. Candidate factors included local antibiotic powder use, age, gender, body mass index, diabetes, tobacco, alcohol, or drug use, a combined variable including closed versus open fracture with Gustilo-Anderson classification for open fractures, fracture location, culture results, and bacteria speciation. Linear regression was used to determine the association of candidate factors and days to deep SSI, applying backward selection to identify relevant covariates and generate a single adjusted model.
Results: Of 1675 patients reviewed, a deep SSI developed in 154 (10%). The median time from definitive fixation to deep SSI was 81 days (interquartile range: 29 to 158 days). The modeling identified 3 factors associated with a delayed presentation of deep SSI. Antibiotic powder use was associated with a 58-day delay in onset of deep SSI (95% CI: 6–109; p = 0.03). Age 65 years or older (mean difference = 61 days; 95% CI: 9–114; p = 0.03) compared to younger than 65 years and male gender, compared to female gender (mean difference = 38 days; 95% CI: 4–72; p = 0.03) were also associated with a delay in presentation of deep SSI.
Conclusion: In this secondary analysis of prospective data, antibiotic powder use, older age, and male gender were associated with delayed onset of infection following fixation of tibial plateau and pilon fractures. Although these findings should be replicated in larger studies, they highlight the potential impact of these modifiable and nonmodifiable factors on the time to infection and their implications for clinical practice for patient counseling, clinician implementation of local antibiotics, and future research.
Annual Meeting Podium AM Podium #65
In-Hospital Sleep After Orthopaedic Trauma and Its Association With Patient-Reported Outcomes: A Prospective Trial
Mara Schenker, MD, MBA; Jack Hudson, MPH; David Marvin, MD; Nicholas Giordano, PhD, RN
Purpose: Sleep quality and pain are interrelated, with poor sleep worsening pain and vice versa. Sleep disturbances may predict future pain more than pain predicts poor sleep. Patients with orthopaedic trauma often face significant pain and disrupted sleep, yet objective studies on sleep patterns in this population are limited. This study examines sleep patterns in patients with orthopaedic trauma during hospitalization and their relationship with patient-reported outcomes.
Methods: This sub-analysis, part of a randomized controlled trial at an urban Level I trauma center, evaluated sleep in adult patients undergoing surgery for isolated orthopaedic trauma. Wrist-based actigraphy devices recorded sleep data from surgery to hospital discharge. Sleep outcomes included total sleep time (TST), wake-after-sleep onset, number and duration of awakenings, and Sleep Fragmentation Index. Patient-reported pain and sleep quality were assessed during hospitalization and at two, six, and 12 weeks post-discharge. Demographic and clinical data were obtained through chart review, and statistical models assessed relationships among inpatient opioid use, sleep metrics, and outcomes up to 3 months postoperatively.
Results: The study included 119 patients, predominantly Black or African-American (73.1%) and female (52.1%), with most undergoing surgery for lower extremity injuries. The median hospital stay was 4.5 days (IQR 3, 7). On average, patients experienced 4 hours and 13 minutes of sleep per night (253.67 minutes ± 83.22), significantly less than the typical 383 minutes in healthy adults (p<.001). Participants averaged 8.99 awakenings per sleep period but exhibited high sleep efficiency (90.3% ± 5.09). Higher opioid use correlated with reduced sleep duration (rs = -0.232, p = 0.021). Poor sleep efficiency during hospitalization was associated with higher Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference scores up to 3 months post-discharge (β = -1.41; 95% Confidence Intervals [CI]: -2.42, -0.41; p =0.008).
Conclusion: Patients with orthopaedic trauma experience significantly reduced and fragmented sleep during hospitalization. Opioid use, contrary to expectations, was linked to shorter sleep durations. Poor sleep efficiency during hospitalization adversely affected pain outcomes for up to 3 months, emphasizing the need for interventions to improve sleep quality during recovery.
Annual Meeting Podium AM Podium #66
Interpretation Accuracy Between Orthopaedic Surgeons and Remote Spanish Interpreters in a Trauma Setting
Todd Jaeblon, DO; Ruben Monarrez, MD; Carlos Julio Molestina, Physician Assistant; Luis DaConceicao, Physician Assistant; Marie-Genevieve Babecki, BA; Brent J Bauer, MD; Sneh Talwar, BS; Haley K Demyanovich, MS
Purpose: Limited English-proficient (LEP) Spanish-speaking patients require readily available, appropriate interpretation to minimize complications, optimize outcomes, and reduce anxiety. Our objective was to evaluate the level of accuracy between remote professional Spanish interpreters and surgeon providers in an orthopaedic trauma setting. The effects of mode and speed of delivery as well as injury complexity were included.
Methods: Three predefined vignettes of increasing complexity describing a surgical fracture, treatments, and outcomes were constructed by a panel experienced in orthopaedics, including fluently bilingual providers, an orthopaedic traumatologist, and a certified medical interpreter (CMI). Vignettes were conveyed in short sentences termed “utterances,” to a remote CMI. Each type of script was read to 10 different randomly sampled, blinded telephone and video interpreters and recorded. The 60 interpretations were back-translated to English, and compared to original vignettes. Data were collected on medical errors (ME), major or moderate-plus errors (MPE), vignette complexity (simple, moderate, complex), mode of interpretation, and delivery speed. Overall interpretation accuracy was determined by investigators and designated as “acceptable,” “borderline,” or “unacceptable.” The effects of complexity, mode, and speed on designation were determined. A sub-analysis was performed among acceptable, borderline, and unacceptable (not acceptable [NA]) interpretations.
Results: The mean (SD) number of MEs and MPEs per utterance by the 60 interpreters was 0.67 (1.06) and 0.32 (0.74) respectively. The average delivery speed was 148 (9.32) words per minute (WPM). There were 28 (46.7%) acceptable, 11 (18.3%) borderline, and 21 (35%) unacceptable interpretations. Complexity (moderate: reference; simple: P = 0.75, OR 0.81, 95% CI, 0.21–2.95; complex: P = 0.59, OR 1.49, 95% CI, 0.36–6.74) and delivery speed (P = 0.53, OR 0.98, 95% CI, 0.92–1.04) did not have a significant effect on overall designation. Sub-analysis revealed 28 (46.7%) of interpretations were acceptable and 32 (53.3%) NA. Video CMI increased the odds of acceptable interpretation for both primary (P<0.01, OR 6.21, 95% CI, 2.17–19.48) and sub-analysis (P<0.01, OR 6.68, 95% CI, 2.00–22.34).
Conclusion: In an orthopaedic trauma setting, 46.7% of Spanish interpretations were considered acceptable, and 35% were unacceptable. The odds of an acceptable interpretation were greater with remote video CMIs versus audio.
Annual Meeting Podium AM Podium #67
The Hidden Cost of Our Job: Cancer Incidence Among Male Orthopaedic Trauma Surgeons
Sara Van Nortwick, MD; Lisa Kaye Cannada, MD; Lyles Addy, BS; Antonia Chen, MD, MBA; Loretta Chou, MD
Purpose: Radiation exposure remains an occupational hazard for orthopaedic surgeons, with potential long-term implications. This study analyzed cancer incidence among male orthopaedic trauma surgeons while incorporating data from a larger survey of male orthopaedic surgeons to understand the relationship between occupational radiation exposure and cancer risk.
Methods: Data were collected from male trauma surgeons (n = 90) through an OTA-approved survey examining demographics, practice patterns, and cancer incidence. Results were compared with a broader survey of 1203 male orthopaedic surgeons across subspecialties, examining cancer incidence and radiation exposure patterns to age-matched population norms.
Results: There were 90 respondents with an average age of 51 years (SD =/– 12.1). Racial distribution included 65% White, 23% Asian, 5% Black, and 7% other. Practice settings were academic (46%), private practice/hospital employed (43%), military (5%), and other/retired (6%). There were six cases of cancer (7%): prostate (3), lung (1), bladder (1), and melanoma (1), with the mean age at diagnosis of 59.5 years. This aligned with findings from the larger cohort, which showed a 10% overall cancer incidence, with prostate cancer being most common (3.7% incidence). The age-matched norm for cancer risk is 0.89%, thus orthopaedic trauma surgeons have a sevenfold increased risk. 69% of male trauma surgeons reported receiving education on radiation safety, while 5% reported not using protective equipment. In the broader study including trauma surgeons, 50% with cancer reported weekly fluoroscopy use, while 53% indicated never receiving radiation safety training. Notably, 7% reported using no radiation protection during procedures.
Conclusion: This study reveals concerning cancer rates among trauma surgeons that parallel broader trends in male orthopaedic surgeons, particularly regarding prostate cancer. The high prevalence of regular fluoroscopy use combined with inadequate radiation safety training represents a concern. There is an urgent need for improved, perhaps mandatory, radiation safety education and consistent use of protective equipment. Regular screening and occupational health monitoring may be warranted, especially given the documented latency period between radiation exposure and cancer development. Future research is focusing on long-term cancer surveillance in male orthopaedic surgeons.
Annual Meeting Podium AM Podium #68
Poor Physical Performance Measures at One Year Following Lower Extremity Fracture Surgery (LEFS) Persist and Can Predict Physical Function and Disability at Two Years
Grace Elizabeth Brooks, B.S.; Gregory Hawk, PhD; Brian Noehren, PT, Ph.D.; Paul Edward Matuszewski, MD
Purpose: Persistent disability affects more than one quarter of lower extremity trauma patients with decreased physical function playing a significant role in its development and hindering reintegration into society. Early identification of patients likely to have persistent disability and poor function is crucial to developing targeted interventions and improving long-term outcomes. The goal of this study was to evaluate the relationship between physical performance metrics at 12 months and patient-reported physical function and disability at 24 months after lower extremity fracture surgery (LEFS).
Methods: From a longitudinal cohort of 120 patients, 65 participants (45.4 ± 15.3 years) underwent physical performance testing 12 months after LEFS and completed PROMIS physical function and disability surveys at 24 months. The testing included maximal isometric hip abduction and quadriceps strength, standing single leg calf raises to failure, a 60-second step down test, and a 6-minute walk test (6MWT). The relationship between 12-month functional assessments and 24-month outcomes was assessed with linear and logistic regression models, as appropriate.
Results: At 24 months, 52% of participants reported below-average physical function (48.8 ± 8.5) and 66% reported some level of disability (median 10 [IQR: 0–20]). The 6MWT (466 ± 112m) had the strongest predictive value for 24-month physical function (R² = 0.38, p<0.001) and disability outcomes (R² = 0.24, p = 0.002). Hip abductor strength (1.1 ± 0.4 Nm/kg) was also significantly associated with physical function (R² = 0.30, p<0.001) and disability (R² = 0.22, p = 0.005). Additionally, rate of torque development (4.2 ± 2.4 Nm/s) was significantly associated with physical function (R² = 0.30, p = 0.002).
Conclusion: A majority of patients have below average function and disability 2 years following lower extremity fracture. Walking capacity and muscle strength 12 months after LEFS predicts self-reported physical function and disability status at 2 years. This suggests that many patients could benefit from some form of intervention, even 1 year after injury. Future studies should investigate if targeted interventions at this time point can improve functional outcome and reduce disability.
Annual Meeting Podium AM Podium #69
A Model in Diversity Reporting 2024: Orthopaedic Trauma Association
Carol Lee, MD; Gregory J Della Rocca, MD, PhD, MBA, FACS; Thuan V Ly, MD; Lisa Kaye Cannada, MD; Jason Davis, MD; Brianna R Fram, MD; Jacqueline Krumrey, MD; Milton Thomas Michael Little, MD; Joshua Namm, MD
Purpose: The persistent lack of diversity in orthopaedics has garnered increasing attention in recent years. This study examines the current gender, racial, and ethnic diversity of the Orthopaedic Trauma Association (OTA) and proposes an implementation plan for assessing membership diversity in professional organizations to improve diversity reporting.
Methods: In 2023, the OTA membership and diversity committees implemented a suggested questionnaire on its website, collecting demographic data, including gender, race, and ethnicity. Members could opt out of any questions by selecting a “prefer not to say” response. Reminders were sent at multiple points throughout the year (eg, OTA Annual Meeting registration, other education event registration, dues renewal, and membership applications). This cross-sectional study analyzes responses from this new data collection system.
Results: Of the 3548 OTA members who participated in the survey, 2862 (80.67%) identified as male, 613 (17.28%) as female, 72 (2.03%) preferred not to disclose, and one (0.03%) identified as nonbinary. Survey respondents indicated their race as follows: 2218 (69.49%) White, 401 (12.56%) Asian, 123 (3.85%) Black, 95 (2.98%) multiracial, 9 (0.28%) Native Hawaiian/Pacific Islander, 7 (0.22%) Native American, 84 (2.63%) other, and 255 (7.99%) who preferred not to disclose. Data for 356 members (11.15%) were missing due to a data capture error that covered several months in 2024. Of the respondents, 2611 (81.75%) indicated that they are not Hispanic/Latino, 197 (6.17%) are Hispanic/Latino, and 386 (12.09%) preferred not to disclose. Data for 354 members (11.08%) were missing because of the same data capture error.
Conclusion: To our knowledge, the OTA is the first orthopaedic society to implement a suggested data collection system resulting in nearly 100% participation. The data confirm that the OTA, like other orthopaedic subspecialties, is insufficiently diverse and does not mirror the general population or the population of medical school graduates in the United States. Accurate demographic reporting is crucial for understanding diversity gaps and for tracking the impact of future initiatives. We recommend that other orthopaedic organizations adopt similar systems to improve diversity reporting that can inform efforts at achieving meaningful change.
Annual Meeting Podium AM Podium #70
Methamphetamine Use in Orthopaedic Trauma: High Infections, Low Follow-up
Shannon Tse, BMBS; Seghen Woldai, BS; Kaya Adelzadeh, BS; Frank J Sierra, BS; Chiara Anna Giordani, MS; David Dallas-Orr, MD, MBA, MTM; Ellen Fitzpatrick, MD; Gillian Soles, MD; Mark Lee, MD; Sean Thomas Campbell, MD; Kent Leach, PhD; Augustine Mark Saiz, M.D.
Purpose: Methamphetamine use is increasingly prevalent among patients with orthopaedic trauma and is associated with unique medical and social challenges. Anecdotally, this may also increase rates of inpatient and postoperative complications. This study evaluates the impact of methamphetamine use on postoperative outcomes and follow-up care in patients with orthopaedic trauma.
Methods: A database of patients with orthopaedic trauma undergoing fracture fixation at a Level I center from 2014 to 2023 with pelvic/long bone/articular fractures was retrospectively analyzed to categorize them into methamphetamine and non-methamphetamine groups. Demographics, injury characteristics, hospital factors, clinical outcomes, and follow up were assessed.
Results: The cohort included 703 patients with 142 methamphetamine users. Demographic, injury, and follow-up comparisons are shown in Table 1A. The methamphetamine group had higher rates of ICU admission, loss to follow up (Table 1A), and superficial and deep infections (Table 1B). Univariate analysis found long bone and open fractures were associated with superficial infections. After adjusting for baseline demographics, multivariate analysis found methamphetamine use (OR: 2.3, 95% CI: 1.0–5.3), open fractures [OR: 7.8, 95% CI: 3.8–16.0), and body mass index (BMI; OR: 1.1, 95% CI: 1.0–1.1) were significant predictors of deep infections.
Conclusion: Methamphetamine use in patients with orthopaedic trauma is linked to higher ICU admission rates, increased deep infection risk, and greater follow-up loss. Targeted strategies may be needed to improve postdischarge care in this high-risk population.
Annual Meeting Podium AM Podium #71
Hidden Violence: Gender Disparities, Delayed Disclosures, and Poor Clinical Outcomes in Orthopaedic Trauma Patients
Natalie Fleming, MSW; Kiara Pannozzo, MPH; Sofia Bzovsky, MSc; Paula McKay, BSc; Marc Gonsalves, BHSc Student; Brad A Petrisor, MD; Jamal Al-Asiri, MD; Bill Ristevski, MD, MSc, FRCSC; Dale Williams, MD; Jodi Gallant, MSc; Kaitlyn Pusztai, ?; Sarah MacRae, ?; Sara Renaud, ?; Kim Madden, PhD; Kimberley Irish, BSW; Moin Khan, MD; Herman Singh Johal, MD MPH; Anthony Adili, MD; Giuseppe Valente, MD; Jaydeep Moro, MD; Vikas Khanna, MD; Sheila Sprague, PhD
Purpose: This prospective cohort study determined the prevalence of intimate partner violence (IPV) across gender groups, investigated timing of disclosures during the usual care follow-up period, and explored the association between IPV and clinical outcomes. All participants presented to their first fracture clinic visit for a fracture or dislocation.
Methods: This study included 314 patients older than age 18 years who presented with orthopaedic injuries to the fracture clinic at two academic hospitals. Participants were asked about experiences with IPV, return to function, and global health at each routine clinical follow-up visit. Cox proportional hazards regression models were used to explore associations among IPV status and return to work, leisure, home responsibilities, and overall functioning.
Results: Of 528 patients approached, 314 consented and completed at least the initial visit. Of these, 181 (57.6%) identified as women, 126 (40.1%) as men, and six (1.9%) as gender-diverse. Compared to 35% of men and 100% of gender-diverse participants, 46% of women reported lifetime experience of any form of IPV. A smaller proportion of men who disclosed IPV did so at their first visit compared to women, especially with respect to sexual IPV (4 [40%] vs 35 [76%]). During the clinical follow-up period, 16 (6.7%) participants, including eight men, seven women, and one gender-diverse participant, disclosed experiencing IPV during their recovery period. Disclosing IPV at any visit was associated with a 45% lower likelihood of returning to pre-injury level of function with respect to work (hazard ratio [HR]: 0.55, 95% CI: 0.33–0.91]; p = 0.021) and a 36% lower likelihood of returning to pre-injury overall level of functioning (HR: 0.64, 95% CI: 0.46–0.90; p = 0.01).
Conclusion: Results show unacceptably high prevalence of IPV in all genders, particularly in gender-diverse individuals. Gender differences in timing of disclosure emphasize the need for tailored approaches in clinical settings and repeated opportunities for IPV disclosure. This study emphasizes the hidden nature of IPV among patients with orthopaedic trauma and its effects on their health and recovery.
Annual Meeting Podium AM Podium #72
Long-Term Revision-Free Survival Following Operative Fixation of Femoral Neck Fractures in Young Adults
Nicholas Michael Panarello, MD; Alex Gu, MD; Sarah Dance, BS; Colin Harrington, MD; Samantha L Ferraro, BS; Chris Renninger, MD; Robert S Sterling, MD; James N DeBritz, MD
Purpose: The purpose of this analysis was to identify the rate of fixation failure following femoral neck fracture (FNF) fixation in young adults within a national all-payer claims database.
Methods: A retrospective cohort analysis was conducted using a national all-payer insurance claims database. Patients between ages 18 and 49 years who underwent surgical fixation for FNF between January 2010 and April 2019 were identified. Pathologic fractures and patients without 5-years of active follow up were excluded. The primary outcome measure was the 5-year risk of revision surgery for fixation failure following surgical management of FNF, including avascular necrosis, malunion/nonunion, and posttraumatic osteoarthritis. Kaplan-Meier survival analyses were performed to compare the 5-year cumulative incidence of revision surgery for fixation failure. Subgroup analyses were conducted based on age and treatment with open or closed management.
Results: A total of 3534 young adults (41.1 ± 3.91 years) underwent surgical fixation of FNF during the study period. The 5-year revision-free survival of young adults who underwent surgical fixation for FNF was 86.1% (95% CI: 85.5–89.1%). 492 patients (13.9%) required revision surgical intervention for fixation failure, including 210 (5.9%) revision fixation procedures and 21 (0.6%) intertrochanteric osteotomies; 261 (7.4%) patients underwent conversion to arthroplasty. There was no significant difference in rate of fixation failure when comparing open (n = 392, 14.9%) and closed (n = 100, 13.3%) reduction techniques (p = 0.351). When stratified by age, 186 (14.26%) patients between ages 18 and 39 treated with open reduction required revision surgical intervention, compared to 31 (9.3%) patients of the same age treated with closed reduction (p = 0.001). Similarly, 206 (14.0%) patients between ages 40 and 49 treated with open reduction required revision surgical intervention, compared to 69 (16.4%) patients of the same age who were treated with closed reduction (p =0.002).
Conclusion: Following surgical management of FNF in young adults, fixation failure due to avascular necrosis, nonunion/malunion, or posttraumatic arthritis occurred at a rate of 13.9%. There was no difference in the rate of treatment failure between open and closed reduction.
Annual Meeting Podium AM Podium #73
Pipkin 4 Femoral Head Fractures: It’s Complicated
Brett Duane Crist, MD; Caleb J. Bischoff, DO; North American Femoral Head Fracture Consortium
Purpose: Our objective was to evaluate treatment strategies, surgical approaches, and outcomes, including complications and conversion to total hip arthroplasty (THA), for Pipkin 4 femoral head fractures (FHF).
Methods: A multicenter retrospective cohort study included 32 ACS Level I academic trauma centers using patient data from 2005 to 2023. This timeframe was chosen to include the increased use of surgical hip dislocation (SHD) in FHF management. Patients older than 60 years with less than six weeks of follow up were excluded. Demographics, injury characteristics, treatment details, complications (defined as femoral head avascular necrosis [AVN], heterotopic ossification [HO], posttraumatic osteoarthritis [PTOA], and infection), and rates of arthroplasty were analyzed. Associations between treatment strategy, surgical approach, acetabular fracture type, and outcomes were statistically assessed.
Results: In total, 955 Pipkin Type 4 fractures were included, with a mean age of 36.9 ± 11.7 years (male, 72.6%). Motor vehicle collision (MVC) was the predominant injury mechanism (83.4%). A posterior hip dislocation was reported in 94% of patients. Posterior wall fractures were the most common acetabular fracture (81.3%), and 92% of FHFs were treated surgically. Posterior surgical approaches without SHD were most common (47.6%), followed by SHD (22.2%), and anterior-based approaches (27.7%). Major complications occurred in 35.3% of patients, including AVN (18.2%), PTOA (15.6%), HO (8.5%), and infection (4.5%), with some patients having more than one complication. Nonoperative treatment had 2.3 times higher odds of complication (p = 0.0004), particularly 2.2 times higher odds of AVN (p = 0.003). Conversion to arthroplasty occurred in 15.8% of patients. Acute THA was performed in 20 patients, with a 10% complication rate with a mean follow up of 36 months (range: 1.7–156 months; median: 15.5 months).
Conclusion: In this large retrospective cohort series, Pipkin 4 FHFs have a relatively high rate of complications (~35%). Nonoperative management was more than two times more likely to be associated with a complication. Unlike previous series, AVN was most common. Of note, primary THA demonstrated a lower complication rate (10%) compared to open reduction and internal fixation (ORIF) (35%), suggesting it may be a viable alternative in select patients. Conversion to arthroplasty was required in 15.8% of patients.
Annual Meeting Podium AM Podium #74
Trauma-Induced Hemorrhage Orchestrates a Distinct Inflammatory Response in Polytrauma Patients With Major Fractures
Greg Gaski, MD; Todd O. McKinley, MD; Landon Katz, BS; Prism Schneider, MD, PHD, FRCSC; Katherine Frey, PhD; Simon Tallowin, BMBS, MSc; Renan Castillo, PhD; Seth Schobel, PhD; Felipe A. Lisboa, MD; Eric Elster, MD; Henry Robertson, PhD; Timothy R Billiar, MD; Laurence B Kempton, MD; Reza Firoozabadi, MD; Joshua Layne Gary, MD; Stephen Warner, MD, PHD; William T Obremskey, MD, MPH, FIOTA; Robert V O'Toole, MD; Arun Aneja, MD, PhD; METRC
Purpose: The immune response to acute hypoperfusion in orthopaedic polytrauma is not well understood. This study investigates the association between hemorrhage and systemic immune activation, focusing on biomarker clusters associated with inflammation (IL-6, IL-8, IL-10), lymphocytes (IL-2, IL-4, IL-5, IL-7), and tissue protective/reparative (IL-21, IL-22, IL-23, IL-33) function.
Methods: This is an a priori planned secondary analysis of a multicenter prospective observational trial of polytrauma patients age 18 to 55 years (ISS>15) with pelvis, acetabulum, femur, and/or diaphyseal tibia fractures. Hemorrhage was measured by shock volume (3 hours, 6 hours, 12 hours, and 24 hours post-admission), lactate (admission and highest value 24 hours post-injury), and pH (admission and lowest 24-hour value). Shock volume (temporal integration of shock index measurements) has shown high correspondence with adverse trauma clinical outcomes including organ dysfunction. A panel of 33 trauma-relevant immunologic mediators were measured at 0 hour, 1 hour, 12 hours, 24 hours, and 48 hours. Inflammation, lymphocyte-associated, and tissue reparative biomarker clusters were evaluated. Regression analyses were conducted for each immune mediator with shock volume, lactate, and pH.
Results: In total, 322 polytrauma patients were enrolled. Shock volume exhibited modest correlation with several pro-inflammation–associated mediators: IL-6 (R2 0.13–0.19, p<0.001); IL-8 (R2 0.16–0.19, p<0.001), and monocyte chemoattractant protein-1 (MCP-1; R2 0.13–0.22, p<0.001). Shock volume was also associated with corresponding anti-inflammation mediators IL-1RA (R2 0.25, p<0.001) and IL-10 (R2 0.18, p<0.001). Lactate and pH showed very similar correspondence to the same inflammation mediators. In contrast, there were no meaningful associations of hemorrhage indices with the lymphocyte or reparative mediator clusters. Associations largely dissolved by 48 hours post injury. The relationships between shock volume and immune mediators were unchanged after performing an adjusted regression analysis controlling for age, sex, body mass index, and injury severity.
Conclusion: These data show that hemorrhage is a key driver of immune activation following trauma. Hemorrhage primarily invokes an innate inflammatory response (IL-6, IL-8, MCP-1) that persists after adjusting for demographics and injury severity with minimal effects on adaptive or reparative immune mediators. An improved characterization of hemorrhage-induced immune dysregulation may aid clinicians in optimizing the timing and magnitude of subsequent surgical interventions to facilitate recovery and avoid secondary systemic insults.
Annual Meeting Podium AM Podium #75
Improving Pulmonary Outcomes in Polytraumatized Patients: Clavicle ORIF in Patients With Concomitant Clavicle and Rib Fractures Decreases Complications
Anna M Jacques, DO; Nicholas Lampasona, DO; Stanley Dennison, BS; Ciarra Gilmore, BS; James L. Cook, DVM, PhD; Bradley Roth, DO; Brian J Cross, DO; Emily Keener, DO; Brett Duane Crist, MD; Edward A Perez, MD
Purpose: Our objective was to further explore the impact of clavicle ORIF on pulmonary outcomes in the polytraumatized population, specifically in relation to the injury severity score (ISS).
Methods: A multicenter retrospective cohort analysis of patients who sustained concomitant clavicle and rib fractures at two academic Level I trauma centers was performed. Operative and nonoperative clavicle treatment groups were compared as a function of the ISS: (1) mild (ISS <9); (2) moderate (ISS = 9–15); (3) severe (ISS = 16–25); and (4) profound (ISS >25). Primary outcome measures were days on supplemental oxygen, total days on room air, pulmonary complications, intensive care unit length of stay (ICU LOS), and hospital LOS (HLOS). We compared groups on the primary outcome variables while controlling for subjects’ sex, race, age, body mass index, and comorbidities using generalized negative binomial models.
Results: In total, 261 patients were included in the study: 108 in the operative clavicle group and 153 in the nonoperative clavicle group. Overall, there was a significant difference (P = 0.02) in total complications between the nonoperative (462) and operative groups (454). Patients with profound ISS required more days of supplemental oxygen; however, those treated operatively transitioned to room air more quickly than their nonoperative counterparts (P = 0.045). In patients with moderate and severe ISS, those treated operatively spent more days on room air compared to those treated nonoperatively in the same ISS categories (P = 0.015, P = 0.006). Although overall HLOS was longer for profoundly injured patients, the LOS was shorter for those who underwent surgical treatment (P = 0.05).
Conclusion: Clavicle ORIF allows polytraumatized patients with concomitant clavicle and rib fractures and higher ISS to transition to room air more quickly, spend more time on room air, and reduce hospital LOS. When stratified by ISS, clavicle fracture ORIF in these polytraumatized patients improves pulmonary function.
Annual Meeting Podium AM Podium #76
Single Antibiotic Use With Ceftriaxone for Prophylaxis of All Open Fractures
Michael William Koulopoulos, MD; Alison Buseck, BS; Katherine Lutz, BS; Olivia Brand, BS; Eleanor Sommers, BS; Conor Lynch, MD; Isaiah Pompo, BS; Andrew J Laychur, MD; Kenneth Mann, PhD; Matthew Sullivan, MD
Purpose: Although many strategies for antimicrobial prophylaxis are described in the literature, a gold standard quorum on antibiotic choice has yet to be reached. This study aimed to determine whether a single antibiotic could effectively be used for prophylaxis for all open fractures, regardless of Gustilo type.
Methods: A retrospective review was conducted of all patients from a single Level I trauma center who underwent surgery for an open fracture over a 6-year period (2016 to 2022). Our institution switched to a single antibiotic regimen for antibiotic prophylaxis of all open fractures in 2018 (CTX group). Previously, patients with Gustilo I and II open fractures received cefazolin, while patients with Gustilo III fractures received either ceftriaxone or a combination of cefazolin and gentamicin (the classic group).
Results: A total of 521 patients met inclusion criteria for this study (see table). The groups did not significantly differ in terms of preoperative characteristics or postoperative outcomes, including deep infection rate. Subgroup analysis of only Type I and II fractures also demonstrated no significant difference in deep infection rate.
Conclusion: Single antibiotic prophylaxis with ceftriaxone for all open fractures is a viable alternative to antibiotic choice based on Gustilo classification. Using ceftriaxone for prophylaxis of all open fractures also simplifies medical decision making to ensure patients with open fractures receive adequate antibiotic prophylaxis.
Annual Meeting Podium AM Podium #77
Intraoperative Lactate: A Marker for Predicting Post-Surgical Complications in Orthopaedic Trauma?
Sai Kashyap Reddy, BS; Fatima Bouftas, BS; Marcus Allen, BS; Mary Kate Erdman, MD; Tony Christiano, MD; Jason Strelzow, MD, FRCSC
Purpose: Serum lactate is widely used as a marker for tissue perfusion perioperatively, with elevated levels associated with poorer outcomes. No available orthopaedic literature has examined intraoperative lactate as a predictor of outcome; however, non-orthopaedic literature demonstrates that early-onset hyperlactatemia develops intraoperatively and may be associated with postoperative complications (POC). The purpose of our study is to assess the relationship between intraoperative lactate and POCs.
Methods: A prospective cohort study was performed at a Level I trauma center. Adult orthopaedic trauma patients who were undergoing surgical fracture management were included. Patients with preexisting conditions influencing baseline lactic acid levels were excluded. A priori power analysis confirmed that 114 subjects were required to detect a clinically meaningful difference with 90% power and α = 0.05. Patient demographics, injury information, Injury Severity Score (ISS), and surgical details were collected. POC rates including elevation of care, surgical site infection, and revision surgeries were collected.
Results: In total, 150 patients were enrolled (male: 80.5%; African American: 61.7%). Motor vehicle accidents (55.6%) and femoral shaft fractures (41.9%) were the most common mechanisms of injury. The mean ISS was 23. Intraoperative lactate ranged from 0.7 to 10.1 mmol/L with a median serum intraoperative lactate of 1.9 mmol/L, which was significantly higher than preoperative levels (1.7 mmol/L, p = 0.02). Overall, 24% of patients experienced a complication during their hospitalization and 31% encountered a complication within 90 days of discharge. Patients with preoperative hyperlactatemia experienced a 1.46-times greater odds of complication during hospitalization (p = 0.01) and a 1.12-times greater odds of complication post discharge (p = 0.042). No correlation between intraoperative lactate and complications was found, although the median lactate did not exceed established thresholds of severe hyperlactatemia (>4.0mmol/L).
Conclusion: This study confirmed that preoperative lactate is an established predictor of all-cause complications following trauma. Surprisingly, intraoperative lactate was not predictive. However, the median intraoperative lactate in this study did not exceed established risk thresholds (>4mmol/L), which likely reflects modern surgical precautions and control of serum lactate perioperatively to monitor patient resuscitation. Further controlled trials may help confirm our conclusion.
Annual Meeting Podium AM Podium #78
Fracture Table vs. Lateral Positioning for Intramedullary Fixation of Femur Fractures (The FLiP Study): The Clinical Outcomes of a Multi-Centre Cluster Randomized Crossover Pilot Study
Daniel Axelrod, MD; Sheila Sprague, PhD; Ernesto Guerra-Farfan, MD; Yaiza Garcia-Sanchez, MS; Brad Meulenkamp, MD; Melanie Dodd-Moher, MHK; Sofia Bzovsky, MSc; Christy Shibu, BSc; Gina Del Fabbro, BPH; Jodi Gallant, MSc; Thomas Mammen, MD; Herman Singh Johal, MD MPH; FLiP Investigators, MD
Purpose: Femoral shaft fractures (FSF) are common and severe injuries. Femoral malrotation is the most common complication following intramedullary nailing of FSFs and is associated with gait disturbance, pain, and reduced health-related quality of life. There is no definitive research comparing two commonly used positions to treat these fractures: lateral positioning on a radiolucent table (LRT) and supine position on a fracture table (SFT).
Methods: A pilot multicenter, prospective cluster randomized crossover trial was performed in three orthopaedic trauma centers. Patients age 18 years and older with FSFs amenable for antegrade intramedullary fixation were included. Randomization was done in clusters by center, with crossovers occurring every 2 months. Patients, outcome assessors, and statisticians were blinded to treatment allocation.
Results: In total, 101 patients were enrolled in the trial; 47 patients were treated with LRT and 54 with SFT. Feasibility outcomes of the trial have been previously reported. The odds of having a femoral malrotation angle of ≥15° versus <15° in patients were 2.56 times higher in the SFT group than in the LRT group (95% CI: 1.02–6.40; p = 0.04). In both groups, patients were more likely to have an external rotation deformity compared to their native anatomy, although external rotation was more common in the SFT group when compared to the LRT group (69.8% vs 59.6%; p = 0.17). No secondary outcomes were found to be clinically important.
Conclusion: In this clinical outcome assessment of patients enrolled in a feasibility trial, patients treated in a supine position on a fracture table were more likely to have clinically important femoral malrotation after treatment of their FSF.
Annual Meeting Podium AM Podium #79
Effects of Smith-Petersen Open vs Closed Reduction on Major Complications for Femoral Neck Fractures in Patients Less than 50 Years of Age Undergoing Repair
Cory A Collinge, MD; Jack Will, BS; Phillip Mitchell, MD; Michael Beltran, MD; Andres Rodriguez-Buitrago, MD; Andrea Finlay, PhD; Michael Archdeacon, MD; Paul Tornetta, MD, PhD, FIOTA; Michael Gardner, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA; Young Hip Fracture Group
Purpose: Our objective was to compare clinical outcomes of a Smith-Petersen open reduction versus a closed reduction method for treating femoral neck fractures (FNF) in patients younger than age 50 years undergoing fracture repair. We hypothesize that open reduction will result in improving reduction accuracy, resulting in lower rates of major complications.
Methods: This multicenter retrospective cohort study included skeletally mature patients younger than age 50 years with isolated FNFs (OTA type 31B) treated at 26 Level I trauma centers in North America. Patients undergoing open versus closed reduction were compared for our primary outcome of major complications (nonunion/failed fixation, malunion, osteonecrosis, and need for major reconstructive surgery) and our secondary outcome of reduction quality using Haidekewych’s method.
Results: In total, 370 patients were included, with 246 undergoing open reductions using a Smith-Petersen approach and 124 undergoing closed reductions. Open reduction patients were younger (35.2 years vs 39.6 years, P<0.001) and more likely to have Pauwels’ III fractures (68.9% vs 57.3%, P = 0.017), but otherwise did not differ by gender, body mass index (BMI), or presence of metabolic bone disease. Open reductions resulted in better reduction quality rated as either good or excellent (88.5% vs 79.4%, P = 0.007) and fewer technical errors (29.8% vs 58.7%, P = 0.011) compared to closed reductions. Major complications were less frequent in open reductions (38.6% vs 48.3%, P = 0.015), with trends suggested for fewer failures from malunion (P = 0.068), osteonecrosis (P = 0.068), and nonunion/failed fixation (P = 0.095).
Conclusion: Open reduction using a Smith-Petersen approach in patients younger than age 50 years with FNFs achieved a higher rate of good and excellent reductions than closed reductions. Open reductions also showed that major complications were less frequent compared to those done with closed methods, and trends suggested fewer failures from malunion, osteonecrosis, and nonunion/failed fixation.
Annual Meeting Podium AM Podium #80
The Diagnostic Accuracy of Micro Electric Mechanical System-Based Continuous Pressure Monitoring
Mohammed Balhareth, MD; Prism Schneider, MD, PHD, FRCSC; Allan S.L. Liew, MD, FRCSC; Pierre Guy, MD, MBA; Jeremy Alan Hall, FRCSC; AbdelRahman Lawendy, MD; Ross Kenneth Leighton, MD, FIOTA
Purpose: Acute compartment syndrome (ACS) is a rare but serious condition in which increased pressure within a confined space leads to ischemia and tissue necrosis. Early diagnosis and management are critical for preventing long-term complications.
Methods: A prospective clinical study was conducted with 100 patients across six sites in Canada. The studies aimed to evaluate the management of ACS using a combination of clinical signs and microelectromechanical system (MEMS)–based continuous-pressure monitoring with a Health Canada- and FDA-licensed device. Patients with a high risk of ACS were included in the study, and their clinical and demographic data were collected. Continuous-pressure monitoring was performed, and the results were compared with the clinical signs of ACS.
Results: The results of the study showed that the combination of clinical signs and continuous-pressure monitoring with the MEMS device improved the accuracy of diagnosis and management of ACS. The results showed that the use of continuous-pressure monitoring reduced the time to diagnosis by 4 to 5 hours, and intervention within that time frame improved patient outcomes. The sensitivity and specificity of the test were both greater than 99% with no missed cases of ACS or false positives. Results indicate that pressure trends predated the onset of clinical signs and could serve as an earlier predictor of ACS, thus avoiding any potential to have a delayed or missed diagnosis.
Conclusion: The study concluded that the combination of clinical signs and continuous-pressure monitoring is a valuable tool for the management of ACS. This study provides evidence for the clinical utility of continuous-pressure monitoring in the management of ACS and highlights the importance of early detection and prompt intervention in the management of this condition. The study also showed the utility of the device in determining the possibility of ACS in neurologically impaired or moribund patients (intubated). The study highlights the need for further prospective trials to evaluate the long-term outcomes and the cost-effectiveness of continuous-pressure monitoring in the management of ACS.
Annual Meeting Podium AM Podium #81
How Safe are Minimally Invasive Photodynamic Intramedullary Implants?
Christen Chalmers, MD; Russell Stitzlein, MD; Amanda Goldin, MD
Purpose: Photodynamic nail implants have shown promise as a means to provide supplemental fixation through a minimally invasive approach. Indications for this implant continue to expand, particularly in pathologic and osteoporotic bone. However, the minimally invasive nature of this procedure may belie the risk profile of this implant. This retrospective review aimed to evaluate the frequency of perioperative complications associated with this implant.
Methods: We retrospectively reviewed all patients who underwent photodynamic nail placement at a tertiary care hospital between March 2022 and December 2024. Demographics, comorbidities, ASA score, surgical technique, and complications were collected. Statistical analysis was performed using Fisher’s exact test and one-way analysis of variance (ANOVA).
Results: In total, 72 patients [mean age: 66.8 years [range: 35–96 years], males: 33 [48.5%]) underwent 76 procedures using the photodynamic implant. The mean Charlson Comorbidity Index (CCI) was 6.01 (range: 0–12) with 69.4% of patients with an ASA score of 3. The implant was used to stabilize impending/pathologic fractures (68.4%), nonpathologic fractures with compromised bone quality (18.4%), and nonunion repairs (13.2%). The most common surgical sites were the humerus (64.4%) and pelvis (21.1%). Additional hardware was used to augment fixation in 55.2% of cases. The overall complication rate was 10.5%, including two intraoperative cardiac arrests with perioperative mortality, one case of transient severe hemodynamic instability requiring pressor support, four hardware failures, and one surgical site infection. Additional hardware fixation was not associated with hardware failure. Oncologic history and CCI were not predictive of complication.
Conclusion: Despite the minimally invasive nature of the procedure, photodynamic nail implant use resulted in higher-than-expected perioperative complications. The mechanism for implant filling causes rapid and broad elevation of intramedullary pressure, which can lead to fat embolism and potential cardiopulmonary collapse. Unlike reamed implants, it is not easily possible to create a “vented” system. Proper communication with anesthesia providers and preoperative counseling regarding these risks is essential, particularly for medically complex patients.
Annual Meeting Podium AM Podium #82
Perioperative Inpatient Anemia is Associated With Long Bone Nonunion
Kathryn Barth, MD; Gregory Vincent Schimizzi, MD PhD; Christian Gabriel Falgons, BA; Christopher Wilson, BA; Cole Payne, BA; Connor Park, BA; Augustine Mark Saiz, M.D.; Patrick Kellam, MD; Stephen Warner, MD, PHD; Timothy S Achor, MD
Purpose: Long bone fractures are common, and nonunion can lead to increased morbidity. Perioperative anemia has been associated with nonunion in select fractures but has not been well evaluated in long bone fractures. This study determined if an association exists between perioperative anemia and union in patients with lower extremity long bone fractures.
Methods: Adult patients who underwent surgery for lower extremity long bone fractures between January 2020 and December 2021 at a single institution were identified. Periprosthetic and pathologic fractures, fractures in skeletally immature patients, and fractures not exclusively involving the diaphysis were excluded. Patients with initial treatment at an outside institution and inadequate follow up were also excluded. Demographic information, injury characteristics, and laboratory values at various timepoints during hospital admission were collected. The primary outcome was fracture union.
Results: In total, 737 patients met inclusion criteria (mean age: 39.7 years [SD: 18.1], male: 67%). Femur fractures accounted for 54% of the long bone fractures. The overall nonunion rate was 9.77%. There was no association between long bone type and nonunion (p = 0.639). The patients with nonunion had a higher percentage of open fractures (53% vs 37%, p = 0.011) and greater Injury Severity Scores (ISS) (19.8 vs 15.1, p = 0.004) compared to patients with union. The nonunion group had lower preoperative hemoglobin (10.7 vs 11.6, p = 0.020) and hematocrit (31.1 vs 33.8, p = 0.011) values on the day of surgery, postoperative day 1 (9.1 vs 9.7, p = 0.021; 26.7 vs 28.5, p = 0.013), and prior to discharge (9.3 vs 9.8, p = 0.009; 27.5 vs 28.8, p = 0.014). The lowest hemoglobin at any point during the admission (7.9 vs 8.9, p = 0.002) was lower in the nonunion group. In addition, the nonunion group had a greater percentage change from admission to lowest hemoglobin (40% vs 32%, p = 0.003), which was associated with nonunion using logistic regression analysis (OR: 6.75).
Conclusion: In our cohort of more than 700 patients with long bone fractures at a single institution, perioperative, inpatient anemia was significantly associated with nonunion. This suggests that we critically evaluate the current thresholds for permissive anemia in patients with trauma.
#1
Use of Ankle Distraction Frames in Treatment of Pilon Fractures: Technical Trick
Katherine Sborov, MD; Lauren Turner, BS; Geoffrey Marecek, MD
Purpose: Tibiotalar arthrodiastasis, or ankle distraction arthroplasty, can facilitate cartilage repair, restore joint space, and improve range of motion for ankle arthritis. We describe an adaptation of this technique for acute treatment of pilon fractures to facilitate immediate weightbearing, early range of motion, maintenance of articular reduction, and chondroprotection due to distraction and motion.
Methods: Four patients underwent open reduction and internal fixation (ORIF) of pilon fractures (AO/OTA 43B or C). An ankle arthrodiastasis frame was applied after definitive internal fixation. All patients were treated by a single orthopaedic fellowship-trained trauma surgeon at a large academic hospital. Patients had the ankle locked in a plantigrade position for 2 weeks while the surgical incisions healed and were permitted range of motion as tolerated thereafter. The frames were removed at 3 months postoperatively.
Results: The mean age was 33.3 years (range: 23–47 years), and three patients were male. Three patients had initial ankle-spanning external fixation using a ringed external fixator (MaxFrame™, Johnson and Johnson, West Chester, PA) followed by modification for ankle distraction after ORIF. One patient had the distraction frame applied after ORIF; no initial spanning was performed. One patient had a contralateral injury that precluded weightbearing on that leg while the others had isolated injuries. Follow up ranged from 3 to 27 months. Mean Patient-Reported Outcomes Measurement Information System (PROMIS) scores for physical function and pain interference were 34 and 62, respectively, at 3 months for all patients and 44 and 61 at >1-year follow up for two patients. There were no complications related to the frame or otherwise. One patient underwent removal of hardware at 1 year.
Conclusion: Distraction arthroplasty in the acute treatment of pilon fractures allows for early weightbearing, immediate ankle range of motion, and the potential biologic and biomechanical properties of arthrodiastasis on articular cartilage and joint function.
#2
Wire-Based Tension and Buttress Plating for Fragment Specific Fixation in Foot and Ankle Trauma
Seghen Woldai, BS; Shannon Tse, BMBS; Sean Thomas Campbell, MD
Purpose: Displacement of small osseous or osteoarticular tension and compression failure fragments may contribute to articular incongruity or instability after foot and ankle trauma. These fragments can be difficult to reduce and stabilize with traditional techniques if they are very small or covered in soft tissue. This study describes a wire-based fragment-specific technique and reports outcomes from a case series. The hypothesis was that this technique has a low rate of complications and a high rate of maintaining reductions.
Methods: A retrospective case series of patients treated with wire-based fragment-specific plating by a single surgeon for foot and ankle trauma from 2022 to 2024 was conducted. The technique uses a small-diameter k-wire to guide compression along the compression side for tension plating or sub-articularly for buttress plating. In tension plating, a mini fragment plate is applied over the wire, and proximal screws set the tension by “pulling” on the wire. In buttress plating, the plate is applied over the wire, and screws are placed proximally to act in buttress mode. The wire directs compression onto the fragment, is triple bent, and is retained.
Results: In total, 18 patients (23 plates) were included. Fracture patterns included 13 rotational ankle fractures, three partial articular posterior pilon fractures, one navicular fracture, and one talar fracture. Plate locations were medial malleolus (13), posterior malleolus (5), Chaput fragments (3), navicular (1), and talar neck/body (1). Plates were applied as tension plates in 17 cases and buttress plates in six. All fractures achieved uneventful union with no loss of reduction or implant failure. One patient required implant removal for prominence.
Conclusion: Wire-based fragment-specific plating effectively stabilizes foot and ankle fractures with low complication and symptomatic implant removal rates. It generates compression, particularly on the tension side of tension-failure injuries, and is useful for securing small fragments difficult to fix with screws, such as small medial malleolar, Chaput, or posterior malleolar fragments.
#3
Tibial Fractures at High Risk of Infection Treated With Intramedullary Nailing: Do Nails With Antibacterial Coatings Make a Difference?
Nikolaos K Kanakaris, MD, PhD; Vasilis Giannoudis, MBChB, MRes; Ritchie Strain, FRCS; Peter V Giannoudis, MD, FACS, FRCS
Purpose: One of the recent prevention strategies of fracture related infections (FRIs) has been to use antibacterial-coated implants. The purpose of this study was to evaluate two commercially available coated tibial nails compared to standard noncoated nails.
Methods: A prospective collection of single center data of high-risk tibial fractures treated with any of the three implants (the PROtect nail, the Bactiguard nail, and a standard noncoated nail) with a minimum follow up of 12 months was analyzed. High-risk was defined as open fractures, fasciotomies, and fractures treated initially with a bridging external fixator, or Tscherne grade 2 or 3 soft-tissue trauma. Exclusion criteria included patients managed with different methods or inadequate follow up. Statistical analysis was performed using Stata software, with a significance level of p<0.05 among the three different groups.
Results: Of the 234 tibial fractures that were analyzed, 102 were treated with the PROtect nail, 41 with the Bactiguard nail, and 91 with a noncoated standard tibial nail. There were no statistically significant differences in the epidemiologic, comorbidity characteristics, severity of associated injuries, fracture types, severity of soft-tissue trauma, or the time-to-definitive fixation or soft-tissue management. Exceptions to this uniformity were the identification of statistically less simple falls (p = 0.028), more patients with a history of excess alcohol use (p = 0.038), more Tscherne grade 3 (p = 0.048), and a shorter mean period with an external fixator (4 vs 6 days, p = 0.015) in the Bactiguard group. An FRI was recorded in eight fractures (7.8%) treated with a PROtect nail, two (4.9%) with a Bactiguard nail, and 12 (13.2%) with noncoated nails. Uncomplicated union within 6 months was recorded in 64.7% versus 65.9% versus 53.8%, respectively. Unplanned secondary interventions were required in 26.5% versus 22% versus 41.8%, respectively. The mean RUST score at the final follow-up was 10 in all groups, while the range of motion of the adjacent knee and ankle joints was also comparable. Power analysis with primary endpoint in the development of an FRI identified the need to randomize 740 patients treated in 1:1 ratio with either coated or noncoated nails.
Conclusion: Our findings suggest that coated tibial nails achieve a lower incidence of fracture-related complications and need for secondary interventions compared to noncoated nails.
#4
Fabricating a Novel Reusable Surgical Drill Cover: A Technical Trick for Low/Middle Income Countries (LMIC)
Joel M Post, DO; Jason Fader, MD
Purpose: Specialty surgical drills can be prohibitive in low/middle income countries (LMIC) for a variety of reasons, such as model generation incompatibility, supply chain limitations, lack of available biotechnical expertise, skyrocketing medical equipment costs, international inflation, etc. The purpose of this study was to demonstrate a video of a technical trick for fabricating a novel, sterilizable, cloth surgical drill cover with chuck extender to go over a nonsterile commercially available power drill.
Methods: Dimensions were calculated from a commercially available drill and oversized by approximately 150%. Nonspecialty cloth (cotton/polyester mix) was used to sew a custom cover (bag). A large hole was left on one end with cloth ties added to completely encase the drill. A ⅜-inch metal grommet was sewn into the cloth at the location of the drill chuck opening.
Results: The cover, chuck extender, and key were sterilized in an autoclave and opened onto the surgical field. The nonsterile drill was placed into the fabricated cloth bag. The chuck extender was then inserted through the grommet into the drill chuck and tightened. Sterile gauze was tied around the grommet–chuck extender for further interface coverage. The drill was then used per routine.
Conclusion: Fabricating a novel, reusable cloth surgical drill cover for a commercially available power drill in resource-limited LMICs is inexpensive and feasible.
#5
Traumaplasty in Elderly Pilon Fractures: Can It Be Done?
Kyle Schweser, MD
Purpose: Our objective was to determine whether open reduction and internal fixation (ORIF)/acute total ankle arthroplasty (TAA) (ie, traumaplasty) in elderly pilon fractures is a safe alternative to traditional ORIF.
Methods: Elderly patients who presented in 2024 with a severely comminuted/impacted pilon fracture, were deemed high risk for complications, and/or had preexisting arthritis were offered ORIF or ORIF/TAA. ORIF/TAA was performed in the same surgical setting, with ORIF occurring first. All were performed through an anteromedial approach, and all TAAs were cemented (see figure). All TAAs were splinted for 2 weeks. Isolated injuries were allowed weightbearing at 2 weeks; otherwise, weightbearing was restricted to 6 weeks. AAOS Foot and Ankle scores and ankle range of motion (ROM) information were collected.
Results: Acute ORIF/TAA was performed on four patients (mean age: 66 years; mean follow up: 6 months) with a 100% implant retention rate (mean AAOS Foot and Ankle score: 70.75; mean dorsiflexion: 5°). All patients had at least one major medical comorbidity; two patients had bilateral lower extremity fractures and one patient had an unplanned return to the operating room with no deep tibiotalar infection/involvement. All patients were satisfied; all had radiographic evidence of healing and stable arthroplasty.
Conclusion: Traumaplasty in elderly pilon fractures, at least short term, has low complication rates, allows earlier return to ambulation, and is associated with good PROS and ROM. Further study and longer-term follow up is needed. *OTA: 6 patients with average f/u of 12 months (8-17 months)
#6
Novel Technique For Treating Atypical Femur Stress Reactions: Cortical Flip Osteotomy
Michael Doany, MD; J Tracy Watson, MD; Djoldas Kuldjanov, MD
Purpose: Atypical femur fractures present a challenge to orthopaedic surgeons. Delayed healing and nonunion are common, even in the setting of prophylactic nailing for stress reactions. This novel technique aims to concurrently address issues with local biology and biomechanics.
Methods: Surgical technique involves a subvastus approach centered over the stress reaction. An osteotomy is planned 8 to 10 cm long and 1 to 1.5 cm high, centered over the beaking. The beak is at the junction of the proximal third and distal two thirds of the osteotomized segment. The segment is flipped 180°, resulting in the beak moving distally out of the subtrochanteric region (see figure), moving the biologically at-risk tissue into a more biomechanically favorable environment for healing. The osteotomy is stabilized with a unicortical small fragment plate before proceeding with a standard intramedullary nailing technique.
Results: Two patients were successfully treated at our institution in the past year. Both were treated for acute atypical femur fractures and diagnosed with contralateral stress reaction. Prophylactic nailing combined with cortical flip osteotomy was done during the same hospital admission. Both healed uneventfully by 6 months.
Conclusion: This novel technique presents a strategy for managing atypical femur fractures that advantageously influences local biology and biomechanics to promote healing. It can be considered in prophylactic stress reactions and recalcitrant nonunions.
#7
Mini-Fragment Fixation in the Treatment of Vancouver B2 Periprosthetic Femur Fractures
Max L. Lee, MA; Alexa Pius, MD; Michael J Gardner, MD; Julius A Bishop, MD; Lawrence Henry Goodnough, MD, PhD
Purpose: The incidence of periprosthetic femur fractures after total hip arthroplasty (THA) continues to rise. The optimal reduction and fixation strategy of trochanteric fragments remains unknown, but in general involves the use of stout, precontoured plates in anti-tension mode. The purpose of our study was to establish the effectiveness of mini-fragment fixation in a small case series of B2 periprosthetic femur fractures. Our hypothesis is that mini-fragment fixation in the treatment of Vancouver B2 periprosthetic femur fractures is safe and effective with rates of fixation failure comparable to historical alternatives.
Methods: A retrospective review of patients treated for Vancouver B2 periprosthetic femur fractures with mini-fragment plate fixation was performed. Surgeries were performed by a trauma fellowship-trained orthopaedic surgeon at an academic Level I trauma center between August 2022 and July 2024. Demographic characteristics and outcome measures (postoperative dislocation, infection, mortality, malunion, nonunion, fixation failure, and instability) were assessed postoperatively.
Results: This case series included five patients, average age 84 years (range, 72–92 years), 40% female, average BMI 28.2 (range, 20–35.3), average ASA classification 2.8. Four patients had a low injury mechanism, and one patient had a high injury mechanism. All patients had uncemented implants from a previous THA and were treated via a lateral or anterolateral approach. Average follow-up was 7.3 months (range, 1.5–24 months). No postoperative complications, such as dislocation, reoperation, infection, nonunion, malunion, fixation failure, instability or symptomatic implants, occurred.
Conclusion: After fixation of Vancouver B2 periprosthetic femur fracture with mini-fragment fixation, there were no instances of fixation failure or reoperation. Our study suggests that mini-fragment plate fixation is a safe and effective fixation strategy for Vancouver B2 periprosthetic fractures and may minimize symptomatic surface implant issues.
#8
Retrograde Nail/Plate Combination for Interprosthetic Femoral Fractures
Mohamad K Shaath, MD; Brendan Page, MD; Brendan Kosko, MD; Griffin Rechter, MD; Bader A. Nasir, BS; Elizabeth Davis Jacobs, MD; George J Haidukewych, MD
Purpose: Our objective was to report the results for a series of patients who underwent fixation of an interprosthetic femoral fracture (IFF) with a retrograde intramedullary nail (rIMN) and the periprosthetic plating system (PPS).
Methods: A retrospective review of patients who underwent fixation of an IFF with combination rIMN and PPS was performed at a Level I trauma center. Demographic and surgical data were extracted. Outcomes included complications, reoperation, or failure of treatment. Postoperatively, patients were allowed to be fully weightbearing.
Results: Thirteen patients met inclusion criteria. There were eight females (62%) with an average age of 80 years (range 62 to 95 years). Mechanism of injury included 11 falls (85%) and two motor vehicle accidents (15%). The median nail diameter was 12 mm (10 to 13 mm). The median nail length was 200 mm (130 to 260 mm). There was an average of six screws (3 to 7 screws) in the femoral condyles and an average of 4 screws (3 to 5 screws) in the femoral shaft proximal to the fracture. Patients had an average follow-up of 6 months (3 to 17 months, see figure). All patients were healed at final follow-up with no instances of implant failure. There were no infections and no revision surgeries.
Conclusion: This study highlights an effective fixation strategy of IFF with a combined rIMN and PPS.
#9
Dual Plating With Medial Twist Plate of Distal Femur Fractures
Hunter Bright Yancey, MD; Maddie C Smith, MD; Nicholas Andring, MD; Mattie Elizabeth Raiford, MD; Sharon Babcock, MD; Holly Tyler-Paris Pilson, MD; Jason Halvorson, MD; Eben A Carroll, MD
Purpose: We present a new surgical technique for dual plating of distal femur fractures. This technique consists of standard lateral locked plating combined with a medial plate contoured such that the distal part of the plate rests directly medial, while the proximal portion of the plate lies in the anterior compartment. By using a medial “twist” plate, this technique obviates risk to proximal femur vascular anatomy and provides an option for dual plating in distal femur fractures requiring long segment medial fixation.
Methods: We used a retrospective chart review of adult patients with distal femur fractures treated surgically with dual implant medial twist constructs. At least 6 months of radiographic and clinic follow up was required for inclusion.
Results: A total of 23 patients met inclusion criteria. Periprosthetic (12) and native (11) femur fractures were included. Average follow up was 13.9 ± 3.5 months. Of the 23 patients, 17 (73.9%) were made immediately weightbearing as tolerated (WBAT) postoperatively; six patients (26.8%) were kept non-weightbearing because of other ipsilateral injuries and/or fracture pattern. Of the 17 patients made WBAT, 14 (82.3%) were truly weightbearing with physical therapy, per therapy notes. 20 of 23 patients had returned to previous ambulatory status at their final follow up. There were no cases of nonunion or malunion requiring revision. Two patients sustained peri-implant fracture at the proximal extent of the construct. Both patients were initially treated with dual plates within two holes of each other in length. After these complications, practice was changed to ensure more range in plate length difference to limit stress-riser forces in the proximal femur.
Conclusion: We present a technique and case series for dual plating of distal femur fractures. This technique can be used to provide long medial segment fixation in select fracture patterns to allow for stable fixation and early weightbearing.
#10
Periprosthetic Femoral Fractures: Utilization of Small Fragment Screw-in-Washer for Easier Fixation of Large Fragment Plates
Daniel Scott Horwitz, MD; Ahmed Nageeb Mahmoud, MD, PhD; Michael Suk, MD, JD, MPH, MBA
Purpose: Our objective was to present a simple method that enables bicortical, large-fragment plate fixation in periprosthetic fractures (PPF) around a femoral component, using small fragment, 3.5-mm screws-in-washer (see figure).
Methods: All patients with PPF at our Level I trauma center between 2011 and 2024 were identified with CPT codes and had their radiographs and clinical data reviewed. Any patient with PPF around a hip arthroplasty who received plate fixation in which 3.5 mm screws-in-7 mm washers were used was included. Patients who did not complete 12 weeks of radiographic follow up were excluded.
Results: Of 82 patients with PPF, 18 patients fit the inclusion criteria while four were excluded for inadequate follow up, leaving 14 patients (female: 9) for analysis. Patients' mean age and body mass index (BMI) at surgery were 79 years and 31.3, respectively. Eleven patients received condylar plates while three received periprosthetic plates; eight patients had Vancouver C fractures while six had Vancouver B1 fractures. After a mean of 65.4 weeks of radiographic follow up, all fractures united without hardware failure. Intraoperative screw head breakage (a titanium screw due to chromium allergy) or drill-bit breakage occurred in two patients. Surgical debridement successfully managed a wound infection in one patient.
Conclusion: Using small fragment screws-in-washers through large fragment plates could provide an easy and timely way to perform strong, bicortical fixation around a femoral stem in periprosthetic fractures.
#11
Osteochondral Autograft From the Proximal Tibiofibular Joint for Reconstruction of Acute Tibial Plateau Fractures With Severe Chondral Defects
Abhinav Nalluri, MD; Adam Schlauch, MD; Pierre Tamer, MD; Alejandro Cortes, MD; Brian Farrell, MD
Purpose: Acute tibial plateau fractures with severe comminution and chondral defects including small free articular fragments can be challenging to reconstruct with open reduction and internal fixation (ORIF). This report demonstrates a novel approach to reconstruction of acute tibial plateau fractures with severe articular defects by using an osteochondral autograft from the ipsilateral proximal tibiofibular joint.
Methods: Two patients with closed acute tibial plateau fractures were treated with this technique. The patients included a male age 37 years with a Schatzker VI tibial plateau fracture and a female age 24 years with a Schatzker II tibial plateau fracture (see figure). Both patients underwent ORIF with harvest of an osteochondral autograft from the ipsilateral proximal tibiofibular joint through a standard lateral approach.
Results: Both patients achieved bony union, and infection developed in neither patient. A postoperative knee flexion contracture developed in the male patient. The contracture completely resolved following open release at 3 months, and the patient was completely pain free at 12 months postoperatively.
Conclusion: There are no prior case reports of the use of autograft from the proximal tibiofibular joint in reconstruction of acute tibial plateau fractures. The harvest of autograft from the proximal tibiofibular joint can be performed through a standard lateral approach to the tibial plateau with minimal morbidity for the patient.
#12
Retrograde Gluteal Cleft Sacral Screw Fixation for a Transverse Sacral Fracture (AO A3) With Cauda Equina
Laurens Aerden, MD; Michiel Herteleer, MD PhD
Purpose: A 75-year-old female sustained a transverse sacral fracture at level S3. There was progressive cauda equina symptomatology, and the patient experienced unmanageable pain. CT and MRI showed a transverse sacral fracture (AO A3) through a large Tarlov cyst.
Methods: The entry point for screw placement was determined with a navigated pointer. A 1-cm skin incision was made at the gluteal cleft, and a 2.8-mm K-wire drill bit was advanced through the navigated drill guide under X-ray control until just proximal to the fracture site (see figure). A 6.5-mm full-threaded 100-mm cannulated screw was then advanced until that same point just distal to the fracture site. Reduction of the S2-S3 fracture was achieved by leveraging the K-wire drill bit and cannulated screw. Subsequently, the K-wire drill bit was progressed up to the proximal endplate of the S1 vertebra. With the drill bit in situ, a new intra-operative 3D scan was made to verify the correct trajectory before the screw was further advanced.
Results: At 6-week follow-up, the patient demonstrated complete recovery of cauda equina function. There was no residual urinary or bowel dysfunction, hypoesthesia, or pain symptoms.
Conclusion: We describe a new technique for retrograde screw fixation of horizontal A3 sacral fractures.
#13
Novel Hip Containment Technique in Setting of Unstable Hip Joint in a Trauma Setting
Andrew P. Collins, MD; Reza Firoozabadi, MD
Purpose: A 39-year-old female who was involved in a motor vehicle collision sustained a right hip posterior wall acetabular fracture-dislocation. Subsequent dislocation was noted at the 4-week point with gross instability and heterotopic ossification (HO). She also sustained a stroke with right-side lower extremity flaccid paralysis. She underwent a hip containment technique using a transfemoral neck tunnel through the quadrilateral surface and FiberTape® for an unstable hip joint with neuromuscular compromise.
Methods: We used a Kocher-Langenbeck approach to remove debris in the joint and attempt to repair the capsule to reduce the small cranial bone fragment. Attention was then turned to the lateral proximal femur, and a wire was inserted through the femoral neck and head into the fossa-acetabuli and quadrilateral surface. An intrapelvic approach via Pfannenstiel incision was performed. Dissection until the pubic root and quadrilateral surface were exposed was performed. A cannulated drill was placed over the guidewire that was subsequently advanced into the pelvis by an assistant while the surgeon was protecting the obturator bundle and visualizing the advancement of the drill under oscillation through the quadrilateral surface, just caudal to the pelvic brim. The drill and guidewire were removed and FiberTape was introduced and tensioned over a 2.7-mm plate on the quadrilateral surface; FiberTape was also introduced on the lateral proximal femur.
Results: Postoperatively, this patient was made non-weightbearing because of lack of muscle tone. Routinely, we would recommend toe touch or foot-flat weightbearing for 6 weeks, followed by progressive weight bearing. Indomethacin was used for 10 days for HO prophylaxis, given the early HO that formed. At 1-year postoperatively, the patient reported improvement in mobility without evidence of repeat dislocation or significant HO.
Conclusion: This case presents a transfemoral neck tunnel through the quadrilateral surface and FiberTape for containing the femoral head within the acetabulum in the traumatic setting for posterior wall fractures not amenable to surgical fixation. This technique can recreate the stabilizing tension of the ligamentum teres, preventing recurrent hip dislocations in the appropriately indicated patient.
#14
Utilization of Calcaneal Mesh Plates for Internal Fixation of Comminuted Posterior Wall Acetabular Fractures: A Novel Technique
Joshua Adam Whitmore, MD; Prachi Lele, MD; Michael J Prayson, MD; Brandon Horne, MD; Jennifer Jerele, MD; David Thompson, DO
Purpose: The primary purpose of this clinical case series is to describe a novel technique for the fixation of posterior wall acetabular fractures not previously described. The secondary objective is to assess the short-term outcomes in a limited clinical series of patients stabilized by this method.
Methods: Three separate patients with comminuted posterior wall acetabular fractures were identified preoperatively on advanced imaging. Each patient consented to open reduction and internal fixation of the acetabulum before proceeding to the operating room. For each patient, the Kocher-Langenbeck approach was used. Following reduction, a 2.4/2.7-mm Synthes variable angle calcaneal mesh plate was contoured to buttress the reduced posterior wall fragments. The fragments were captured and secured through selective screws placed through the mesh plate. Each fracture was unique, with some requiring additional fixation specific to the aspects of concomitantly fractured parts of the acetabulum. Each patient was made non-weightbearing immediately postoperatively and followed up on an outpatient basis for an average of six months.
Results: Each fracture displayed stable reduction intraoperatively, and initial outpatient follow up began at 2 to 3 weeks postoperatively. All patients were allowed to increase their weightbearing status progressively at each postoperative visit, and eventually all were made weightbearing as tolerated. Subsequent follow up showed good clinical progress with no radiographic evidence of hardware failure up to 6 months postoperatively.
Conclusion: Acetabular fractures typically result from high-energy mechanisms, often with involvement and comminution of the posterior wall. Although there are several developed techniques for the fixation of these diverse injuries, no true gold standard exists. The use of a calcaneal mesh plate allows for fixation of comminuted posterior wall fractures as well as optimization of overall reduction and stability when combined with traditional fixation techniques for complex acetabular fracture patterns. This novel technique offers the advantages of a single construct that is modifiable and adaptable to the unique characteristics of the posterior wall injury. In our limited clinical experience, there has been consistent demonstration of adequate fixation and construct stabilization to warrant further investigation.
#15
Combined Anterior Intrapelvic Approach for Internal Fixation With Direct Anterior Approach for Acute Total Hip Arthroplasty for Geriatric Acetabular Fractures
Tyler Moon, M.D.; George Ochenjele, MD
Purpose: This technique is presented as a combined anterior intrapelvic (AIP) approach for open reduction and internal fixation (ORIF) of the columns followed by a direct anterior total hip arthroplasty (DA-THA) in the treatment of geriatric acetabular fractures.
Methods: In this series, seven patients underwent combined acetabular ORIF via the AIP approach and acute DA-THA in the same surgical setting. Patients were positioned supine on a Hana fracture table (Mizuho, CA, USA) with the pelvis and operative thigh included in the surgical field. Reduction of the columns was assisted by axial traction through the Hana table and completed with a ball spike pusher. A single precontoured 3.5-mm suprapectineal plate (6 patients) or recon pelvic plate (1 patient) was used to buttress the anterior column. Joint impaction was unable to be corrected in any patient. DA-THA was completed through a Smith-Petersen approach using noncemented primary THA implants with a multi-hole acetabular shell for screw fixation into the acetabulum (mean: 3.6 screws). No positional hip precautions were required postoperatively.
Results: Patients' mean age was 82 years. Six were anterior column-posterior hemitransverse fractures, and one was an associated both-column fracture. All patients had acetabular dome impaction, five patients had acetabular protrusio, and one had femoral head impaction. Mean surgical time was 245 minutes. Mean blood loss was 628 mL. Four patients required postoperative blood transfusion. No neurovascular injuries, infection, dislocation events, or revision surgeries were reported. One patient died during acute hospitalization because of aspiration-induced acute respiratory failure. Two patients sustained a submassive pulmonary embolism treated with oral anticoagulation. All surviving patients progressed to union. At the time of the final follow up, three patients were ambulatory without an assistive device and three patients were ambulatory with a walker.
Conclusion: Acetabular ORIF using the AIP approach combined with DA-THA is a safe and effective technique for management of anterior acetabular fractures with severe articular injury in the geriatric patient. This approach can limit surgical time and blood loss while minimizing the need for position changes.
#16
A Novel Technique to Maintain Skeletal Traction During CT Imaging for Acetabular Fractures With Mechanical Instability
Allen Champagne, MD PhD; Grant H. Cabell, MD; Alexander W. Parsons, MD; Jason S. Long, MD; Emily J. Harman, MD; Jacob S. Torrey, MD; Malcolm Rutledge DeBaun, MD
Purpose: Skeletal traction provides a temporizing measure in mechanically unstable pelvic injuries to maintain reduction and offload the hip joint. To date, preserving skeletal traction during CT imaging remains a challenge, with limited options that accommodate the sliding gantry. Here, we propose a safe and effective technique to maintain skeletal traction during CT imaging.
Methods: Prior to transferring the patient onto the CT gantry, the Kirschner traction bow is attached to a ratchet strap (Figure 1A–C) that is connected to a digital scale (Figure 1D). Tension is held manually during transfer, and the apparatus is then hooked onto the CT sliding gantry, without disrupting the safety mechanism (Figure 1E). Tension matching the weight hung to maintain reduction can be dialed in precisely using the ratchet (Figure 1D).
Results: This apparatus was implemented in the emergency department after complications were noted in a polytrauma patient with a large posterior wall fracture and multiple hip dislocations associated with serial CTs (Figure 1F). Since implementation, effective skeletal traction in 15 (meanage = 47.5 ± 22 years, 9 males, 6 females) mechanically unstable acetabular fractures resulted in no dislocation episodes around CT imaging. This technique was tested with multiple CT vendors (ie, GE, SIEMENS, Phillips).
Conclusion: The proposed apparatus provides a low-cost technique with a small footprint to maintain skeletal traction during CT imaging, when indicated, without additional radiation exposure.
#17
Simplified Cable Transport for Tibial Bone Defects
Stephen Wallace, MD
Purpose: The purpose of this video is to demonstrate a simplified method to build a cable transport frame for tibial defects that allows for the efficient execution of a bifocal or trifocal balanced cable transport with or without automation.
Methods: This video presents a step-by-step guide on how to efficiently pass cables, anchor transport segments, and connect cables in a manner that maximizes stroke length and decreases transport time.
Results: The figure shows a screenshot of the frame setup for a video demonstration. New elements include a floating ring, cable anchor attachment, cable routing elements, and automatic struts. The video will also include a time-lapse of the frame functioning automatically on a tibia model.
Conclusion: This simplified cable transport frame makes cable transport for tibial defects more accessible to surgeons with easier cable passing techniques, decreased surgical time, and improved transport efficiency. It allows for management of large tibia defects with the benefits of frame treatment such as full weightbearing and the potential for transport automation.
#18
A New Percutaneous Osteotomy for Better Regenerate
Stephen Wallace, MD
Purpose: Distraction osteogenesis is used for both bone lengthening and bone transport in complex deformity and bone defect cases. Traditional techniques involve creating a transverse osteotomy that is perpendicular to the long axis of the bone. The geometry of this transverse osteotomy minimizes bony surface area for regenerate potential. The purpose of this video is to demonstrate a new technique to perform a controlled oblique osteotomy to increase cross-sectional area of the osteotomy through a percutaneous procedure.
Methods: This video will demonstrate a novel technique to perform a 45° osteotomy in a long bone that is soft-tissue sparing.
Results: In a cylindrical bone model, a 45° osteotomy increases cross-sectional area by 41%. This has clinical implications for more robust regenerate formation and faster lengthening and transport times.
Conclusion: This novel percutaneous technique allowed for creation of an oblique osteotomy to increase cross-sectional area that increases volume of bony regenerate and decreases distraction time during long bone lengthening and transport.
#19
Removing Broken Intramedullary Nails in Less Than Ten Minutes With No Additional Trauma
Alejandro Ordas-Bayon, MD, FEBOT; Matija Krkovic, MD, PhD
Purpose: Removal of metalwork can be surgically challenging, particularly in the case of broken nails. However, although being very hard and time consuming, extraction is mandatory in order to carry on with nonunion surgery. The purpose of this study is to present an effective and atraumatic technique for removing the inaccessible part of femur and tibia nails.
Methods: In a retrospective review of four nonunion cases where a broken nail was present (one short cephalomedullary femur nail, one long cephalomedullary femur nail, and two tibial nails), average extraction time and number of attempts were inferred from C-arm imaging. First, an intact distal-locking screw hole containing a screw is selected (see figure). The original unbent olive-tipped guidewire is inserted and advanced down. The proximal part of the nail is then removed. The distal locking screw is exchanged for a 2-mm screw and advanced until it matches the nail’s diameter. Lastly, the guidewire is carefully pulled back until it gets jammed with the screw. Gentle pulling from the guidewire retrieves the broken nail.
Results: All broken nails were successfully extracted. The average extraction time was 9 minutes while the average number of attempts was 1.5.
Conclusion: This technique has the advantage of using previous incisions, therefore not necessitating further exposures or tissue damage.
#20
Blocking Wire Technique for Femoral and Tibial Shaft Fracture Reduction Yields Comparable Radiographic Outcomes to Blocking Screws
Abdullah Ghali, MD; Corey Bindner, MD; Neal Mody-Bailey, MD; Christopher Heath Perkins, MD; John Dawson, MD; Omar Hammad Atassi, MD
Purpose: Blocking screws are a well-established technique for fracture reduction in intramedullary nailing of long bones, yet literature on the blocking wire technique remains limited. This study evaluates whether blocking wires, which are removed after reduction, provide comparable radiographic outcomes to traditional blocking screws in femoral and tibial shaft fractures. We aim to present a technique video detailing the effectiveness and utility of blocking wires.
Methods: A retrospective cohort study was conducted at a Level I trauma center and a private hospital, including patients age 18 years and older who underwent intramedullary nailing for AO-32 and AO-42 fractures from August 2013 to June 2022. Patients were stratified into two groups: those treated with the blocking wire technique and those using blocking screws. The primary outcome was the change in coronal and sagittal alignment at final follow up. Statistical analysis included t-tests, Mann-Whitney U tests, and χ2 tests, as appropriate.
Results: After a review of 1040 femoral and tibial diaphyseal fractures treated with intramedullary nailing, 15 patients met inclusion criteria for the blocking wire group and 16 for the blocking screw group. No significant differences were found in demographics, fracture characteristics, or follow-up duration between groups (5.7 vs 7.6 weeks, p = 0.49). The mean change in coronal and sagittal alignment was 0.6° ± 0.8° and 0.4° ± 0.7° in the blocking wire group, compared to 0.8° ± 0.9° and 0.8° ± 1.1° in the blocking screw group. No significant differences were observed in coronal (p = 0.28) or sagittal (p = 0.66) alignment changes, and complication rates, including nonunion, were similar (p = 0.12).
Conclusion: The blocking wire technique demonstrated non-inferior radiographic alignment compared to blocking screws in femoral and tibial shaft fractures. This method may offer advantages in ease of placement and cost-effectiveness while maintaining reduction without increasing complications.
#21
Early Experience With On-Axis Percutaneous Retrograde Intramedullary Nailing of Humeral Shaft Fractures
Chiara Anna Giordani, MS; Shannon Tse, BMBS; Nick Andring, MD; Zoe Beatrice Cheung, MD, MS; Megan Terle, MD; Ellen Fitzpatrick, MD; Gillian Soles, MD; Sean Thomas Campbell, MD; Augustine Mark Saiz, M.D.; Mark Lee, MD
Purpose: Antegrade or retrograde intramedullary nailing (IMN) of humeral shaft fractures has gained increasing attention over the last decade. Antegrade nailing (AN) poses risks of iatrogenic rotator cuff injuries and postoperative shoulder pain, while retrograde nailing (RN) risks iatrogenic supracondylar fracture and postoperative elbow weakness. Although less common, RN is described as a viable surgical approach; however, there remains scarce data on outcomes for this technique in the literature. This study aims to describe early results for RN at our institution.
Methods: A retrospective case series was conducted on skeletally mature patients with extra-articular humeral shaft fractures treated with RN by a single senior, fellowship-trained orthopaedic trauma surgeon from 2018 to 2024. Patient demographics, fracture type, AO/OTA classification, and postoperative weightbearing protocols were recorded. Postoperative complications, including nonunion, delayed union, radial nerve palsy, infection, and reoperation were tracked to final follow up.
Results: The study included 21 patients, 43% female, with a mean age of 45.9 years (range 16 to 86) and BMI 25.8 (18 to 36). Based on the AO/OTA classification, fractures were classified as 62% 12A, 14% 12B, and 24% 12C, with 24% being open fractures. In nearly all patients, an IMN was used exclusively. Postoperatively, 24% of patients were made non-weightbearing, 43% partial weightbearing, and 33% were allowed to bear weight as tolerated. Among 17 patients with at least one follow up (median 60 days, IQR 247.0), one required early return for surgical site infection debridement. Follow up beyond 6 weeks occurred for 11 patients: two required nonunion repair, three had delayed union, two had subsequent falls after union with peri-implant fractures treated conservatively, and one had hardware removal for loss of terminal extension. No radial nerve palsies were observed postoperatively.
Conclusion: We have developed a minimally invasive, percutaneous RN technique for humeral shaft fractures that demonstrates no acute perioperative complications such as intraoperative fracture or radial nerve injury. However, nonunion, delayed union, and diminished elbow motion, were observed in a subset of patients. These findings highlight the need for further research evaluating the mid- and longer-term efficacy and safety of this technique.
#22
The Treatment of Complex Proximal Humerus Fractures With a New External Fixation Device
Nicola Godi, trauma surgeon
Purpose: Proximal humeral fractures represent 5% to 6% of all fractures and 25% of humerus fractures. Minimally invasive treatment with a dedicated external fixator is a valid treatment option. The purpose of this study is to prospectively evaluate the functional and radiographic outcome at a medium- and long-term follow up of treatment of proximal humerus fractures with a dedicated external fixator.
Methods: From January 2020 to December 2023, 64 patients with proximal humerus fractures were surgically treated with reduction (open or closed) and a new external fixation device. Inclusion criteria were 2-3-4 part proximal humeral fractures according to the Neer classification, preoperative independence in daily activities, and a minimum clinical follow up of 6 months. Exclusion criteria were pathologic fractures and cognitive deficits. We recorded the classification of the fracture, the type of reduction, and the maintenance time of the external fixator. Clinical and radiographic follow up was performed at 3, 6, and 12 months. The clinical outcome was assessed using the Constant score.
Results: A total of 53 patients (42 female, mean age: 67.27 years [SD ± 9.6] was included. According to the Neer classification, 52.8% (28) of the fractures were classified as three fragments, 30.1% (16) as four fragments, and 17% (9) as two fragments. Clinical and radiographic healing was achieved in all fractures, the external fixator was removed 4 to 6 weeks after implantation. In 90.6% of cases (48), the reduction was obtained closed, and in the remaining 9.4% of cases it was necessary to perform mini access or a deltoid-pectoral approach to allow the reduction. The mean Constant score at 3 months of follow up was 59.8 (SD ± 15.9), at 6 months 69.3 (SD ± 23.47), and at 1 year 82.5 (SD ± 17.9 ). The overall complication rate was 5.2%, with only one patient having a pinworm infection. The average hospital stay was 2 days.
Conclusion: In our experience, we achieved good radiographic and functional results. Following the recent literature, we can affirm that external fixation with a dedicated external fixator is a good alternative in treating complex proximal humerus fractures.
#23
Non-Operative Treatment of Proximal Humerus Fractures via Focus Rigidity Casting: A Technique Video
Kevin Johnson, BS biology; Paul Whiting, MD
Purpose: Proximal humerus fractures are commonly treated nonoperatively. Nonoperative management consists of functional bracing. Prefabricated braces are most commonly used; however, because of complex anatomy, they may not be the best method of stabilization. This article and video will demonstrate a method to stabilize proximal humerus fractures using focus rigidity casting (FRC) (see figure).
Methods: We provide a step-by-step video demonstration of the proper fabrication and fitting of the FRC.
Results: The FRC method received excellent satisfactory reports from surgeons, excellent stabilization on radiographic images, and better patient satisfaction compared to plastic prefabricated devices.
Conclusion: FRC application offers a more customizable approach to fracture stabilization as compared to prefabricated braces.
#24
A Novel Minimally Invasive Approach for Intra-Articular Scapular Fracture Fixation
Hans Peter Van Lancker, MD, MBA; Donald Fejfar, MD; Jason Young, MD; Yasser Bouklouch, PharmD MPH; Edward J Harvey, MD, FIOTA, FAAOS, FRCSC; John Esposito, MD, MSc, FRCSC
Purpose: Traditional open approaches to intraarticular scapular fractures, such as the Judet approach, can be associated with significant soft-tissue dissection, increased blood loss, and prolonged recovery. This article describes a novel minimally invasive surgical technique for the treatment of select intraarticular scapular fractures, representing an open modification of the Neviaser portal, designed to minimize these morbidities.
Methods: Three patients with intra-articular scapular fractures underwent this novel minimally invasive procedure. The procedure is performed under general anesthesia with the patient in the beach chair position, using a Trimano arm positioner. Fluoroscopic guidance is employed throughout the procedure. Fracture manipulation is achieved using a 4-mm external fixator pin as a joystick, and fixation is accomplished with cannulated screws. Data collected included surgical time, estimated blood loss, and postoperative functional outcomes.
Results: All three patients achieved good clinical outcomes with a return to near-normal function. The average case duration was less than 1 hour, and blood loss was minimal in all patients. All patients were discharged on the same day.
Conclusion: This minimally invasive approach demonstrates promising results for specific intraarticular scapular fracture patterns. By minimizing soft-tissue disruption and blood loss, this technique offers potential advantages over traditional open techniques, potentially facilitating faster recovery and reducing morbidity associated with larger open approaches like the Judet approach. This modified Neviaser portal approach represents a valuable alternative for select intraarticular scapular fractures.
Biomechanical Testing of 3D-Printed Implants for the Fixation of OTA Type B Ankle Fractures
Myles Dworkin, MD, MPH; Michael Bergen, MD; Eleanor Burstein, MD; Rachel Schilkowsky, M.S.; Joseph Cusano, MD; Janine Molino, PhDD; Brad Blankenhorn, MD, MS
Purpose: 3D printing is an affordable manufacturing option that offers many advantages for healthcare delivery. The purpose of this study was to evaluate the use of 3D-printed one-third tubular plates compared to standard manufactured plates for the fixation of OTA type B ankle fractures.
Methods: Carbon-fiber–reinforced polyetheretherketone one-third tubular plates were designed and printed using Fused Deposition Modeling printers by the study authors. A cadaveric biomechanical comparison between fractures stabilized using 3D-printed plates and those stabilized using standard manufactured plates was performed. Match-paired specimens underwent axial cyclic loading and torsional load to failure defined as 2 mm of fracture displacement. A 4-point bend test was performed. Generalized estimating equations were used to compare results.
Results: Ten match-paired specimens underwent mechanical testing. All specimens survived 100,000 cycles loaded to 875N. Torque at failure did not significantly differ between groups (p = 0.14). During torsional load to failure, all 10 specimens (100%) with the standard plate failed because of screw pullout. Five specimens (50%) with the 3D plate failed because of screw pullout, and five (50%) failed because of plate fracture. Eight plates (four 3D, four standard) underwent a 4-point bending test. Stiffness was significantly lower in the 3D plate (p<0.0001). The intraclass correlation coefficient was 0.98 for the 3D-printed plates and 0.96 for the standard manufactured plates demonstrating high consistency within groups.
Conclusion: These results demonstrate that fixation constructs composed of 3D-printed one-third tubular plates performed similarly to standard manufactured devices in simulated clinical tests despite differences in mechanical properties. There was no significant difference between the two groups with regard to performance during cyclic axial load or torsional force to failure, indicating that there may be a role for 3D-printed devices such as these in clinical practice. Furthermore, the 3D-printed devices were able to be reliably reproduced with each plate performing similarly. The ultimate stiffness and mode of failure, however, were different. As 3D printing becomes more prevalent, it is essential to understand their design, their potential benefits, and how they differ from standard manufacturing in order to optimize function and prevent complications.
Parallel Trajectory of Cannulated Screws Is Biomechanically Advantageous to Diverging Trajectory in Moderate Pauwels Angle Femoral Neck Fractures
Cory Hewitt, MD; Alyssa Peterson, BS; Raghunandan Nayak, BS; Rohan Patel, BS; Tomer Korabelnikov, BS; Nathan Deming, BS; Krystyna Gielo-Perczak, PhD; Adam Lindsay, MD; Alyssa Peterson, BS
Purpose: Femoral neck fractures are significant injuries with a high morbidity and mortality rate in the geriatric population. Surgical treatment is recommended for improved mobilization. The current gold standard includes internal fixation with three screws in a parallel trajectory and inverted triangle formation. The purpose of this study is to determine if parallel or diverging screw trajectories have a biomechanical advantage in treating moderate Pauwel’s angle transcervical femoral neck fractures.
Methods: This study used 32 identical femur models; one-half were assigned to the parallel trajectory group and the rest to diverging trajectory. A 3D printed guide was used to make femoral neck cuts and insert K-wires for both screw trajectories. The fractures were made at a Pauwel’s angle of 40° before fixation with 6.5 mm partially threaded, cannulated, stainless steel screws in an inverted triangle arrangement. To test torsional stiffness, torque was applied in a vertical axis through the femoral head. Axial stiffness and load to failure (LTF) involved vertical axial loads applied through the center of the femoral head. Models were examined for anatomic points of failure.
Results: Thirty femurs were included for final analysis. One model from each group exceeded the testing machine’s limits and were excluded. Parallel screws demonstrated significantly greater axial stiffness compared to the diverging screws (431 N/mm ± 45 N/mm vs 367 N/mm ± 104 N/mm respectively, p = 0.032). No significant difference was found for torsional stiffness (6.36 Nmm/deg ± 2.46 Nmm/deg vs 6.69 Nmm/deg ± 2.14 Nmm/deg respectively, p = 0.691). The parallel screw group was able to withstand more load than the divergent group and approached statistical significance (4461 N ± 402 N vs 4095 N ± 601 N respectively, p = 0.063). No significant differences were found in modes of failure (P>0.05).
Conclusion: Parallel screws provide greater axial stiffness values and are noninferior with regard to torsional stiffness and axial LTF when compared to diverging screws for moderate Pauwel’s angle femoral neck fractures. The diverging screws presented a challenge in consistent placement and reproducibility of trajectory.
Cell Attachment to Orthopaedic Implants Is Affected by Local Fracture Conditions
Sarah Romereim, Ph.D.; Hailey Bennett, M2; Matthew Smykowski, BS; Xue Ma, MD, PhD; Joseph C Wenke, phd; Rachel Seymour, PHD; Joseph R Hsu, MD; Bailey Fearing, PhD; and EMIT
Purpose: Orthopaedic implant-related infections occur in open fractures at a 20% infection rate. Recent work has established that endogenous cell attachment to implants is critical for protection from bacterial adhesion and biofilm formation. We use external fixator (ex-fix) pins as a model of human host cell attachment to implants to investigate the effect of fracture type on implant-adhered cell phenotype toward the goal of improved implant-associated infection prevention and care. We hypothesize that differences in the implanted pin microenvironment will affect cell type prevalence in the implant-adherent cells.
Methods: This study was approved by the Institutional Review Board (IRB00091189). Upon removal, ex-fix pins were treated with an enzymatic solution to isolate the adherent cells, followed by density gradient separation of erythrocytes from mononuclear cells. The resulting implant-adherent cell population was stained for flow cytometric analysis. Four main cell populations were identified as fibroblasts, fibrocytes, innate lymphoid, and leukocytes (including the subtypes of monocytes, macrophages, and other leukocytes). Statistical analysis was performed in GraphPad Prism, version 10.3.0.
Results: In the initial cohort of this ongoing study, 31 patients have been enrolled. A total of 41 samples were analyzed, including 21 pins from fractured bones and 20 pins from adjacent, uninjured bones used for injury stabilization. There were no significant differences in cell type prevalence based on patient age or sex or whether the implant location of the ex-fix pin was a fractured bone or an uninjured bone. Within the pins that were implanted in a fractured bone, there were significant differences in the main cell types based on whether the fracture was open or closed (2-way ANOVA, p<0.00005) but no differences in leukocyte subtypes.
Conclusion: The present study observed that distinct cell populations adhered to orthopaedic implants based on open or closed fracture type. Further patient accrual and planned in vitro and animal model studies will provide mechanistic insight into the potential difference in cell type recruitment, adhesion, or proliferation under different injury conditions, and this may provide discrete treatment targets for improved host cell integration with implants via implant surface coatings or modifications.
Association Between Mechanical Alignment of the Knee and Regional Bone Density Patterns in the Distal Femur and Proximal Tibia
Craig E. Klinger, MPH; Douglas N. Mintz, MD; Robert Bilodeau, BS; William M Ricci, MD; Kathryn A. Barth, MD; Elizabeth Gausden, MD; Ashley Weaver, PhD; Hollis G Potter, MD; Derek G. Hansen, MD
Purpose: Computed tomography (CT) Hounsfield Units (HU) are an established measure of bone mineral density (BMD). This study aimed to assess the association between knee alignment and both distal femoral and proximal tibial epiphyseal BMD using CT HU.
Methods: A records search was conducted for patients with both noncontrast knee CT and standing long-leg radiographs. Individuals with femoral or tibial fractures, surgery, or known metabolic bone pathology other than osteopenia and osteoporosis were excluded. Trabecular HU were measured on three consecutive axial CT images. Measured regions included medial femoral condyle (MFC), lateral femoral condyle (LFC), medial tibial plateau (MTP), and lateral tibial plateau (LTP). Knee alignment was measured on standing long-leg radiographs using hip-knee-ankle angles (HKAA). Medial-to-lateral ratio (MLR) was calculated using regional mean CT HU. MLR was calculated for five groups: major varus (≤170°), varus (>170°, <178°), neutral (178°–182°), valgus (>182°, <190°), and major valgus (≥190°).
Results: Of the 103 cases analyzed (mean age 68 years, SD 8.7; 84 females); 36.9% had neutral alignment, 34.0% had varus, 5.8% had major varus, 22.3% had valgus, and 1.0% had major valgus. In 94.6%, LFC had higher BMD than MFC (P<0.001), and in 85.1%, MTP had higher BMD than LTP (P<0.001). HKAA was moderately negatively correlated with distal femur epiphysis MLR (Spearman’s rho = –0.519, P<0.001), and proximal tibia epiphysis MLR (rho = –0.498, P<0.001). With increasing varus, a gradient was found of increasing epiphyseal BMD medially, within the distal femur and proximal tibia. Significant MLR differences were found between groups for distal femur (varus vs valgus: P<0.001, varus vs neutral: P = 0.041, valgus vs major varus: P = 0.006), and proximal tibia (varus vs valgus: P<0.001, varus vs neutral: P = 0.008). In neutral knees, a 25.5% BMD deficit was found for MFC versus LFC and 28.4% for LTP versus MTP.
Conclusion: Increased varus correlates with increased medial epiphyseal BMD along the distal femur and proximal tibia. Regional BMD deficits are common in the distal femur and proximal tibia epiphysis and may have implications for fracture risk and surgical planning.
Effects of Halicin on S Aureus Small Colony Variants
Allison Wintring, MD; Akira Morita, MD, PhD; Joash Suryavanshi, MD; Roman M Natoli, MD, PHD; Edward Greenfield, PhD
Purpose: Small colony variants (SCV) of Staphylococcus aureus cause persistent orthopaedic infections because of antibiotic tolerance and immune system evasion. Environmental stressors, including biofilm formation and subtherapeutic antibiotic exposure (especially aminoglycosides), induce these small, slow-growth colonies. Halicin, a novel antimicrobial agent, is effective against biofilms, including those formed by S aureus on orthopaedic implants. We hypothesized that halicin would prevent SCV emergence in S aureus biofilms treated with aminoglycosides.
Methods: S aureus-Xen36 biofilms grew on titanium alloy (Ti6Al4V) disks for 24 hours (less mature) or 7 days (more mature) and were treated with halicin and/or an aminoglycoside. Wild-type biofilm colony forming unit (CFU) counts were measured after 24 hours of growth on kanamycin-treated agar. We identified SCVs as colonies with a diameter <1 mm after 72 hours of growth on gentamicin-treated agar (2 µg/mL) to prevent overgrowth by wild-type colonies.
Results: Subtherapeutic levels of halicin monotherapy (<250 µM, one quarter of its minimum biofilm eradication concentration [MBEC]) induced accumulation of low levels of SCVs (<100 CFUs). In contrast, subtherapeutic levels of aminoglycoside monotherapy (<40 µM tobramycin MBEC, <32 µM gentamicin MBEC) induced high levels of SCVs with up to 106 CFUs per disk. Combining 250 µM halicin with either aminoglycoside inhibited SCV accumulation at concentrations that induced SCVs as monotherapy (see figure).
Conclusion: Halicin substantially reduces (>100-fold) the induction of SCVs by aminoglycosides. SCVs should be taken into account when studying antibiotics and recalcitrant infections.
Multi-Omic Profiling Reveals Dose-Dependent Immune Response to BMP-2 in Preclinical Critically Sized Defect Fracture Model
Lia Katherine Strait, B.E, PhD Candidate; Tyler Guyer, PhD candidate; Kelly Leguineche, PhD candidate; Dylan Gill, B.S.; Robert E Guldberg, PhD
Purpose: Bone morphogenetic protein-2 (BMP-2) is a potent osteoinductive agent, but it carries significant risk because of side effects, including inflammation. In this study, we delivered BMP-2 using an injectable alginate system in a rat critically sized defect fracture model to investigate the impact of BMP-2 dose on bone regeneration and associated immune response.
Methods: Segmental bone defects (6 mm) were surgically created in femurs of female Wistar rats. Defects were internally stabilized and treated with 0 µg (control), 3 µg (minimal effective), or 30 µg (supraphysiologic) BMP-2 (n = 7–8/group) (see figure). Bone regeneration was analyzed using radiographs and micro-CT. Longitudinal blood samples were collected to evaluate immune cells, cytokines, and metabolites. Additional subjects were euthanized at days 7 and 14 for cellular analysis of bone marrow, defect tissues, and quadriceps.
Results: A minimal effective BMP-2 dose regenerated significantly less ectopic bone (p<0.04) while inducing robust healing within the defect without significantly modulating immune cell dynamics or the cytokine profile. Contrastingly, in addition to inducing ectopic bone, a supraphysiologic dose significantly modulated immune cells systemically and locally (p<0.05) and upregulated immunomodulatory cytokines (p<0.05), deviating from an endogenous healing response. Concurrently, metabolite expression exhibited dose dependency.
Conclusion: BMP-2 dose potently affects bone formation, circulating and local immune cells, cytokines, and metabolites, reinforcing the need for further preclinical work tuning dose-response, enabling lower clinical doses.
Multifunctional Medical Foam (MF) to Enhance Wound Management In Situ
Lynn Pezzanite, DVM, PhD; Nicholas Alfonso, MD; Amelia Stoner, BS; Steven Dow, DVM PhD; Kirk McGilvray, PHD
Purpose: Effective management of open injuries is critical for improving outcomes and reducing morbidity in austere resource-limited environments. Open wounds are susceptible to infection, delayed healing, and significant blood loss. These complications exacerbate injury severity, increase the risk of systemic complications, and result in greater levels of medical care. To address these challenges, we developed a medical foam (MF) that enables providers to efficiently deliver the antibiotic vancomycin and the hemostatic agent tranexamic acid (TXA) topically in situ at the point of injury.
Methods: A biopolymer-based MF was developed with adjustable viscosity and tailored release kinetics, providing a wound-filling composition capable of delivering multifunctional therapeutics into wounds. Our MF was optimized in vitro for quick-release and slow-release formulations. Mechanical properties, temporal breakdown profiles, biocompatibility, and bacterial killing were systematically evaluated. We hypothesized that MF would enhance therapeutic effectiveness by increasing wound coverage and contact time while minimizing systemic side effects through local delivery.
Results: MF biomechanical testing demonstrated wound-filling capabilities that are adaptable to various wound geometries. MF exhibited a 22% increase in yield strain compared to the base biopolymer solution, indicating enhanced protective wound coverage under mechanical stress. Temporal degradation profiles showed a 200% difference in volumetric breakdown and a 185% difference in volumetric stability between quick-release and slow-release formulations, underscoring precise control over therapeutic release kinetics and wound-filling properties. Human fibroblast viability assays confirmed that MF was biocompatible over both acute (4-hour) and chronic (24-, 48-, and 72-hour) exposure periods in a time- and concentration-dependent fashion. MF significantly reduced USA300 methicillin-resistant Staphylococcus aureus colony formation by 3 to 4 log-fold, which increased with prolonged exposure (4 vs 48–72 hours). MF increased whole blood clot robustness by more than 20% compared to direct agent delivery in saline.
Conclusion: Our MF is a versatile platform for delivering active wound care agents in situ, and its tailorable properties make it ideal for treating a spectrum of open wounds. These early findings demonstrate that MF offers a possible transformative solution, combining biocompatibility, adaptability, and therapeutic precision to enhance wound care in austere combat environments.
OTA Grant
Point-of-Care Neutrophil Analysis to Determine Post-Traumatic Neutrophil Cell Surface Receptor Alterations: An International Validation Study
Christian T Hübner, MD; Roman Pfeifer, MD; Emma de Fraiture, MD; Nathalie Piaz, Ms. ; Paolo Cinelli, PhD; Leo Koenderman, PhD; Falco Hietbrink, PhD; Michel Paul Johan Teuben, MD, PhD; Hans-Christoph Pape, MD, FACS, FAAOS, FOA, FIOTA
Purpose: Changes in cell surface receptors on circulation neutrophils provide valuable insights into the posttraumatic immune response. Recent advances in point-of-care (POC) technologies allow for rapid onsite neutrophil analysis. In a pilot study, posttraumatic alterations of relevant cell surface receptors on neutrophils were measured, and the impact of trauma severity has been studied by POC analysis.
Methods: We implemented a trauma bay POC neutrophil analysis system, adapted from a different laboratory, at a Level I trauma center. Patients with polytrauma (injury severity score [ISS] >25) were included, and flow studies on systemic neutrophils were conducted using an AQUIOS® Flow Cytometer with tailored device settings. We analyzed the neutrophil surface patterns CD10, CD11b, and CD62L and compared expression levels with the ISS and data from a second international laboratory, as well as with data from large animal experiments.
Results: In total, 23 patients with polytrauma with a median ISS of 27.8 were included. Mean time between accident and measurement was 181 minutes. Circulating neutrophil counts, as well as cellular activation status, measured by CD10, CD11b, and CD62L correlated with ISS. These findings were consistent with findings from both standardized animal studies and clinical analysis at another trauma laboratory.
Conclusion: This study demonstrates the successful establishing of a POC neutrophil analysis infrastructure at a Level I trauma center. Posttraumatic neutrophil receptor alterations are similar with findings from other trauma laboratories, as well as with standardized animal experiments. POC neutrophil analysis should thereby be considered as an interesting immunomonitoring tool that could help improve clinical decision-making and patients’ outcomes in the future.
Simulated Weight-Bearing CT Improves Hindfoot Alignment Assessment and Offers an Alternative to True Weight-Bearing CT Scanners
Joon Soo Ha, MBBS FRCSC; Prism Schneider, MD, PHD, FRCSC; Gareth Rooke, FRACS; Jeremy F Kubik, MD, FRCSC; Kimberly Rondeau, BSc MSc; Andrew Dodd, MD
Purpose: Accurate assessment of hindfoot alignment following calcaneal fractures is critical for guiding surgical and rehabilitative decisions. Although joint reduction has traditionally been considered the primary determinant of functional outcome, recent perspectives suggest that restoration of foot shape and alignment may be more predictive of long-term functional outcomes. This study investigated the impact of simulated weightbearing (SWB) CT scans on hindfoot alignment and their potential as an economical alternative to true weightbearing (WB) CT imaging.
Methods: In total, 41 patients (male: 85%, mean age: 45 years, SD = 12) with unilateral displaced intraarticular calcaneus fractures (AO/OTA 82C1-3) that were treated surgically were included in this multicenter prospective cohort study. Standard and simulated WB CT scans were obtained at 3 months post-injury for both injured and uninjured calcanei. WB conditions were simulated using a custom dynamic simulator, in which the patient wore a harness connected to a force plate located under the heels. This system allowed for controlled compression by adjusting the side straps while ensuring the patient remained motionless. Key anatomic parameters were measured, including medial (MCVA) and central calcaneal varus angle (CCVA). The difference between WB- and non–WB-injured and uninjured ankles were analyzed using paired t-tests.
Results: Simulated WB conditions significantly altered hindfoot alignment in both injured and uninjured calcanei. For injured calcanei, MCVA changed from 7.5° in the non-WB images to –3.5° with SWB (p<0.0001), while CCVA decreased from 13.1° (non-WB) to 6.5° (WB) (p = 0.0002). In uninjured calcanei, MCVA was reduced from 14.5° (non-WB) to 2.5° (WB) (p<0.0001), and CCVA decreased from 19.3° (non-WB) to 11.8° (WB) (p<0.0001). These findings suggest that SWB imaging more accurately represents the functional alignment of the hindfoot compared to standard non-WB CT scans.
Conclusion: Simulated weightbearing CT scans significantly alter the measured alignment of the hindfoot, providing a more functionally relevant assessment of residual deformity after calcaneal fractures. Given their ability to approximate true WB conditions without requiring specialized WB CT scanners, SWB scans present an accessible alternative for clinical and research applications.
Accuracy and Precision of Biplanar Videoradiography to Quantify Tibial Fracture Motion After Fixation
Stephen Warner, MD, PHD; Conor Smith, PhD; Tomasz J Bugajski, PhD; Augustine Mark Saiz, M.D.; Patrick Kellam, MD; John Wesley Munz, MD; Andrew M Choo, MD; Timothy S Achor, MD; Jonathan G Eastman, MD; Payam J Zandiyeh, PhD
Purpose: Understanding the biomechanical factors contributing to fracture healing necessitates a precise and minimally invasive quantitative system. Dynamic Biplanar Videoradiography (DBVR) represents an advanced imaging technique that can observe and quantify 3D bone movements in real time during muscle-driven activities. The purpose of this study was to demonstrate the feasibility of using DBVR paired with radio-opaque markers to quantify interfragmentary fracture motion in humans.
Methods: In total, three patients with tibial diaphyseal fractures treated with an intramedullary nail were included. Three to five radio-opaque Tantalum beads were implanted non-collinearly into the tibia immediately above and below the fracture site. DBVR imaging was conducted at 6, 12, 24, and 36 weeks postoperatively during weight transition and walking gait activities. The CT scans for each subject were segmented to acquire bone models of the proximal and distal tibia segments to acquire locations of the radiostereometric analysis (RSA) bead centroids and to determine anatomic coordinate systems. Afterward, the 3D to 2D registration of movement trials was performed using the following two methods: (1) RSA method to locate the centroids of the beads in each frame, and (2) model-based method to register the contours of the bone models to the DBVR images frame-by-frame semi-automatically.
Results: On average, the RSA method demonstrated submillimeter precision, ranging from 0.12 mm to 0.29 mm (0.19 ± 0.09 mm). Similarly, the accuracy ranged from 0.36 mm to 0.40 mm (0.38 ± 0.02 mm). The model-based method also showed submillimeter precision and accuracy but higher magnitudes. The precision of the model-based method ranged from 0.50 mm to 0.58 mm (0.54 ± 0.04 mm), and the accuracy ranged from 0.68 mm to 1.41 mm (1.04 ± 0.37 mm).
Conclusion: This study successfully validated the use of DBVR for measuring interfragmentary motion at tibial diaphyseal fracture sites. The RSA method demonstrated high precision (0.19 mm) and accuracy (0.38 mm), confirming that DBVR can reliably assess interfragmentary kinematics. Future clinical studies using this technology are needed to determine clinically significant changes and assess whether model-based tracking alone is sufficient or if RSA beads are necessary for accurately monitoring fracture motion and union over time.
A New Method to Estimate the Anteversion Angle of the Femur From Femoral Head Size
Olasode Israel Akinmokun, MBBS, MD; UtibeAbasi Ime Edem, BSc, MB;BCh
Purpose: Femoral neck anteversion (FNA) is the degree of torsion of the femur. It refers to the orientation of the femoral neck in relation to the condyles and is estimated using various methods. This study proposed a new method to estimate FNA.
Methods: The FNAs of 40 dry femoral bones were determined. Digital photography of proximal femurs were taken in two positions. In the anatomic position (P1), the two condyles were in contact with the table and the head was lifted off. In the version-corrected position (P2), the head was in contact with the table and the lateral condyle was lifted. The distance between the camera and the table was 30 cm. A graph paper was used as a scale. For each bone, two proximal femoral images were obtained. Two femoral head (FH) diameters were measured and documented for each bone, and the results obtained were analyzed.
Results: FH diameters obtained at P1 were persistently larger than those obtained at P2 (mean: 46.1 ± 3 mm and 43.7 ± 2.7 mm, respectively). The differences between FH diameters at P1 and P2 for each bone ranged from 0.5 mm to 6.5 mm (mean: 2.4 ± 1.3 mm). The differences were larger as the FNA increased (P = 0.0001). Regression analysis yielded the following equation: anteversion angle (0) = (2 * difference in head diameters at P1 and P2) + 13. The value obtained from the equation is ± 60 of the FNA.
Conclusion: This study revealed that the position of the proximal femur at the point of radiologic investigations could alter the FH diameters and result in inaccuracies when FH diameter is measured. This study also revealed that FNA can be estimated using the equation: anteversion angle (0) = (2 * difference in head diameters at P1 and P2) + 13. Clinically, this is applicable by taking two plain radiographs of the pelvis, without and with correction of the anteversion of the lower limb. The difference obtained between the measured FH sizes is substituted into the equation to obtain an estimated value of FNA.
Hospital Service Burden After Internal Fixation: An Analysis of Nationally Linked Hospital Care Records
Omar Musbahi, MBBS(MD); Walter Muruet-Gutierrez, PhD; Caroline Hing, FRCS; Alex Bottle, PhD
Purpose: Hospital length of stay (LOS) is a major driver of healthcare costs. Understanding patterns in LOS after fracture reduction and identifying preoperative patient characteristics associated with prolonged hospitalization can inform clinical decision-making and resource allocation.
Methods: An analysis of linked hospital episode statistics and emergency episode statistics was conducted, including all admissions with a primary OPCS code for open reduction and other internal fixation procedures. The study population consisted of 630,589 admissions of adults (age 18 or older) between 2013 and 2023 in National Health Service (NHS) hospitals and independent sector providers funded by the NHS in England. The primary outcome measure was postprocedure LOS in days and factors predicting LOS.
Results: Postprocedure LOS varied with the anatomic site of fracture and procedure type. Femoral and pelvic internal fixation procedures had the longest median LOS, ranging from 6 to 15 days and 4 to 9 days, respectively. Several factors were associated with increased LOS, including demographic variables (age, sex, ethnic group), emergency admission status, presence of delirium, comorbidity burden, frailty, anatomic site, and procedure type.
Conclusion: Patient characteristics, the anatomic site of fracture, and the type of orthopaedic procedure performed significantly impact postprocedure LOS. A deeper understanding of these factors, as well as the identification of additional determinants, is crucial for improving patient care quality and optimizing healthcare costs for health services.
Have New Plate Designs Reduced the Rate of Hardware Removal Following Midshaft Clavicle Fracture Fixation?
Maria Oulianski, M.D.; Yoram A Weil, MD, FIOTA; Omer Ben Yehuda, M.D.; Rami Mosheiff, MD; Mahmoud Jammal, MD. / MSc.
Purpose: Surgical fixation of displaced midshaft clavicle fractures has become the standard of care in recent years, based on evidence supporting its effectiveness. However, this practice presents challenges because of the complex S-shaped morphology of the clavicle and its subcutaneous location. Despite the introduction of anatomically precontoured plates, achieving an optimal implant-to-bone fit remains difficult, prompting the development of newer plate generations. The aim of this study was to compare the hardware removal rates of second-generation plates (SGP) with first-generation plates (FGP).
Methods: A retrospective comparative cohort study was conducted at a Level I trauma center. A total of 187 patients received FGP, and 67 received SGP, both positioned on the superior bone surface. All surgeries were performed by fellowship-trained surgeons, with patients followed for at least 1 year. Data were extracted from medical records and a picture archiving and communication system (PACS).
Results: The patients' demographics (age: 32.86 vs 33.14 years; gender: 16.85% male vs 14.92% female) and fracture type (AO/OTA) were similar between the two groups. The rate of implant removal (20.1% vs 20.9%) did not differ significantly between groups. Complications included nonunion (1.6% vs 1.7%, not statistically significant) and infection (3 cases in the FGP group, none in the SGP group).
Conclusion: Despite the high success rate of clavicle fixation procedures, the rate of superior clavicular plate removal remains significant, regardless of the implant design.
Evaluation of the Anterior Ankle Syndesmosis Using the Posterolateral Approach Results in Fewer Wound Complications Compared to the Anterolateral Approach in the Treatment of Lateral Malleolar Fractures
Guy Putzeys, MD, FIOTA; Xaviera Berende, MD
Purpose: Evaluation of the anterior syndesmosis complex in the treatment of ankle fractures involving the lateral malleolus has gained importance, but it is unclear which is the best approach for visualization. We compared a fork-shaped anterolateral (AL) approach with a hockey-stick–shaped posterolateral (PL) approach (see Figure). We hypothesized that the AL approach would result in more postoperative wound complications than the PL approach.
Methods: A retrospective study was conducted with prospectively collected data in a single center with a single surgeon. The minimum follow up was 6 months. Exclusion criteria were age younger than 14 years, a PL approach for addressing a posterior malleolus fracture, open ankle fracture, concomitant ipsilateral distal tibia fracture, and early loss of follow up.
Results: In total, 62 consecutive patients were recruited between 2014 and 2024; 37 patients had an AL approach (group A) and 25 patients had the PL approach (group B). Both groups were statistically comparable. In group A, 11 patients had a wound problem that was statistically significant (Mann Whitney U test, p = 0.02) compared to only one patient in group B. No risk factor could be identified for wound healing problems.
Conclusion: The PL ankle approach for visualization of the anterior syndesmosis had significantly fewer wound complications than the AL approach when treating lateral malleolus fractures.
Fabricating a Novel "Reverse Aerator" Negative Pressure Wound Therapy Device in Low/Middle Income Countries
Joel M Post, DO; Jason Fader , MD
Purpose: Commercially distributed wound vacuums can be prohibitive in low/middle income countries (LMIC) secondary to single use components, supply chain limitations, and excessive cost. We aim to describe a novel technique for fabricating a negative pressure wound therapy device.
Methods: A low-expense, commercially available, 60 gallon/110 volt fish tank aerator was easily modified to reverse the flow of air (pull instead of push) (see figure). A plastic occlusive dressing or adhesive dressings were used to achieve a suction seal. Plastic tubing was used to connect the aerator to a cannister to drain and collect exudate.
Results: This “reverse aerator” was connected to a pressure gauge and was found to consistently draw about 100 mmHg. Plastic tubing and cannisters can be washed, sterilized, and re-used as indicated. By design, the aerator can be run continuously and can last years.
Conclusion: The “reverse aerator” device can be easily reproduced with minimal expense and waste while providing the predictable benefits of negative pressure wound therapy in clinically appropriate settings in LMIC.
Fracture-Related Infection in Open Long-Bone Fractures: A Bicenter Study in a Limited Resource Country
Alazar Menbere Haile, MD; Binyam Dagnaw; Mengistu Gebeyehu; Solomon Mengesha; Tinsae Yoseph; Hannan Nigussie; Tobistiya Woldemariam; Biruk Lambisso Wamisho; Kalid Zaki
Purpose: Fracture-related infections (FRI) are estimated to complicate approximately 1% of closed fractures and 30% of open fractures globally. These statistics, however, can vary significantly by region, with low- and middle-income countries experiencing a disproportionately high burden. The studies in these regions are often underpowered to evaluate the local prevalence and contributing factors of FRI. The objectives of this study are to assess the prevalence of FRI in open long bone injuries and to investigate the association between FRI and various risk factors identified in previous research.
Methods: A 5-year age- and sex-matched case-control study was conducted at two high-volume trauma centers in a limited-resource country. Closed fractures, infected fractures at presentation, incomplete documentation, follow-up periods shorter than 6 months, and superficial infections not requiring debridement were excluded. Independent variables included were patient demographics, anatomic region, injury mechanism, Gustilo-Anderson grade, definitive fixation used, smoking status, history of blood transfusion, and timing to antibiotic administration, debridement, and soft-tissue cover. The primary outcome was the presence of FRI, defined according to Metsemakers et al. Data analysis was conducted using the R package.
Results: A total of 706 cases was reviewed, showing a 13.2% prevalence of FRI. The 84 infected cases and 168 matched controls were analyzed. Most patients experienced delays in antibiotics (77.4%) beyond 3 hours and debridement (76.6%) beyond 24 hours. Multivariate logistic regression revealed statistical significance only for a delay in antibiotic administration exceeding 12 hours (p = 0.007), the presence of polytrauma (p = 0.008) and non-intramedullary nail (IMN) mode of fixation (p<0.001). Delays in debridement more than 24 hours (p = 0.09), soft-tissue coverage more than 7 days (p = 0.06), and antibiotic administration (3 to 12 hours) did not show statistically significant associations with an increased risk of infection.
Conclusion: Our study highlights the critical importance of prompt antibiotic administration, especially for high-energy wounds such as polytrauma, in reducing infection risk. A key strength of this study is that it stands as one of the few well-powered investigations conducted in resource-limited settings, where delayed presentations are prevalent.
Open Intra-Articular Distal Tibial Fractures: Retrospective Cohort of Intramedullary Nailing Versus Traditional Open Reduction and Internal Fixation With Plates
Jayne Ward, MBBS, MRCS, FRCS trauma&orth; Thomas Paul Cloake, MBChB, BMedSc
Purpose: Open distal tibial fractures with articular involvement (ODTFAI) are complex injuries that pose numerous difficulties for the surgeons treating them. Prognosis is often poor, and the best method of fixation is a source of contention. Previous studies have reviewed the efficacy of intramedullary nailing (IMN) and internal plate fixation (IPF) in distal tibial fractures, but these studies often exclude fractures with intra-articular involvement and fractures that are open. The aim of this study is to compare IMN to IPF in open distal tibial fractures with articular involvement using rates of nonunion, infection, return to theatre, and other complications as outcome measures.
Methods: A retrospective analysis was conducted using data collected from University Hospital Coventry and Warwickshire. The cohort included 51 adult patients between April 2015 and December 2022. Of these, 23 were treated with IMN and 28 were treated with IPF. Statistical analysis was performed in SPSS.
Results: Sex distribution, injury characteristics, and grade of open fracture were the same in both groups. IMN patients were found to have a higher mean age (p = 0.0440). Low-energy trauma was significantly higher in the IMN group (p = 0.022). The proportion of patients returning to theatre was significantly higher in the IPF group (p = 0.030). No statistically significant differences were found for other complications, but they were higher in frequency in the IPF group.
Conclusion: A return to theatre is significantly more likely when ODTFAIs are treated with IPF compared to IMN. Other complication rates were higher at a clinical level in terms of their proportion, but this was not statistically significant. Although factors that could negatively impact prognosis, such as age and mean OTA arterial score, were higher in the IMN group, this method still yielded fewer complications. Despite not being the traditional method of fixation for intra-articular distal tibial fractures, IMN could be the superior method of treatment in ODTFAI when compared to IPF.
Subtalar Preserving Tibiotalar Hindfoot Nail as New Technique for Managing Fragility Fractures
Jayne Ward, MBBS, MRCS, FRCS trauma&orth; Thomas Paul Cloake, MBChB, BMedSc; rosemary wall, FRCS
Purpose: Unstable ankle fractures present a challenge in the frail elderly population because of their impact on mobility with typically poor outcomes. Management should permit full weightbearing, but osteoporotic bone and poor soft tissues make traditional open reduction and internal fixation or close contact casting a high risk for wound breakdown and loss of reduction. Tibio-talar-calcaneal (TTC) nailing provides an alternative surgical option; however, TTC nailing is associated with a significant incidence of screw migration from the calcaneum and peri-implant fractures because of a stiff hindfoot. We present a new technique using a retrograde femoral nail that enters the hindfoot and is inserted farther so the nail and all screws gain purchase in the talus, avoiding metal work in the calcaneum and preserving the subtalar joint.
Methods: In total, 14 patients were identified between February 2021 and February 2025. Data were collected from case notes reviews, operative records, and radiographs. We present complications of any cause and mortality.
Results: Of the 14 patients (11 female), mean age was 85 years, and 10 fractures were open. The average American Society of Anesthesiologists (ASA) score was 3. All patients were allowed immediate weightbearing without restrictions. One patient died during admission, and one died within a year of follow up. There were two superficial infections; both were open fractures, and neither needed readmission. There were no fractures of the calcaneum or tip of the nail, no metal work problems, and no screws backed out. No patients needed to return to the theatre.
Conclusion: Hindfoot nailing for elderly distal tibial and ankle fractures is a reliable way to allow unrestricted weightbearing. In our series, by inserting the nail farther, we have had no complications of screw backout or peri-implant fractures, commonly associated with TTC nails. We have not observed any fractures of the calcaneum, suggesting that a tibio-talar nail is a safe technique with fewer complications than a traditional TCC nail.
The Influence of Optimal Reduction on Mortality in Extracapsular Hip Fractures: An Analysis of 620 Patients
Felipe Patterson, MD; Gonzalo Guillermo García Barreiro, MD; Danilo Taype Zamboni, MD; Juan Colom, MD; Guido Carabelli, MD; Lionel Llano, MD; Jorge Barla, MD
Purpose: Several studies suggest that achieving optimal postoperative reduction not only reduces the likelihood of reoperation but also significantly impacts long-term survival outcomes. The primary aim of this study is to analyze the effect of reduction quality on 1-year mortality. Specific objectives include classifying reduction based on Chang's criteria, comparing 1-year and 30-day mortality rates postsurgery, assessing functional changes 1 year after surgery, and evaluating surgical times.
Methods: We conducted a retrospective analysis using a prospective database from our institutional hip fracture registry. The study included patients who sustained pertrochanteric fractures and underwent surgical intervention between October 2020 and June 2023. Chang's classification and the date of death or last follow up were retrospectively added to the database for analysis. To assess the causal association between reduction quality and survival within 1 year, we applied a Cox regression model adjusted for propensity scores using Inverse Probability Weighting (IPTW). We also assessed 30-day mortality using the same regression model. Functional outcomes were evaluated using the New Mobility Score (NMS) and were stratified by reduction quality. Finally, the relationship between surgical time and reduction quality was analyzed using logistic regression adjusted by IPTW.
Results: A total of 620 patients with pertrochanteric fractures treated with an intramedullary nail was included. The 30-day mortality rate was 4.68%, and the 1-year mortality rate was 24.6%. Patients with “excellent” reduction according to Chang’s criteria had lower mortality, with an unadjusted hazard ratio (HR) of 0.52 (95% CI: 0.4–0.68) and an adjusted HR using IPTW of 0.6 (95% CI: 0.45–0.8). In patients with “acceptable” reduction, the median decline in NMS was –1 [IQR 0, –3], while in patients with “excellent” reduction, the median decline was 0 [IQR 0, –2]; however, this difference was not statistically significant (p = 0.4). We also found that patients with “acceptable” reduction had a longer median surgical time compared to those with “excellent” reduction.
Conclusion: Our findings suggest an association between postoperative reduction quality and 1-year mortality. Surgeons treating these fractures should aim for optimal reduction to improve patient outcomes.
Effect of Intraoperative Tranexamic Acid on Postoperative Changes of Serum Interleukin 6 Levels in Elderly Male Patients With Intertrochanteric Fracture
Xiangxu Chen, PhD; Huanyi Zhu, MD; Yunfeng Rui, PhD
Purpose: Our objective was to examine the impact of intraoperative tranexamic acid on early postoperative interleukin-6 (IL-6) levels in elderly male patients with intertrochanteric fractures, with a focus on those with osteoporosis, and to suggest new therapeutic directions for inflammation control in this patient group.
Methods: A retrospective analysis was conducted on 92 elderly male patients with intertrochanteric fractures who underwent surgery from January 2020 to December 2022. Patients were categorized into four groups based on the use of tranexamic acid during surgery and the presence of osteoporosis: Group A (no tranexamic acid, no osteoporosis, n = 32), Group B (no tranexamic acid, osteoporosis, n = 14), Group C (tranexamic acid, no osteoporosis, n = 32), and Group D (tranexamic acid, osteoporosis, n = 14). Serum IL-6 levels were measured on postoperative days 1, 3, 5, and 7. Intraoperative blood loss, postoperative complications, and 1-year mortality were also recorded.
Results: No significant differences were observed in baseline characteristics (age, smoking history, drinking history, body mass index [BMI], comorbidities, laboratory indicators, and intraoperative blood loss) among the four groups (p>0.05). Patients with osteoporosis had higher intraoperative blood loss. On postoperative days 1 and 3, IL-6 levels were significantly higher in Group B than in Group A (p<0.05). However, in Group D, IL-6 levels were significantly lower than in Group B (p<0.05). No significant differences in IL-6 levels were noted on postoperative days 5 and 7. The incidence of in-hospital complications was 28.1% in Group A, 35.7% in Group B, 18.8% in Group C, and 21.4% in Group D. One-year mortality rates were 15.6%, 28.6%, 12.5%, and 14.3% for Groups A, B, C, and D, respectively. Patients with osteoporosis (Groups B and D) had higher rates of in-hospital complications and 1-year mortality, while those treated with tranexamic acid (Groups C and D) had lower rates, although these differences were not statistically significant (p>0.05).
Conclusion: Intraoperative tranexamic acid effectively reduces early postoperative IL-6 levels in elderly male patients with intertrochanteric fractures, particularly in those with osteoporosis.
"The Joint Above": The Impact of a Previous Proximal Implant in a Distal Femur Fracture
Reginald O Chinweze, MD, LLM; Neha Biju, MBBS; Osayi M Osadolor, MBBS; Piyush Upadhyay, PhD, FRCS; Jayachandran Jayadeep, MBBS, FRCS
Purpose: With an aging population and increasing arthroplasty rates, distal femur fractures in patients with proximal implants represent a growing challenge. This study aims to evaluate outcomes and explore the relationship between distal femur fractures occurring in patients and their preexisting ipsilateral proximal implants.
Methods: This was a retrospective study involving 53 patients with distal femur fractures and ipsilateral proximal implants treated between 2013 and 2023. Patient demographics, surgical approaches, and outcomes were analyzed with an additional radiographic assessment of previous ipsilateral implant types subsequently placed into four groups: total hip replacement (THR), dynamic hip screw (DHS), intramedullary (IM) nail, and others. The primary outcomes of our study included postoperative complications, mortality, and length of hospital stay (LOS).
Results: Of the 53 patients included, the average age was 79 years (range 34–96 years) and 79.2% were female. Single lateral plate fixation was the most commonly used method of fixation in 69.8% of cases, followed by IM nailing in 22.6%. The overall complication rate in our patient group was 7.5%, with an average LOS of 21.3 days. We noted that, at 30 days postoperatively, there was a 3.8% return-to-theatre rate and a 5.7% mortality rate. Despite this, the presence of a previous ipsilateral implant did not significantly affect complication rates (p = 0.423) or survival (log rank, p = 0.362).
Conclusion: Despite the technical challenges that the presence of a previous implant can pose, distal femur fractures in patients with proximal implants can be managed effectively with standard fixation techniques. Neither implant type nor fixation method significantly impacted complications or mortality, suggesting that individual patient factors should guide treatment decisions.
Multidisciplinary Hip Fracture Management: Current Standards and Practices in Latin America
Aleksandar Munjin, MD; Verena Oberlohr, BS; Madeline C. MacKechnie, PhD; Horacio Tabares, MD, PhD; Alvaro Cordero Herrera, MD; David Escalante, MD; Igor Escalante, MD; Luis Padilla, MD; Jose Eduardo Quintero, MD; Marcelo Rio, MD; Julio Segovia, MD; Rogelio Rey Nande, MD; Vincenzo Giordano, MD PhD FBCS; Ivan Salce, MD; Tomás Minueza, MD; Rita Maria Tobia, MD; Dino Aguilar, MD; Mario Garuz, MD; Edwin Martinez Dominguez, MD; Jose Rafael Silverio, MD; Theodore Miclau, MD, FIOTA
Purpose: Osteoporosis and resultant hip fractures continue to burden patients and healthcare systems globally. Addressing this growing problem will require a multidisciplinary approach to improve postfracture care and refracture prevention. This study intends to identify key gaps in the comprehensive hip fracture management and prevention strategies throughout Latin America.
Methods: A survey was developed and distributed through REDCap using a snowball sampling method. A surgeon-leader was identified from the Latin American countries active in the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR) network. Each leader identified up to 10 national surgeons experienced in treating hip fractures to participate in the questionnaire. The multiple-choice survey assessed current standards for the perioperative management of hip fractures, resource availability, and methods of prevention throughout the region.
Results: In total, 163 orthopaedic surgeons representing 18 countries throughout Latin America participated in the survey. Although geriatric-specific hip fracture protocols are unavailable to most surgeons (57%), 91% of respondents reported having access to specialist consultation (with orthogeriatricians, endocrinologists, nutritionists, or physiotherapists) on the care of these patients. Patients with hip fractures were most commonly assessed for fall risk (50%) and bone mineral density (51%) during or following hospitalization, although Patient-Reported Outcome Measures were evaluated by only 14% of respondents. The use of dual-energy X-ray absorptiometry (DEXA) scans to evaluate bone density was reported by 57% of surgeons, while 6% reported using quantitative CT or quantitative ultrasound. Multidisciplinary rehabilitation services are available to 75% of respondents, of which most are rendered in the hospital (81%), followed by home-based (58%), and community-based (33%) services. Although postoperative supplements, antiresorptive, and/or anabolic drugs are commonly prescribed by respondents (66%), fall prevention programs and fracture liaison services remain largely unavailable, as reported by 73% of respondents.
Conclusion: Resources for fall prevention, risk assessments, and routine screening among vulnerable patients with hip fractures remain inconsistent in Latin American countries. This study serves to identify current hip fracture intervention strategies and practice guidelines to direct future advancements in multidisciplinary hip fracture care throughout the region.
Radiographic Comparison of Compression Hip Screws and Cephalomedullary Nails in Stable Femoral Trochanteric Fractures
Shota Nakagawa, MD; Hiroaki Minehara, MD, PhD; Takeshi Sawaguchi, MD; Takashi Matsushita, PhD, FIOTA
Purpose: Both compression hip screws (CHS) and intramedullary nails (IMN) are used for stable intertrochanteric femur fractures. In Japan, medial cortical support is highlighted as a factor reducing postoperative cut-out risk. However, no study has compared postoperative femoral offset (FO) changes based on implant and reduction differences. This study aimed to compare postoperative femoral neck-shaft angle (NSA), FO, and lower limb length discrepancy (LLD) between CHS and IMN.
Methods: This single-center retrospective cohort study included patients with AO/OTA 31A1 intertrochanteric fractures treated at our institution from October 2020 to March 2024. Exclusion criteria were follow up less than 3 months, contralateral fracture history, and inadequate radiographs. Patient demographics, fracture type, surgery time, and reduction quality were evaluated. Preoperative radiographs measured contralateral FO and CCD. Postoperative and final follow-up radiographs measured FO, CCD, LLD, and telescoping. X-ray magnification was adjusted using femoral head diameter, and femoral rotation was corrected based on Lechler et al's implant-specific CCD. Postoperative ambulatory ability was also compared. Statistical analysis used the Mann-Whitney U test and Fisher’s exact test (significance: p<0.05).
Results: The study included 27 IMN and 32 CHS patients (mean age: 83.8 years, 11 men, 48 women). Mean radiographic follow up was 9.0 months. There was no significant difference in preoperative contralateral FO or CCD. Postoperative CCD was 125.7° (IMN) versus 131.6° (CHS). LLD was –3.58 mm (IMN) versus 1.08 mm (CHS), showing significance (CCD: p = 0.003, LLD: p<0.001). FO showed no significant difference (38.9 mm vs 41.1 mm). At final follow up, CCD remained significantly different (p = 0.013), but FO, LLD, and telescoping (4.0 mm vs 4.3 mm) did not. From the non-fractured side, CHS preserves femoral offset over IMN, but not significantly (IMN 104.9% vs CHS 102.3%). No difference in postoperative ambulatory ability was observed.
Conclusion: The IMN group had significantly greater varus fixation and LLD than the CHS group. Although ambulatory ability did not differ, radiographic findings suggest CHS may be more advantageous for stable intertrochanteric fractures.
Dual Nail-Plate Fixation: A New Method to Solve Old Problems
Samuel Gordon Hoare, MA; Giuliana Caiti, PhD; Kathleen Kurtenbach, MS; Claudia Beimel, MSc; Stefan Maartense, MD, PhD
Purpose: Distal femoral fractures (DFF) are considered clinically challenging fractures, often resulting in major complications such as nonunion and implant failure. Dual nail plate (DNP) fixation has gained recent attention as an alternative surgical treatment method to address these problems. However, clinical outcomes of DNP fixation, typical fracture characteristics, and target patient groups treated remain poorly described. This literature review addresses these aspects.
Methods: A systematic literature review using PubMed and Embase was performed. Primary surgical indication (including OTA/AO classification), age, and body mass index (BMI) were extracted where available. Minimum follow up for study inclusion was ≥ 6 months or until fracture consolidation. The clinical outcomes included bone consolidation, reoperations to promote bone consolidation, and patient weightbearing status in the immediate postoperative period. Safety outcomes assessed included surgical site infection (SSI), nonunion, and implant failure. Proportion meta-analyses were performed using a DerSimonian-Laird random effects model to calculate pooled estimates for the outcomes assessed.
Results: A total of 226 DNP patients was identified in 16 studies, including 99 periprosthetic (PP) fractures and 17 nonunions as primary indications for DNP. The remaining 110 patients had OTA/AO 33-A or 33-C DFFs, many constituting complex and comminuted fractures. Patients with fragility fractures were well represented with 11 studies reporting average cohort ages of ≥ 65 years. Overweight/obese patients were also present with 7 studies reporting average patient cohort BMIs ≥ 25 kg/m2. Estimated rates of bone consolidation and reoperation were 97.8% (95% CI: 95.4%; 99.3%) and 2.2% (95% CI:0.7%; 4.6%) respectively. Most studies (12) placed some or all patients on an immediate full weightbearing-as-tolerated postoperative regime, not resulting in major complications. Estimated rates of SSI, implant failure, and nonunion were 7.9% (4.5%; 12.1%), 1.5% (<0.1%; 4.8%), and 1.2% (<0.1%; 4.1%) respectively.
Conclusion: DNP fixation has shown promising results in the treatment of DFFs, demonstrating high bone consolidation and low reoperation rates, with a safety profile characterized by low rates of nonunion and implant failure. DNP fixation was effectively used in treatment of complex and comminuted DFFs and PP DFFs, which included geriatric/frail and overweight/obese patients.
Prevalence of Sacral Dysmorphism Findings in Adult Patients on Abdominopelvic and Pelvic Computed Tomographic Scans at Tibebe Ghion Hospital, Bahirdar, Northwest Ethiopa
Biniyam Teshome Addisu, MD; Jemal T Husen , MD; Andualem T Basazinew, MD
Purpose: Sacral dysmorphism is an anatomic variation that deviates from the normal anatomy of the sacral and lumbosacral junction that causes complications when some surgical procedures are attempted. Percutaneous screw fixation is a standard procedure performed for unstable pelvic ring lesions, but modifications of screw placement are necessary in cases of anatomic variations. Because sacral dysmorphism patterns are very common, preoperative computed tomography (CT) imaging is considered mandatory to identify them and therefore avoid damage to surrounding structures when surgical procedures are attempted. The objective of this study was to determine the proportion of sacral dysmorphism findings in patients 18 years and older on abdominopelvic and pelvic CT scans performed at Tibebe Ghion Specialized Hospital (TGSH) from November 2023 to February 2024.
Methods: The institution-based cross-sectional study design was carried out at the Tibebe Ghion Specialized Hospital. Patients age 18 and older with abdominopelvic or pelvic CT scans were included, and a simple random sampling technique was used. Data collection sheets were used to record demographic information and imaging findings of sacral dysmorphism on 184 CT scans. Data collection was performed by radiology residents to improve its quality. The data was cleaned, stored, checked for completeness, and entered into an SPSS 27 version for analysis. Descriptive statistics and logistic regression were used to generate and summarize frequencies and associations.
Results: The overall prevalence of sacral dysmorphism was 58.2%. The first residual sacral disk and dysmorphic neural foramina revealed the most common findings of sacral dysmorphism. The female sex showed an increased prevalence of tongue-in-groove morphology and dysmorphic neural foramen with statistical significance (P = 0.021 and 0.034 respectively). Younger age was also associated with an increased prevalence of the residual first sacral disk (P = 0.017, Confidence Interval [CI] = 95%).
Conclusion: The prevalence of sacral dysmorphism in this population was high. Careful evaluation of sacral morphology by CT scan is mandatory in pelvic trauma patients as part of preoperative planning, especially if iliosacral screw fixation is planned.
Traumatic Abdominal Wall Injuries in Pelvic Fractures: A CT-Based Pilot Study Utilizing the Dennis Classification
Stefano Cattaneo, MD; Nicola Carapella, MD; Abramo Fratus, MD; Elisa Lamberti, MD; Claudio Galante, MD; Giuseppe Milano, MD; Alessandro Casiraghi, MD, FIOTA
Purpose: Although underreported, traumatic abdominal wall injuries (AWI) may significantly impact outcomes in pelvic fractures. This pilot study evaluates the prevalence, severity, and distribution of AWIs in surgically managed pelvic fractures using preoperative CT imaging and the Dennis classification system.
Methods: A retrospective analysis of 20 consecutive patients undergoing pelvic fracture fixation at a Level I trauma center was conducted. Inclusion required preoperative CT imaging and surgical management; nonoperative cases were excluded. AWIs were classified by a musculoskeletal radiologist using the Dennis system (Grades I–VI). Pelvic fractures were categorized via AO/OTA criteria (types A/B/C). Demographics, injury mechanisms, AWI characteristics, and associated injuries were analyzed.
Results: AWIs were identified in 65% (13 of 20) of patients, predominantly Grade I subcutaneous contusions (8 of 13). Unstable C-type fractures exhibited the highest AWI prevalence (80%, 4 of 5), including severe injuries: two Grade V (complete muscle disruption with herniation), one Grade III (single muscle disruption), and one Grade II (muscle hematoma). B-type fractures demonstrated a 60% AWI prevalence (9 of 15), primarily Grade I (8 of 9) with one Grade II.
Conclusion: This pilot study highlights a high prevalence of AWIs in pelvic fractures, with severe injuries (Grades II–V) strongly associated with unstable C-type fractures. The Dennis classification effectively characterizes AWIs on preoperative CT, underscoring its utility in guiding clinical evaluation to enhance detection and prevent delayed complications. These findings advocate for routine CT assessment of AWIs in pelvic trauma. Larger prospective studies are needed to validate these results and refine management protocols.
Four Pelvic Injury Consensus Statements by Expert Pelvic and Acetabular Surgeons From the UK’s Major Trauma Centres
Chris Jordan, MEng, MBBS; James Bassett, MBChB; Mez Acharya, MBBS; Sharon Scott, MBBS; Mark Chamberlain, MBBS
Purpose: These statements address key areas in managing pelvic injuries with considerable variation across treatment centers. They focus on lateral compression fractures, venothromboembolic (VTE) prophylaxis, prevention of heterotopic ossification, and management of acetabular fractures in the elderly.
Methods: We present the collaborative efforts of expert pelvic and acetabular surgeons from the UK's major trauma centers, representing the British Association of Pelvic and Acetabular Surgeons (BAPAS) in formulating and refining four critical consensus statements.
Results: 1) The consensus statement on managing lateral compression fractures aims to standardize treatment protocols to improve patient outcomes and reduce referral burden to tertiary units for stable injuries. It includes diagnostic criteria, nonoperative versus operative management, and post-injury rehabilitation strategies. Early and accurate diagnosis using advanced imaging and a multidisciplinary treatment approach are highlighted. 2) The statement on VTE prophylaxis after pelvic injuries proposes rigorous advice tailored to the injury severity and patients' individual risk factors. Recommendations include pharmacologic agents, mechanical prophylaxis, and early mobilization, addressing the timing and duration of prophylaxis to balance VTE risk and bleeding complications. 3) The statement on the prevention of heterotopic ossification (HO) in pelvic injuries offers guidelines for prophylactic measures such as nonsteroidal anti-inflammatory drugs (NSAID), radiation therapy, and surgical intervention. It emphasizes early identification of high-risk patients and the implementation of preventive strategies during initial treatment. 4) The statement on the management of elderly patients with acetabular fracture brings together expert opinion and evidence to advise on the preferred management options of the complex subset of acetabular fractures with low bone density. This challenging group has complex injury patterns and functional demands that differ from traditional high-energy acetabular fractures.
Conclusion: These consensus statements mark a significant step forward in standardizing care for patients with pelvic injury. They result from extensive discussions, literature review, and expert opinion from leading surgeons across the UK's major trauma centers. The implementation of these guidelines aims to enhance patient outcomes, reduce complications, streamline management processes, and provide clarity to the wider orthopaedic community.
Biomechanical Stability Optimization in Preoperative Planning for Tibial Plateau Fractures
Lea Sommerhalder, MSc; Simon Comtesse, MSc.; Lara Zamboni; Thomas Zumbrunn; Arvind von Keudell, MD
Purpose: Complex tibial plateau fractures challenge orthopaedic surgery, with plate and screw fixation strategies still debated. Finite element modeling (FEM) can quantitatively evaluate various osteosynthesis constructs under physiologic loads. Aiming to improve conventional preoperative planning by using FEM as a measure for assessing and optimizing biomechanical performance, we hypothesized that optimized osteosynthesis configurations provide greater stability than standard approaches.
Methods: Six human cadaveric tibias with Schatzker IV fractures (Rimasys, Germany) underwent a CT scan, after which the tibia fragments were segmented and realigned. Fractures were fixed with a medial variable angle locking plate (Pangea, Stryker, Switzerland), and initially positioned based on standard surgical planning by a fellowship-trained surgeon. FEM was used iteratively to optimize plate and screw placement. Stability was assessed by biomechanical simulations in Abaqus (Simulia, Dassault Systèmes, France). Knee joint reaction forces were scaled according to patient weight, and patient-specific Hounsfield-Unit–derived bone material properties were applied to the 3D model.
Results: Mean maximal displacement magnitude decreased significantly from the initial configuration to the optimized configurations (MInitial = 1.171 mm, SD = 0.431, MOptimized = 0.658 mm, SD = 0.185, p = 0.01), significantly reducing maximal displacement without altering the mean amount of screws used (MInitial = 11, SD = 1.265, MOptimized = 11, SD = 0.894, p = 0.5) but slightly reducing individual screw count (MInitial = 2.3, SD = 0.516, MOptimized = 1.83, SD = 0.753, p = 0.08).
Conclusion: Optimizing plate and screw positioning significantly reduced displacement compared to conventional planning, especially in initially unstable constructs (see figure). Finite element analysis (FEA) data offer valuable insights into fracture stability, aiding patient-specific surgical planning.
Prosthetic Provision for Transtibial Amputees Improves Function and Quality of Life
Charlotte Wahle, BA; Shravya Kakulamarri, BS; Francisco Javier Gomez Alvarado, Bachelor's; Babapelumi Adejuyigbe, BA; Michael Flores, MD; Abigail Cortez, MD; Alexander Hetherington, Certified and Licensed Prosthetist and Orthotist; Corin Shirley, Certified and Licensed Prosthetist and Orthotist; Geofrey Mwakasungula, Prosthetist; Billy Thomson Haonga, MD; Saam Morshed, MD, PhD; David Shearer, MD, MPH
Purpose: Traumatic events requiring amputation are a major source of disability in lower middle-income countries (LMIC). Despite this, most amputees do not have access to prostheses, exacerbating their disability. Prior research in transfemoral amputations has demonstrated that prosthetic provision can provide patients with major improvements in functional outcomes and quality of life. However, research regarding the impact of prosthetic provision to transtibial amputees in LMICs is limited.
Methods: This study identified transtibial amputees fitted for prostheses from January 2022 to September 2023. This was a double-arm study that enrolled patients at two major orthopaedic trauma centers in a low-resource area. Prosthesis usage, function, return-to-work, and quality-of-life data (as measured by EQ5D, PLUS-M™, and AMPPRO questionnaires) were collected.
Results: Of 23 patients fitted with a prothesis, 18 (78%) completed 1-year follow up. The indications for amputation included 12 (68%) trauma, 4 (22%) diabetes, 1 (6%) tumor, and 1 (6%) congenital. The average age was 45.3 years (SD = 16.8). Over the course of 1 year of wear, a total of three feet and three sockets were repaired or replaced. At the time of 1-year follow up, an additional three feet were recommended for replacement. At 1-year follow up, 15 of 18 (83%) patients were actively using their prosthesis. The reason for abandonment in all three patients was a result of need for repair. EQ5D and Plus-M scores were significantly higher in those patients actively using their prosthesis at 1 year compared to those not using their prosthesis (p = 0.05, p<0.01, respectively). Overall, the EQ5D score improved from 0.76 immediately postamputation to 0.93 at 1 year (p<0.01). The Plus M score improved from 39.4 at amputation to 52.9 at 1 year (p<0.01). The AMPPRO score improved from 32.7 prior to prosthetic to 39.3 at 1 year (p<0.001).
Conclusion: At 1-year follow up, low-cost prosthetic provision for transtibial amputees demonstrates positive impacts on return-to-work and overall quality of life. The impact was significantly greater for those who continued use over time, placing a strong emphasis on the importance of repair or replacement. The findings of this work demonstrate that low-cost prostheses in transtibial amputees offer sustained positive impacts at 1-year follow up.
An Algorithm for the Management of Acute and Posttraumatic Bone Defects
Peter Cay, MA (Oxon), MB BChir; Alastair Robertson, FRCS; Enis Guryel, FRCS
Purpose: The management of bone defects resulting from complex trauma has always been an extremely difficult problem, with even greater challenges to surmount in the presence of infection or associated soft-tissue defects. Many centers now work closely with plastic surgeons in an integrated orthoplastic approach. This approach has expanded the limb salvage options, as the ability to use all-internal fixation methods have become possible due to the robust soft-tissue coverage offered by plastic surgeons at the time of definitive stabilization. This has meant that early complex decisions are required, and we propose an algorithm for the management of bony defects based on our clinical experience and present a retrospective analysis to support this proposal.
Methods: Patients who had an acute bony defect following debridement were analyzed intraoperatively and declared incomplete, subcritical, and critical/segmental as per the classification proposed by the OTA on bone defects. Patients underwent fixation at the time of definitive closure, and bony defects were managed according to their size with a synthetic bone void filler, a cement spacer followed by a 2nd-stage Masquelet technique, or bone transport with an internal lengthening nail.
Results: A synthetic bone void filler was used in 83 patients with 56 patients (67%) achieving infection-free union and consolidation of the bone defect. The Masquelet technique was performed in 20 patients; consolidation of their bony defect resulted in 17 (85%) patients. An internal lengthening device was used in 4 patients with 100% consolidation of the regenerate and union of the docking site.
Conclusion: An orthoplastic approach to the management of complex trauma and posttraumatic conditions such as infection has allowed orthopaedic surgeons to use alternative methods for the management of bony defects. We propose an algorithm to guide surgeons in their decision-making for these complex problems.
Semi-Extended Tibial Nailing Through the Suprapatellar Portal: Incidence of Intraarticular Placement and Difficulties With Extraction. A Cause of Concern?
Paul Rodham, Mres FRCS; Vasilis Giannoudis, MBChB, MRes; Sotirios G Themistokleous, MD; Nikolaos K Kanakaris, MD, PhD; Peter V Giannoudis, MD, FACS, FRCS
Purpose: Although the tibial nail entry point is well defined by Tornetta et al (2001), our unit has noted difficulty in removing nails sited via the suprapatellar portal, frequently necessitating arthrotomy. The presented study aims to define the achieved entry point using the suprapatellar portal and highlight any difficulty where the nail required extraction.
Methods: Patients presenting with tibial fractures managed via suprapatellar nailing were included. Exclusions included patients younger than age 18 years and patients in whom an alternate approach was used. AP and lateral radiographs were reviewed by two assessors to establish the entry point as per the radiologic methods described by Tornetta et al. Clinical outcomes including union and postoperative complications were collated from the patient notes.
Results: Across a 4-year period including 200 tibial nailing procedures, 99 patients (mean age: 48 years [range: 17–97 years], male: 69) were included. In the coronal plate, the mean entry point was 1.6 ± 4.3 mm medial to the midline (51.1% ± 5.4% of the width of the plateau working from lateral to medial). The entry point was medial to the midline in 68 patients (mean: 1.6 ± 4.3 mm) and lateral to the midline in 31 patients (mean: 3.7 ± 2mm). In the sagittal plane, the entry point was on average 6.6 ± 2.9 mm from the radiologic articular margin. The nail path breached the articular surface in 42 patients (mean: 1.8 ± 1.4 mm intra-articular). In total, 13 complications were observed, the most common of which were fracture-related infections (4) and nonunions (3). Metalwork removal was required in seven patients. Of the 42 intra-articular nails, four required extraction, of which three necessitated a formal arthrotomy. Moreover, on evaluating the remaining 38 and assessing the removal trajectory, most would similarly require an arthrotomy.
Conclusion: Suprapatellar nailing was associated with a medial entry point and frequent breach of the articular surface (42%). Where nail removal was required, an arthrotomy was necessary in 75% of patients in whom the articular surface was breached. Surgeons should be aware of this, and, prior to the index procedure, patients should be forewarned about the need of arthrotomy.
Coracoid Base Fractures: A Missed Variant of the Rockwood's Acromioclavicular Joint Injuries
Bhavin Jadav, FRACS(Orth)
Purpose: The coracoid process makes up an important part of the superior shoulder suspensory complex (SSSC) to the extent that it has been referred to as the "lighthouse of the shoulder." We present our experience and understanding of uncommon coracoid process injuries, which are reported sparsely as case reports and have no consensus on preferred fixation methods. The observation of the coracoid base fractures associated with acromioclavicular (AC) joint injuries, which are sometimes subtle, implies this is a missed variation in the Rockwood classification scheme, where the point of failure is at the base of the coracoid instead of the coracoclavicular ligaments.
Methods: We report on five cases of coracoid base avulsion fractures that were identified as SSSC failures and managed surgically. The AC joint reduction and referencing with the intact part of the acromion with the help of a hook plate results in reduction of the coracoid as well as functional off-loading of the coracoid process, allowing it to heal in a reduced position. The hook plate is later removed after osseous union of the coracoid is confirmed.
Results: Fixation of the SSSC injuries with coracoid base avulsion and of the AC joint injury with a hook plate resulted in indirect reduction of the coracoid, removing the necessity of direct reduction and/or fixation of the coracoid process itself and allowed healing of the injury in all cases. Appropriate technique and timely removal of the hook plate avoided problems of acromial erosion in all cases and allowed appropriate healing of the shoulder girdle with a much simpler procedure, without having to directly manipulate or fix the coracoid.
Conclusion: The understanding of the injury mechanics reinforced by the fact that the derived surgical technique worked reliably and reproducibly suggests that the particular injury pattern is within the spectrum of the AC joint injuries as described and classified with Rockwood classification, although the failure point is osseous at the base of the coracoid rather than through the coracoclavicular ligaments. Explaining these injuries in this manner will simplify their management in the hands of upper limb and trauma surgeons.
Cost of Orthopaedic Trauma Surgery Is Not Meaningfully Associated With Industry Payments to Surgeons
Harsh Wadhwa, MD; Gavin Touponse, BS; Guan Li, BS; Julius A Bishop, MD; Corinna Zygourakis, MD
Purpose: The purpose of this study is to examine the relationship between industry payments and total cost of orthopaedic trauma surgery. The secondary purpose is to investigate the relationship among industry payments and operating room cost, length of stay, 30-day mortality, and 30-day readmission.
Methods: Open Payments data was matched across a 20% sample of Medicare beneficiaries undergoing orthopaedic trauma surgery (n = 110,242) with 9036 surgeons, from January 2006 to December 2015. Total and operating room costs, length of stay, mortality, and readmissions were recorded. Multivariable linear and logistic regression models were used to identify the risk-adjusted relationship between industry payments and primary and secondary outcomes.
Results: Industry payments were received by 99.9% of orthopaedic trauma surgeons. After multivariable risk adjustment, for each $1000 increase in industry payments, total and operating room cost of cases increased by $2.25 and $1.26 (0.003% and 0.008% of total cost) respectively. Industry payments were not associated with length of stay, 30-day mortality, or readmission after orthopaedic trauma surgery. Total and operating room cost was approximately $8920; it was $1481 higher for surgeons receiving the highest 5% of industry payments. These surgeons generally practiced in large urban areas, in hospitals with a higher number of beds, and with a higher wage index.
Conclusion: Although most orthopaedic trauma surgeons receive industry payments, a minority of surgeons receive the majority of payments. Although industry payments may lead to conflicts for some surgeons, these conflicts do not meaningfully affect the cost of fracture care.
The Silent Money Pit: The Cost of Poorly Managed Central Supply
Austin Helton, MS4; Nicholas Mazza Cavil, MD; Bruce H Ziran, MD, FACS
Purpose: We have noted that surgical instrument tray preparation by the central processing department is frequently flawed, prompting the “opening” of additional trays to subsidize deficiencies. Each tray incurs a tangible cost, suggesting significant financial and safety implications. Industry representatives often manage tray readiness, but their potential reduction raises concerns about cost and quality issues as it applies to equipment management. We hypothesize that flawed tray preparation leads to increased costs and potential patient safety risks.
Methods: We analyzed the rate of new tray openings (NTO) because of faulty preparation over a set 3-month time period. Operating room (OR) nurses documented each NTO, categorizing causes as missing instruments, damaged/faulty instruments, or sterility breaches. Tray preparation costs were obtained from financial and OR processing records at our institution. The results were compared across specialties and to the total inpatient surgical volume.
Results: Among 3020 inpatient cases, 315 NTOs occurred (10.4% rate), averaging 105 per month. Causes included missing components (32%), damaged instruments (1%), and sterility breaches (67%). With an average tray preparation cost of $75 (range $60–$92), the estimated annual cost of improperly prepared trays ranged from $75,600 to $115,920.
Conclusion: Significant costs and inefficiencies stem from poor central supply processes, with sterility breaches (67%) and missing components (32%) being the primary causes. Our study likely underestimates true costs, as the NTO data collection was not a formal OR policy. We propose reevaluating central supply processes, providing quality control metrics, considering incentivizing performance of central supply employees, or future innovation in technology that could mitigate such costs and potential safety hazards.
Economic Benefits of Continuous Pressure Monitoring as an Aid for the Diagnosis of Acute Compartment Syndrome
Yasser Bouklouch, PharmD MPH; Milan K Sen, MD ,FRCSC, FAAOS, FIOTA
Purpose: Acute compartment syndrome (ACS) is a serious complication following a traumatic injury. The current standard of care relies on clinical assessment, which has a low sensitivity and specificity. Recent clinical trials have shown that microelectromechanical systems (MEMS) used for continuous pressure monitoring have near-perfect sensitivity and specificity when used for the diagnosis of ACS in extremity fractures. We have analyzed their economic impact.
Methods: The model makes use of a decision-tree structure to estimate the cost of tibial shaft and plateau fractures at 60 days and 1 year after admission and in the patient’s lifetime. The model follows the UK's NICE guideline methodology.
Results: The inflation-adjusted cost of uncomplicated tibial fractures is on average $57,144. The performance of an unnecessary fasciotomy (Gr1) increased that cost by $27,789. This increase was largely driven by the increased risk of deep surgical site infection followed by the increased risk of nonunion. The maximum 60-day cost was attributed to ACS cases leading to an amputation (Gr5) with a total cost of $276,661. The improved specificity of the continuous pressure monitoring reduced the number of unnecessary fasciotomies by 94%. The small differences in sensitivity had limited impact on the ability to detect ACS. Over a 60-day time horizon, the model showed a decrease in length of stay estimated at 2.73 days on average per patient. The gain in quality-adjusted life-year (QALY) was limited to 0.004 per patient with a net health benefit of 0.04 QALY with the willingness-to-pay threshold at $50,000 per QALY. The net monetary benefit was a positive $1,541 in favor of the continuous pressure monitoring strategy. This gain improved substantially with the increased time horizon reaching a peak of $4,573 over the lifetime of the patient. Most importantly, the continuous pressure monitoring showed dominance over the standard of care with the incremental cost-effectiveness ratio (ICER) set at $50,000.
Conclusion: The sensor cost incursion is offset by the reduction in unnecessary fasciotomies and the costsassociated with their complications such as infection, nonunion, and amputation.
Is Pre-Operative CT Economically Justifiable to Identify Occult Posterior Malleolus Fractures in Patients With Tibial Shaft Fractures?
Shawn Michael Hines, MD; Michael James Anderson, MD; Nicholas Bertha, MD; Gregory Kirchner, MD; Henry Aidoo Boateng, MD
Purpose: Contemporary evidence suggests that occult posterior malleolar fractures (43B1) in the setting of tibial shaft fractures (42A/B/C) are rarely clinically significant. We hypothesized that preoperative computed tomography (CT) of the distal tibia is not economically justifiable in identifying concomitant clinically significant posterior malleolus fractures that would otherwise be missed.
Methods: The costs of CT imaging and return to the operating room to address a displaced posterior malleolus fracture following fixation of tibial shaft fractures were obtained from the authors’ institution. The rate of missed postoperatively displaced posterior malleolus fractures was obtained from contemporary literature, and clinical significance was defined as >30% articular involvement and 1 to 2 mm displacement. A break-even analysis was used to determine the rate of missed displaced posterior malleolus fractures that would need to be identified with CT imaging in order for its routine use to be economically justified. Using the calculated rate, an absolute risk reduction (ARR) of missed posterior malleolus fractures was derived. Finally, costs and rates were varied to determine break-even cost boundaries.
Results: At a rate of 0.83% for clinically significant displaced posterior malleolus fractures identified postoperatively, the ARR required to break even on cost was 5.00% at CT cost of $500 and additional operating costs of $10,000. Adjusting the cost of a preoperative CT demonstrates that CT can become economically justifiable at costs less than or equal to $83. Adjusting cost of return to the operating room demonstrated that preoperative CT can become economically justifiable at costs greater than or equal to $60,000. The rate of clinically significant posterior malleolus fractures would need to be equal to or greater than 5% in order for preoperative CT imaging to become potentially economically justifiable.
Conclusion: Preoperative CT imaging would need to identify one clinically significant occult posterior malleolus fracture in every 20 tibial shaft fractures for its routine use to be economically justifiable, which is well above the expected 1% incidence as suggested by the current literature. This suggests the utility of preoperative CT imaging in the setting of tibial shaft fractures is limited.
The Financial and Qualitative Benefits of AI-Powered Scribing in Orthopaedic Outpatient Clinics
Hans Peter Van Lancker, MD, MBA; Donald Fejfar, MD; Yasser Bouklouch, PharmD MPH; John Esposito, MD, MSc, FRCSC; Jillian Gruber, MD; Edward J Harvey, MD, FIOTA, FAAOS, FRCSC
Purpose: This study investigated the impact of implementing an artificial intelligence (AI)-powered scribe for documenting orthopaedic outpatient clinic visits on both financial performance and content quality, aiming to quantify the return on investment (ROI) and assess the qualitative benefits for providers, staff, and clinic efficiency.
Methods: Orthopaedic outpatient clinic visits were documented using an AI-powered scribe. Data were collected on patient volume, billing revenue, and provider-reported time spent on documentation. Subjective assessments of note content detail and provider satisfaction were also gathered. The cost of the AI scribe service was factored into the ROI calculation. Workflow impacts on clinic staff and overall clinic efficiency were also evaluated qualitatively.
Results: The AI scribe demonstrably increased the detail and comprehensiveness of patient visit documentation. Quantitatively, the scribe enabled providers to see an average of three or more additional patients per day. With an average gross revenue of $195 per visit, this increased patient volume translated to substantial revenue gains. The service cost of $600 per month per provider represented a highly favorable ROI. Providers reported a significant decrease in at-home note writing time, improved documentation accuracy, and increased overall job satisfaction. Furthermore, the faster turnaround time for completed notes facilitated more timely billing. The AI scribe also contributed to improved clinic efficiency and reduced administrative burden on staff, streamlining workflows.
Conclusion: These combined financial and qualitative improvements demonstrate the significant value proposition of AI-powered scribing for orthopaedic outpatient clinics, enhancing both patient care and organizational performance by increasing revenue, improving documentation quality and accuracy, boosting provider satisfaction, and streamlining clinic operations.
Missed Opportunities: Underbilling of Non-Operative Fracture Care is Common in Orthopedic Polytrauma Patients
Douglas Zhang, BA; Jeffrey Blibo, BS; Miriyam Ghali, MD MBA; Gregory Vincent Schimizzi, MD PhD; Tony Christiano, MD; Mary Kate Erdman, MD
Purpose: Literature has demonstrated the occurrence of missed injuries in patients with severe polytrauma, often attributed to the presence of distracting injuries. Similarly, the documentation of surgical fracture care may “distract” the surgeon from comprehensive billing, and services for nonoperative fracture care of lesser injuries may go unrecognized. The purpose of this study is to quantify underbilling of nonoperative care in orthopaedic patients with polytrauma and to measure the economic impact of nonoperative care that goes unbilled.
Methods: This retrospective study included adult and pediatric patients presenting to a single Level I trauma center between July 2019 and July 2023; patients had an injury severity score >16 and multiple orthopaedic injuries. Only patients with at least one surgically treated orthopaedic injury, not including operations performed by a hand or spine surgeon, were included. A billing database was queried to obtain all CPT codes submitted for billing. A list of managed diagnoses was obtained for each patient through chart review. A list of missed CPT codes for nonoperative care was derived via reconciling the list of submitted CPT codes with the managed diagnoses for each patient. Lost revenue was calculated using the 2025 Centers for Medicare & Medicaid Services Physician Fee Schedule.
Results: In total, 123 patients were included; 69 (56%) patients had a total of 127 missed codes for nonoperative orthopaedic care. Lost revenue totaled $35,797.06 overall, corresponding to losses of $8,949.26 per year and $518.80 per patient with missed codes. Most missed codes (55.91%) were related to lower extremity diagnoses (n = 71 codes). The most common missed codes were for closed treatment of metatarsal (n = 20 codes; 8 patients), scapula (n = 15; 14 patients), and tarsal (n = 15; 7 patients) fractures, which correspond to total losses of $4414.60, $4060.05, and $3097.50 for each fracture type, respectively.
Conclusion: Underbilling of nonoperative fracture care occurs in most heavily traumatized patients who undergo orthopaedic surgery. The strict inclusion criteria of this study likely underestimate the total occurrence of underbilling and subsequent lost revenue. Surgeons should be mindful of this pattern to ensure appropriate reimbursement for all services rendered.
Pediatric Orthopedic Trauma at a Level II Trauma Center: Benefits of Coverage by Traumatologists
Dietrich Walker Riepen, MD; Joseph Gardner, BS; Pierce Johnson, MD; Peter Althausen, MD, MBA
Purpose: Our objective was to compare implant costs and case duration of pediatric trauma cases performed by fellowship-trained orthopaedic traumatologists versus fellowship-trained pediatric orthopaedists.
Methods: In this retrospective analysis at a Level II trauma center, trauma cases involving patients age 18 years or younger were identified over a 20-month period (January 2023 to August 2024). Cases by four traumatologists were compared with similar cases by two pediatric orthopaedists. Case types were deemed similar if they had the same CPT code and similar fracture type, means of reduction, and manner of fixation. Mean implant costs and case duration (incision to closure) were compared using two-tailed t-testing.
Results: In total, 307 pediatric trauma cases were identified (246 by traumatologists and 61 by pediatric orthopaedists). Details of the 12 similar case types are shown in Figure 1. For 9 of 12 case types, traumatologists had lower implant costs and shorter case duration. When average implant costs are combined, trauma surgeons used implants that were 52% less expensive than pediatric surgeons. Pediatric surgeons also took 35% longer than trauma surgeons, on average, for these 12 case types. Unplanned reoperation rates were similar.
Conclusion: For comparable pediatric trauma cases, traumatologists completed cases 26% faster with 52% less expensive implants than pediatric orthopaedists. Pediatric trauma coverage by traumatologists may improve hospital resource allocation, improve operating room utilization, and financially benefit patients and the healthcare system.
Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?
Steven M Hadley, BA; Rachel Bergman, MD; John J Peabody, MD; Sarah J Westvold, MPH; Ryan Filler, MD; Milap Patel, DO; Anish R Kadakia, MD; John Wesley Munz, MD
Purpose: It remains unclear whether the syndesmotic fixation technique [Tightrope, InternalBrace (IB), and screw] impacts complication rates and outcomes. This study aims to determine which technique results in the fewest complications and best functional outcomes as measured by Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). We hypothesized that Tightrope and IB would reduce complications and improve PROMIS scores compared to screws.
Methods: 782 patients who underwent ankle fracture surgery at a single institution from 2016 to 2021 were reviewed retrospectively. Two foot and ankle fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. 328 patients with syndesmotic ruptures were sent postoperative questionnaires. 159 patients with minimum 1-year follow-up were analyzed for complications. 70 patients who completed PROMIS CATs were analyzed for functional outcomes. The Kruskal-Wallis test compared PROMIS scores across repair types. PROMIS scores were modeled by technique using linear regression. This study had 80% power to detect large effect sizes (Cohen’s f = 0.40) but was underpowered for small and medium effects.
Results: Overall complication rates with screw were 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 0% end-stage arthritis, 6.5% (4/62) syndesmotic malreduction. Complication rate in Tightrope was 1.7% (1/59):1.7% (1/59) DJD. IB had no radiographic complications. Mean PF was 50.38 ± 9.39 screw, 53.87 ± 9.70 Tightrope, and 52.18 ± 13.08 IB (p = 0.71). Mean PI was 49.28 ± 8.22 screw, 47.91 ± 8.80 Tightrope, and 49.15 ± 10.46 IB (p = 0.79). Compared to screws, adjusted models demonstrated mean PF 4.00 points greater for Tightrope (p = 0.17) and 2.94 points greater for IB (p = 0.34). Adjusted models for PI revealed mean scores 2.05 points less for Tightrope (p = 0.42) and 1.23 points less for IB (p = 0.65) compared to screws.
Conclusion: Compared to screws, Tightrope and IB resulted in fewer complications and clinically relevant increases in PF, as the modeled PROMIS PF scores reached the lower end range of the minimal clinically important difference for this outcome measure reported in the literature.
Does Deltoid Ligament Repair Reduce Complications and Improve Functional Outcomes Measured by PROMIS Scores Following Ankle Fracture Surgery?
Steven M Hadley, BA; Rachel Bergman, MD; John J Peabody, MD; Sarah J Westvold, MPH; Ryan Filler, MD; Milap Patel, DO; Anish R Kadakia, MD
Purpose: Deltoid repair (DR) in ankle fracture surgery remains controversial. We sought to determine whether DR reduces complications and improves functional outcomes measured by Patient Reported Outcomes Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). We hypothesized that DR would reduce complications and improve PROMIS scores.
Methods: This was a retrospective study of 782 patients at a single institution who underwent ankle fracture surgery from 2016 to 2021. Two fellowship-trained foot and ankle orthopaedic surgeons independently reviewed all radiographs and assessed reduction quality and complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. All 345 patients with deltoid ruptures were sent PROMIS CATs. 265 patients with minimum 1-year follow-up were analyzed for complications. 112 patients who completed CATs were analyzed for functional outcomes. The Wilcoxon Rank Sum test compared PROMIS scores between groups. Linear regression modeled the effect of DR on PROMIS. This study had 80% power to detect a large effect size (Cohen’s d=0.68).
Results: 50/265 (18.9%) underwent DR. Radiographic complications incidence among 215 patients (81.1%) without repair was 14.42%: seven (3.26%) degenerative joint disease, three (1.40%) ankle joint malreduction, four (1.86%) syndesmotic malreduction, and eight (3.72%) malleolar malunion. The DR group had no radiographic complications. Among patients who completed CATs (n = 112), DR (n = 21) had non-significantly higher mean PF (54.31 ± 9.83 vs 52.79 ± 10.42, p = 0.71) and non-significantly lower mean PI (47.21 ± 7.82 vs 48.53 ± 8.37, p = 0.59). Adjusted regression models estimated 1.89-point increase in PF and 1.67 decrease in PI for DR versus no repair.
Conclusion: DR reduces complications following ankle fracture surgery, likely due to improved ankle stabilization and alignment. Although this study was underpowered to detect small effect sizes in PROMIS PF and PI, small improvements in functional outcomes observed in our study suggest DR may improve patient-reported outcomes. Unlike patients without DR, patients with DR achieved higher PROMIS PF in the minimal clinically important difference range reported in the literature for this outcome measure compared to the population mean score of 50.
How Good Are We at Getting It Right? Anatomic Reductions Are Rarely Achieved for Severely Displaced Pilon Fractures and This Portends Severe Osteoarthritis
Lauren Morris, BS; Reinaldo Eugenio Colon-Morillo, MD; Keenan Masami Onodera, Md; Connor A. Wallace, BS; Zachary A. Wuthrich, MD; Nicholas Alfonso, MD; Joshua Parry, MD
Purpose: To evaluate the association among initial articular displacement of pilon fractures, articular reduction quality, and the development of severe osteoarthritis.
Methods: A retrospective review of patients with pilon fractures treated with open reduction and internal fixation was performed. Three orthopaedic surgeons reviewed injury, intraoperative, and postoperative radiographs to grade the initial articular displacement as <2 mm, 2–5 mm, or >5 mm, the postoperative residual articular displacement as 0 mm (anatomic), ≤2 mm, or >2 mm, and the Kellgren and Lawrence (KL) osteoarthritis (OA) grade as 0 (none), 1 (doubtful), 2 (minimal), 3 (moderate), and 4 (severe). The associations between initial and residual articular displacement and the development of grade 4 OA were evaluated.
Results: The review included 115 pilon fractures. The interobserver reliability among the three observers, for initial articular displacement, residual articular displacement, and KL OA grade were all considered to be moderate. Initial articular displacement on injury radiographs was associated with residual articular displacement on postoperative radiographs with 100.0% (28/28) of patients with <2 mm of initial articular displacement having 0 mm of residual articular displacement, compared to 51.7% (15/29) and 17.2% (10/58) of patients with 2–5 mm and >5 mm of initial articular displacement (p<0.0001). The development of KL grade 4 OA was significantly associated with both initial articular displacement (p<0.0001) and residual articular displacement (p<0.0001). All patients with an initial articular displacement <2 mm achieved 0 mm of residual articular displacement, and there were no cases of grade 4 OA. In contrast, grade 4 OA developed in 66.7% (4/6) and 85.7% (18/21) of patients with an initial displacement between 2–5 mm and >5 mm that had residual displacement >2 mm.
Conclusion: Anatomic reductions were achieved in only 17.2% of pilon fractures with >5 mm of initial articular displacement. Severe OA developed in 50% of these fractures, and the rate increased to 85.7% if there was a residual articular displacement >2 mm. Future studies are necessary to determine if high-risk fractures are better served by acute arthrodesis.
The Influence of GLP-1RA Medications on Fracture Risk in the Diabetic Foot and Ankle Patient Population
Samantha Nikole Olson, BS; Alexandra Vaughan-Masamitsu, BS; Michael Levidy , MD; lincoln Dutcher , MD; jana Davis , MD
Purpose: Diabetes mellitus (DM) is associated with an elevated risk for sustaining a fracture, driven by both direct and indirect mechanisms. Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RAs) are a newer class of medication being used in the management of DM. Prior studies have demonstrated that certain GLP-1RAs promote bone formation by reducing osteoclast activity and stimulating osteoblast differentiation. However, the evidence of their impact on fracture risk remains inconclusive. This study seeks to investigate the association between GLP-1RAs and ankle fracture risk in diabetic patients, aiming to clarify their potential clinical effects.
Methods: The global collaborative network on the TriNetX online health record database retrospectively compared ankle fracture risk across diabetic patients. Patents were excluded if they were taking any alternative diabetes medication aside from metformin, had a diagnosis of diabetic neuropathy or osteoporosis with or without a current pathologic fracture, or used corticosteroids. The two cohorts either included or excluded GLP-1RA. Propensity score matching for age, sex, tobacco use, and alcohol abuse yielded 129,332 patients. ICD-10 codes for ankle fracture types included bimalleolar, trimalleolar, lateral malleolar, medial malleolar, and fracture of the lower leg including the ankle.
Results: The mean age of patients was 56±15 years. The patient demographics included 52.9% female, 60.6% not Hispanic or Latino, and 54.5% White. In all ankle fracture cohorts, GLP-1RA usage was associated with a significant reduction in risk (P<0.05). The risk of bimalleolar fracture of the lower leg had the highest risk ratio of 2.195 (95% CI:1.517–3.175), odds ratio of 2.196 (95% CI: 1.518–3.177), and nearly double the risk for those not taking GLP-1RA medications (P<0.0001). The risk ratios of all the remaining cohorts were statistically significant and ranged from 1.865 to 1.482.
Conclusion: The results of this study demonstrate a statistically significant lower risk of ankle fracture in diabetic patients who are taking a GLP-1RA medication as compared to those who are not. This study’s findings contribute to the growing body of evidence that GLP-1RA medications may exert a protective effect on bone and could potentially reduce fracture risk in patients with DM.
Decreased Rates of Avascular Necrosis in Displaced Talar Neck Fractures When Using Plate Fixation Versus Screw Fixation Alone
Brendan Page, MD; Griffin Rechter, MD; Adam Nasir, BS; Joshua Langford, MD; Mohamad K Shaath, MD; George J Haidukewych, MD
Purpose: This study sought to compare the rates of complications in talar neck fractures treated with screw fixation compared to plate fixation, specifically avascular necrosis (AVN), arthritis, infection, and the need for secondary salvage procedures.
Methods: This retrospective chart review took place in a single academic Level I trauma center. Patient selection criteria included patients who underwent fixation of a vertical talar neck fracture over a 5-year period (2017 to 2022) and had at least 3 months of postoperative follow up. Patients were grouped based on the implant used: screws only or plate and screw fixation. Each group was subdivided based on Hawkins Classifications (I, II, III, and IV). The primary outcome measured was the rate of AVN between treatment groups. Secondary outcomes were posttraumatic hindfoot arthrosis, postoperative infections, and the need for secondary procedures.
Results: In this review, 70 patients were identified—37 in the plate fixation group and 33 in the screw fixation group. There were higher rates of all complications in the screw fixation group, with a significantly higher rate of AVN compared to the plate fixation group (52% vs 22%, p<0.05). When stratifying for fracture severity, there were significantly higher rates of AVN in the screw fixation group for type II fractures (47% vs 6%, p<0.05). There were also higher rates of AVN in type III and type IV fractures; however, this did not reach statistical significance. Rates of subtalar arthrosis were uniformly high in both groups. There was a greater difference in the rate of AVN between the screw fixation and plate fixation groups in smokers (68.8% vs 30%), which approached statistical significance (p = 0.0536). Open fractures had a high rate of AVN and posttraumatic arthritis, 83% and 75%, respectively. In open fracture patients, those treated with screws alone had higher rates of AVN compared to plate fixation, which trended toward statistical significance (89% vs 33%, p = 0.05846).
Conclusion: In agreement with previous biomechanical data, plate fixation appears to provide the most sufficient mechanical stability to control for comminution and prevent AVN when compared to screw fixation.
Lower Implant Removal Rates Occur Following Posterolateral Antiglide Fixation for Distal Fibula Fractures
Logan John Woods, MD; Golpira Elmi Assadzadeh, PhD; Andrew Caines, MD; Prism Schneider, MD, PHD, FRCSC
Purpose: Distal fibula fractures are a common injury, often requiring surgical management, and multiple surgical fixation techniques are used. Biomechanical studies have shown antiglide plating to be superior to lateral plating. However, lateral plating remains the most commonly performed technique. This study sought to compare the outcomes of posterolateral antiglide fixation for distal fibula fractures with those of lateral plating, dual plating, locking plate fixation, and intramedullary fixation. We hypothesized that the antiglide plating technique will have lower rates of implant removal, wound complications, and infection.
Methods: A multicenter retrospective observational cohort study was performed using data collected from a large healthcare data repository. Eligible patients were 18 years and older with an isolated ankle fracture that underwent surgical fixation from July 1 to December 31, 2016, and July 1 to December 31, 2019. Patients had at minimum two follow-up visits postoperatively. Those with multiple injuries, open fractures, pathologic fractures, and preexisting ankle implants were excluded. Radiographic and chart reviews were performed on included patients. Chi-squared, ANOVA, Kruskal-Wallis rank sum, t-tests, and Fisher’s exact tests were used, as appropriate.
Results: This study included 1525 patients (mean age 47 years [SD = 17.2], 55.9% female). Lateral plating was the most common technique (74.2%). Secondary surgery for implant removal was performed on 364 patients (23.8%). Pain was the most frequent reason for secondary surgery for implant removal. The rate of implant removal was lowest with antiglide plating (9.9%) compared to lateral plate (18.7%) and other fixation methods (p = 0.004). The odds ratio of implant removal for lateral plating and locked plating versus antiglide plating was 2.2 (CI: 1.4–3.5) and 2.5 (CI: 1.2–5.2), respectively. The rate of antibiotic use was lower in antiglide plating (27.4%) than lateral plating (30.9%; p = 0.001).
Conclusion: Lateral plating continues to be the most commonly used method of distal fibular fixation. The implant removal rate was similar to previously published rates. Posterolateral antiglide plating had the lowest rate of implant removal and was more than two-times less likely to be removed compared to lateral plating.
The Not So Simple Ankle Fracture: A Strict Assessment of Complications Following Open Reduction and Internal Fixation of Rotational Ankle Fractures
Jack Gagne, MD; Jacob Linker, BA; Nirmal C Tejwani, MD; Nicole M Stevens, MD; Steven Rivero, MD; Kenneth A Egol, MD
Purpose: The primary aim of this study was to investigate the incidence and spectrum of complications associated with open reduction and internal fixation (ORIF) of rotational ankle fractures. A secondary aim of this study was to identify patient demographic factors, medical comorbidities, and injury characteristics associated with these complications.
Methods: All patients who underwent ORIF for rotational ankle fracture at one institution over a 10-year period with a minimum follow-up time of 6 months were reviewed. Data on patient factors (eg, age, sex, body mass index [BMI], Charlson comorbidity index [CCI], smoking status), injury characteristics (eg, mechanism of injury, open versus closed fracture, Lauge-Hansen classification), surgical procedures, and outcomes were analyzed. All issues that required any deviation from the normal postoperative routine or affected patients in any negative way were considered a “complication.” These included postoperative sensory deficits, hardware failure, suspected and confirmed fracture-related infection (FRI), and fracture nonunion.
Results: A total of 681 patients was included with a mean follow-up time of 16 months. There were 245 (36.0%) males and 436 (64.0%) females, with an average age of 48.9 years. There were 37 (5.4%) OTA 44-A, 516 (75.8%) 44-B, and 128 (18.8%) 44-C fractures. The most common Lauge-Hansen fracture type was SER IV, occurring in 67.8% of cases. Overall, a complication developed in 175 patients (25.7%), with suspected FRI (6.8%) being the most common. Rates of nonunion and confirmed FRI were lower at 2.2% and 3.8%, respectively. The overall reoperation rate was 21.7%, including 133 (19.5%) cases of hardware removal. Multivariate analysis revealed a significant association between initial open fractures and overall complication rate (p = 0.006). The need for eventual hardware removal was associated with open fracture (p = 0.007) and younger age (p = 0.01). Fracture nonunion was associated with open fracture (p = 0.004) as well.
Conclusion: The overall postoperative complication rate following ORIF for rotational ankle fractures, using very strict criteria, was 25.7%. Complications were highly associated with open fractures.
Impact of Preoperative Osteoporosis on Short- and Long-Term Complications Following Ankle ORIF: A Multi-Institutional Propensity-Matched Analysis
Jad Lawand, MD; Abdullah Ghali, MD; Umar Ghilzai, MD; Kareem Horani, MD; John Christian Hagedorn, MD
Purpose: This study evaluates the relationship between preoperative osteoporosis and postoperative complications in patients undergoing ankle open reduction and internal fixation (ORIF).
Methods: A retrospective cohort study was conducted using multi-institutional electronic medical-derived data to evaluate complication rates following ankle ORIF. Patients who underwent surgery between 2004 and 2022 with a preoperative osteoporosis diagnosis and a minimum of 2 years of follow up were identified using CPT, ICD-9, and ICD-10 codes. Patients were stratified based on osteoporosis status, and a 1:1 propensity-matched analysis controlling for demographics and comorbidities was performed. Complication rates at 90 days and 2 years, including deep infection, hardware removal, nonunion, deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), stroke, and transfusion, were assessed.
Results: A total of 4190 patients was included in the propensity-matched cohort (2095 with osteoporosis and 2095 controls). At 90 days, patients with osteoporosis had a significantly higher risk of deep infection compared to controls (1.0% vs 0.5%, relative risk [RR]: 2.1, 95% CI: 0.99–4.45, P = 0.047). At 2 years, osteoporosis was associated with increased risks of hardware removal (14.2% vs 11.6%, RR: 1.23, 95% CI: 1.05–1.44, P = 0.011), deep infection (2.6% vs 1.4%, RR: 1.80, 95% CI: 1.16–2.8, P = 0.008), DVT (2.5% vs 1.6%, RR: 1.574, 95% CI: 1.01–2.45, P = 0.042), transfusion (3.9% vs 2.3%, RR: 1.673, 95% CI: 1.181–2.372, P = 0.003), and stroke (2.8% vs 1.7%, RR: 1.58, 95% CI: 1.039–2.41, P = 0.031). No significant differences were observed in nonunion, posttraumatic osteoarthritis, malunion, MI, or PE between groups at either time point (P>0.05).
Conclusion: Preoperative osteoporosis increases the risk of short- and long-term complications after ankle ORIF, including deep infection, hardware removal, DVT, transfusion, and stroke. Surgeons should address these risks and optimize patients preoperatively to reduce complications.
Impact of Preoperative Malnutrition on Medical and Implant Complications Following Ankle ORIF: A Multi-Institutional Retrospective Study
Abdullah Ghali, MD; Keenan Horani, MD; Jad Jack Lawand, MS; Umar Ghilzai, MD; John Christian Hagedorn, MD
Purpose: This study evaluated the relationship between malnutrition and postoperative complications in patients undergoing ankle open reduction and internal fixation (ORIF).
Methods: Patients who underwent ankle ORIF from 2004 to 2022 with preoperative lab values available for analysis and with a record for a minimum of 2 years of follow up were identified using CPT, ICD-9, and ICD-10 codes. Patients were stratified according to those with and without a preoperative lab value for nutrition defined as any transferrin <204 mg/dL or total leukocyte count <1500/µL within 3 months of surgery, between October 8, 2004, and October 8, 2022. Follow-up data were assessed up to October 8, 2024. Complication rates included 90-day readmissions, infection, hardware removal, nonunion, amputation, infection from the hardware, myocardial infarction (MI), pulmonary embolism (PE), deep vein thrombosis (DVT), transfusion, and stroke. Patients were additionally compared with a 1:1 matched analysis that controlled for demographics and comorbidities.
Results: In total, 46,843 patients with preoperative lab values and ankle fractures were identified and propensity matched. At 90 days, patients with malnutrition had higher rates of hardware removal, infection around the device, MI, PE, DVT, and transfusion compared to the control group (P< 0.05). Notably, the risk ratio (RR) for hardware removal was 1.680 (95% CI: 1.322–2.134, P< 0.001) and for transfusion, it was 3.212 (95% CI: 2.179–4.734, P< 0.001). Malnutrition was associated with a higher risk of amputation at 90 days [RR: 2.106, 95% CI: 0.993–4.466, P = 0.047] and at 2 years [RR: 4.089, 95% CI: 2.233–7.486, P<0.001].
Conclusion: Malnutrition significantly increased the risk of postoperative complications in patients undergoing ankle ORIF, including hardware removal, infections around the device, MI, PE, DVT, and transfusion. These trends were consistent across both the 90-day and 2-year follow-up periods. The findings suggest that malnutrition is a critical risk factor for both short- and long-term adverse outcomes, including higher rates of amputation. Surgeons should carefully consider malnutrition as part of preoperative risk stratification and provide patients with tailored counseling regarding the increased risk of complications following ankle ORIF.
Antidepressant Use Increases Postoperative and Long-Term Complications Following Ankle ORIF
Abdullah Ghali, MD; Amir Alsaidi, BS; Katie Mcbee, BS; Harris Hafeez, BS; Nathaniel G Loyd, MD; Jad Jack Lawand, MS; Elias Nasser, BS; Khaled Saleh, MD, FAAOS
Purpose: This study evaluated the relationship between antidepressant prescription (ADP) use and postoperative complications in patients undergoing ankle open reduction and internal fixation (ORIF).
Methods: A retrospective cohort study was conducted using multi-institutional data from the TriNetX research platform. Patients who underwent ankle ORIF on or before December 10, 2024, with at least two doses of ADP and a minimum of two years of follow up were identified via CPT and ICD-10 codes. Propensity score matching controlled for demographics and comorbidities. Primary outcomes included 90-day postoperative complications (eg, infection, opioid use, wound disruption) and long-term complications (eg, hardware failure, nonunion). Statistical comparisons were performed using χ2 and t-tests, with significance set at p<0.05.
Results: Of 43,170 patients analyzed, 10,683 (25%) used antidepressants; 32,487 (75%) were non-users. Propensity score matching yielded 6882 patients in each cohort. Within 90 days postoperatively, antidepressant users had significantly higher rates of surgical site infection (4.80% vs 2.22%, p<0.001), wound disruption (3.62% vs 2.31%, p<0.001), sepsis (0.91% vs 0.28%, p<0.001), stroke (0.47% vs 0.19%, p = 0.006), myocardial infarction (0.48% vs 0.25%, p = 0.030), pulmonary embolism (0.93% vs 0.47%, p = 0.002), pneumonia (2.12% vs 0.94%, p<0.001), transfusion (1.89% vs 0.61%, p<0.001), renal failure (1.56% vs 0.67%, p<0.001), readmission (16.52% vs 5.80%, p<0.001), emergency department visits (16.06% vs 8.73%, p<0.001), and inpatient hospitalizations (37.43% vs 21.85%, p<0.001). Long-term complications were also significantly higher in antidepressant users, including hardware removal (19.40% vs 14.45%, p<0.001), post-traumatic osteoarthritis (3.20% vs 1.87%, p<0.001), hardware failure (12.22% vs 9.38%, p<0.001), nonunion (1.08% vs 0.62%, p = 0.003), infection around the device (2.64% vs 1.19%, p<0.001), and amputation (0.82% vs 0.27%, p<0.001).
Conclusion: Antidepressant use is associated with significantly increased rates of both postoperative and long-term complications following ankle ORIF. These findings highlight the importance of tailored perioperative management, including enhanced infection prevention, mental health support, and close monitoring of patients using antidepressants to mitigate risks.
Vascular Calcifications Predict Early Complications After Ankle Fracture Surgery: A Matched Cohort Study
Taylor Harris, MD; Gabriella Smith, BA; Katelin J Isakoff, BS; Henry Wong, MS; Nicole Segovia Pham, MPH; Carina Tedesco, BS; Sandhya Chandar, BS; Lawrence Henry Goodnough, MD, PhD; Michael J Gardner, MD; Julius A Bishop, MD
Purpose: Vascular calcifications are associated with chronic diseases known to impact healing after ankle fracture surgery. However, the presence of incidentally noted vascular calcifications on perioperative radiographs has not been studied as an independent risk factor for complications. The purpose of this study was to assess the relationship between calcifications and postoperative complications in patients undergoing ankle fracture surgery.
Methods: Patients with unstable rotational ankle fractures treated at hospitals affiliated with an academic Level I trauma center over a 5-year period were identified using ICD-10 codes. Perioperative radiographs of the foot and ankle were evaluated for presence of vascular calcifications. Patients with and without vascular calcifications were matched on demographic data, injury characteristics, and comorbidities such as diabetes, renal disease, peripheral vascular disease, smoking, and osteoporosis. Outcome data were then collected for each group.
Results: In total, 752 patients were treated surgically for unstable ankle fractures during the study period and were screened for inclusion. Of these, 29 patients eligible for inclusion were noted to have vascular calcifications on injury radiographs and were matched to a similar cohort of 29 patients without vascular calcifications. In the vascular calcification cohort, 6.9% of patients had superficial surgical site infections, 13.8% had other wound complications, and 10.3% had fixation failure requiring additional surgery. In the cohort without vascular calcification, none had superficial surgical site infections, 6.9% experienced other wound complications, and none had fixation failure requiring additional surgery. The overall complication rate was higher in the vascular calcification group (37.9% vs 13.8%, p = 0.07).
Conclusion: Vascular calcifications seen on perioperative radiographs of patients with unstable ankle fractures are clinically significant independent risk factors for increased rate of postoperative complications. Surgeons should account for these calcifications on injury radiographs and incorporate this information into patient counseling. Future ankle fracture studies should report on the presence or absence of vascular calcifications. Further study is warranted to determine which specific adverse outcomes are most strongly associated with calcifications, as well as opportunities to decrease risk in this patient population.
Primary TTC Nailing vs. Open Reduction Internal Fixation for Extra-Articular Ankle Fractures in High-Risk Patients
Divya Jeyasingh, MS; Mark Arthur, MD; Niloofar Dehghan, MD, MSc, FRCSC
Purpose: Open reduction and internal fixation (ORIF) is the standard treatment of unstable ankle fractures. However, in high-risk patients, particularly those with diabetes and compromised soft tissues, ORIF is associated with a high complication rate. Primary tibiotalocalcaneal (TTC) nailing has been proposed as an alternative treatment that may reduce complication risk while maintaining stability. This study compares the complication rates between ORIF and TTC nailing in patients with diabetes with ankle fractures.
Methods: A retrospective review of patients with diabetes who underwent surgical management of an acute ankle fracture between 2017 and 2024 was performed. Patients with pilon fractures were excluded. Patients were divided into ORIF and TTC groups, then matched based on age, sex, diabetes, tobacco use, and body mass index (BMI) in a 4:1 fashion. The primary outcome was postoperative complications, including infection, wound-healing delay, fixation failure, and need for revision surgery. Multivariable logistic regression was also used to identify factors associated with complications, taking into account patient age, sex, diabetes, and tobacco use.
Results: In total, 214 patients were included. In the matching analysis, the ORIF (n = 174) group had a complication rate of 41.9%, while the TTC (n = 31) group had a rate of 38.7% (p = 0.803). Re-operations occurred in 19.6% of the ORIF group and 29.7% of the TTC group (p = 0.356). In the multivariable analysis, diabetes was associated with increased complication risk in the ORIF (n = 174) group (OR: 2.20, p = 0.054), but not in the TTC (n = 40) group (OR: 0.63, p = 0.524). Despite a higher reoperation rate in the TTC group, no individual factor significantly increased the risk of reoperation following TTC.
Conclusion: Patients with diabetes who underwent ORIF for unstable ankle fractures demonstrated a trend toward increased complication risk. Although TTC had a similar overall complication rate, it was not significantly affected by diabetes. These findings suggest that TTC nailing may be a viable alternative in high-risk patients with diabetes, potentially mitigating the impact of diabetes on postoperative complications. Further studies with larger sample sizes are warranted to confirm these findings.
Randomized Pilot Trial for Pain Control Following Operatively Treated Ankle Fractures
David Wilson Skinner, BS; Eric Swart, MD; Eric Scott Moghadamian, MD; Raymond Dayne Wright, MD; Daniel D Primm, MD; Grace Elizabeth Brooks, B.S.; Paul Edward Matuszewski, MD
Purpose: Ankle fractures are often treated surgically in an outpatient setting. Postoperative pain control is achieved via a multimodal regimen, regional block, or local injection cocktail. It is unknown whether any of these methods is superior with regard to pain level, opioid usage, or quality of recovery. The goal of this trial was to assess if any method demonstrated improved pain control or quality of recovery.
Methods: In a two-center, randomized, patient-blinded controlled trial, patients with surgically treated ankle fractures using two incisions were included. Patients with a history of substance use disorder, active opioid use, or pain disorder were excluded. Patients were randomized to receiving multimodal, regional block, or a local cocktail consisting of ropivacaine, epinephrine, clonidine, and ketorolac. Patients were given a pain journal and recorded their pain scores at 24, 48, and 72 hours. Morphine milligram equivalents (MME) were recorded in the post-anesthesia care unit (PACU) and through 72 hours. Quality of recovery (QOR) score was assessed via telephone at 24, 48, and 72 hours. Outcomes were assessed using ANOVA and regression methods.
Results: In total, 40 patients participated (average age: 43 years). There was no difference observed in pain scores at 24, 48, and 72 hours among the groups (visual analogue scale [VAS] at 24 hours: 4.9, SD: 2.6, p = 0.94; VAS at 48 hours: 4, SD: 2.38, p = 0.71; and VAS at 72 hours: 3.3, SD: 2.1, p = 0.71). There was no difference in MME among groups in either the PACU or home (PACU: Mean MME: 40.0, SD: 59.3, p = .22; 72: Mean MME: 71.8, SD: 40.5, p = .51). QOR at 24 hours was similar between the cocktail and block, but improved over multimodal (24-hour QOR: 15.2, 15.2, and 13, respectively, p = 0.024). At 48 and 72 hours, the block demonstrated slight improvement over both, with multimodal lowest (48-hour QOR: 16.5, 15.7, and 13.5, respectively, p= 0.03; 72-hour QOR: 17.2, 16.3, 15,respectively, p = 0.03).
Conclusion: Although none of the methods demonstrated a statistically significant difference in pain score and opioid usage, the cocktail and block were associated with a clinically significant increase in QOR in the first 24 hours, with this diverging through 48 and 72 hours.
Complications of Ankle Fracture Open Reduction and Internal Fixation Performed by Podiatrists vs. Orthopedists: A Systematic Review and Appraisal of National Policy Guidelines
Gabriella Schreiner, MS4; Stephen Fucaloro, MS4; Michaela Jordan, MS3; Jordan Zajac, MS3; Scott P Ryan, MD
Purpose: The primary aim of this study is to compare complications following ankle fixation performed by orthopaedic surgeons and by podiatrists. A secondary outcome was to review legislature regarding podiatric practice guidelines to determine which states allow podiatrists to operate at the ankle.
Methods: PubMed, Embase, Web of Science, and Cochrane databases were queried for articles comparing complication rates for orthopaedic surgeons and podiatrists. Inclusion criteria were comparative studies such as randomized controlled trials, case controls, or matched cohort studies that compared complications between orthopaedists and podiatrists. Studies were excluded if they were abstract-only publications, basic science research, technique articles, systematic reviews or review articles, case reports, or if they were not published in English. Additionally, state legislature was reviewed using the Federation of Podiatric Medical Boards website.
Results: Four studies were identified for study inclusion, with a total of 24,012 surgeries completed by orthopaedic surgeons and 3156 by podiatrists. The 30-day rehospitalization was significantly higher for podiatrists (1.2%) compared to orthopaedic surgeons (0.1%, p<0.01). The 90-day rehospitalization was similarly higher for podiatrists (1.6% vs 0.3%, p<0.01). Surgeries completed by orthopaedists had higher rates of postoperative infection (4.8% vs 3.3%, p<0.01), revision surgery (1.9% vs 1.1%, p<0.01), and nonunion (2.1% vs 1.5%, p<0.01). Upon review of state legislature, it was determined that 47 out of 50 states in the United States allow podiatrists to operate on the ankle. Furthermore, 17 out of 50 states explicitly outlaw podiatrists from operating on the entire leg.
Conclusion: Surgeries completed by podiatrists require rehospitalization more frequently than those completed by orthopaedic surgeons, indicating that patients may be at higher risk of more serious complications following surgery completed by podiatrists. Surgeries completed by orthopaedic surgeons had higher rates of typical and less severe complications such as revision surgery, infections, and nonunion. This is likely due to orthopaedic surgeons performing surgeries on more severe or complex ankle fractures.
No Difference in Rates of Radiographic Union, Total Complications, or Reoperation Between Nail Versus Plate Fibular Fixation in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Anthony Baumann, DPT; Albert T Anastasio, MD; Omkar Anaspure, BA; Shiv Patel, BA; Ziad Hassan, BS; Shahab Yazdanpanah, MS; Tyler Sanda, MD; Michael Makowski, MD
Purpose: The purpose of this study is to examine the high-level evidence comparing nail versus plate fixation in adult patients to enhance surgical decision-making and guide future trial methodology to improve patient care.
Methods: A systematic review and meta-analysis of randomized controlled trials (RCT) was performed by searching PubMed, Scopus, CINAHL, and Web of Science from database inception until October 1, 2024. Inclusion criteria were RCTs that compared nail versus plate fixation for fibular fractures in adults. Outcome measures were the risk ratio (RR) with 95% confidence intervals (CI) for rate of radiographic union, total complications, and reoperation.
Results: A total of six RCTs were included from the 730 articles initially retrieved. Patients (n = 486) had an average age of 51.8 ± 11.3 years (87.7% of patients reported) and received either nail (n = 243) or plate (n = 243) fixation for fibular fracture. There was no statistically significant difference in the rate of radiographic union between patients treated with nail fixation (n = 201) and patients treated with plate fixation (n = 204) via meta-analysis of five RCTs (p = 0.8698; RR: 1.00 [95% CI: 0.99–1.01], 98.0% vs 97.5%). In addition, there was no statistically significant difference in the rate of total complications between patients treated with nail fixation (n = 243) and patients treated with plate fixation (n = 243) via meta-analysis of six RCTs (p = 0.1572; RR: 0.52 [95% CI: 0.18–1.44]; 17.3% vs 28.8%), although this finding was possibly underpowered because of the large absolute difference in complication rate. Finally, there was no statistically significant difference in the reoperation rate between patients treated with nail fixation (n = 156) and patients treated with plate fixation (n = 158) via meta-analysis of three RCTs (p = 0.5944; RR: 1.24 [95% CI: 0.28–5.54]; 17.9% vs 15.8%).
Conclusion: There appears to be no statistically significant difference in rate of radiographic union, total complications, or reoperation between nail and plate fixation for distal fibular fractures in adult patients based on high-level data from RCTs.
Use of Intraoperative Vancomycin Powder and its Effects on the Incidence of Surgical Site Infection in Orthopaedic Trauma: A Systematic Review and Meta-Analysis
Troy B Puga, DO; McKenna W Box, MD; Mason Poffenbarger, MD; Alan Lam, BS; Claire Ferguson, BS; Cornelis Potgieter, PhD; Kisan Parikh, MD; John Riehl, MD
Purpose: Surgical site infection (SSI) in orthopaedic trauma can have devastating consequences for patients. The aim of this systematic review is to evaluate the evidence for the use of powdered vancomycin in orthopaedic trauma surgery for the prevention of SSI.
Methods: A search was conducted across Pubmed/Medline, Cochrane, and Embase databases to evaluate for the use of powdered vancomycin in orthopaedic trauma surgery for the prevention of SSIs. The search used a combination of keywords and MeSH terms. Titles and abstracts were screened for inclusion criteria eligibility. Full texts were screened and included if they met eligibility criteria. A meta-analysis was completed in order to evaluate the effects of vancomycin in orthopaedic trauma surgery for the prevention of SSIs. Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) standards were followed.
Results: Eight studies met final inclusion criteria for this systematic review. Three were Level I evidence studies, and the remaining five were Level III evidence studies. Of the eight studies, a statistically significant reduction in either surgical site/fracture-related infection or reduction in gram-positive SSIs were found in five. No studies found any effect on the rate of gram-negative infections. Meta-analysis demonstrated a decrease in overall SSI when powdered vancomycin was used (Odds Ratio [OR] = 0.49, 95% CI: 0.33–0.72, P = 0.0003) and a decrease in the incidence of gram-positive SSI (OR = 0.35, 95% CI: 0.14–0.84, P = 0.0185).
Conclusion: Powdered vancomycin is a safe and effective treatment option that reduces the rate of overall SSI and gram-positive SSI in orthopaedic trauma surgery patients. However, powdered vancomycin does not reduce gram-negative SSI in orthopaedic trauma patients. There was also no evidence that powdered vancomycin demonstrated any increase in the rates of aseptic wound complications, fracture nonunion, or impaired fracture healing. Powdered vancomycin can be safely used in the orthopaedic trauma setting to help reduce the incidence of SSI.
Early Weight Bearing Is Associated with Improved Gait Metrics Within 6 Months of Fracture Fixation: An Analysis of iPhone Health Data
Patrick McGlone, MD; Hammad Baqai, BS; Prateek Swamykumar, BS; Patrick McGinnis, BS; Maggie Manchester, BS; Brian Shear, MD; Dane Brodke, MD; Gerard P Slobogean, MD, MPH, FRCSC; Robert V O'Toole, MD; Nathan O'Hara, PhD, MHA
Purpose: There is interest in accelerated weightbearing protocols after certain lower extremity fractures; however, little is known about how this might affect gait over time. We hypothesized that early weightbearing is associated with improved gait outcomes after controlling for confounders.
Methods: The cohort study included 74 adult patients with lower-extremity fracture (mean age, 46 years [SD 19]; 43% female) who underwent surgery. For inclusion, patients were required to have a unilateral injury and at least 6 months of follow up. Postoperative weightbearing status was classified as early weightbearing (as tolerated within 3 weeks post-fixation [n = 27]) versus delayed (non- or limited weightbearing for >6 weeks post-fixation [n = 47]). The primary outcome was step count measured by the Apple iPhone Health application within 12 weeks of injury. Secondary outcomes were walking speed and asymmetry measured by the smartphone and an extended observation to 26 weeks post-injury. Outcomes were compared by weightbearing group, controlling for pre-injury mobility, age, sex, open fracture, and fracture location.
Results: Daily step counts within 12 weeks of injury were significantly higher in the early weightbearing group (mean 1723; 95% CI, 1179–2267) compared to the delayed weightbearing group (mean, 673; 95% CI, 330–1016; mean difference, 1050; 95% CI, 373–1727; p = 0.002). The secondary outcomes did not differ between groups within 12 weeks of injury. However, by 26 weeks after injury, early weightbearing patients had faster walking speeds (mean difference, 0.13m/s; 95% CI, 0.04–0.22; p = 0.004) and less walking asymmetry (mean difference, –12.2%; 95% CI, –21.3% to –3.1%; p = 0.008) than delayed weightbearing patients.
Conclusion: To our knowledge, this is the first study assessing the association of weightbearing status with gait after fracture fixation using iPhone data. Even after controlling for confounders, smartphone-collected step counts were markedly higher in early versus delayed weightbearing patients within 12 weeks of injury. Interestingly, the benefits of early weightbearing on walking speed and symmetry were realized closer to 6 months post-injury. Clinicians should be aware that weightbearing decisions might have benefits beyond the initial postoperative period.
OTA Grant
Surgical and Microbiological Characteristics Associated With Reoperation to Promote Bone Healing After Fracture-Related Infection Diagnosis
Doriann Marie Alcaide, MD; Nigel Blackwood, MD; Matthew Yeager, BA; Robert Rutz, MD; Elizabeth Benson, MS; Karen Joyce Carter, BS; Clay Spitler, MD; Joseph Johnson, MD
Purpose: Although fracture-related infections (FRI) have been associated with a higher rate of non-union, data on how surgical factors and independent microbes in FRIs impact non-union have been poorly described. The purpose of this study was to compare the surgical and microbiological characteristics of patients with FRI who had union and those that required subsequent surgery to promote bone healing. We hypothesize that patients infected with methicillin-resistant Staphylococcus aureus (MRSA) will have a higher risk of requiring reoperations to promote bone healing.
Methods: This was a retrospective study at a single Level I trauma center from 2013 to 2021. Patients older than age 18 years with FRIs were identified via an institutional database on musculoskeletal infections maintained by the infectious disease and the orthopaedic surgery departments. Inclusion criteria encompassed surgically managed fractures with evidence of FRI and at least 6 months of follow up postdiagnosis. Cases of osteomyelitis without surgical fixation were excluded. The primary outcomes assessed were surgical and microbiological characteristics of fractures that required reoperation to promote bone healing after diagnosis and treatment of FRI. A 5% significance level was used for all statistical analyses.
Results: Of 247 included patients, 55 (22.2%) required reoperations to promote bone healing after diagnosis of FRI. Patients who received topical antibiotics at closure (30.8%) during fracture fixation had higher risk for requiring reoperations to promote bone healing (p = 0.028). Infection with Pseudomonas aeruginosa was associated with a lower risk for requiring reoperations to promote bone healing (0%, p = 0.027). Rates of patients requiring reoperations to promote bone healing in patients infected with MRSA were similar to those infected with methicillin-sensitive S aureus (MSSA) (19.6% vs 20.9%, p = 0.874) and other pathogens (19.6% vs 23%; p = 0.591).
Conclusion: Use of topical antibiotics during initial fixation of fracture increases the risk of requiring reoperation to promote bone healing, while infection with P aeruginosa decreases said risk. Infection with MRSA or MSSA did not increase risk for requiring surgical intervention to promote bone healing after an FRI diagnosis. Further prospective studies should examine the impact of topical antibiotics during fracture surgery on development of FRI.
Pain and Function in Individuals With Lower Limb Amputations: Exploring Indications for Nerve Surgery to Address Neuropathic Pain
Victoria Comunale, BS; Samara Moll, BS; Samuel Sverev, BS; Jacques Hacquebord, MD
Purpose: Approximately 60% of individuals with amputations experience persistent post-amputation pain. Targeted Muscle Reinnervation (TMR) is among the promising interventions that have been suggested to alleviate pain and improve prosthetic functional outcomes. This study investigates subgroups of individuals with lower limb loss—based on their level of amputation and underlying cause—and their pain levels. The purpose is to determine who may benefit most from advanced nerve surgeries to treat or prevent neuropathic pain.
Methods: This cross-sectional study included 129 individuals with unilateral lower-limb amputations, classified by amputation level (above-knee amputation [AKA] versus below-knee amputation [BKA]) and indication (diabetes, trauma, arterial insufficiency, and malignancy). Patient-reported outcomes were assessed using the PROMIS Pain Intensity, PROMIS Pain Interference, PROMIS Neuropathic Pain Quality, and Neuro-QOL Lower Extremity Function forms. Differences between groups were analyzed using Welch's t-test for AKA versus BKA and ANOVA with post-hoc Tukey tests for differences by amputation indication.
Results: Pain intensity was significantly higher in patients with AKA compared to those with BKA (44.07 vs 48.11, p = 0.04678); however, no significant differences in pain interference or quality were found. Furthermore, BKA patients reported worse functional outcomes without a prosthesis compared to AKA patients, and this finding was borderline significant (33.10 vs 36.87, p = 0.05007). This may be explained by the fact that, relative to AKA patients, BKA patients generally experience better functional outcomes with prostheses, leading them to perceive their baseline function without it as worse. Analysis by amputation indication revealed that patients with diabetes reported significantly lower pain intensity and pain interference compared to those with trauma or arterial insufficiency. Furthermore, patients in the malignancy group showed better lower limb quality of life without a prosthesis compared to all other groups.
Conclusion: TMR may be more beneficial for patients with AKA and those with trauma or arterial insufficiency indications because they experience higher pain levels and greater daily pain interference. BKA and diabetic amputations may benefit less from TMR because of lower pain intensity and lower daily interference in the diabetic cohort.
Incidence of Allergic Reactions to Cefazolin in Patients With Penicillin Allergy Undergoing Operative Repair of Pelvis or Extremity Fracture
Lachlan Anderson, BS; Marisa Fat, BS; Hans Drawbert, MD, MS; John Riehl, MD
Purpose: Surgical site infections (SSI) account for 20% of all healthcare-associated infections with an estimated yearly cost of $3.3 billion in the United States alone. Cefazolin (Ancef) is a commonly used prophylactic antibiotic in orthopaedic surgery and has been shown to reduce SSI compared to other antibiotics, but potential cross-reactivity in patients with a penicillin allergy (PA) leads to concerns regarding the safety of cefazolin administration. This study evaluates the incidence of allergic reactions to cefazolin in patients undergoing orthopaedic surgery.
Methods: A retrospective cross-sectional database review study was conducted. Patients age 18 or older who underwent surgical repair of pelvic or extremity fractures were included. The primary outcome was anaphylaxis or other allergic reaction (defined as skin rash or hives). Logistic regression analysis controlled for variables such as age, sex, race, body mass index (BMI), and comorbidities.
Results: A total of 5823 patients received cefazolin while undergoing orthopaedic surgery (PA: n = 354, No allergy: n = 5469). The PA group was found to have an allergic reaction frequency of 2.50% compared to 0.70% in the non-PA group (p = 0.0016). The PA group was found to have anaphylaxis frequency of 2.30% versus 0.60% in the non-PA group (p = 0.0019) and a skin rash frequency of 0.3% versus 0.1% (P = 0.314). Logistic regression revealed odds of allergic reaction are 3.574 times with PA compared to without PA (p = 0.0004, 95% CI: 1.773–7.205).
Conclusion: Patients with PA who received cefazolin while undergoing orthopaedic procedures had a low likelihood of having any allergic reaction (2.5%). Cefazolin has a different R1 side chain than penicillin and other cephalosporins, and this study confirmed a low cross-reactivity in the setting of orthopaedic surgical prophylaxis. Patients with a listed PA are, however, more likely to experience an allergic reaction or anaphylaxis than patients without PA. Because of the broad spectrum gram positive coverage and high bone penetration of cefazolin with a low overall rate of allergic reaction, it remains the preferred choice for prophylactic antibiotics in orthopaedic surgery. Patients with a known anaphylactic PA could be considered for treatment with other prophylactic antibiotics.
Dermal Matrix and Its Potential in Orthopaedic Trauma
Micah Christenson, BA; Sydney C Boike, BS; Sandy Vang, BA; Stephen Doxey, DO; Fernando Huyke-Hernandez, MD; Brian Patrick Cunningham, MD; Gennadiy Busel, MD
Purpose: This study’s intent was to evaluate outcomes of patients treated by orthopaedic surgeons with dermal matrix (DM) for wound management.
Methods: Data collection in a multicenter retrospective chart review of patients with nonclosable wounds treated with DM was completed for demographics and comorbidities, alongside origin, treatment, and wound healing. Exclusion criteria were lost to follow up and ongoing treatment.
Results: DM was applied to 55 wounds in 54 patients; four patients were lost to follow up, seven had ongoing treatment, and three died. The final cohort consisted of 40 patients, with 41 wounds. There were 22 males and 18 females, (average age 59 ± 20.1 years). Wound origins were from postoperative (n = 12), traumatic (n = 16), and infectious (n = 13) etiologies. The average number of washouts prior to application was 2.2 ± 1.0. One patient required salvage plastic surgery involving the sural flap. One wound had failure of a skin graft after DM with subsequent treatment by secondary healing. In 32 of 41 (78.0%) wounds with DM, healing occurred without subsequent skin graft. Average documented time to healing was 163.5 ± 138.8 days, which was inflated because of lost follow up and reappearance well after healing. Multiple patients in the study had wounds with exposed bone, tendon, or hardware at the time of DM application (see figure).
Conclusion: DM is a reliable alternative for wound management that does not require subspecialty training.
Revisiting Large Trials: Novel Insights With the Win Ratio
Sofia Bzovsky, MSc; Nathan O'Hara, PhD, MHA; Gerard P Slobogean, MD, MPH, FRCSC; Sheila Sprague, PhD; Daniel Axelrod, MD; Graeme Hoit, MD; Kiara Pannozzo, MSc; Mohit Bhandari, MD, PhD, FRCSC; Marc F Swiontkowski, MD, FIOTA; Emil H Schemitsch, MD, FIOTA; Rudolf W Poolman, MD, PhD; FAITH Investigators, MD
Purpose: Many orthopaedic trials use unplanned reoperation as the primary outcome, but this overlooks other patient-important outcomes. Using a high-quality hip fracture trial, we demonstrate how the relative importance of multiple outcomes can be effectively incorporated into data analysis, providing a more comprehensive understanding of treatment impact.
Methods: The FAITH trial randomized 1079 patients older than 50 years with a low-energy femoral neck fracture to treatment with a sliding hip screw (SHS) or cancellous screws (CS), with unplanned revision surgery as the primary outcome. Our analysis instead used a composite outcome of all-cause mortality at 4 months, ambulation status at 10 weeks (measured by the EQ-5D mobility dimension), and days at home within 4 months. Days at home were calculated by subtracting the average length of hospital stay (including initial surgery, reoperations, and adverse events) from the last known observation within 4 months. We assessed outcomes hierarchically using the win ratio method, comparing each patient with every other patient in the alternative treatment group in a pairwise manner. Subgroup analyses explored smoking status as a potential effect modifier at 4 months.
Results: Of 1079 participants, 741 had EQ-5D data available, yielding 137,114 pairwise comparisons. SHS was superior to CS in 65,158 (47.5%) comparisons, inferior to CS in 63,378 (46.2%) comparisons, and tied in 8578 (6.3%), leading to a win ratio of 1.03 (95% CI: 0.86–1.23), but this difference was not statistically significant (p = 0.76). Mortality (5.5% vs 7.3%), ambulation status (no problems walking: 18.3% vs 16.2%), and days at home (111.7 vs 111.0) were similar between groups. In the subgroup analysis, SHS was superior to CS in current smokers (win ratio 1.41, 95% CI: 0.92–2.17), but this difference was not statistically significant (p = 0.09).
Conclusion: This analysis approach should be considered for future orthopaedic trials as it was consistent with the FAITH primary analysis findings but yielded a more nuanced interpretation of composite data and offers deeper insights into intervention effectiveness. The bounds of the 95% CI meet many standard definitions of equivalence, suggesting surgeons can assume similar patient-important outcomes with either treatment.
Next-Generation Sequencing as a Valuable Tool for Determination of Causative Microbial Agents in Bone and Soft-Tissue Infection
Aaron Ishmael, B.S.; Medical Student; Hannah Werner, B.A.; Bennie Lindeque, MD, PhD
Purpose: Bone and soft-tissue infections (BSTI) pose a serious and often debilitating threat to patient health. Although the gold standard for determination remains culture-based, it is not without fault. Cultures struggle with polymicrobial infections, overlook difficult-to-grow microbes, and cannot incubate organisms killed by antibiotics. Further, fungal and acid-fast bacilli (AFB) cultures have extensive turn-around times (TAT), worsening patient outcomes. We sought to improve the identification of BSTIs by supplementing the use of culture with a DNA-based approach in the form of next-generation sequencing (NGS).
Methods: We performed a review of prospectively collected data of 26 patients at a tertiary referral center presenting with previously confirmed or suspected BSTIs requiring surgical incision and drainage (I&D) or biopsy from May 2023 to August 2024. Patients received cultures from our institution and NGS from a third party.
Results: Group I included negative NGS results/positive cultures (5 of 26, 19.2%); Group II, positive NGS results/negative cultures (6 of 26, 23.1%); Group III, negative NGS results/negative cultures (7 of 26, 26.9%); and Group IV, positive NGS results/positive cultures (8 of 26, 30.8%). Within Group IV, 5 of 8 (62.5%) had partial agreement, 2 of 8 (25.0%) had full agreement, and 1 of 8 (12.5%) had no agreement. Mean and median TATs in days: aerobic (x̄ = 4.8; x̃ = 5), anaerobic (x̄ = 9.28; x̃ = 7), fungal (x̄ = 29.9; x̃ = 30), AFB (x̄ = 54.5; x̃ = 57), NGS collected-to-reported (x̄ = 6.96; x̃ = 6), and NGS received-to-reported (x̄ = 4.52; x̃ = 5). NGS was 42.5% cheaper than cultures.
Conclusion: We recommend NGS as a timely, affordable, and informative tool for concurrent use alongside culture-based detection in suspected or confirmed BSTIs requiring surgical intervention. NGS may improve patient outcomes by bypassing fungal and AFB wait times; by providing a determination when cultures are negative, such as after antibiotic use; and by highlighting the identity of rare or difficult-to-culture organisms in polymicrobial infections, the identity of which may be important in latent and recurring infections.
What is the Ideal Orthopaedic Call Plan for a Level I Trauma Center?
Cameron Foster, MD; Porter Young, MD; Parth Patel, BS; Katja Brutus, BS; Rockey Dahiya, MBBS
Purpose: Level I trauma centers employ various orthopaedic call strategies based on their resources. There has not been a study that compares patient outcomes based on the surgeon subspecialty taking call. We hypothesize that when only surgeons fellowship trained in trauma are on call, patient outcomes will be improved compared to a hybrid plan.
Methods: We performed a retrospective cohort study from two 24-month time periods at our academic Level I trauma center. The first cohort consisted of only trauma surgeons taking call. The second cohort consisted of a combination of trauma and other subspecialties taking call. The primary outcome analyzed was time from admission to the operating room for hip, femoral shaft, distal femur, tibial shaft, pelvic ring, and acetabulum fractures. Secondary outcomes analyzed included length of stay, 90-day incidence of reoperation, mortality, venous thromboembolism (VTE), and readmission.
Results: A total of 857 patients in the trauma cohort and 992 patients in the combined cohort met the inclusion criteria. The trauma cohort was younger (47.2 years vs 53.8 years, p<0.001) with lower Charlson Comorbidity Index scores (0.9 vs 1.6, p<0.001), but there was no significant difference in cohorts in terms of sex, body mass index (BMI), or Injury Severity Score (15.5 vs 14.7). The time from admission to the index surgical procedure was shorter in the trauma cohort (1.7 vs 2.4, p<0.001). Length of stay (8.95 vs 11 days, p<0.001) and 90-day mortality (1.8% vs 3.8%, p = 0.013) were improved in the trauma cohort. There was no difference in the 90-day rate of VTE (3.6% vs 3.9%), readmission (24.1% vs 22.3%), or reoperation (6.3% vs 7.6%). When stratifying based on fracture pattern, length of stay and time to the operating room in pelvic ring injuries and acetabulum fractures were doubled compared to the hybrid group (p<0.001).
Conclusion: Our findings suggest that when trauma fellowship-trained surgeons are the only ones taking call, patients have a shorter time from admission to the index surgical procedure and length of stay, and a lower mortality rate. These findings should be considered when managing call resources within a Level I trauma center.
The Impact of Patients’ Expected Return to Baseline Physical Function on Short-Term Recovery
Insup Hong, MA, BS; Hanna House, MD; Jenna Somberg, BS; Joseph Bowman Cohen, MD; Hobie Summers, MD; Ashley Elizabeth Levack, MD
Purpose: Predicting long-term recovery following injury is essential for optimizing rehabilitation strategies. This study examines whether higher expected return to baseline (RTB) physical function at the time of injury is associated with better actual functional outcomes.
Methods: A retrospective study of prospectively collected data was performed at a single Level I trauma center. Patients who presented with an orthopaedic trauma injury and were assessed for their expected RTB following surgery from 0 to 100% were identified. Of those patients, those who completed RTB self-assessments at 6-week (6w) and 6-month (6m) follow ups were included. A multivariable linear regression model was used to evaluate the association between expected RTB and RTB at 6m, adjusting for patient demographics (age and sex), history of mental health disorders, injury severity, and injury type (upper or lower extremity injuries). Patient factors that might influence expected RTB scores were evaluated, specifically history of mental health with a Mann-Whitney U test and socioeconomic status (SES) represented by Area Deprivation Index (ADI) state deciles and national percentiles with Spearman’s Rank Correlation tests.
Results: A total of 186 patients was identified. Every 10% increase in expected RTB at the time of injury was associated with a 2.1% increase in RTB at 6m, after controlling for other covariates (95% CI: 0.082, 0.341, p = 0.002). No other factors had significant associations. Of note, patients with a history of mental health disorders reported higher expected RTB assessments (p = 0.001) while patients with higher SES were weakly associated with lower expected RTB assessments (p = 0.002).
Conclusion: This study demonstrates that patients with higher expectations of returning to baseline function at the time of injury had a marginally greater functional recovery self-assessment at 6m postoperatively. These findings were statistically significant, but require further studies to determine clinical significance to determine if expectation-based interventions may improve patient perceptions of recovery in the short term.
The Fallacy of Patient-Reported Outcome Measures: Why Patient-Reported Outcome Measures are Bad for Clinical Trials
Nathan O'Hara, PhD, MHA; Dane Brodke, MD; Ashley Elizabeth Levack, MD; Gerard P Slobogean, MD, MPH, FRCSC
Purpose: Patient-reported outcome measures are increasingly common in orthopaedic trauma research, yet they routinely fail to detect clinically meaningful differences in clinical trials. We assessed whether orthopaedic trauma studies are more likely to detect clinically important differences with a binary outcome, such as nonunion, or a continuous patient-reported outcome sensitive to important clinical differences.
Methods: We constructed a hypothetical clinical trial comparing two treatments of tibial shaft fractures. We assumed the true nonunion rate was 10% in the treatment group and 20% in the control group. Based on recent publications, we assumed patients with nonunion had a mean PROMIS physical function score of 40 (SD: 10) and patients with union had a mean score of 50 (SD: 10), a difference that is double the minimum clinically important difference. Based on these expected distributions, we simulated 10,000 trials with a sample size of 400 patients to assess the probability of detecting a significant difference between treatment groups at p<0.05. The trial results were analyzed using the binary outcome of nonunion surgery and PROMIS physical function.
Results: Of the 10,000 simulated trials with a 400-patient sample, the observed difference in nonunion surgery between the treatment groups was statistically significant 80.9% of the time. In contrast, the 400-patient sample detected a statistically significant difference between groups in PROMIS physical function only 4.2% of the time.
Conclusion: Even if patient-reported outcome measures are sensitive to important clinical events, most studies will fail to detect statistically significant differences between the treatment groups when the important clinical outcome occurs in a minority of the overall sample. Orthopaedic traumatologists should be aware of this limitation when designing and appraising studies that compare treatments with patient-reported outcomes.
iPhone Gait Metrics Benchmark Functional Recovery After Ankle Fracture
Daniel C Fitzpatrick, MD; Michael E Hahn, PhD; Kate Spitzley, PhD; Brandon G Wilkinson, MD; Spencer B Dowdle, MD; Nicholas L Strasser, MD; Tessa K Kirkpatrick, BS, CCRC; Cindy Headlee, N/A; Ellie C DeLoretto, BS; Leila M Hollis, MS; Erin Callahan Owen, PhD
Purpose: Quantifying recovery after injury is limited by the absence of pre-injury functional data. iPhone mobility metrics provide a novel opportunity to objectively compare pre-injury and post-injury gait patterns, offering individualized baselines for functional recovery. This study leverages passively collected iPhone gait data to track changes in mobility following ankle fracture, allowing for precise measurement of deficits and improvements over time.
Methods: In total, 91 patients with ankle fracture were enrolled and monitored for 6 months following treatment. A custom iPhone application was developed to passively collect gait metrics, capturing data from 30 days prior to injury through 6 months post-treatment. Each metric was analyzed as a percentage of the patient’s pre-injury baseline at 6-week, 3-month, and 6-month time points, with 100% indicating full recovery. Mean gait metrics assessed included step count (n = 47), walking distance (n = 46), walking speed (n = 45), step length (n = 45), double support percentage (n = 45), and walking asymmetry (n = 40).
Results: All gait metrics declined at 6 weeks post-injury and improved over time. Step count and walking-distance fell to less than 60% at 6 weeks, but recovered to near 90% by 6 months. Walking asymmetry peaked at 650% at 6 weeks, improving to 132% by 6 months but remaining above baseline. Walking speed and step length recovered from 82% and 91% at 6 weeks to 97% and 97% by 6 months. Double support percentage remained elevated (105% at 6 weeks), improving slightly to 102% at 6 months, indicating persistent gait alterations.
Conclusion: iPhone gait metrics captured the initial decline and gradual recovery following ankle fracture. Although most improved over 6 months, asymmetry and gait stability remained impaired, indicating incomplete recovery and potential long-term functional limitations. These findings support iPhone gait monitoring as a tool for tracking recovery, identifying subtle deficits, and guiding rehabilitation strategies to optimize patient outcomes.
OTA Grant
Increased Efficiency With Use of a Mini C Arm in Emergency Department Closed Reductions
Mara Bajic, Medical Student; Carolyn Marcella Meinerz, MD; Matthew Laprade, MD; Andrew Kleven, MD, DPT; Peyton Keeling, MD; Steven Matthew Cherney, MD; Elizabeth Nolte, MD
Purpose: The purpose of this study was to evaluate the effects of mini C-arms versus traditional radiography on patient radiation exposure, the frequency of repeat closed reductions, and emergency department (ED) efficiency.
Methods: A retrospective chart review was conducted of adult patients with an isolated distal radius, bimalleolar, or trimalleolar ankle fracture requiring closed reduction by the orthopaedic surgery team in a busy academic Level I trauma center ED from 2013 to 2023. Pediatric patients and patients with pathologic or non-isolated fractures were excluded. Cases in which mini C-arms were used for imaging were compared to cases in which traditional postreduction radiographs were used. Total radiation exposure to the patient during the encounter was compared using the calculated radiation dose (mGy). The number of repeated reductions in the ED was also compared. Efficiency was compared using orthopaedic consult time, doctor visit to discharge time, and time under sedation (if applicable).
Results: In total, 199 subjects met inclusion criteria (81 ankle fractures and 118 distal radius fractures). The results showed that radiation exposure was significantly lower (p<0.001) in the mini C-arm group compared to the traditional radiograph group. There was also a significant reduction in the time from doctor visit to discharge (p<0.001), orthopaedic consult time (p<0.001), and time spent under sedation (p = 0.046) when a mini C-arm was used, as opposed to traditional radiographs. The reduction in radiation exposure (mGy) indicates a marked increase in patient safety; the decreased doctor visit to discharge time, orthopaedic consult time, and time under sedation indicate an increase in ED efficiency. Additionally, the decrease in repeated reductions when mini C-arms were used could suggest an improvement in the quality of patient care as well as efficiency.
Conclusion: This study suggests that the use of mini C-arms instead of traditional postreduction radiographs improves ED efficiency, safety, and patient care.
Orthopaedic Surgeons Don't Care How Much it Costs: A Discrete Choice Experiment on Femoral Locking Plate Choice
John Morellato, MD; Abigail Koons, BS; Peter Mittwede, MD, PhD; Gerard P Slobogean, MD, MPH, FRCSC; Marcus F Sciadini, MD; Robert V O'Toole, MD; Andrew N Pollak, MD, FIOTA; Nathan O'Hara, PhD, MHA
Purpose: Hospitals are interested in implant stewardship, encouraging surgeons to consider cost when choosing one implant over another. However, other factors can influence the implant decision-making process for orthopaedic surgeons. We aimed to determine what factors had the strongest influence on orthopaedic surgeons when selecting a plate and screw construct for distal femur fixation.
Methods: We performed a discrete choice experiment to assess the relative importance (ri) of the following factors: implant cost, familiarity with the implant, ease of instrumentation, modularity of screw and plate options, and implant representative support. Each factor was described by one of three levels ranging from most to least desirable. We recruited OTA members through the association’s websites to complete the discrete choice experiment. Each participant was presented with 15 hypothetical construct options described by the five factors with varying levels. We used multinomial logit modeling to assess the relative importance of the factors on a scale of 0 to 100% as well as the utility derived from the levels on an absolute scale centered on a grand mean of zero, with higher values indicating greater utility and lower values greater disutility.
Results: In total, 63 OTA members participated in the study, 73% in academic practice. Support from company representatives was the most important factor (ri, 44%). Surgeons’ familiarity with the implant was the second most important attribute (ri, 31%). Ease of use of the construct (ri, 15%) and modularity of the implant (ri, 8%) were of lesser importance. Implant cost was least important (ri, 1%). Surgeons indicated the most utility from simple-to-use plate systems (utility, 2.33), with which they were very familiar (utility, 2.00), those for which representative support was available (utility, 1.37) or knowledgeable (utility, 0.52). Surgeons would avoid constructs they were unfamiliar with (utility, –2.25) and those with unavailable representatives (utility, –1.90).
Conclusion: The findings suggest surgeons are not cost-conscious when selecting distal femur implants. Representative support and implant familiarity were the most influential factors. Hospitals may need to consider targeted strategies to change surgeon behavior and promote implant stewardship.
Pain and Baseline Physical Function Predict Physical Function at One Year After Severe Extremity Trauma
Phillip T Grisdela, MD; Soroush Shabani, BS; Garrett Thomas Maxwell, MD; Anthony R. Carlini, MS; Robert V O'Toole, MD; Renan Castillo, PhD; Joshua Layne Gary, MD; Joseph Thomas Patterson, MD
Purpose: Pain, depression, and anxiety are common after orthopaedic trauma and may negatively affect patients’ physical function. We hypothesize that pain, depression, anxiety, interactions among these experiences, and baseline characteristics predict patient-reported physical function following severe extremity fractures.
Methods: This is a secondary analysis of the STREAM aggregate of Patient-Reported Outcomes Measurement Information System (PROMIS) data from six prospective Major Extremity Trauma Research Consortium (METRC) studies (FIXIT, OUTLET, TAOS, VANCO, OXYGEN, and PAIN). Patients with severe fractures of the humerus, tibia, midfoot, and hindfoot and complete data including PROMIS pain, anxiety, depression, and physical function at 12 months after injury were included. The outcome of the PROMIS physical function score at 12 months was predicted using multivariate linear regression considering baseline patient and injury characteristics, as well as PROMIS pain, anxiety, and depression scores at baseline and 12 months. Iterative optimization using the Akaike Information Criteria determined change in pain as the primary contributor to the physical outcome score.
Results: In total, 708 of 1000 (70.8%) patients were included. The average age was 42 years, 477 patients (67%) were male, 539 patients (76%) identified as White, 559 patients (79%) were working or active duty prior to injury, and 309 patients (44%) never smoked. From baseline to 12 months after injury, PROMIS scores for anxiety (56–53, p<0.001), pain (60–57, p<0.001), and depression (53–50, p<0.001) decreased while physical function scores improved (32–41, p<0.001). Linear regression demonstrated that physical function at 12 months was negatively associated with baseline pain by –0.55 points per pain point (95% confidence interval [CI]: –0.65, –0.44, p<0.001) and pain at 12 months by –0.66 points per pain point (95% CI: –0.71, –0.60, p<0.001). It was positively associated with baseline physical function by 0.24 points per physical function point (95% CI: –0.18, 0.30, p<0.001).
Conclusion: Patient-reported pain at baseline and at 1 year after injury, as well as lower baseline physical function, were associated with inferior physical function at 1 year following severe extremity trauma.
Antibiotic Treatment Compliance Among Patients With Fracture Related Infections: A Secondary Analysis of the POvIV trial
Elsa Rodriquez-Baron, MD MPH; Alicia Hymel, MS; Jacqueline Pennings, PhD; Thomas Talbot, MD; Madhav A Karunakar, MD; Robert V O'Toole, MD; Heather A Vallier, MD, FIOTA; Saam Morshed, MD, PhD; William T Obremskey, MD, MPH, FIOTA; METRC
Purpose: It is unknown how medication compliance varies between per os (PO) and intravenous (IV) treatment of fracture-related infections. We hypothesized that higher compliance would be associated with lower reinfection, rehospitalization rate, and the number of study–injury-related surgeries within 1 year.
Methods: This is a secondary analysis of the POvIV study, which randomized antibiotic treatment to PO or IV after fracture-related infections. Antibiotic compliance required all three of the following criteria: (1) 80% or more doses taken as prescribed for 6 weeks, (2) three or more of the weekly interviews properly completed, and (3) the antibiotic course completed "as indicated" by the research and orthopaedic surgeon. The primary outcome was patient compliance with the antibiotic regimen for 6 weeks. Secondary outcomes included the number of study–injury-related surgical interventions within a year, reinfection, and rehospitalization as a function of patient compliance.
Results: This analysis included 233 patients randomized in the POvIV trial: 120 in the PO only group and 113 in the any-IV group. Most patients were male (77%), non-Hispanic (94%), and White (70%), and the mean age was 46 years (SD: 13.9). No difference in antibiotic compliance was found among patients who took PO only antibiotics compared to those who took any IV (48% vs 53%, p = 0.45) and percentage compliance (98% vs 99%, p = 0.95). Of the patients who had reinfection, 36 (33%) were considered compliant, and 28 (26%) were not compliant with the administered antibiotic regimen (p = 0.28). There were no appreciable differences between compliant status concerning reinfection, rehospitalization rate, and return to the OR.
Conclusion: Our results show no significant difference in compliance to antibiotics with PO treatment compared to IV treatment. Finally, no significant correlation was seen between secondary outcomes of reinfection, rehospitalization, or the number of secondary operations and compliant status.
Is Tranexamic Acid Administration Associated With Decreased Rates of Heterotopic Ossification in Combat Casualties?
Colin Harrington, MD; Kara Churovich, MPH; Sydney Eierle, BS; Benjamin Kyle Potter, MD; Julio Rivera, PhD; Ashley Bee Anderson, MD
Purpose: Heterotopic ossification (HO) is common following combat-related extremity trauma and can lead to recalcitrant pain, decreased mobility, skin ulceration, and soft-tissue irritation. Although previous prophylactic modalities for HO prevention have varying effectiveness, tranexamic acid (TXA) administration has demonstrated decreased rates of HO formation with a favorable safety profile.
Methods: Using the Department of Defense Trauma Registry, service members who received TXA or were diagnosed with HO were identified between 2003 and 2023. Demographics and injury characteristics were described using means and counts for categorical groups. We performed unpaired t-tests and χ2 analysis between the groups to evaluate for an association between TXA administration and the development of HO.
Results: During the study period, 93 patients received TXA and HO developed in 124 patients. Of the patients who received TXA following initial injury, HO developed in none. There were no significant differences between groups aside from higher Injury Severity Scores (ISS) (28 vs 24, p<0.05) and more penetrating injuries (89% vs 63%, p<0.05) in the TXA group.
Conclusion: HO did not develop in patients who received TXA following combat-related trauma, despite higher ISS scores with more penetrating injuries. These results are promising and align with recent studies demonstrating the effectiveness of TXA in preventing HO formation. A randomized trial evaluating TXA administration and the development of HO is warranted.
5 Year Fracture Risk in Astronauts Upon Return from Space Flight
Jad Jack Lawand, MS; Benjamin Fiedler, MD; Srikhar Chilukuri, BS; Joshua Morrow, BS; Jeffery Hauk, BS; Abdullah Ghali, MD; Meghana Jami, MD; Adil Shahzad Ahmed, M.D.
Purpose: Exposure to space flight and microgravity environments has been implicated in causing large reductions in bone mineral density (BMD) in astronauts. Additional evidence suggests that although BMD recovers upon return from space flight, bone health may not return to preflight levels. Although low BMD is a known risk factor for fracture, there have been no reported cases of intra-flight fracture, and very little documentation of post–space-flight fracture. With NASA plans for longer distance and duration missions such as missions to the moon and Mars, fracture upon return to gravitational environment has potential to pose significant risk to astronaut health and endanger mission success. As a result, the present study sought to review incidence of fracture within 5 years of return from space flight.
Methods: Using the Lifetime Surveillance of Astronaut Health epidemiology database at NASA, a retrospective cohort study was conducted to identify incidence of fracture in the 5-year post–space-flight period. All astronauts who participated in space flight with 5-year post-flight medical data were included for review. Patient demographics were compared between the fracture and nonfracture cohorts.
Results: In total, 242 astronauts met the inclusion criteria for review. Of the 242 astronauts, seven (2.9%) sustained fractures in the 5 years post–space flight; three of the post–space-flight fractures occurred in the hip or spine and six fractures occurred within 2 years of return from space flight. Space flight length, age, and time from space flight were not statistically significantly associated with increased risk for fracture.
Conclusion: Fracture upon return to gravitational environment is a serious risk for astronauts that has the potential to significantly jeopardize astronaut health and mission success. Fractures of the hip and spine specifically are associated with decreased BMD. Although incidence of these fractures is roughly 1%, the substantial negative implications including high 1-month and 1-year mortality rates and functional implications emphasize the need to optimize bone health and fracture treatment protocols.
Orthopaedic Trauma Patients Have Substantial Caloric and Protein Deficiencies in the Early Postoperative Period
Bison Woods, MD; Steele McCulley, BS; Ashley Kochuyt, B.S.; Janessa J Sharratt, BS; Natalie Glass, PhD; Bridget Drapeaux, MA; Michael Willey, MD
Purpose: Nutrition deficiencies are increasingly recognized as a modifiable risk factor for complications and loss of function after surgical treatment of fractures. The American Society for Parenteral and Enteral Nutrition (ASPEN) recommends nutrition support in critically ill adult patients that includes caloric intake of 12 to 25 kcal/kg/day and protein intake of 1.2 to 2.0 g/kg/day. The purpose of this study was to determine if orthopaedic trauma inpatients are ordering hospital meals from nutrition services that meet the ASPEN recommendations for appropriate caloric and protein intake.
Methods: An observational clinical trial was performed for consecutive adult patients who underwent surgical treatment of acute extremity and pelvis fractures and were admitted for at least two nights after surgery. Nutrition services at our hospital records and stores all meals ordered by inpatients. Demographics, comorbidities, and total macronutrient content of meals ordered per day for up to the first 3 full postoperative days were recorded retrospectively. Descriptive statistics reported the number of patients who ordered daily meals that met caloric intake, protein, and carbohydrate needs.
Results: Data were collected for 70 consecutive participants (female: 57%; median age: 67 years [range: 54–79]). Diabetes was present in 24% of patients, chronic kidney disease in 20%. On postoperative day 1, 31 of 69 (51%) patients did not meet recommended caloric intake; 52 of 69 (75%) did not meet recommended protein intake. On postoperative day 2, 33 of 59 (56%) patients did not meet recommended caloric intake; 44 of 59 (75%) did not meet recommended protein intake. On postoperative day 3, 23 of 45 (51%) patients did not meet recommended caloric intake; 32 of 45 (71%) did not meet recommended protein intake.
Conclusion: ASPEN recommendations for caloric and protein needs in critically ill patients are not commonly met by patients admitted to the hospital after undergoing surgical treatment of extremity and pelvis fractures. These nutrition deficiencies likely contribute to negative outcomes after orthopaedic trauma. Patient education on healthy food choices and the importance of nutrition for healing after injury may be an effective intervention to improve outcomes.
Impact of Fractures on Five-Year Mortality and Morbidity Following Solid-Organ Transplantation: A Propensity Score-Matched Analysis
Warren Austin, BS; Rachit Saggar, MBBS; Joseph Mullen, BS; Abdulganeey Olawin, BS; Gele Moloney, MD; George V Russell, MD
Purpose: Fractures in solid-organ transplant recipients may contribute to increased morbidity and mortality. However, their independent impact on long-term outcomes remains unclear. This study evaluates the association between fractures and 5-year mortality and major complications.
Methods: A retrospective cohort study was conducted using the TriNetX research network, a federated database compiling de-identified electronic health records. Adult transplant recipients were identified using CPT codes, and fractures were defined using ICD-10 and ICD-9 codes for upper and lower extremities. Only post-transplant fractures occurring 1 week or more after transplant were included. Propensity score matching (PSM; 1:1) adjusted for age, sex, and major comorbidities (cardiovascular, musculoskeletal, respiratory, nervous system, infectious diseases, and neoplasms). Logistic regression estimated odds ratios (OR) with 95% confidence intervals (CI) for 5-year mortality, sepsis, cerebral infarction, heart failure, pulmonary embolism, and deep vein thrombosis (p<0.05).
Results: Among 60,591 transplant recipients, 876 had post-transplant fractures. After 1:1 propensity matching, 1752 patients were analyzed. Before matching, fracture patients were older (mean age: 63.6 ± 14.5 vs 56.6 ± 17 years, p<0.0001) and had higher rates of diabetes (80%), malnutrition (46%), and infections (81%). After matching, baseline characteristics were balanced. Before PSM, fractures were associated with significantly higher odds of sepsis (19.6% vs 14.7%, OR: 1.42, p = 0.0010), death (22.3% vs 10.8%, OR: 2.37, p<0.0001), cerebral infarction (4.64% vs 3.12%, OR: 1.51, p = 0.0157), and heart failure (15.1% vs 3.12%, OR: 1.56, p = 0.0006). After PSM, mortality remained significantly elevated (22.3% vs 18.3%, OR: 1.28, p = 0.0345), while other associations weakened. No other outcomes were statistically significant.
Conclusion: Fractures independently increase 5-year mortality in transplant recipients, even after adjusting for comorbidities. Increased risks of sepsis, cerebral infarction, and heart failure suggest fractures contribute to systemic complications beyond mechanical injury. These findings highlight the need to reduce fracture occurrence and improve postfracture management to mitigate long-term mortality and morbidity in transplant recipients.
The Relationship Between Insomnia Severity and Postoperative Pain Management: A Survey Study of 96 Orthopaedic Trauma Patients
Austin Taylor Gregg, BS; Thomas Policicchio, BA; Adam Musick, BS; Maaz Muhammad, MD; Carla H. Lehle, MD; Robert K. Wagner, MD; Maarten A Van Weezenbeek, BS; Sikun Fan, Bsc; Stephen C. Moye, BS; David Landy, MD; Arun Aneja, MD, PhD
Purpose: Sleep disturbance is common among patients with orthopaedic trauma and may influence pain perception and management. This study evaluated the association between insomnia and postoperative opioid use, as well as its relationship with pain interference and opioid refill requests.
Methods: In total, 96 consecutive patients with orthopaedic trauma were surveyed at 2-week follow-up visits after orthopaedic surgery or injury at an academic Level I trauma center. Insomnia severity was assessed using the Insomnia Severity Index, categorized into four severity levels. Pain interference and opioid use were evaluated using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Score and prescription refill data. A two-sample t-test compared pain interference scores between patients with and without significant insomnia, and Fisher’s exact test assessed the relationship between insomnia severity and opioid refill requests.
Results: This study included 96 patients (median age: 62 years [IQR: 45–71.5], female: 40 [58.3%]). Surveys were administered at a mean follow up of 15.2 days after surgery or injury. Among participants, 76 (79.2%) reported no or subclinical insomnia, while 13 (13.5%) and 7 (7.3%) reported moderate or severe insomnia, respectively. Patients with moderate or severe insomnia had significantly higher PROMIS Pain Interference Scores (21.4, 95% CI: 18.0–24.9) compared to those without (15.3, 95% CI: 13.4–17.3, p = 0.002). Additionally, 40.0% of patients with insomnia requested opioid refills compared to 17.1% of those without insomnia (p = 0.037).
Conclusion: Insomnia severity is strongly associated with greater pain interference and higher opioid refill requests in patients with orthopaedic trauma. These findings highlight the critical role of sleep in postoperative pain perception and opioid consumption. Addressing sleep dysfunction as part of postoperative pain management may improve patient outcomes and reduce opioid reliance, underscoring the importance of interdisciplinary approaches to trauma recovery.
Understanding Lost to Follow-Up in Orthopaedic Trauma: Patient Perspectives and Outcomes
Thomas James Spackman, BA; Christian Gabriel Falgons, MD; Stephen Warner, MD, PHD
Purpose: Loss to follow up (LTF) is a prevalent issue in orthopaedic trauma care, impacting patient outcomes and clinical research. This study aimed to determine reasons for LTF, assess functional outcomes of LTF patients, and evaluate whether conventional follow-up durations align with patient needs.
Methods: A cross-sectional observational study was conducted at a Level I trauma center, analyzing 1000 consecutive patients who underwent orthopaedic trauma surgery between June 2021 and September 2021. Patients were categorized as completing all follow ups (CAF) or LTF, defined as failing to return after being advised to by their surgeon. Demographic, clinical, and socioeconomic factors were assessed for predictors of follow-up adherence. A subset of LTF patients was contacted to determine reasons for noncompliance and assess patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS). Statistical analyses included χ2 tests for categorical variables and Welch’s t-tests for continuous variables.
Results: Of the 1000 patients analyzed, 611 (61.1%) were LTF. Among the 196 LTF patients successfully contacted, the primary reason for nonadherence was a perceived lack of necessity for follow up (55.6%), while only 6.6% cited cost as a factor. Caucasian patients demonstrated higher follow-up rates (p = 0.04), whereas homelessness (p = 0.05) and substance use (p = 0.002) were associated with LTF. Patients with complications requiring additional procedures were more likely to complete follow up (p<0.001), suggesting potential bias in research relying on long-term follow-up data. PROMIS assessments indicated that LTF patients had pain (T = 51, 95% CI: 44–57) and physical function (T = 48, 95% CI: 41–56) scores near population norms, suggesting satisfactory recovery despite LTF.
Conclusion: Our cross-sectional observational study assessed patient-reported outcomes of patients with orthopaedic trauma lost to follow up and showed that many of these patients reported functional recovery. These findings challenge the necessity of extended, rigid follow-up schedules. Additionally, research dependent on long-term follow up may be biased, as patients experiencing complications are more likely to adhere. Future initiatives should emphasize patient education and targeted interventions to enhance follow-up adherence, especially for at-risk populations. A reassessment of follow-up duration requirements is needed to balance clinical relevance, patient engagement, and research feasibility.
Blood Culture Testing in Fracture-Related Infections: Low Yield and Near-Zero Concordance with Deep Tissue Pathogens
Lauren A Merrell, BA; Sara Solasz, BA; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: The purpose of this study was to assess the concordance between blood culture isolates and intraoperative deep tissue cultures in patients with confirmed fracture-related infection (FRI).
Methods: This Institutional Review Board-approved study included patients diagnosed with a confirmed FRI according to the FRI Consensus Group criteria. Included patients underwent deep tissue sampling at time of irrigation and debridement (I&D), as well as concurrent blood culture testing at the onset of infection symptoms. Microbiologic data were reviewed from the electronic medical record. Infections were classified as monomicrobial (either gram-positive or gram-negative), polymicrobial, or culture-negative. Pathogen concordance between blood and intraoperative tissue cultures was analyzed.
Results: Of 297 patients identified with confirmed FRI, 84 underwent both intraoperative deep tissue sampling and concurrent blood culture testing. Microbial analysis of deep tissue specimens identified 29 gram-positive infections, 18 gram-negative infections, 33 polymicrobial infections, and 4 culture-negative cases. Blood culture results were discordant with their respective deep tissue culture isolates in 76 of 84 (90.4%) patients; blood tests were able to identify at least one pathogen sampled from deep tissue in only eight (9.6%) patients. Of the 84 blood cultures analyzed, 69 (82.1%) were culture-negative and 15 (17.9%) were culture-positive, whereas only 4.8% of deep tissue samples were culture-negative and 95.2% of deep tissue samples were culture-positive. Overall, blood samples yielded negative culture results 17 times as often as deep tissue samples. McNemar’s test revealed a highly significant difference in culture-positivity rates (χ2 = 65, p<0.0001), and Cohen’s Kappa for agreement was 0.022, indicating near-zero concordance between blood and deep tissue culture results.
Conclusion: These results suggest that blood cultures neither reflect the true pathogens nor contribute meaningful diagnostic information in most cases of confirmed FRI. Routine blood culture testing in patients with FRI appears unnecessary, and a more judicious approach to ordering these tests is recommended to avoid resource waste.
The Effect of Multiple Doses of Intravenous Tranexamic Acid on Blood Transfusions, Complications, and Cost in Fragility Hip Fractures
Stephen Lawrence Davis, MD; Matthew J Solomito, PhD; Caitlin McCracken, MS; Mandeep Kumar, MD
Purpose: Fragility fractures are associated with significant blood loss and poor outcomes. Studies have demonstrated that intravenous tranexamic acid (TXA) can improve outcomes. However, few studies have investigated the utility of multiple TXA doses. The purpose of this study was to evaluate differences in transfusions, complications, and cost for patients treated for a fragility hip fracture that received no TXA, a single dose of TXA, or multiple doses of TXA.
Methods: Patients 50 years and older who underwent surgical treatment for a fragility fracture of the neck, intertrochanteric, or subtrochanteric aspect of the femur between January 1, 2018, and January 1, 2024, were evaluated. Patients were excluded if they sustained bilateral hip fractures, high energy injuries, polytrauma, or a periprosthetic hip fracture. Patients were grouped by TXA utilization. Regression and χ2 analyses were used to determine the influence of TXA on outcomes.
Results: This study included 1691 patients (71.5% female, age 80.7 ± 11.1); 551 received a single dose of TXA and 508 received multiple doses. There were no differences in medical comorbidities or demographics among the groups. There was a statistically significant difference in transfusion rates between patients who received TXA and those who did not: 31.8% no TXA, 15.9% a single dose, 14.7% multidose (p<0.001). There were no differences in 30-day emergency department visits (p = 0.545), deaths (p = 0.432), or venous thromboembolism (p = 0.154). Logistic regression indicated a 245% (p<0.001, 95%CI: 180% to 320%) increased likelihood of a transfusion when no TXA was given compared to a single dose. Multiple doses further reduced transfusion rates by 5% beyond a single dose, but this was not significant (p = 0.451). The administration of TXA, single or multidose, was associated with a $9900 cost savings per hospital stay compared to patients who did not receive TXA (p = 0.028).
Conclusion: The use of TXA in the surgical treatment of fragility hip fractures reduces transfusion rates and costs compared to no TXA use with similar complication rates. This study does not show a statistically significant additional benefit for multiple doses of TXA over the course of treatment.
Fixation Within 48 Hours in Geriatric Acetabular Fractures Decreases Transfusion Requirements
Doriann Marie Alcaide, MD; Travis Fortin, MD; Nigel Blackwood, MD; Matthew Yeager, BA; Hassan Ghomrawi, PHD,MPH; Clay Spitler, MD; Joseph Johnson, MD
Purpose: Early fixation of acetabular fractures in geriatric patients has been noted to reduce postoperative complications. However, the possible benefits of early fixation on transfusion rates in geriatric patients with acetabular fractures has not been well studied. The objective of this study is to determine if fixation within 48 hours of injury reduces risk for transfusion in geriatric patients with acetabular fractures.
Methods: This is a retrospective study at a single Level I trauma center from 2010 to 2023 looking at patients with open reduction and internal fixation (ORIF) for acetabular fractures. Patients who were younger than 65 years and those managed nonoperatively or with closed reduction percutaneous fixation were excluded. The primary outcome was differences in transfusion requirements between patients who had early fixation (within 48 hours) and those who had delayed fixation (after 48 hours). Secondary outcomes included differences in length of stay (LOS), estimated blood loss (EBL), surgical site infection (SSI), and mortality. Patient demographics, comorbidities, fracture characteristics, and perioperative, intraoperative, and postoperative data were collected.
Results: Of 159 patients included in the study, 98 (61.9%) underwent early fixation. Patients with early fixation had lower preoperative (13.3% vs 31.1%; p = 0.006) and intraoperative (33.7% vs 59.0%; p = 0.002) rates of transfusion. Patients in the early fixation group also had lower rates of overall transfusion during their hospital stay (59.2% vs 77.0%, p = 0.021). Early fixation was associated with a lower number of units transfused preoperatively (1.5 vs 4.6; p = 0.041) and during their overall hospital stay (2.2 vs 3.6; p = 0.019). Early fixation was also associated with shorter LOS (8.3 days vs 16.3 days; p<0.001) and lower risk for SSI (1% vs 9.8%, p<0.001). There was no significant difference in the number of units received intraoperatively or postoperatively, EBL, or mortality.
Conclusion: Geriatric patients with acetabular fractures who undergo early ORIF had lower intraoperative transfusion rates and required fewer transfusions overall. The higher rate of transfusion and of complications associated with delayed fixation should prompt surgeons to consider fixation within 48 hours in geriatric patients with acetabular fractures.
Proximal vs Distal Fragility Femur Fractures: Differences in Outcomes
Stephen Lawrence Davis, MD; Matthew J Solomito, PhD; Jordan Tyburski, BS; Mandeep Kumar, MD
Purpose: Fragility fractures are becoming increasingly prevalent as the population ages. Although there is extensive research focused on proximal femur fragility fractures, there is a paucity of research on the outcomes and treatment of distal femur fragility fractures. Therefore, the purpose of this study was to investigate differences in outcomes and treatment between distal and proximal femur fragility fractures.
Methods: Patients age 50 years and older who underwent surgical treatment for a fragility fracture of the neck, intertrochanteric, subtrochanteric, or supracondylar region of the femur between March 2018 and April 2023 were evaluated. Patients were excluded if they sustained high-energy injuries or polytrauma. Patients were grouped by fracture location. Tranexamic acid (TXA) administration, need for blood transfusion, time to the operating room (TTOR), and mortality within 1 year of surgical intervention were compared between groups.
Results: This study included 828 patients (74% female, age 79.4 ± 11.3 years), of which 674 sustained a proximal fracture and 154 sustained a distal fracture. There were no differences between groups with the exception of age; the distal group was on average 7 years younger (p<0.001). TXA was used less frequently in the distal group compared to the proximal group (53% vs 71%, p<0.001). There was no difference in transfusion rates (28% proximal vs 32% distal, p = 0.351). Complications including venous thromboembolism within 90 days and emergency department visits within 30 days were similar between groups (p = 0.989 and p = 0.861, respectively). One-year mortality rates between the two groups were also similar (17.6% proximal vs 16.9% distal, p = 0.756). Patients with a distal fracture had on average 13 hours longer TTOR compared to those with a proximal fractures (p<0.001). Regression analysis demonstrated that TTOR was significantly associated with mortality regardless of fracture location, with a 23% increased risk of mortality per 24 hours delay in TTOR (p = 0.011, 95% CI: 1.05–1.44).
Conclusion: This work indicated that distal femur fragility fractures have similarly poor outcomes compared to those of proximal femur fragility fractures. Given the findings concerning TTOR and transfusion rates, consideration should be given to treating distal femur fragility fractures with the same urgency and diligence as proximal femur fragility fractures.
The Road Home: A Multi-Disciplinary Care Team Decreases Skilled Nursing Facility Utilization While Maintaining Quality Metrics After Geriatric Hip Fracture Surgery
Rajeev Garapati, MD; Arif Ali, MD; Alexander Manuel Crespo, MD
Purpose: Geriatric hip fracture care continues to increase nationwide with a reciprocal increase in cost of care, a large portion of which is attributed to prolonged stay within skilled nursing facilities (SNFs). An abundance of literature exists demonstrating a “home is best” approach to recovery after joint arthroplasty with benefits of decreased infection, readmission, and cost of care. We sought to determine whether a multidisciplinary approach to hip fracture care would result in a decreased SNF utilization rate while maintaining safe, high-quality care.
Methods: A multidisciplinary team, consisting of an attending trauma surgeon, a physician assistant, a nurse manager, and a social work manager, was installed. The team studied all geriatric hip and femur fractures admitted to our facility daily for a 3-month trial period. The following metrics were documented: SNF utilization, readmission, length of stay, and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. We then compared these variables with a matched cohort of patients who were treated prior to the installation of this care team.
Results: There were 111 total patients treated during the trial period. The discharge to SNF rate was 51% in the intervention group, which was significantly improved from 62% prior to intervention. The overall readmission rate was 26 of 111 (23%). The readmission rate from an SNF facility was significantly higher than from those who were discharged to home (40% SNF; 12% home). Of the 26 readmissions, SNF readmissions accounted for 20 patients (77%). Length of stay did not significantly increase (4.8 days vs 5.0 days, p>0.1). HCAHPS scores significantly increased among “Physician communication” and “Nursing communication” domains (76.3 vs 82.5 and 69.5 vs 80.0, respectively; p<0.05). “Care coordination” and “Kindness” domains also improved, although they did not reach statistical significance.
Conclusion: A multidisciplinary effort can not only decrease SNF utilization, but result in increased quality of care and patient satisfaction with regard to their experience. Most importantly, discharge to home can be done safely. This has fiscal impacts for individual hospital systems partaking in Bundled Care Payment programs, but also for societal cost of care as a whole.
Impact of COVID-19 Vaccination Status on Mortality Rates After Operative Treatment for Hip Fracture.
Aidan Troy Morrell, MD; Graham John DeKeyser, MD; Ryland Kagan, MD; Andrew Avins, MD, MPH; Lusine Gigoyan, MD; John Cox, MD
Purpose: There are limited data on the risk of mortality in patients undergoing surgical treatment for hip fracture in the setting of prior COVID-19 infection. This study aimed to identify the effect of vaccination status on the incidence and risk of mortality among patients undergoing surgical treatment for hip fracture.
Methods: Adult Kaiser Permanente health plan members undergoing surgical treatment for hip fracture from 2020 to 2022 were identified using internal procedure codes. A total of 3674 patients of varying levels of vaccination, with or without SARS-CoV-2 infection within 6 months prior to surgery were compared. Regression analysis compared patients adjusting for baseline demographics, comorbidities, and COVID-19 status to produce incidence rate ratios (IRR). The primary outcome was a 90-day mortality rate.
Results: Patients undergoing surgery for hip fracture with or without recent COVID-19 infection had a 90-day mortality rate of 11%. Those with COVID-19 infection within 6 months of surgery who were unvaccinated or partially vaccinated were at 4.49 times the risk of mortality compared to those who were fully vaccinated (IRR 4.49, 95% CI: 3.72–5.42).
Conclusion: COVID-19 vaccine status may be protective against mortality for patients with recent COVID-19 infection undergoing urgent surgery for hip fracture. Future studies should explore if vaccination of patients with hip fracture at or around the time of surgery is a potentially modifiable risk factor for reducing mortality risk.
Clinical Disparities in Geriatric Orthopedic Trauma: A Retrospective Analysis of Housed vs Unhoused Patients Using National Trauma Databank (NTDB)
Kinsley Wang, BSc; Angeli Sirilan, BSc; Rose Zach, BSc; Annie Jia, BSc; Nimit Agarwal, MD, MBA; Niloofar Dehghan, MD, MSc, FRCSC
Purpose: Ground-level falls are a primary cause of injury among older adults. Unhoused individuals have an even higher risk of falls, with approximately one-third of those ≥50 years reporting a fall in the past 6 months, a rate comparable to housed individuals 20 years older. Yet, limited research has examined this issue within orthopaedic surgery. Given their increased vulnerability, unhoused individuals age ≥50 years are classified as geriatric. This retrospective cohort study evaluates the differences in clinical outcomes between housed and unhoused older adults hospitalized for ground-level falls.
Methods: Using the National Trauma Databank (NTDB) from 2021 to 2022, patients ≥50 years hospitalized for ground-level falls were identified using external ICD codes. The primary outcome was hospital length of stay (LOS); secondary outcomes included ICU admission and complication. A multivariable logistic regression analysis was conducted adjusting for homelessness, demographics, and comorbidities to evaluate risk factors associated with extended LOS.
Results: The study identified 1324 unhoused and 403,493 housed geriatric fall patients (mean age, 74.5 years; female, 60.0%). Compared to housed individuals, unhoused individuals were younger (mean age, 64.8 years vs 74.6 years), with a greater proportion ages 50 to 64 years (55.9% vs 17.9%, p<0.0001). Rate of fractures sustained after a fall was 50.0% in unhoused and 57.2% in housed patients (p<0.0001). Despite younger age and lower rate of fractures, unhoused patients experienced significantly worse outcomes. Homelessness was independently associated with prolonged hospital stays (LOS ≥7 days, OR 1.75, 95% CI: 1.46–2.10, p<0.0001), and mean LOS (8.08 days vs 6.17 days, p<0.0001). They were also more likely to require ICU admission (23.6% vs 18.0%, p<0.0001) and experienced higher rates of complications (5.6% vs 4.0%, p = 0.003), including delirium and unanticipated ICU admissions.
Conclusion: Unhoused geriatric patients were younger and had lower rates of fractures. Despite this, they experienced significantly worse outcomes, with longer hospital LOS, ICU admissions, and increased complications. These differences highlight significant disparities driven by homelessness and underscore the need for integrated care models addressing both medical and social determinants of health to improve outcomes for this vulnerable population.
Evaluation of a Hybrid Virtual and In-person Outpatient Fracture Liaison Service: Personalized Osteoporosis Care with Early Recognition (POWER Program)
Prism Schneider, MD, PHD, FRCSC; Leah Kennedy, BSc; Souvik Maiti, BSc; Jessica Duong, PhD; Richard E Buckley, MD; Andrew Dodd, MD; Paul Duffy, MD; Ryan Martin, MD; Robert Korley, MDCM
Purpose: Patients with osteoporosis (OP)-related fragility fractures (FF) have low rates (<20%) of OP treatment initiation. A fracture liaison service (FLS) using a 3i model of care, which identifies FF, organizes investigations, and initiates treatments, was shown to be cost-effective for hip fracture care. However, there is a paucity of 3i FLS programs for non-hip FF (comprises 50% of FF). This study aimed to evaluate the effectiveness, feasibility, and sustainability of a multidisciplinary outpatient FLS to address gaps in OP care.
Methods: This was a prospective cohort study of adult patients presenting to a fracture clinic with non-hip and non-vertebral FFs. The study nurse completed the active case finding, a bone health history, followed by a case discussion with the FLS orthopaedic surgeon. The nurse provided education, ordered blood tests and bone density scans, and initiated pharmacotherapy, as appropriate. Virtual multidisciplinary case conferences were held with an endocrinologist to review complex patients. Follow up was completed at 1 year postfracture. Patient satisfaction surveys were completed, and descriptive statistics are presented with direct cost-savings estimates.
Results: A total of 360 patients were recruited between August 2020 and August 2023 (average age, 66.1 ± 9.7 years; 85% female). The most common fractures were distal radius (63%) and proximal humerus (18%). The cases of 133 patients were discussed with the endocrinologist (requiring less than 9 hours of specialist time), and 31 patients were referred for in-person assessment at an osteoporosis center, avoiding more than 100 in-person consultations for a minimum estimated direct cost-savings of $27,030. A total of 138 (38%) patients were started on OP medications, with Alendronate as the most prescribed pharmacotherapy (56%). A total of 97% of participants felt the program should “probably” or “definitely” be continued, and 98% rated the program as “good” or “excellent.”
Conclusion: Nearly 40% of the patients presenting to an outpatient FLS were appropriately started on OP medications. This effective hybrid model of in-person and virtual care provides increased accessibility to a 3i outpatient FLS for non-hip and non-vertebral body fracture patients, and cost-savings.
Proximal Protection After Femoral Shaft Fragility Fractures – Striking Reduction in Peri-Implant Fractures During the First Postoperative Year and Beyond
William Lack, MD; Micah Christenson, BA; Michael Murphy, BS; Zac Novaczyk, MD; Nick Bostrom, BS; Patrick Mark, BS; Kaden Kunz, BS; Hobie Summers, MD; Joseph Bowman Cohen, MD; Mai Nguyen, MD
Purpose: We assessed the incidence and chronicity of peri-implant fractures after fixation of femoral shaft fragility fractures with and without proximal femur protection.
Methods: We performed a multicenter retrospective study (four trauma centers) of patients older than age 50 years with low-energy femoral shaft fractures (AO/OTA 32A,B,C) from 2005 to 2024, assessing demographics, comorbidities, and fixation (± proximal protection). Cumulative incidence of peri-implant fracture was compared with Kaplan Meier analysis.
Results: There were 251 patients (median age 75 years, median Charlson Comorbidity Index 4, and 78.1% women). There were 8 peri-implant fractures among 132 proximally unprotected cases and 0 among 119 proximally protected cases. Age (p = 0.37), sex (p = 0.83), and comorbidities (p = 0.89) were not associated with peri-implant fracture. Cumulative incidence of peri-implant fracture rose precipitously for proximally unprotected cases to 4.8% within 3 months, increased further until plateauing at 8.5% within 10 months, while remaining at 0% with proximal protection (log-rank p<0.01). Figure 1 presents both cumulative incidence curves and the 95% CI for proximally unprotected cases.
Conclusion: Proximal femur protection strikingly reduces the risk of subsequent peri-implant fracture in the early postoperative period following fixation of femoral shaft fragility fractures. This benefit increases over time and is maintained for years.
Operative Versus Nonoperative Management of Olecranon Fractures in Older Patients: A Cohort Comparison of Functional Outcomes and Predictors of Failure
Taylor Woolnough, MD; Shaelene Standing, BHSc; Wassim Elmasry, MDCM; J Pollock, MD FRCSC; Steven Ray Papp, MD FRCSC
Purpose: For patients ≥ age 70 years with displaced olecranon fractures, surgical management is the traditional standard of care although recent evidence has supported nonoperative treatment in frail and/or elderly patients. In the general population of older patients, and in those of moderate functional demands, no evidence exists guiding treatment. The aim of this investigation was to explore patient and treatment factors associated with outcome after displaced olecranon fractures in individuals ≥ age 70 years.
Methods: This was a retrospective cohort study with prospective data collection of patients older than age 70 years with isolated, closed, olecranon fractures. Operative patients were treated with 2.7/3.5 mm precontoured olecranon plates (n = 68) or tension band wiring (n = 6) with progressive mobilization after 2 weeks while nonoperatively treated patients (n = 39) were immobilized for a median of 3 weeks followed by mobilization. Frailty was quantified using the Frailty Rating Scale. Outcomes included Quick Disability of the Arm, Shoulder, Hand (QuickDASH), arc of motion, PROMIS global health, and complications. Mean time from injury to outcome collection was 16 ± 2 months.
Results: Mean QuickDASH (ie, disability) was lower in the operative cohort (MD –8.3; 95% CI: 0.4–16.2; p = 0.021) although the difference was not clinically meaningful. Subgroup analysis by clinical frailty scale revealed no differences in the managing well, mildly frail, or moderately to severely frail subgroups. Logistic regression analysis of patients treated with plate fixation revealed proximal fragment fixation with three or more screws to be associated with reduced proximal fragment escape (β = –5.493, SE = 1.277, OR = 0.004, 95% CI: <0.001–0.050, p<0.001) independent of sagittal plane fragment size, comminution, and triceps reinforcement. In the nonoperative treatment group, increasing duration of immobilization was associated with decreased arc of motion.
Conclusion: In patients not considered to be “fit” or “very fit”, surgical management is unlikely to result in meaningful improvements in disability relative to nonoperative management. Randomized studies comparing plate fixation or suture-based techniques to nonoperative management in moderately functional older individuals are needed to further refine treatment indications.
The Effects of Hallway Bed Placement on Elderly Hip Fracture Patients
Max Vaickus, MD; Riku Yamaji, BS; John McDonald, MD; Christine Decker Bub, MD
Purpose: Tertiary care centers have strained hospital capacities as the population ages and small hospitals close. As such, use of hallway beds (HB) in the emergency department (ED) has become more common. We hypothesize that elderly patients with hip fracture placed in an HB will have higher rates of delirium, higher 90-day readmissions, and longer hospital length of stay.
Methods: Patients age 50 years and older who were admitted to a single Level I trauma center and underwent surgery for isolated OTA31A and 31B fractures from 2020 to 2024 were retrospectively reviewed from a prospectively collected database. Patients with additional traumatic injuries were excluded. Patients were stratified into HB and non-hallway bed (NHB) patients. Additional pre- and postoperative data up to 1 year after surgery were also collected.
Results: A total of 401 patients met inclusion criteria; 231 (57.6%) were NHB patients and 170 (42.4%) were HB patients. Across groups, the mean age was 80.3 years, and the most common ASA score was 3 (75%). Patients placed in an HB for any amount of time had statistically significantly increased discharge to a skilled nursing facility versus patients in an NHB (57.6% vs 45.8%, p = 0.09), overall time in the ED (31.61 hours vs 16.8 hours, p<0.00001), and time to surgery (36.9 hours vs 28.2 hours, p = 0.001). HB patients who spent 8+ hours in a hallway bed trended toward more rehospitalizations within 90 days versus NHB patients (35% vs 33.7%, p = 0.8) as well as in-hospital delirium (8.0% vs 6.5%, p = 0.57); however, these were not significant. There was no difference in ASA score distribution, 1:1 monitoring, antipsychotics, or 1-year mortality between groups.
Conclusion: Our data show that HB patients have a longer ED stay, discharge to a skilled nursing facility at a higher rate, and wait longer for surgery. There were nonsignificant trends toward increased rates of delirium and 90-day rehospitalization. Further analysis is needed to characterize how placement in an HB affects elderly patients with hip fracture, as placement in an NHB is a potentially simple optimization for a vulnerable orthopaedic population.
Retrograde Nailing of Periprosthetic Distal Femur Fractures Can Cause Iatrogenic Flexion Instability in Cruciate-Retaining Total Knees
Neal Richard Krentz, DO; Kallie Chen, MD; Mark Kodsy, MD; John K Sontich, MD
Purpose: Retrograde intramedullary nailing (rIMN) is an effective treatment for supracondylar (AO/OTA 33A) periprosthetic distal femur fractures (PPDFF) in patients with compatible total knee arthroplasty (TKA) implants. In cruciate-retaining designs (CR-TKA), the posteriorly displaced starting point forced by the femoral component may cause iatrogenic posterior cruciate ligament (PCL) injury and subsequent flexion instability (FI). The purpose of this study was to investigate clinical outcomes in patients with PPDFF who undergo rIMN including subsequent revision and subjective and/or objective evidence of instability.
Methods: A retrospective query was performed for all patients with prior TKA who underwent rIMN for PPDFF treated at a single Level I trauma center. Patients were excluded if they had documented prior TKA instability, less than 3 months of follow up, or surgery was performed by an orthopaedic surgeon without trauma specialty training. Clinic notes and radiographs from preoperative to the final follow-up visit were reviewed. The primary outcome was rate of revision TKA. Secondary outcomes included subjective complaints, objective and radiographic findings suggestive of instability, radiographic alignment, union, and complications. Standard descriptive statistics were used to summarize the cohort.
Results: A total of 73 patients (61 females) was included. Average age was 73.8 ± 12.3 years, and median length of follow up was 294 days (IQR: 156, 411 days). Four (6.2%) patients underwent revision TKA, three with prior CR-TKA and one PS-TKA. All three CR-TKA knees were revised for instability. Revision TKAs performed were two polyethylene exchanges, one CR to total stabilized, and one PS-TKA to hinged TKA following femoral component loosening. Five (6.8%) patients reported symptoms and seven (9.6%) had positive physical exam findings suggestive of FI. Using the contact point ratio, lateral knee radiographs demonstrated that 22 (30.1%) patients had posterior tibial translation, suggesting a loose flexion gap seen in FI.
Conclusion: Our retrospective review suggests that iatrogenic FI caused by damage to the PCL is a potential complication following retrograde nailing of PPDFFs. Future studies are required to confirm these preliminary findings.
Delayed Surgical Fixation Is Associated With Increased Mortality in Patients with Distal Femur Fractures
Muhammad Umar Jawad, MD; Leeann M Qubain, MD; Haroon M Kisana, MD; Joseph B Walker, MD; Andrew Adamczyk, MD; Michael D McKee, MD; Niloofar Dehghan, MD
Purpose: Our objective was to address the conflicting evidence in the literature regarding time to surgery and its impact on outcomes for distal femoral fractures.
Methods: This is a retrospective review of the American College of Surgeons’ (ACS) National Surgical Quality Improvement Program (NSQIP®) database, which collects data from 680 hospitals across the United States. The database was queried from 2010 to 2021. Case selection was done by use of ICD-9 and ICD-10 codes for native distal femoral fractures and periprosthetic distal femur fractures, along with CPT codes for surgical fixation of the distal femur, total knee arthroplasty, and revision knee arthroplasty. Preoperative, operative, and postoperative factors were compared for patients undergoing surgery on hospital day 0 or 1 (HD≤1) to patients undergoing surgery after hospital day 1 (HD>1). Primary outcome measure was 30-day mortality. χ2 and logistic regression were used for univariable and multivariable analyses, respectively.
Results: A total of 6857 cases was identified (mean age: 71.5 years). Of them, 84.5% underwent surgery on HD≤1, and 15.5% on HD>1. The mortality rate was 1.37% and 3.26%, respectively. Patients who underwent surgical fixation of distal femoral fracture on HD≤1 had a 40% risk reduction compared to fixation on HD>1 (odds ratio [OR] 0.587; p = 0.031). A multivariable analysis revealed that presence of dyspnea (OR 4.338, p = 0.005), preoperative blood transfusion (OR 2.32, p = 0.001), and bleeding disorder (OR 1.727, p = 0.03) were associated with increased mortality at 30 days on multivariable analysis, while younger age (OR 0.216; p = 0.001) had a protective effect.
Conclusion: Delayed surgical fixation is associated with increased 30-day mortality for patients with distal femoral fractures. Further studies will help determine if the increased mortality is caused by the delay itself or by other confounding variables not identified in this study that may be associated with the reason for the delay.
Preoperative Metabolic and Nutritional Status Have Greater Association With Perioperative Complications Than Frailty Following Surgical Intervention for Proximal Humerus Fractures
Tyler K Williamson, DO; Adam O Aziz, BA; James B Bluhm, BS; Casey McDonald, MD; Matthew Glazier, DO; Jake Checketts, DO; Anil Dutta, MD
Purpose: Proximal humerus fractures (PHF) often occur in an elderly population at-risk for complications following surgery. Acute preoperative metabolic and nutritional (M+N) status may be better linked to these poor outcomes compared to more chronic physiologic assessment such as frailty. The purpose of this study is to compare the associations of an M+N index versus frailty with the outcomes of surgical intervention for PHFs.
Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2020 for patients undergoing surgical management of PHFs. Tiered frailty scores were calculated as defined by the revised Risk Analysis Index (RAI-rev). The M+N index was derived using backward stepwise logistic regression modeling to identify preoperative nutritional and metabolic lab values associated with development of any complication following surgery. Outcomes included 30-day mortality, readmission, length of stay, and complications. ANOVA and binary logistic regression were used to assess associations with odds ratio (OR) and 95% confidence interval (CI). Discriminatory accuracy was quantified by receiver operating characteristic curve analysis and C-statistics.
Results: A total of 6639 patients with PHFs underwent surgical intervention (60% ORIF, 30% rTSA). The generated M+N index was composed of the following variables significantly associated with complications: creatinine, albumin, hematocrit, international normalized ratios (INR), and sodium. The M+N index had superior predictability to RAI-rev for any complication (AUC: 0.749 vs 0.674), postoperative blood transfusion (AUC: 0.812 vs 0.704), length of stay greater than 3 days (0.901 vs 0.679) and reoperation (AUC: 0.656 vs 0.542), with each significant association also seen in a frail-only cohort. In a mixed effects model, M+N index factors and RAI-rev generated independent significant effects (both p<.001).
Conclusion: Although frailty assessment may play a role in evaluating surgical risk, preoperative metabolic and nutritional status may have greater association with perioperative complications and disposition following surgery for PHF. These values may also be more readily optimized in the inpatient setting and, therefore, future studies should focus on the effects of management strategies to alter metabolic and nutritional status to potentially mitigate perioperative risk.
LVN-led Transitional Care Coordinator Program for Hip Fractures Reduces Mortality
Peter Aldo Giammanco, BS; Veranika Mejbaryan, LVN; Kathleen M Breda, MSN, BSN, BBA; Michelle Keller, PhD, MPH; Carol Alice Lin, MA, MD
Purpose: Hip fractures pose an increased risk of morbidity and mortality in geriatric patients as postoperative care often involves multiple providers and transitions of care. This study analyzed the effects that a licensed vocational nurse (LVN)-led transitional care program had on outcomes of geriatric patients with hip fracture in a large urban health system.
Methods: A cross-sectional study with a nonrandomized control group was performed from July 2018 to April 2024. An LVN was trained to be a transitional care coordinator (TCC) for the academic orthopaedic faculty and remained under the day-to-day supervision of an adult, geriatric, acute care nurse practitioner at a single academic urban institution. The TCC was provided with orthopaedic postoperative protocols for pain, mobilization, DVT prophylaxis, and wound care following hip fracture surgery and performed phone calls to patients at 7-, 14-, 30-, and 90-days postdischarge. The TCC answered patient questions when feasible, or otherwise escalated questions directly to the orthopaedic surgeon or primary care provider. The study groups included patients contacted by the TCC, and the control groups included those not contacted by the TCC. Bivariate analyses were conducted for primary outcomes, including 90-day emergency department visits, 90-day readmission rates, 90-day mortality, and 1-year mortality.
Results: A total of 1569 patients underwent hip fracture care during the study period, 620 (39.5%) of which included TCC. The control group and TCC group were similar in age (83.13 ± 8.73 years [60–105] vs 82.58 ± 8.73 years [65–103], p = 0.182) and sex (67.0% vs 71.1% female, p = 0.086). No differences were seen in 90-day emergency department visits between control and TCC groups (6.9% vs 8.7%, p = 0.175) or 90-day readmission rates (23.7% vs 19.7%, p = 0.06). The TCC group had lower 90-day mortality rates (7.8% vs 3.5%, p = 0.001) and 1-year mortality rates (11.6% vs 7.1%, p = 0.003).
Conclusion: The implementation of an LVN-led transitional care program improved outcomes for geriatric patients with hip fracture by reducing 90-day and 1-year mortality rates. These findings highlight the benefits and importance of a TCC program because it reduced mortality and potentially addressed gaps of postdischarge care.
Perioperative Outcomes Following Open vs Closed Geriatric Ankle Fractures: A Large, Propensity-Matched Cohort Study
Logan M Good, MD; Alexander N Berk, MD; Harkirat Jawanda, MD; Samuel A Florentino, MD; Jeremy M Adelstein, MD; Robert Wetzel, MD; George Ochenjele, MD; Joshua Kyle Napora, MD
Purpose: Open ankle fractures in the geriatric population display poor outcomes. However, limited data exist comparing surgical outcomes between open and closed geriatric ankle fractures. Our purpose was to investigate differences in perioperative complications and mortality among open and closed ankle fractures in geriatric patients.
Methods: The TriNetX US collaborative network database was queried to identify patients age 65 and older who experienced surgically treated, isolated open or closed ankle fractures between 2014 and 2024. Patients were divided into two propensity-matched cohorts depending on open versus closed injuries, further stratifying bimalleolar and trimalleolar ankle fractures. Rates of complications and mortality were compared between surgically treated open and closed ankle fractures in geriatric patients.
Results: Overall, 27,860 patients met inclusion criteria. Of these, 25,257 (90.7%) sustained closed ankle fractures and 2603 (9.3%) sustained open ankle fractures. After 1:1 propensity matching, each cohort included 2565 patients. At early time points (<30 days), deep vein thrombosis (DVT), myocardial infarction (MI), sepsis, pneumonia, acute kidney injury (AKI), acute blood loss anemia (ABLA), opioid use, deep infection, emergency department (ED) visits, and rehospitalizations were higher in open ankle fractures (p<0.05). At delayed time points from 90 days to 1 year, DVT, pneumonia, acute respiratory distress syndrome (ARDS), AKI, ABLA, surgical site infection (SSI), deep infection, sepsis, below knee amputation (BKA), ED visits, rehospitalizations, and death remained significantly higher in open ankle fractures (p<0.05). Notably, open ankle fractures had significantly increased rates of mortality at 90 days (OR: 1.685, 95% CI: 1.145–2.481; p = 0.007), 180 days (OR: 1.614, 95% CI: 1.166–2.235; p = 0.004), and 1 year (OR: 1.73, 95% CI: 1.334–2.243; p<0.0001). At 1 year, bimalleolar and trimalleolar open ankle fractures also demonstrated significantly higher mortality rates (OR: 1.579, 95% CI: 1.032–2.416, p = 0.034; OR: 1.57, 95% CI: 1.04–2.371, p =0.0306), respectively.
Conclusion: Open geriatric ankle fractures, irrespective of fracture morphology, demonstrate significantly higher rates of mortality and postoperative complications including DVT, MI, pneumonia, AKI, sepsis, SSI, deep infections, BKA, ED visits, and rehospitalizations. Our findings suggest the need for enhanced perioperative counseling and preventive strategies to address modifiable risk factors in geriatric orthopaedic patients undergoing surgical fixation for open ankle fractures.
Real-World Experience and Patient Satisfaction with Local Osteo-Enhancement Procedure (LOEP): An Open Label Study in Patients with High Fracture Risk
Jo De Schepper, MD; Koen Bulterys, Mr. ; Jonathan Shaul, PhD
Purpose: Our objective was to evaluate the safety and patient satisfaction of the percutaneous local osteo-enhancement procedure (LOEP) using a resorbable calcium-based implant material (AGN1) in bone voids in the hips of patients with osteopenia or osteoporosis.
Methods: This was a retrospective, open-label, single-surgeon study of 43 adults with osteopenia or osteoporosis receiving AGN1 LOEP treatment of their proximal femurs (N = 50 hips). Informed consent was obtained from all participants. Evaluations consisted of medical record review, including radiographs, pain and functional assessments, and a participant experience questionnaire. All subjects met at least one criterion for high or very high fracture risk based on bone mineral density (BMD) T-scores, fracture history, and fracture risk assessment (FRAX®) scores.
Results: Postoperative dual-energy X-ray absorptiometry (DXA) scans performed on average 397 ± 216 days after LOEP indicated that mean femoral neck and total hip BMD increased 25% and 28%, respectively (Fig 1). Participants reported high satisfaction scores average 81.3 ± 25.3 (maximum = 100). In 25 of the 26 evaluable radiographs gathered during medical review, AGN1 resorption and regional bone formation were evident. 21 adverse events (AE) were recorded, eight of which were classified as serious adverse events (SAE). Eight adverse events related to the device or procedure were observed in a total of 43 participants (18.6%). These events were categorized as mild and related to wound complications (pain, bruising, seroma) or implant material leakage. Four of the eight events were device related and consisted of discomfort, localized pain, and material leakage.
Conclusion: This real-world study supports the safety and patient satisfaction of AGN1 LOEP for treating bone voids associated with osteopenia and osteoporosis in the hip.
Artificial Intelligence Can Effectively Predict Low Bone Density on DEXA Using Simple Hip and Pelvis Radiographs
Taylor Matthew Murray, MHA; Ashley Kochuyt, BS; William Dodd, MD, PhD; Lori Fitton, PhD; Michael Willey, MD
Purpose: Identifying older adults with low bone mineral density (BMD) allows for initiation of effective treatments to prevent fragility fracture. Dual-energy X-ray absorptiometry (DEXA) is the current standard imaging method for diagnosing osteoporosis; however, widespread utilization is limited by cost, time, requirement of specialized equipment, and need for trained providers. This study assesses the ability of artificial intelligence (AI)-assisted imaging analysis to identify decreased BMD using standard of care hip radiographs compared to DEXA.
Methods: Clinical and imaging data were retrospectively collected from a single center to identify patients age 50 years or older with a DEXA and radiographs of the hip or pelvis from within 12 months. Patients with existing fracture fixation implants or hip replacement were excluded. Radiographs were analyzed by the Naitive OsteoSight™ software to generate a BMD score that was compared to T-scores as determined by DEXA. A receiver operating characteristic (ROC) curve was generated to measure the ability of OsteoSight™ to detect patients with DEXA T-scores of less than –1.0, consistent with a diagnosis of low BMD.
Results: Of the 208 cases identified, 136 distinct patients met inclusion criteria, passed the image processing pipeline, and were included in the final analysis. OsteoSight™ analysis of hip radiographs had a specificity (95% CI) of 0.97 (0.90–1.00]), sensitivity of 0.40 (0.25–0.76), and an area under a receiver operating characteristic (AUROC) of 0.85 (0.78–0.92) for detecting patients with low BMD as determined by DEXA.
Conclusion: AI-assisted radiograph analysis has high specificity for detecting decreased BMD compared to DEXA. This technique could be implemented as a convenient, accessible, and low-cost screening tool to identify patients with decreased BMD at risk of fragility fracture.
Mortality for Patients Older Than 65 Years Old After Their Treatment for a Hip Fracture: A Retrospective and Comparative Cohort Analysis Between Fractured and Non Fractured Patients
Jorge D Barla, MD; Guido Sebastian Carabelli, MD; Danilo Taype Zamboni, MD; Lionel Llano, MD; Ivan Huespe, MD; Gonzalo Garcia Bareiro, MD; Carlos F Sancineto, MD
Purpose: Elderly, frail, and patients with comorbidities are at an increased risk of mortality. Suffering a hip fracture further exacerbates this risk.
Methods: We conducted a retrospective cohort study comparing patients older than 65 years treated for a hip fracture with a matched nonfractured population (control). Both groups were adjusted using a propensity score analysis to ensure a similar distribution of potential confounders, including age, sex, Hospital Frailty Risk Score (HFRS), body mass index, corticosteroid use, and comorbidities. A Cox regression model was used to evaluate mortality at 2 and 4 years after the index event.
Results: Before propensity adjustment, the study included 8574 patients, with 2386 in the fracture group and 6188 in the control group. After adjustment, the sample consisted of 4700 individuals. Hazard ratio (HR) analysis showed a 44% increased risk of death in the fracture group (95% CI: 95%). The HR dropped significantly after 2 years, with a 24% increased risk of death in the fracture group. Notably, after 4 years, there were no significant differences in mortality between the groups. A regression analysis was performed to account for potential confounders. Among all evaluated risk factors, frailty, as measured by the HFRS, was the most significant predictor of mortality. When stratified by age, the HR for mortality was higher in patients younger than age 80 years (1.87; 95% CI: 1.38–2.54) compared to those age 90 years or older (1.39; 95% CI: 1.18–1.64).
Conclusion: Frail patients treated for a hip fracture had a 44% increased risk of mortality, which decreased to 24% after 2 years. However, survivors in the fracture group did not exhibit a significantly increased risk of death after 4 years compared to the matched control group.
Increased Risk of Pulmonary Complications With Long Cephalomedullary Nails in Geriatric Intertrochanteric Femur Fractures: A Retrospective Review of 881 Patients
Maaz Muhammad, MD; Griffin Green, MS; Wyatt Southall, BS; Adam Musick, BS; Austin Taylor Gregg, BS; Carlos Rafael Sierra-Arce, MS; Jarod Griffin, MD; Jeffrey Austin Foster, MD; Thomas Policicchio, BA; Jacob Samuel Wolf Borgida, B.S.; Robert K. Wagner, MD; Gregory S. Hawk, PhD; Arun Aneja, MD, PhD
Purpose: Pulmonary complications following treatment of intertrochanteric (IT) femur fractures have significant morbidity; however, the impact of cephalomedullary nail (CMN) length in geriatric patients is not well established. This study compared rates of postoperative pulmonary complications in geriatric patients with IT femur fractures treated with short/intermediate or long CMNs.
Methods: Consecutive patients age 65 years or older with AO/OTA 31A1-A3 fractures treated with either short/intermediate CMNs (SIN) or long CMNs (LN) between 2008 and 2020 were retrospectively identified at a single Level I trauma center. The primary outcome was postoperative pulmonary complications. Secondary outcomes included patient mortality, surgical duration, and postoperative complications. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated using logistic regression to adjust for surgical duration, chronic obstructive pulmonary disease (COPD), smoking status, age, OTA classification, and an ASA score of 3 or more.
Results: In total, 881 patients were treated with either an SIN (n = 327) or an LN (n = 554). The SIN group was older (80.7 ± 9.1 vs 79.3 ± 8.4 years, p = 0.016), had a higher proportion of AO/OTA 31A1 fractures (p<0.001), and included more patients with an ASA score of 3 or more (89% vs 84%, p = 0.035). Median surgical duration was shorter in the SIN group (60 vs 81 minutes, p<0.001). Postoperative pneumonia was more likely to develop in patients treated with LNs (AOR: 2.24; 95% CI: 1.09–5.00; p = 0.028), as well as pulmonary embolism (AOR: 4.44; 95% CI: 1.11 – 29.8; p = 0.033), and the need for transfusion (AOR: 1.42; 95% CI: 1.06–1.91; p = 0.020). There were no differences in patient mortality or other postoperative complications (p>0.05).
Conclusion: Geriatric patients with IT femur fractures treated with LNs had increased surgical duration; postoperative pneumonia, pulmonary embolism, and the need for transfusion were more likely to develop. However, mortality and other postoperative complications were comparable. Surgeons should consider the potential for increased pulmonary complications in addition to patient-specific factors when selecting the appropriate CMN length.
The Impact of Bone Mineral-Reducing Medications Following Open Reduction Internal Fixation of Ankle Fractures: A Propensity Score-Matched Analysis
Abdullah Ghali, MD; Jad Jack Lawand, MS; Amir Alsaidi, BS; Keenan Horani, MD; Umar Ghilzai, MD; John Christian Hagedorn, MD
Purpose: Bone mineral-reducing medications (BMRM) are commonly prescribed for chronic conditions such as osteoporosis, epilepsy, and psychiatric disorders. However, their effects on fracture healing and surgical outcomes remain unclear. This study evaluates the impact of the ten most frequently prescribed BMRMs on postoperative complications following open reduction and internal fixation (ORIF) of ankle fractures.
Methods: Patients undergoing ORIF for ankle fractures were retrospectively identified using the TriNetX database, requiring a minimum of 2 years of postoperative follow up. Perioperative medication exposure was defined as at least two documented doses within 6 months pre- or post-surgery. The ten most common BMRMs analyzed included proton pump inhibitors (PPI), glucocorticoids, loop diuretics, thiazolidinediones, calcineurin inhibitors, aromatase inhibitors, selective serotonin reuptake inhibitors (SSRI), first-generation antipsychotic (FGA) medications, second-generation antipsychotic (SGA) medications, and anti-epilepsy medications.
Results: In total, 32,199 patients who underwent ORIF for ankle fractures were identified; of these, 25,043 (77.7%) had documented perioperative BMRM use. A total of 4414 patients in each was identified after 1:1 propensity score matching for age, sex, race, demographics, and other comorbidities that included diabetes mellitus, chronic obstructive pulmonary disease (COPD), liver diseases, chronic kidney disease (CKD), heart failure, hypertensive diseases, nicotine dependence, and body mass index (BMI). Exposure to specific BMRMs was associated with higher complication rates. Anti-epilepsy medications were linked to amputation (0.97% vs 0.12%, p<0.001) and nonunion (1.38% vs 0.45%, p<0.001). Glucocorticoids were associated with revision ORIF (5.14% vs 2.40%, p<0.001), deep infection (2.36% vs 1.53%, p<0.001), and nonunion (1.11% vs 0.36%, p<0.001). PPIs increased rates of revision ORIF (4.64% vs 2.06%, p<0.001), deep infection (3.07% vs 1.34%, p<0.001), and amputation (0.86% vs 0.28%, p<0.001). Among psychiatric medications, FGAs had the highest risk for deep infection (5.01% vs 1.21%, p<0.001) and revision ORIF (7.39% vs 2.07%, p<0.001).
Conclusion: Perioperative use of BMRMs is associated with an increased risk of postoperative complications following ankle ORIF. Patients taking anti-epilepsy medications, PPIs, glucocorticoids, and loop diuretics exhibited the highest risk for nonunion, revision surgery, infection, and amputation. Additionally, patients taking multiple BMRMs experienced compounded adverse effects.
Geriatric Hip Fracture With Proximal Upper Extremity Fracture Increases Morbidity, Mortality, and Cost
Zachary Jodoin, MD; Kyle Paul, MD; Ravi Arvind Karia, MD; Case Martin, MD; Thomas Hand, MD
Purpose: Hip fracture incidence continues to increase globally. Approximately 5% of patients with hip fractures have a concomitant upper extremity fracture, and patients with both upper extremity and hip fractures may experience significantly greater risk of complications and poor outcomes. This study aims to investigate the differences in medical, surgical, and hospital-related outcomes within 30 days between patients with a hip fracture with and without concomitant upper extremity fracture, with further subgroup analysis based on fracture location.
Methods: This retrospective cohort study assessed the impact of concomitant upper extremity fractures on 30-day outcomes in the setting of a hip fracture by querying a national database. ICD-10 codes were used to identify geriatric patients with hip fracture with and without a concomitant upper extremity fracture. Patients were subclassified as having a shoulder girdle, humerus, forearm, or hand fracture. Demographics, complications, cost, and in-house mortality were recorded. Validated logistic and linear regression models were used to determine significance.
Results: In total, 367,007 patients sustained a hip fracture, and 19,852 had a concomitant upper extremity fracture. Aggregate data for hip fracture with any upper extremity fracture had an increased risk of mortality, length of stay, cost, and medical and surgical complication (p<0.001). There was a 41% increase in mortality across all upper extremity fractures, a 77% to 83% increased chance of in-hospital mortality with a concomitant proximal upper extremity fracture (humerus and shoulder), and no significant change in mortality in the forearm and hand subgroup (p<0.001). Concomitant shoulder and humerus fractures had an increased risk of all-cause medical complication (p<0.001). Concomitant humerus and forearm fractures had an increased risk of all-cause surgical complication (p = 0.003).
Conclusion: There is increased risk of mortality, complications, and cost of geriatric hip fractures with concomitant upper extremity fracture. These effects are most pronounced in proximal—versus more distal—upper extremity fractures. Surgeons should be aware of these increased risks for prognostic purposes, and, with future research, may consider surgical intervention of the concomitant proximal upper extremity injury aimed at producing a functional and weightbearing upper extremity to help optimize postoperative recovery.
High Surgical Complication Rate for Ballistic Proximal Femur Fractures Regardless of Fracture Location
Chad Ishmael, MD; Nainisha Chintalapudi, MD; Rachel Seymour, PHD; Ziqing Yu, PhD; Madhav A Karunakar, MD; and EMIT
Purpose: Outcomes of ballistic proximal femur fractures are not well documented, and reported complications are high. These fractures are often difficult to treat, and evidence regarding management and clinical results remains scarce. This study reports the outcomes following surgical management of low-velocity ballistic OTA 31 (A/B/C) proximal femur fractures. We hypothesized that outcomes would vary based on fracture location, with inferior outcomes occurring for intracapsular (OTA 31 B/C) versus extracapsular (OTA 31A) injuries.
Methods: A retrospective review of 44 patients, age older than 18 years, treated surgically for low-velocity ballistic proximal femur fractures (AO/OTA Type 31) at a single Level I trauma center between 2011 and 2021 was performed. Demographics, injury characteristics, and complications (infection, nonunion, reoperation, implant failure) were recorded. Patients with intracapsular (31 B/C) and extracapsular (31A) injuries were compared, with univariate analysis and multivariate Cox regression performed to examine associations.
Results: There were 26 extracapsular and 18 intracapsular ballistic proximal femur fractures in patients with a mean age of 26.5 years (range 19.1–77). In the extracapsular group, 80.8% of fractures were stabilized with an intramedullary nail; in the intracapsular group, 33.3% were stabilized with screws and 22.2% by intramedullary nail or plate fixation. The overall surgical complication rate was 22.7%, with no significant difference between the groups (31A: 19.2%; 31B/C: 28%, p = 0.74). This included an 11.4% implant failure rate, 9.1% nonunion rate, and 9.1% reoperation rate. There was an 11.1% reoperation rate in the intracapsular cohort and 7.7% in the extracapsular group. Intracapsular fractures had twice the rate of implant failure as extracapsular fractures (16.7% vs 7.7%). There were two nonunions per group. There was one malunion and one case of avascular necrosis, both in the intracapsular group. There were two infections, both in the extracapsular group.
Conclusion: We found that more than 20% of ballistic proximal femur fractures had a major surgical complication. There was no significant difference between intracapsular and extracapsular injuries. Complications differed between the two groups: intracapsular injuries had twice the rate of implant failure and more infections developed in extracapsular injuries.
Weightbearing After Distal Femur Fractures: Does the Surgeon's Postoperative Protocol Matter?
Ryan Serbin, MD; Blake Hodgens, MD; Miles Mayberry, MD; Ziqing Yu, PhD; Susan M Odum, PhD; Rachel Seymour, PHD; Joseph Hsu, MD; Laurence B Kempton, MD
Purpose: Optimal postoperative weightbearing protocol after surgical fixation of distal femur fractures remains controversial, with limited evidence to guide surgeons' decision making, potentially impacting patient outcomes. We sought to determine the factors that increase the risk for complications in OTA 33A/C fractures, hypothesizing that postoperatively assigned weightbearing would not be associated with adverse outcomes.
Methods: A retrospective cohort study was conducted on 137 patients (>18 years old) with surgically treated OTA 33 distal femur fractures from 2018 to 2022 at a Level I trauma center with a minimum 6-month follow-up. Patients were categorized based on surgeons’ postoperative protocols: weightbearing-as-tolerated (WBAT) (n = 38) or restricted weightbearing (RWB) (n = 99). Demographics, injury and surgery characteristics, union rates, alignment, complications, and assistive device use were compared. Multivariable logistic regression analyzed the association of weightbearing protocol with complications, adjusting for key variables.
Results: The WBAT group was older than the RWB group (60.5 years vs 55 years, p = 0.029), was predominantly female (76% vs 47%, p<0.001), and had more low-energy injuries (79% vs 36%, p<0.001). WBAT patients had faster time to union (modified Radiographic Union Score for Tibia [mRUST] > 10) (209.5 vs 365 days, P = 0.001) and higher union rates by 6 months (16% vs 4%, p = 0.028). Changes in coronal (median 1° vs 2°, p = 0.55) and sagittal alignment (median 2° vs 1°, p = 0.13) were similar between groups, as was assistive device use at final follow-up (45% vs 35%, p = 0.37). Multivariable analysis revealed closed fracture status as the only significant predictor of lower complication odds (OR 0.436, 95% CI 0.194–0.980, p = 0.045). Weightbearing protocol, OTA classification, injury energy, age, and sex were not significant predictors of complications.
Conclusion: Closed fracture was the sole independent predictor of lower complication risk, suggesting soft-tissue injury, rather than weightbearing protocol, may primarily drive adverse outcomes. Larger, prospective studies would clarify the impact of postoperative weightbearing protocols on patient outcomes and inform evidence-based decision making.
“Does Adding a Plate Really Take Just 10 Minutes?”: A Comparative Analysis of Resource Utilization and Early Outcomes in Distal Femur Fracture Fixation
Ryan Serbin, MD; Calvin Chandler, MD; Timothy Chun-Tien Yin, BA; Ziqing Yu, PhD; Rachel Seymour, PHD; Joseph Hsu, MD; Kevin D Phelps, MD; and EMIT
Purpose: Implications of implant choice for distal femur fractures on resource utilization and outcomes are unclear. This study compares intramedullary nailing (IMN), plating, and IMN + plate for surgical duration, radiation, blood loss, weightbearing, and complications.
Methods: In a retrospective review of 89 isolated OTA 33A–C distal femur fractures treated surgically from 2018 to 2022 at a Level I trauma center, patients were grouped by fixation: IMN (n = 41), plate (n = 21), or IMN + plate (n = 27). Outcomes measured included surgical time, radiation dose, estimated blood loss (EBL), weightbearing status, nonunion, and complications. Multivariable regression analyzed association of implant choice with surgical time, adjusting for key variables.
Results: Adding a plate to IMN increased median surgical time by 114 minutes compared to IMN alone (230 vs 114) and 76 minutes compared to plate alone (230 vs 154). IMN + plate had significantly higher median radiation dose (50.6 mGy) compared to IMN (20.8 mGy; p = 0.0006) and plate (19.5 mGy) groups, with no significant difference between IMN and plate groups. Median EBL was significantly higher in the IMN + plate group (250 mL) compared to the IMN group (150 mL) but not the plate fixation group (200 mL). Postoperative weightbearing differed significantly between IMN (58.5%) and plate (14.3%) groups, and between plate and IMN + plate (51.9%) groups. Nonunion rates were significantly lower in the IMN + plate group compared to the plate group (3.7% vs 33.3%) , but not the IMN group (24.4%). Overall complication rates did not differ significantly. Fixation method remained significantly associated with surgical time after adjusting for OTA classification, injury energy, open fracture, age, and sex.
Conclusion: Adding a plate to IMN significantly increased median surgical time, radiation, and EBL compared to IMN or plate alone. However, the IMN + plate group demonstrated a significantly lower nonunion rate compared to plate fixation only. These findings highlight the importance of considering resource utilization and patient outcomes when determining the optimal implant selection.
Usefulness of Traction View Radiographs in Basicervical-Type Hip Fractures for Experienced Orthopaedic Surgeons
Christopher John Chermside-Scabbo, MD, PhD; Sandy Vang, BA; Robert Wojahn, MD; Mai Nguyen, MD
Purpose: Optimal hip fracture treatment requires accurate fracture characterization. However, basicervical-type hip fractures can be challenging to characterize because of femoral neck anteversion paired with the displacement of the fracture. Traction view radiographs have been shown to improve hip fracture classification for junior-level trainees and radiologists. However, obtaining traction views is highly variable across trauma centers, and the extent to which traction view radiographs actually impact treatment remains unknown. The purpose of this study was to determine the usefulness of traction-view radiographs for experienced orthopaedic surgeons.
Methods: This was a single-institution surgeon survey of 10 surgeons who take call at a Level I trauma center. De-identified hip fracture radiographs and their respective traction view were collected for 10 basicervical-type hip fracture cases. All orthopaedic surgeons who take trauma call at a single Level I trauma hospital were invited to participate in a REDCap survey. Each surgeon was presented with non-traction AP and cross-table lateral radiographs and asked a set of questions about the diagnosis, implant choice, and reduction strategy. Then, in a different and randomized order, they were presented the same cases with the corresponding traction view and asked to answer the same questions. They were also asked whether the traction view was helpful or changed the confidence in the preoperative plan.
Results: All ten surgeons were surveyed with a 100% response rate and had at least 5 years of experience. More than half of the respondents completed a trauma fellowship. Traction views changed the diagnosis 24% of the time and the implant choice 27% of the time. When applicable, the reduction strategy changed 37% of the time. From 1–10, the average confidence in surgical planning increased by approximately 1 point (CI 0.5 to 1.4). The traction view was rated to be helpful 44% of the time.
Conclusion: We found that traction view radiographs in basicervical-type hip fractures can change the diagnosis, implant choice, and reduction strategy in experienced orthopaedic surgeons. Further work should validate these findings with larger case numbers and at other institutions.
Distal Femur Fracture Outcomes and Complications of Dual Implant Fixation Compared to Single Plate Fixation – A Multicenter Review
Joseph Larson, BS; Nicholas Bostrom, MD; Sandy Vang, BA; Mir Ibrahim Sajid, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA; Gennadiy Busel, MD; Mai Nguyen, MD
Purpose: The purpose of this study is to compare outcomes and complications between patients treated with dual implant versus single plate for distal femur fractures.
Methods: A retrospective review was completed for distal femur fractures treated with surgical fixation from January 2018 through September 2024 at three trauma centers. Inclusion criteria were adult patients 18 years or older with distal femur fractures treated with single plating (SP) or dual implant (DI: nail/plate or dual plate). Exclusion criteria were patients with less than three months of follow up or with pathologic fractures. Data was collected for analysis on patient demographics, injury characteristics, treatment, surgical statistics, time to weightbearing, complications (90-day mortality, 90-day readmission, reoperations, and deep venous thrombosis), and nonunions. Comparative analyses were performed between the SP and DI groups with statistical significance set at <0.05.
Results: In the study, 361 patients with distal femur fractures were included; 273 (75.6%) were in the SP group and 88 (24.3%) were in the DI group. Patient sex, BMI, and smoking status distributions were similar in both groups (P>0.05). Procedure duration, estimated blood loss, and transfusion rates were higher for the DI group compared to the SP group (3.2 hours vs 2.2 hours, P<0.001, 292 cc vs 229 cc, P = 0.008, 30.7% vs 19.5%, P = 0.028, respectively). DI patients advanced to full weightbearing significantly faster than SP patients (5.2 weeks vs 9.0 weeks, respectively; P<0.001). Compared to the SI patients, DI patients had more reoperations for wound infections (5.7 % vs 0.4%, P<0.001) and septic non-unions (2.3% vs 0, P = 0.01). No significant difference was observed in the aseptic nonunion rate (2.3% DI vs 4.0% SI, P = 0.4). The total complication rates were similar in both groups (25.0% in DI vs 16.8% in SP, P = 0.10).
Conclusion: Although DI allows for a shorter time to full weightbearing, it is associated with longer surgical time, more blood loss, and a higher transfusion rate, which may contribute to higher infection rates for the DI group.
Closed Reduction Of Posterior Hip Fracture-Dislocations With An Interposed Posterior Wall Fragment
Connor Park, BS; Christian Gabriel Falgons, MD; Jonathan G Eastman, MD; Milton L Routt, MD; Jonahs Galloway, BS; Samantha Gardner, BS; Stephen Warner, MD, PHD
Purpose: Our primary objective was to investigate if the position of an interposed posterior wall fragment relative to the femoral head prior to closed reduction of a posterior hip fracture-dislocation was associated with intra-articular displacement. Secondarily, the initial positioning was assessed in relation to success of a congruent closed reduction.
Methods: At a regional Level I trauma center, patients who sustained isolated posterior wall, posterior column with a posterior wall, or a transverse posterior wall acetabular fracture-dislocation with pre- and postreduction CT imaging from January 2019 to December 2023 were evaluated. CT imaging was reviewed in patients on initial dislocation. Axial and sagittal imaging were used to assign location of the interposed posterior wall fragment relative to the femoral head. CT scans following closed reduction were analyzed to discern intra-articular displacement.
Results: Of the 44 included patients, 21 (47%) had an intra-articular posterior wall fragment following closed reduction. Interposed posterior wall fragments were medial to the femoral head in all instances in which they were displaced into the joint and in 26.09% of instances in which they remained extra-articular (p<0.001). Fragments were inferior to the femoral head in 95.24% of instances in which they were displaced into the joint and in 34.78% of instances in which they remained extra-articular (OR = 37.5 ; CI = 4.22, 333.06; p<0.001). The average length of interposed posterior wall fragments that were found to be intra-articular was 2.57 cm (SD 1.10 cm) and extra-articular was 3.55 cm (SD 0.98 cm) (CI = –1.6, –0.36; p = 0.003). Fragments were medial to the femoral head 74.19% of the time in incongruent reductions and 30.77% in congruent reductions (OR = 6.47 ; CI = 1.55, 26.93; p = 0.015).
Conclusion: This study found that smaller, interposed posterior wall fragments that are inferior and medial to the femoral head prior to closed reduction are significantly associated with intra-articular translation. Additionally, this injury pattern carried a high rate of incongruent closed reduction and required surgical intervention in all but one patient. Recognizing this risk, multiple closed reduction maneuvers of this injury pattern should be avoided, and fragment retrieval is anticipated.
Revision and Postoperative Complication Rates After Conversion Total Hip Arthroplasty After Cephalomedullary Nailing of Intertrochanteric Femur Fractures: Systematic Review and Meta-Analysis
Harsh Wadhwa, MD; Harmon Khela, BS; Henry Wong, MS; Lawrence Henry Goodnough, MD, PhD
Purpose: Failed intertrochanteric (IT) fracture fixation often requires conversion total hip arthroplasty (cTHA). Femoral component fixation during cTHA can be challenging because of implant removal complexity, deformity, and poor bone quality. Ideal femoral fixation strategy is unknown. The purpose of this study was to compare femoral fixation types and revision and postoperative complication rates of cTHA after cephalomedullary nailing of IT fractures.
Methods: PubMed and Embase databases were queried for studies examining outcomes of cTHA after prior cephalomedullary nailing for IT fracture. Rates of revision, infection, dislocation, and periprosthetic fracture (PPF) were assessed. Risk of bias was assessed using the Newcastle-Ottawa Scale. A random-effects model was employed to pool overall complication rates across studies. Subgroup analysis was performed to compare outcomes based on femoral component type.
Results: Seventeen studies, in which 1253 patients underwent cTHA, were included. Femoral component fixation type was specified in 799 cases. Primary cementless stems were most frequently used (47.9%), followed by primary cemented (38.8%), diaphyseal cementless (12.0%), and diaphyseal cemented (1.3%) stems. The overall pooled revision rate was 7% (5%–8%). Postoperative complication rates were 3% (2%–5%) for infection, 4% (3%–6%) for dislocation, and 6% (4%–8%) for PPF. Subgroup analysis compared primary cementless (n = 265), primary cemented (n = 220), and diaphyseal cementless (n = 17) implants. Primary cementless stems exhibited higher rates of revision (9.81% vs 2.27%), subsidence (7.92% vs 3.63%), dislocation (2.64% vs 2.27%), and PPF (7.17% vs 3.18%) relative to cemented stems. Diaphyseal cementless stems had no revision, subsidence, or PPF, but showed elevated dislocation (11.8%) and infection (5.9%) rates.
Conclusion: cTHA is an effective salvage option for failed IT fracture fixation but carries notable risks. In a limited sample size, primary cementless stems were associated with higher rates of revision, subsidence, and PPF. Optimal outcomes are achieved through careful selection of femoral components tailored to patient-specific factors.
No One Is Too Sick for a Life Saving Operation!
Lauren A Merrell, BA; Garrett W. Esper, MD; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: The purpose of this study was to quantify and elucidate outcomes in patients with significant medical comorbidities who undergo fixation following hip fracture.
Methods: This study was approved by the Institutional Review Board. All patients who underwent surgical fixation of an OTA 31A/31B/32A hip fracture were identified. This dataset was queried for patients with extensive and severe comorbidity profiles, those who were deemed the “highest-risk” at presentation for hip fracture. Patients were classified as “highest-risk” by one or more of the following conditions: kidney failure on hemodialysis, cirrhosis Child class C, cardiac stents within 6 months, acute myocardial infarction (ST elevation or enzymes), severe mitral stenosis or critical aortic stenosis, severe pulmonary hypertension, need for neurosurgical intervention, or chronic heart failure (class 3 and 4). Each patient was reviewed for demographics, medical history, hospital quality measures (including need for pre-, intra-, or postoperative procedures), and outcomes. Descriptive statistics were performed to evaluate outcomes of this highly vulnerable population.
Results: Of 2846 hip fracture patients, 152 (5.3%) were deemed the “highest-risk,” presenting with one or more of the above comorbidities. The mean age of patients was 81.77 ± 9.96 years. This cohort was admitted for an average of 8.48 ± 5.17 days and spent an average of 2.51 ± 4.56 days in the ICU. An immediate, pre- or postoperative intervention for medical stability was required in 42 (27.6%) patients. Only four (2.6%) patients required immediate intraoperative medical intervention during hip fracture repair, 114 (75.0%) patients experienced a minor complication while admitted for hip fracture, and 28 (25.0%) experienced a major complication. The most frequent inpatient complications were anemia (48.7%), acute kidney/renal failure (19.7%), and urinary tract infection (18.8%). Six (3.9%) patients expired during admission, 12 (7.9%) within 30 days of surgery, and 27 (17.8%) within 1 year of surgery. Of the entire cohort, 38 (25%) patients were readmitted within 30 days and 50 (32.9%) within 90 days.
Conclusion: Highest-risk hip fracture patients experience prolonged hospitalizations, concurrent procedures, and a high incidence of inpatient complications. Despite these challenges, most tolerated their hip fracture surgical procedures well, with a low need for intraoperative intervention while under orthopaedic care.
Nail Plate Combination Outperforms Single Device Constructs in Supracondylar Distal Femur Fractures: A Retrospective Comparative Analysis.
Urvi J. Patel, MD, MS; Melissa Holloway, MD; Carla R. Guedikian, BS; Noah Michael Joseph, MD; John P Ketz, MD
Purpose: The purpose of this study was to investigate clinical, radiographic, and patient-reported outcomes following surgical intervention for distal femur fractures (DFFs) among patients undergoing fixation with a locked lateral plate (LLP), retrograde intramedullary nail (rIMN), or nail-plate combination (NPC).
Methods: We conducted a retrospective review at a single, academic, tertiary Level I trauma center. The inclusion criteria were patients with distal femur fractures (OTA/AO 33) treated surgically with LLP, rIMN, or NPC between January 2011 and December 2023 with a minimum follow up of 9 months or until reoperation. Exclusion criteria were pathologic fractures and patients younger than age 18 years. Radiographic fracture healing, complication rates, weightbearing status, length of stay, and patient-reported outcomes using the Patient-Reported Outcomes Measurement Information System (PROMIS) were investigated. Multivariable regression models were employed to identify predictors of non-weightbearing status, discharge disposition, and postoperative complications.
Results: A total of 402 patients was included, with 293 treated with LLP, 67 with rIMN, and 42 with NPC constructs. The NPC cohort demonstrated significantly higher rates of immediate postoperative weightbearing as tolerated (WBAT) (p<0.01), higher rates of discharge to home (p = 0.04), and lower rates of gait impairment at 6 months postoperatively (p = 0.03) compared to LLP and rIMN cohorts. There were no significant differences in fracture union rates (p = 0.51) or hardware failure (p = 0.81) across groups. NPC constructs were associated with increased intraoperative blood loss (p<0.01) and postoperative transfusion requirements (p = 0.02). PROMIS Physical Function scores were higher in the NPC cohort at 6 weeks postoperatively (p<0.01), but no differences were observed at the 3 month to 1 year time points.
Conclusion: NPC constructs for distal femur fractures allows for earlier postoperative mobilization with improved functional recovery, especially in patients with complex fracture patterns, without compromising union or complication rates. However, compared to single device constructs, NPC was associated with longer surgical times and greater intraoperative blood loss. These findings support NPC as a valuable fixation strategy, particularly for patients who would benefit from early mobilization.
Complementary Effects of Postoperative Delirium and Frailty on 30-Day Outcomes Following Surgically Managed Hip Fractures
Hikmat Ramen Chmait, MS; Omar Sbaih, .; Hannah Grimmett, BS; Michael DiCosmo, MD; Mitchell Gray, MD; Mark Haimes, MD
Purpose: Hip fractures in older adults pose considerable risks, including postoperative delirium (POD) and increased mortality. Frailty is a known predictor of adverse outcomes, yet the optimal frailty measure for predicting POD remains uncertain. This study aimed to compare the Risk Analysis Index (RAI) and the 5-item Modified Frailty Index (mFI-5) in predicting POD and short-term outcomes among patients undergoing hip surgery.
Methods: The 2021 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients aged ≥75 years who had surgical management of hip fractures. Frailty status was assessed using the RAI and mFI-5. Outcomes assessed included POD, 30-day mortality, extended length of stay (eLOS), discharge to non-home destinations (NHD), readmissions, reoperations, and complications. Predictive value of frailty was assessed with multivariate logistic regression and discriminatory accuracy was quantified by receiver operating characteristic (ROC) curves. A mediation analysis examined whether POD mediated the relationship between frailty and adverse 30-day outcomes.
Results: There were 2,036 hip fracture patients (median age 82 (IQR: 75–89)) who developed POD. Higher frailty categories (RAI frail or very frail; mFI-5 frail or severely frail) were significantly associated with an elevated risk of POD compared to robust groups. The RAI showed superior discriminative performance for POD (AUC: 0.72) relative to mFI-5 (AUC: 0.60, p<0.001). POD independently increased the odds of 30-day mortality (OR: 4.29), eLOS (OR: 4.16), NHD (OR: 2.23), and complications (OR: 2.09). There was a significant complementary mediation effect of POD on frailty’s contribution to 30-day mortality (frail: 29.6% and very frail: 19.4%).
Conclusion: The RAI more accurately predicts POD and short-term postoperative risks than mFI-5 in elderly patients undergoing hip fracture surgery. Moreover, POD plays a substantial role in increasing the risk of adverse postoperative outcomes in frail hip fracture patients. Thus, the RAI may be used for preoperative risk stratification to identify patients at risk of developing POD, improving patient outcomes.
Risk Factors for Delayed Conversion to Total Hip Arthroplasty After Femoral Head Fracture: A Multicenter Review
Anastasia Hunt, MD; Henry Wong, MS; Jayme Koltsov, PhD; Lawrence Henry Goodnough, MD, PhD; Julius A Bishop, MD; Michael J Gardner, MD; North American Femoral Head Fracture Consortium
Purpose: Our objective was to determine the risk factors associated with delayed conversion to total hip arthroplasty (THA) in patients with femoral head fracture (FHF).
Methods: A retrospective review of adults age 18 to 60 years who sustained FHFs (AO/OTA Classification 31C) between 2005 and 2023 was performed across 32 ACS Level I trauma centers. Patients with less than 3 months of follow up were excluded. Patient demographics, injury characteristics, treatment, and complications data were collected. Patients were grouped based on whether or not they underwent delayed THA. Descriptive statistics were presented as means and standard deviations for continuous variables and counts and percentages for categorical variables. Uni- and multivariable mixed-effect models evaluated the relationship among patient factors, treatment, and postoperative clinical course.
Results: Within the study period, 711 patients with FHF (37 ± 11 years, 30.3% female) were identified. Of those identified, 156 (21.9%) underwent delayed THA. Patients undergoing delayed THA were older (mean age 41 vs 35, p<0.001), heavier (body mass index [BMI] 32.1 vs 29.1, p = 0.002), and underwent unplanned procedures (15.3% vs 7.1%, p = 0.006). Avascular necrosis (AVN) and post-traumatic osteoarthritis (PTOA) developed at higher rates (45.5% vs 11.6%, p<0.001; 53.2% vs 7.9%, p<0.001, respectively). After risk adjustment, older age (p<0.001) and increased BMI (p = 0.003) remained associated with delayed THA. Odds of conversion to THA increased 4.8-fold if AVN developed (95% CI: 1.7–13.0; p = 0.002) and 8.4-fold (95% CI: 3.4–20.5; p<0.001) if PTOA developed. Having an unplanned procedure was not statistically significant in multivariate models. Pipkin classification, surgical approach, fixation of the femoral head, and excision of the labrum, femoral head fragments, or a foreign body (eg, bullet) were not associated with undergoing delayed THA.
Conclusion: FHFs are rare, devastating injuries with high rates of conversion to THA. Conversion is more likely in older, heavier patients in whom AVN or PTOA develop. During the index treatment, patients sustaining an FHF should be counseled appropriately about their risk of conversion to THA, so that early shared decision-making between the patient and the surgeon can occur.
Slimming the Risks: GLP-1 Receptor Agonist Therapy May Reduce In-Hospital Complications Following Hip Fracture Surgery Compared to Obese Patients Not on These Medications
Amelia R Goldstein, BS; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Philipp Leucht, MD; Kenneth A Egol, MD
Purpose: Emerging evidence suggests that glucagon-like peptide-1 (GLP-1) receptor agonists may influence overall general health and potentially bone health. The effects of this class of medication on fracture outcomes has not been studied. The purpose of this study was to evaluate the impact of prolonged GLP-1 usage on the incidence of major and minor in-hospital complications following hip fracture surgery across various body mass index (BMI) strata.
Methods: A prospective hip fracture database was queried. Between 2016 and 2023, 58 patients who sustained a hip fracture and were on GLP-1 therapy for obesity for ≥6 months were identified (Group A). This group had a mean pretreatment BMI of 33.16 ± 4.82 and a mean time of injury BMI of 29.04 ± 5.97. Group A was matched to patients of varying BMI, not on GLP-1 therapy, Group B (BMI 18.5–25), Group C (BMI 25–30), and Group D (BMI ≥30). Matching incorporated age, injury type, and comorbidities (age-unadjusted Charlson Comorbidity Index). Major postoperative complications were defined as events requiring additional surgery or interventional procedures, prolonging hospitalization, or substantially impairing patient function (eg, pulmonary embolism, organ failure). Minor complications were defined as issues managed with minimal treatment (eg, superficial wound infection, mild nausea). Chi-square tests with standardized adjusted residual tests were used.
Results: A total of 232 patients (58 per group) were included. Minor complication rates differed significantly (x2≈15.25, p<0.01), ranging from 21.15% (Group A) to 51.92% (Groups C and D). Post hoc standardized residuals indicated that Group A had significantly fewer minor complications than expected (|r|≈ –2.49), while the other groups did not deviate significantly (|r|<1.96). Overall complication rates also differed significantly (x2≈17.33, p<0.001), ranging from 28.85% (Group A) to 67.31% (Group D). Significantly fewer overall complications than expected (|r| ≈ –2.30) developed in Group A, whereas Groups B, C, and D did not deviate significantly (|r|<1.96). Major complications (9.62%–23.08%) did not differ significantly among the four groups (x2 = 4.06, p>0.05).
Conclusion: Long-term GLP-1 receptor agonist therapy is associated with a reduction in overall and minor in-hospital complications in obese patients undergoing hip fracture surgery.
Restoring Femoral Version in the Comminuted Diaphyseal Femur Fracture: A Radiologic Study Comparing Correction Methods in 219 Healthy Patients
Megan Anderson, BA; Meera Dhopdapkar, MD; Nicholas Rhodes, MD; Jaimo Ahn, MD, PhD; Krystin Hidden, MD; Brandon Yuan, MD
Purpose: In a comminuted diaphyseal femoral fracture, the restoration of appropriate femoral version (FV) can be one of the most challenging aspects of the reduction. Two primary methods of achieving rotational correction are commonly employed: matching the contralateral femur (MC) or correcting to a standard 15° anteversion (SC). This study assessed for differences in correction accuracy and rates of malrotation between MC and SC.
Methods: This retrospective radiologic study included all patients who underwent bilateral lower extremity CT between 2006 and 2024. Patients with a history of anatomy-altering femoral pathology were excluded. The left femur was theoretically considered as the “fractured” side. Its innate version, measured by CT, was the standard for a perfect rotational reduction. Two hypothetical FV corrections by technique were then calculated. SC assumed fractured FV correction to an anatomic average of 15° anteversion. MC theoretically matched the "fractured" FV to the contralateral uninjured side. FV after SC versus FV after MC was compared to known left FV by CT, and correctional error was calculated for each method. The proportion of femurs deviating from innate FV by more than 15° was recorded for SC and MC.
Results: In this study, 219 patients with a mean FV of 14.9° ± 10.5° anteversion were included (149 female [68%]; mean age, 34 years). Measures of FV did not differ significantly between left and right femurs. MC resulted in fewer degrees of malrotation for patients within 5° of cohort mean (5.0° vs 5.5°, p = 0.042), as well as for patients whose FV in the affected femur deviated at least 5° from cohort mean (5.5° vs 9.7°; p≤0.001). Significantly fewer femurs were malrotated by 15° with MC than with SC (4.6% vs 15.1%; p<0.001).
Conclusion: In this radiologic study assessing two methods of FV correction using CT scans of healthy patients, MC to mirror the uninjured side resulted in less rotational error than SC to 15° anteversion, although differences may not be clinically significant. A 3-fold increase in the rate of malrotation >15° was observed with SC.
Which Surgical Approach Provides the Greatest Exposure of the Femoral Head? A Comparison of the Smith-Petersen and Trochanteric Flip Osteotomy Approaches
Raul Angel Davalos, MD; Laura Mourafetis, MD; Trevor Tompane, MD, MPH; Benjamin Wheatley, MD; Harrison Diaz, MD
Purpose: Femoral head fractures are relatively rare injuries that occur because of high-energy trauma. Although rare, these injuries necessitate prompt and skillful orthopaedic treatment to avoid long-term functional sequalae for the patient. Choosing an appropriate surgical approach is therefore an essential part of preoperative planning, with multiple viable options. The purpose of our study was to calculate and compare the surface area exposed by two different surgical approaches to the femoral head (the Smith-Petersen and the trochanteric flip osteotomy). A qualitative comparison of the location of exposure between the two approaches was also conducted.
Methods: Dissections were conducted on eight cadaver pelvises, with a Smith-Petersen approach performed on one side and a trochanteric flip osteotomy performed on the other (16 approaches total with one of each approach performed on each pelvis). Each approach included a surgical hip dislocation. The amount of femoral head surface area exposed via each approach was calculated using digital image-capture software (ImageJ, Bethesda, MD). The calculations of area exposed were then compared using a paired sample t-test.
Results: The Smith-Petersen approach provided a significantly greater amount of exposure compared to the trochanteric flip osteotomy (1328 mm2 ± 379 mm2 vs 1086 mm2 ± 270 mm2; p = 0.017). Qualitative comparisons of the location exposure demonstrated that the Smith-Petersen approach provided improved exposure of the anteroinferior head while the trochanteric flip osteotomy provided improved exposure of the posterosuperior head.
Conclusion: Both the Smith-Petersen with surgical hip dislocation and trochanteric flip osteotomy approaches are viable options for approach to the femoral head. Although the Smith-Petersen approach did provide a statistically greater area of exposure, both approaches provided a significant amount of exposure. This study also suggests that the region of exposure may vary between the two approaches with the Smith-Petersen providing improved exposure of the anteroinferior head while the trochanteric flip osteotomy provided a greater amount of exposure in the posterosuperior head.
Do Arthroplasty Outcomes Differ Between Displaced and Non-Displaced Femoral Neck Fractures? A Short-Term Comparative Analysis
Benjamin Hammond, BS; Danielle M Olson, MS; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: Femoral neck fractures (AO/OTA types 31B1) have been classified as “displaced” and “nondisplaced” and represent patterns that may be indicated for arthroplasty (hemiarthroplasty or total hip arthroplasty [THA]). The purpose of this study was to assess outcomes following arthroplasty for femoral neck fractures based on displacement, as these distinctions may guide clinical decision-making and postoperative care planning.
Methods: A total of 830 consecutive patients treated with arthroplasty for femoral neck fractures from 2014 to the present were identified in a prospective hip fracture research database. Those with minimally impacted or nondisplaced fractures (Types 31B1.1 and 1.2; n = 116) were compared to those with displaced fractures (Type 31B1.3; n = 714) to assess for short-term outcomes following either hemiarthroplasty or THA. Continuous variables were analyzed using Independent Samples T–tests, while categorical variables were assessed using χ2 tests with standardized adjusted residuals.
Results: No significant differences were observed in age, sex, race, or baseline ambulatory status. Pre-injury use of assistive devices was higher in those who sustained a displaced fracture (54.6%) compared to nondisplaced (39.7%; p = 0.003). Patients with displaced femoral necks were sicker than those with impacted or nondisplaced fractures (CCI, STTGMA, ASA all significant; p < 0.05). Interestingly, nondisplaced fractures were more likely to need THA compared to the displaced fracture group (p<0.001). Length of stay was longer in the displaced group (6.64 days) compared to nondisplaced (5.31 days; p = 0.004). 30-day readmission rates were significantly higher in the displaced group (10.4%) compared to nondisplaced (2.6%; p = 0.007), and this pattern persisted at 90 days (13.2% vs 6.0%; p = 0.029). No significant differences were observed in major and minor in-hospital complications, mortality rates, revision rates, or rates of infection and dislocation (p>0.05).
Conclusion: Surgeons and patients can expect different outcome profiles following arthroplasty for femoral neck fracture based on initial fracture displacement. Those with displaced fractures were characterized by a poorer baseline health status, longer hospital stays, and higher readmission rates, underscoring the need for tailored post-acute care strategies addressing these differences.
Using the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) to Cluster High-Risk Hip Fracture Patients for Hospice Discharge
Benjamin Hammond, BS; Danielle M Olson, MS; Abhishek Ganta, MD; Kenneth A Egol, MD; Sanjit Reddy Konda, MD
Purpose: Patients with hip fracture can be considered candidates for hospice care if their life expectancy is less than 6 months. This study evaluates the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) score’s ability to accurately cluster high-risk patients with hip fracture for hospice discharge directly from their index hospitalization, enabling personalized end-of-life post-acute care planning.
Methods: A retrospective review of a hip fracture database in a single institution from 2014 to 2024 was performed. Inclusion criteria were age older than 55 years, low-energy mechanism, OTA 31A-B, 32C hip fractures, and minimum follow up of 6 months. Patients were stratified into STTGMA risk groups: minimal risk (50%), low risk (30%), moderate risk (17.5%), and high risk (2.5%). Baseline demographics, injury characteristics, and treatment types were recorded. Hospital quality measures and 6-month mortality were recorded. Patients with inpatient mortality greater than 48 hours after surgery and less than 6 months after surgery were categorized as ‘Hospice Discharge Candidates’ (HDC). Two-way Analysis of Variance (ANOVA) tests were performed to compare characteristics among STTGMA risk groups. American Anesthesia Society (ASA) score was calculated for all patients and compared to STTGMA for the ability to cluster HDCs using area under receiver operating characteristic (AUROC) analysis and the Delong test. Statistical significance was set at p<0.05.
Results: There were 3493 patients with hip fracture who met inclusion criteria (mean age, 80.83 ± 10.08 years; 70.0% female). Mortality within 6 months of surgery increased significantly with STTGMA risk level: 0.5% (minimal risk), 2.5% (low risk), 8.3% (moderate risk), and 25.3% (high risk) (p<0.05). Only 8.8% of patients classified as ASA 4 were HDCs. Additionally, STTGMA demonstrated a significantly better ability to discriminate HDCs compared to ASA (0.823 vs 0.642, p<0.001).
Conclusion: The STTGMA score effectively identifies HDCs and is better than ASA at this task. High-risk patients with hip fracture classified by STTGMA show a high probability of mortality within 6 months of surgery and should be prioritized for hospice discharge upon admission.
Basicervical Fractures and Fixation Strategies
Benjamin Hammond, BS; Chloe Cecile Fong, BA; Danielle M Olson, MS; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: Basicervical (31B3) hip fractures are rare and represent a unique subset of proximal femoral fractures with distinct anatomic and biomechanical properties. Despite their rarity, these fractures pose significant challenges in fixation and functional recovery, with limited evidence on how their outcomes compare to other hip fracture types. This study evaluates functional recovery, complication rates, and the impact of fixation constructs in basicervical fractures compared to intertrochanteric (31A1.2, 31A1.3) and femoral neck fractures that undergo fixation (31B1.1).
Methods: From a cohort of 5152 hip fractures, 145 (2.8%) were classified as 31B3 and met inclusion criteria. For comparison, two cohorts of patients, impacted femoral necks (31B1.1) and intertrochanteric (31A1.2, and 31A1.3) fractures, were matched. Fixation constructs for the 31B3 group comprised 23.3% treated with plate and screws, 3.33% with cannulated screws only, and 73.3% with intramedullary nails. Outcomes included fracture healing, complications, return to baseline assistive device usage, and 30- and 90-day readmissions. In-hospital complications included shock, pneumonia, deep vein thrombosis, pulmonary embolism, acute kidney injury, stroke, ulcer, urinary tract infection, acute respiratory failure, cardiac arrest, postoperative delirium, among other unexpected medical events. Statistical significance was set at p<0.05.
Results: Patients analyzed had ≥ 6 months follow up (average: 9 months). Healing rates were similar across groups (p = 0.453): 100% of 31A1.2, 98.7% of 31A1.3, 97.4% of 31B1.1, and 96.7% of 31B3 fractures healed. Return to baseline assistive device usage was highest in 31B3 fractures (80%) compared to 31B1.1 (67.5%), 31A1.2 (64.3%), and 31A1.3 (55.8%), with a near-significant difference favoring 31B3 over 31A1.3 (p = 0.112). In-hospital complications were significantly higher in 31B3 fractures (63.3%) compared to 31B1.1 (17.1%) (p<0.001). No significant differences were observed in 30-day (p = 0.096) or 90-day (p = 0.132) readmissions.
Conclusion: Basicervical hip fracture patterns were associated with higher in-hospital complication rates. However, no difference in healing or revision surgical rates were seen.
Regional Block Only is Safe and Effective for Surgical Management of Subtrochanteric Fractures: A Feasibility Study
Alexander M Lashgari, BA; Chloe Cecile Fong, BA; David L Furgiuele, MD; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: The purpose of this study was to examine the efficacy of the lateral femoral cutaneous and over the hip (LOH) block as the only anesthesia for subtrochanteric femur fracture repair.
Methods: A retrospective review of an Institutional Review Board (IRB)-approved subtrochanteric database from 2012 to 2024 was conducted. Demographics, injury and surgical details, hospital quality measures, complications, readmissions, mortality, and functional outcomes during the index admission were recorded. Patients were divided into three groups (LOH block, neuraxial, and general) according to the anesthetic modality administered during their surgery. A 1:1:1 propensity score match was conducted based on the patients’ score for trauma triage in the geriatric and middle aged population (STTGMA, a validated in-patient mortality risk assessment tool). Statistical comparisons were made using Pearson χ2 testing and one-way analysis of variance (ANOVA) in SPSS, version 29 (Armonk, NY).
Results: A total of 36 patients with an average age of 76.08 ± 10.85 years was included in the final analysis (12 per group). The groups were similar in age, BMI, comorbidity index, energy of injury, race, pre-injury ambulatory status, OTA fracture classification, and fixation method. There was no difference in coronal alignment (p = 0.599) or sagittal alignment (p= 0.453) postoperatively. The LOH group had the shortest anesthesia time (14.58 vs 22.92 [neuraxial] vs 28.67 minutes [general], p = 0.01) and trended toward the shortest total operating room time (124.58 vs 146.58 vs 169.75 minutes, p = 0.070). The general group displayed the longest time to ambulation (3.36 vs 1.42 [neuraxial] vs 1.58 days [LOH], p = 0.026) and trended toward shorter ambulation distance upon discharge compared to the LOH group (22.83 vs 126.92 feet, p = 0.061). There were no significant differences among groups in anesthesia-related complications, palliative care consults, complication rates, readmission rates, or postoperative mortality.
Conclusion: This study suggests that the regional (LOH block) only approach is a safe and effective anesthetic modality in the context of subtrochanteric fracture repair. The use of a regional anesthesia only does not impede the ability to obtain an acceptable alignment. Additionally, this strategy may impart benefits in earlier postoperative ambulation.
Redefining the Critical Window for Elderly Hip Fracture Surgery: ‘Next Day Surgery’ has Equivalent Outcomes Compared to Surgery Performed Less than 24 Hours from Emergency Room Arrival.
Benjamin Hammond, BS; Danielle M Olson, MS; Abhishek Ganta, MD; Kenneth A Egol, MD; Sanjit Reddy Konda, MD
Purpose: Our objective was to compare the outcomes of patients who undergo "Next Day Surgery" (NDS) versus those who undergo "Less than 24-Hour Surgery" (<24S).
Methods: A retrospective review of a hip fracture database in a single institution from 2014 to 2024 was performed. Inclusion criteria were age older than 65 years, OTA 31A-B hip fracture, surgical treatment, and follow up for 1 year. Demographics, injury, hospital quality measures, and postoperative mortality were recorded up to 1 year. The study cohort was divided into two groups based on time from emergency department arrival to surgery start time: <24S and NDS more than 24 hours from arrival. Univariate analysis was performed to compare outcomes. Multivariate linear regression analysis was performed to adjust for age and risk-profile (STTGMA score). Significance was set to p<0.05.
Results: There were 1873 patients included in the study analysis, of which 1090 (58.20%) were <24S and 783 (41.80%) were NDS. The overall mean age was 79.21 years. Univariate analysis revealed no differences between <24S and NDS cohorts for average in-hospital complications (0.51 vs 0.54, p = 0.427), inpatient mortality (0.5% vs 1.1%, p = 0.087), 30-day (5.8% vs 6.3%, p = 0.667) and 90-day (8.6% vs 11.0%, p = 0.087) readmission, and 30-day (2.3% vs 2.6%, p = 0.716) and 1-year (4.5% vs 6.1%, p = 0.115) mortality. Length of stay (5.16 [3.25] vs 5.65 [3.39], p = 0.002) and discharge location (36.9% home discharge vs 30.7%, p = 0.005) were both noted to favor the <24S cohort. After adjusting for confounding factors, only length of stay was found to be associated with the <24S cohort (B = –0.446, p<0.001).
Conclusion: There are no significant differences in meaningful patient outcomes for elderly patients undergoing hip fracture surgery less than 24 hours from emergency department arrival versus those who undergo NDS more than 24 hours after arrival. This study suggests that NDS can be performed safely without increased risk to the patient.
Combined Femoral Head and Neck Fractures
Andrew Ronald, MD; Christian Gabriel Falgons, MD; Jonahs Galloway, BS; Jonathan G Eastman, MD; Stephen Warner, MD, PHD; Kristin Sheaffer, MD; John Charles Weinlein, MD; Christopher Bloise, MD; Peter Carl Krause, MD; Ahmed Nageeb, MD, PhD; Daniel Scott Horwitz, MD; Joseph T Gutbrod, BS; Anna N Miller, MD, FACS, FIOTA; Mir Ibrahim Sajid, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA; Clayton Robert Welsh, MD; Joel C Williams, MD; Nikolaos K Kanakaris, MD, PhD; Peter V Giannoudis, MD, FACS, FRCS; Ridge Maxson, BS; Lauren M Tatman, MD; Anastasia Hunt, MD; Michael J Gardner, MD; Yu Min Suh, MD; Andrew T. Chen, MD, MPH; Emily Williams, MS; Kyle J Jeray, MD; Megan Anderson, BA; Krystin Hidden, MD; Umar Abbas Khan, MD; Greg Gaski, MD; Kristoff Rewi Reid, MD; Langdon A Hartsock, MD; Daniel Martin, BS; Brian H Mullis, MD, FIOTA; Caleb J. Bischoff, DO; Brett Duane Crist, MD; Paul Tornetta, MD, PhD, FIOTA
Purpose: Combined ipsilateral femoral head and neck fractures are a rare and complex injury pattern with few existing reports in the orthopaedic literature. This study aimed to establish baseline patient demographics, injury characteristics, and treatment methods and to compare how they affect patient outcomes.
Methods: This was a multicenter retrospective cohort study of patients with combined ipsilateral femoral head and neck fractures from 2004 through 2022 treated at 17 Level I academic trauma centers. The data assessed included demographics, injury characteristics (mechanism, presence/direction of hip dislocation, iatrogenic femoral neck fracture, associated injuries), treatment (ORIF, arthroplasty, surgical approach), and patient outcomes (development of avascular necrosis [AVN], conversion to arthroplasty).
Results: A total of 63 patients (79% males) was identified with a mean age of 38.5 years. The most common injury mechanism was motor vehicle collision (n = 26, 41.3%), followed by gunshot injury (n = 23, 36.5%). A minority of patients’ injuries were associated with a hip dislocation (n = 24, 38.1%), of which most were posterior dislocations (95.8%). Five patients’ (7.9%) femoral neck fractures were iatrogenic, occurring during attempted closed reduction of a posterior hip dislocation. Associated injuries were seen in 43 patients (68.3%), the most common being an ipsilateral acetabular fracture (n = 18, 28.6%). Of the 63 patients, 38 patients underwent surgical fixation (60.3%), 18 underwent primary arthroplasty (28.6%), 5 were treated nonoperatively (7.9%), and 2 underwent only surgical excision of incarcerated bone fragments (3.2%). Patients with gunshot injuries more often underwent fixation (78.3% ORIF vs 13.0% arthroplasty), compared to those with blunt injuries (50.0% ORIF vs 37.5% arthroplasty). For fracture fixation, surgical approach was most commonly direct anterior (36.8%), with a minority of patients undergoing a surgical hip dislocation (18.4%). Among patients who underwent fixation and had more than 6 months of follow up (n = 22), AVN developed in 54.6% and 36.4% went on to conversion arthroplasty.
Conclusion: This study represents the largest reported cohort of patients with combined ipsilateral femoral head and neck fractures. This injury pattern occurs most often in young patients, and most patients underwent surgery for fracture fixation. Complications following surgical fixation were high with more than one-third of patients requiring conversion arthroplasty.
Surgery Outcomes for Subtrochanteric Femur Fracture Nonunions
Sophia A. Traven, MD; Joshua E Simson, MD; Andres F Moreno-Diaz, MD; Joseph R Cave, MD; Juanita Velasco-Castro, MD; Jordan Dunson, MD; Joseph R Duff, MD; Andrew W Wilson, MD; Neil Jain, MD; Jonathan McKeeman, MD; Nareena Imam, MD; Akhil Sharma, MD; Samantha Nicole Weiss, MD; Dustin Greenhill, MD; Robert Brandon Ponce, MD; Sean Wrenn, MD; Douglas W Lundy, MD, FIOTA; Warren E Gardner, MD; William T Obremskey, MD, MPH, FIOTA
Purpose: Subtrochanteric femur fractures are common, accounting for about 25% of all proximal femur fractures, and complication rates such as nonunion are estimated to occur in up to 23% of patients. Currently, no standardized treatment method for subtrochanteric nonunion exists, and no large series reports outcomes of revision fixation or predictors of recalcitrant nonunions. The aim of this study is to perform a multicenter retrospective review of subtrochanteric nonunions, including treatment strategies, perioperative outcomes, and complications and predictors of recalcitrant nonunions.
Methods: This is a retrospective study of all subtrochanteric nonunions treated between 2011 and 2023 at three Level I trauma centers. Patient demographics, mechanism of injury, open or closed nature of the injury, and implants used for the primary and revision surgery were collected. Nonunion characteristics were also collected, including type of nonunion, presence of infection, and the use of bone graft. Outcomes collected include fracture union, revision fixation surgery, other complications, weightbearing status at final follow up, and modified Radiological Union Scale for Tibia fractures (mRUST) scores.
Results: A total of 54 patients was identified with a subtrochanteric nonunion and a mean follow up of 20 months. Fixation constructs of the nonunions included nail (31%), plate (46%), nail-plate combination (13%), and other constructs such as arthroplasty (10%). Autogenous bone graft augmentation was used in most patients (86%). More than one revision surgery to achieve union was required in 31% of patients; the most significant predictor of this was older age (OR: 0.93, p = 0.015). However, the risk of requiring more than one revision surgery to achieve union was not significant among fixation constructs (p>0.176). At final follow up, 88% of patients achieved union and had a mean mRUST score of 12.7, while 12% of patients were converted to an arthroplasty construct.
Conclusion: Surgery for subtrochanteric nonunions have a high recalcitrant nonunion rate of 31% regardless of fixation construct used. Older age is the most significant predictor of this risk. Although 88% of patients eventually attained union after secondary or tertiary procedures, 12% of patients were converted to an arthroplasty following failed revision fixation.
Routine Screening of Preoperative Troponin as a Predictor of Adverse Events in Hip Fracture Patients
Aly Samory Toure, BS; Bryan Medilien, BS; Kene Okafor, BS; Joshua Parry, MD; Roberto C Hernandez-Irizarry, MD; Jaimo Ahn, MD, PhD; Mara Schenker, MD
Purpose: The 2024 AHA Guideline for Perioperative Management of Noncardiac Surgery includes troponin as a preoperative biomarker for risk stratification. The guideline acknowledges that preoperative high-sensitivity cardiac troponin can identify myocardial injury and elevated perioperative risk, but there is limited evidence on its ability to predict adverse outcomes in routine preoperative screening. This study evaluates preoperative troponin as a predictor of in-hospital cardiac events, kidney injury, and mortality in patients with hip fracture.
Methods: A retrospective cohort study was conducted of 173 patients with hip fracture at a Level I trauma hospital from January 2022 to July 2024. Perioperative troponin values were routinely collected as part of a hip fracture pathway, and cases were matched to the institutional hip fracture registry. Troponin levels were categorized as normal (<30 ng/L), elevated (30–100 ng/L), and significantly elevated (>100 ng/L). Adverse outcomes were assessed using ICD-10 codes during hospitalization. Associations between troponin and outcomes were evaluated using logistic regression and χ2 tests, with odds ratios (OR) and 95% confidence intervals (CI).
Results: χ2 analysis demonstrated a significant association between perioperative troponin and cardiac events (χ² = 20.53, p = 0.000035) and mortality (χ² = 12.53, p =0.002). Logistic regression showed that patients with significantly elevated troponin (>100 ng/L) had 26.2 higher odds of mortality (OR = 26.2; 95% CI: 2.18, 314.46; p = 0.010) and 43.67 higher odds of a cardiac event (OR = 43.67; 95% CI: 4.12, 463.30; p = 0.002) compared to those with normal troponin. Patients with elevated troponin (30–100 ng/L) also had increased odds of cardiac events (OR = 9.70, p = 0.067), although the association did not reach statistical significance. The association between troponin and kidney injury was not statistically significant (χ² = 2.9429, p = 0.230).
Conclusion: Routine collection of perioperative troponin predicts in-hospital cardiac events and mortality after hip fracture surgery. Additionally, it is imperative to understand the etiology of the elevated troponin—ischemic cardiac (MINS) versus extra-cardiac (eg, pulmonary embolus or sepsis)—to guide treatment. Further, a larger patient cohort is needed to determine the impact of surgery timing on outcomes; specifically, does any preoperative intervention in these patients improve outcomes or should accelerated time to surgery be the goal?
Is the Use of Cerclage Wires Associated With Increased Complications Following ORIF of Periprosthetic Femur Fractures?
Phillip T Grisdela, MD; Robert K. Wagner, MD; Jarod Griffin, MD; Maaz Muhammad, MD; Jacob Samuel Wolf Borgida, B.S.; Bryce Michael Jensen, MS; Sravya Challa, MD; Hayley Daniell, MD; Mitchel B Harris, MD; Thuan V Ly, MD; Arun Aneja, MD, PhD; Michael John Weaver, MD; Derek S Stenquist, MD
Purpose: Periprosthetic femur fractures (PFF) are increasingly common and are challenging to treat. Open reduction with cerclage wires may facilitate fixation, but concerns remain about negative effects on fracture vascularity. The objective of this study was to compare outcomes and complications between PFFs repaired with and those repaired without cerclage wires for fracture reduction.
Methods: This was a retrospective study of patients with a PFF around a hip prosthesis treated with a single lateral locked plate (LLP) at two Level I trauma centers between 2010 and 2023. Demographics, injury characteristics, surgical data, and complications were collected. Primary outcomes were unplanned reoperation, nonunion, deep infection, and time to weightbearing. Baseline characteristics and outcomes were compared according to reduction strategy (cerclage vs no cerclage) for both Vancouver B1 (V-B) and Vancouver C (V-C) fractures.
Results: In total, 1141 patients were reviewed, and 116 met inclusion criteria (median age 78 years, 79% female, 96% low-energy falls). There were 39 (34%) V-B and 77 (66%) V-C fractures. There were no differences in baseline demographic characteristics. Patients treated with cerclage were less likely to have a total knee or supracondylar fracture (p<0.05). Cerclage wires were used for reduction in 30 (71%) of the V-B and 22 (26%) of the V-C fractures. Among V-B fractures treated with or without cerclage, there was no difference in reoperation (22% vs 17%, P>0.99), nonunion (3.7% vs 17%, p = 0.22), deep infection (11% vs 0%, P = 0.54), and time to weightbearing (14 weeks vs 12 weeks, p = 0.56). Patients with V-C fractures with or without cerclage also had similar rates of reoperation (0% vs 12%, P = 0.18), nonunion (0% vs 5.3%, P = 0.56), deep infection (0% vs 3.5%, P>0.99), and time to weightbearing (9 weeks vs 13 weeks, P = 0.085).
Conclusion: In this cohort of V-B and V-C PPFs repaired with LLP, there was no significant difference in outcomes between patients treated with and those treated without cerclage wiring for fracture reduction. Surgeons may consider cerclage wiring for reduction, understanding that randomized prospective studies are needed to characterize potential biologic tradeoffs associated with open reduction and circumferential wiring.
Ipsilateral Femoral Shaft and Neck Fractures: Unraveling the Risk Factors for Nonunion
Zachary Allen Rockov, MD; Andrew P. Collins, MD; Romney Hanson, MD; Ellen Goldberg, MD; Lillia Steffenson, MD; Lisa A Taitsman, MD, MPH; Erika Roddy, MD; Reza Firoozabadi, MD
Purpose: Ipsilateral femoral shaft and neck fractures are common in patients who sustain high-energy trauma; a recent study indicated a 22% femoral shaft nonunion rate. However, the specific risk factors for nonunion remain unclear. This study aims to evaluate the nonunion rate and associated risk factors in patients with these injuries at a single Level I trauma center.
Methods: A retrospective review was conducted on adult patients with ipsilateral femoral shaft and neck fractures treated between 2005 and 2024. The primary outcome was femoral shaft fracture union. Patient demographics, injury characteristics, surgical details, and radiographs were analyzed. Patients with less than 6 months of follow up or without both fractures were excluded.
Results: In total, 118 patients were included (male: 72.9%; mean age: 39.0 ± 14.7 years; body mass index [BMI]: 29.8 ± 6.8; ASA score: 2.5 ± 1.0; active nicotine use: 27.8%). Among them, 22.5% had open femoral shaft fractures, 19.7% had AO/OTA 32C fractures, and 60.7% had displaced femoral neck fractures (mean Pauwels angle: 63.1 ± 12.2). Open reduction was performed in 55.1% of femoral neck fractures and 33.6% of femoral shaft fractures. Femoral shaft nonunion occurred in 9.3% (11 patients), whereas femoral neck fractures healed in 99.2%. Nonunion was associated with AO/OTA Type C fractures, higher Garden classification, and open reduction of both femoral neck and shaft fractures. Multivariable regression identified open reduction of femoral neck fractures (relative risk [RR]: 1.94; p = 0.009) and higher Garden classification (RR: 3.72; p = 0.003) as independent risk factors for nonunion.
Conclusion: Despite the high union rate of femoral neck fractures, ipsilateral femoral shaft fractures have a 9.3% nonunion rate. Nonunion is associated with displaced femoral neck fractures requiring open reduction, likely serving as a surrogate for high-energy trauma, increased blood loss, and prolonged surgical time. However, the precise mechanisms underlying this relationship remain unclear.
Using RUST and mRUST in the Distal Femur: The Same, but Different
David J Stockton, MD MASc FRCSC; Andreas Flury, MD; Marc-Olivier Dion, MD; Jeffrey M Potter, MD, FRCSC; Kelly A Lefaivre, MD, FRCSC; Canadian Orthopaedic Trauma Society
Purpose: The purpose of this study was to identify early, reliable radiographic predictors of uneventful union and conversely, factors that predict implant failure for distal femur fractures fixed with lateral locked plates.
Methods: Radiographs from a prospective cohort of 196 patients who sustained a distal femur fracture (OTA 33-A, B, C) and underwent open reduction and internal fixation with a lateral locked plate as part of an international, multicenter, randomized controlled trial were retrospectively reviewed by four fellowship-trained orthopaedic trauma surgeons. Radiographs were scored using the Radiographic Union Score for the Tibia (RUST) and the modified version (mRUST) at 6 weeks, 3 months, 6 months, and 1 year. Raters also made a gestalt determination of whether or not they thought the radiograph indicated the fracture was healed. We fit binary generalized estimating equations (GEE) models to identify thresholds for RUST and mRUST that corresponded to a fracture appearing healed. Using reoperation as a proxy for nonunion, we fit GEE models to identify scores at 6 weeks and 3 months that predicted eventual union. Finally, we computed Kappa statistics to determine the minimum number of bridged cortices best associated with complete union.
Results: Rater gestalt supports traditional interpretation of union using RUST and mRUST, with scores of 10/12 for the RUST and 12/16 for mRUST associated with a greater than 90% chance of the distal femur fracture being called healed. At 3 months, using RUST or mRUST to predict failure showed an inflection point between 5 and 6, with likelihood of failure clustered between 28% to 32% at 5 or less, and 12% or less at 6 or higher. This corresponds to the finding that, if at any timepoint, at least one cortex is deemed ‘bridged’ using the RUST score, there is a 98% chance of the fracture being deemed healed.
Conclusion: Scores of 5 or lower on the RUST and mRUST at the 3-month mark are associated with at least 30% and 28% risk of nonunion, respectively. Conversely, if at least one cortex was deemed ‘bridged’ using the RUST score, this corresponded to a 98% chance of union.
Serial Thrombelastography Identifies Distinct Pathophysiologic Responses Based on Fracture Type
Prism Schneider, MD, PHD, FRCSC; Golpira Assadzadeh, PhD; Casandra Tan, BSc; Ahmed Negm, MD, PhD; Souvik Maiti, BSc; Jessica Duong, PhD; Paul Cantle, MD; Andrew Dodd, MD; Paul Duffy, MD; Herman Singh Johal, MD MPH; Robert Korley, MDCM
Purpose: Venous thromboembolism (VTE) risk remains high in patients with major orthopaedic fractures, despite thromboprophylaxis. Thrombelastography (TEG) is a whole-blood assay that provides a comprehensive analysis of hemostasis from clot initiation to fibrinolysis (clot breakdown). This study aimed to use serial TEG analyses to determine the distinct patterns of coagulopathy that emerge following major orthopaedic fractures.
Methods: This is a single-center prospective cohort study of patients with pelvic, acetabular, hip, or femoral diaphyseal fractures requiring surgical management. Patients underwent serial TEG analysis (TEG6s) at admission, preoperatively, then on postoperative day 1 (POD-1). Symptomatic and image-confirmed VTE events were captured. Most patients were receiving low molecular weight heparin thromboprophylaxis. The Kruskal-Wallis test was conducted to compare TEG parameters between groups, with post-hoc Dunn's test to adjust the p-values and identify pairwise group differences.
Results: In total, 487 patients were included (86 pelvic or acetabular fractures, 283 hip fractures, and 118 femur fractures; median age: 69 years [IQR: 49.0, 81.0], female: 52.2%). There were a total of 27 VTE events (5.5%), with 11 VTEs in patients with pelvic or acetabular fractures (12.8%), 11 in patients with hip fractures (3.9%), and five in patients with femur fractures (4.2%). On POD-1, patients with femur fractures had a significantly lengthened k-time compared to those with hip fractures (p = 0.03), but k-time was similar to those with pelvic or acetabular fractures (p = 0.057). Patients with pelvic fractures had a significantly elevated alpha-angle on POD-1 compared to those with femur fractures (p = 0.0486), but alpha-angle was similar to those with hip fractures (p = 0.788). On POD-1, all patients demonstrated fibrinolytic shutdown (reduced LY-30), but patients with hip fractures had significantly lower LY-30 compared to those with femur fractures (p = 0.003).
Conclusion: This study demonstrated a high risk for VTE, particularly following pelvic, acetabular, and femur fractures (5.5%–12.8%). Serial TEG analyses identified distinct pathophysiologic responses to injury type and surgical intervention. This study supports the need for further investigation into personalized thromboprophylaxis based on injury type and individualized response to injury and surgical intervention.
The Impact of Dementia on Outcomes Following Hemiarthroplasty for Femoral Neck Fracture (OTA Type 31B1.3) Patients
Danielle M Olson, MS; Benjamin Hammond, BS; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: Our objective was to evaluate the impact of baseline dementia on postoperative outcomes in patients with hip fracture undergoing hemiarthroplasty.
Methods: This retrospective review, conducted over the study period from 2015 to 2024, involved a 4:1 matched comparison of patients with hip fracture who underwent hemiarthroplasty for a displaced femoral neck fracture. Dementia (D) was identified from the medical record using ICD-10 codes (eg, F01–F03, G30). Matching of non-dementia patients (ND) was based on the Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA), a validated risk stratification tool that accounts for factors such as comorbidities, injury severity, physiologic parameters, and functional status to predict mortality risk in geriatric and middle-aged patients with trauma. Descriptive statistics were used to ensure baseline similarity between groups. Outcomes analyzed included readmission rates, mortality, length of stay (LOS), revision surgery, in-hospital complications, and time to death. Statistical analyses included Student's t-tests and χ2 tests.
Results: A total of 732 patients met inclusion criteria, with 117 D patients. Baseline similarity was observed between the D and ND groups. D patients had significantly higher readmission rates (p = 0.000003) and overall mortality (p = 0.0078) compared to ND patients. The average time to death postoperatively for D patients was 705 days (SD: 826 days). No significant differences were observed between groups for revision surgery (p = 0.91), infection rates (p = 0.68), dislocation (p = 0.32), LOS (p = 0.54), 36-hour postoperative mortality (p = 0.32), 48-hour postoperative mortality (p = 0.16), death during admission (p = 0.38), or death within 30 days (p = 0.87).
Conclusion: Dementia is associated with significantly higher readmission and overall mortality rates in patients with hip fracture undergoing hemiarthroplasty. Despite increased mortality, early postoperative outcomes and in-hospital complications did not differ significantly between the D and ND groups.
Impact of Proton Pump Inhibitors and H2 Antagonists on Postoperative Complications Following Femur Fracture Repair With Total Hip Arthroplasty: A Matched Cohort Study
Uttsav Patel, BS; Rafael Madera, BS; Brian Lynch, MD
Purpose: This study evaluated the impact of proton pump inhibitors (PPI) and H2 receptor antagonists (H2s) initiated at the time of total hip arthroplasty (THA) for femur fracture repair on postoperative complications.
Methods: This retrospective cohort study used the TriNetX research network to analyze 5175 patients prescribed PPIs and 2327 patients prescribed H2s, all without prior use of these medications. Treatment began at the time of THA following femur fracture. After propensity score matching for demographics and comorbidities, each group included 2295 patients. Outcomes included 90-day surgical and medical complications and 2-year surgical complications, identified using ICD and CPT codes. Risk ratios (RR) and 95% confidence intervals (CI) were calculated to compare complication risks between groups.
Results: At 90 days, the PPI group had higher rates of pneumonia (4.3% vs 2.5%; RR: 1.71, 95% CI: 1.24–2.35, P = 0.0009). The H2 group had higher rates of transfusion (17.0% vs 14.1%; RR: 0.83, 95% CI: 0.73–0.95, P = 0.0081) and readmission (11.9% vs 9.9%; RR: 0.83, 95% CI: 0.70–0.98, P = 0.0293). At 2 years, the PPI group had increased rates of periprosthetic fractures (5.4% vs 3.6%; RR: 1.48, 95% CI: 1.13–1.95, P = 0.0043), periprosthetic inflammation (3.3% vs 2.3%; RR: 1.44, 95% CI: 1.02–2.05, P = 0.0385), reoperations (2.1% vs 0.8%; RR: 2.53, 95% CI: 1.49–4.28, P = 0.0004), and mechanical loosening (1.5% vs 0.8%; RR: 1.84, 95% CI: 1.06–3.21, P = 0.0285). The overall mechanical complication rate was also higher in the PPI group (5.9% vs 4.6%; RR: 1.28, 95% CI: 1.00–1.64, P = 0.0475).
Conclusion: PPI use at the time of THA for femur fracture repair was associated with increased short- and long-term complications, including pneumonia, periprosthetic fractures, inflammation, reoperations, and mechanical loosening. In contrast, H2 antagonists were linked to higher short-term transfusion and readmission rates but fewer long-term complications. These findings suggest H2 antagonists may be a preferable option for gastrointestinal prophylaxis in this patient population.
Closed Reduction and Percutaneous Pinning (CRPP) of Low-Energy 31B1 and 31B2 Femoral Neck Fractures has Decreased 1-year Mortality Compared to Hemiarthroplasty
Danielle M Olson, MS; Benjamin Hammond, BS; Kenneth A Egol, MD; Sanjit Reddy Konda, MD
Purpose: Our objective was to compare 1-year mortality rates after closed reduction and percutaneous pinning (CRPP) versus hemiarthroplasty (HA) of OTA 31B1 and OTA 31B2 femoral neck fractures. Secondarily, the purpose was to compare other quality metrics between the cohorts.
Methods: A retrospective review of a hip fracture database from 2014 to 2024 at a single institution was performed. Patients older than age 55 years with low-energy mechanisms and OTA 31A-B, 32C hip fractures were included. The primary outcome was 1-year mortality. Secondary outcomes included inpatient and 30-day mortality, 90-day readmission, reoperation, and in-hospital complications. Patients were stratified into Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) risk groups: low risk (<50th percentile), moderate risk (50th–80th percentile), high risk (80th–95th percentile), and very high risk (95th–100th percentile), using cutoffs from the HA cohort. Demographics, injury characteristics, and primary and secondary outcomes were compared using t-tests and χ2 tests, with significance set at p<0.05.
Results: A total of 842 patients met the inclusion criteria: 701 (83%) underwent HA and 141 (17%) underwent CRPP. In the CRPP cohort, there were 137 31B1 and four 31B2 fractures compared to 619 31B1 and 82 31B2 fractures in the HA cohort. In the CRPP group, 63.1% were low risk, 22.0% moderate risk, 11.3% high risk, and 3.5% very high risk. There were no demographic differences among similar risk groups between cohorts. Moderate risk, high risk, and very high risk CRPP groups demonstrated consistently lower 1-year mortality rates than similar risk HA groups (moderate: 20.0% vs 8.5%, p = 0.014, high risk: 28.5% vs 15.0%, p = 0.056, very high risk: 35.0% vs 18.5%, p = 0.041). These same CRPP groups demonstrated consistently lower inpatient and 30-day mortality rates compared to similar risk HA groups.
Conclusion: CRPP of OTA 31B1 and 31B2 femoral neck fractures has lower rates of 1-year mortality compared to HA in moderate risk, high risk, and very high risk STTGMA cohorts. The reoperation rate for CRPP is low (<1%). For high risk and very high risk patients, consideration should be given to CRPP over HA to minimize risk of mortality.
Outcomes Following Distal Femur Replacement for Fracture: A Multi-Institutional Retrospective Review
David C Landy, MD, PhD; Wyatt GS Southall, BS; Stephen T Duncan, MD; Michael T. Archdeacon, MD; William T Obremskey, MD, MPH, FIOTA; Joshua M Lawrenz, MD; Christopher Lee, MD; Michael S. Sridhar, MD; Jeffrey Austin Foster, MD; Arun Aneja, MD, PhD; DFR Research Group
Purpose: Distal femur replacement (DFR) is increasingly used to treat distal femur fracture (DFF), especially for patients with limited bone stock, poor bone quality, and advanced age. Although DFR does not rely on bony healing and allows early weightbearing, complications can be devastating, especially periprosthetic joint infection (PJI). Meta-analytic studies have reported lower than expected complication rates, but may be limited by publication bias. The objective of this study was to estimate representative outcomes of patients who underwent DFR for DFF.
Methods: A retrospective cohort study was conducted at 12 academic trauma centers. Adult patients who underwent DFR for native or periprosthetic DFF from 2010 to 2022 were identified; infectious, oncologic, and any other indications were excluded. The primary outcome was PJI. Secondary outcomes included reoperation, mortality, and function. Outcomes were estimated using proportions and Kaplan-Meier curves with 95% confidence intervals (CI) and stratified by periprosthetic fracture with Fisher's exact testing.
Results: In total, 173 patients were included with 130 (75%) having a periprosthetic DFF. Patients were older (median age 77 years, interquartile range 70-84), women (84%), and had more severe medical comorbidities (63% ASA class III and 24% ASA class IV). The rate of PJI was 5.8% (95% CI, 3.1-10.5%); this was lower for native compared to periprosthetic DFF although not statistically significant (2.3% vs 6.9%, P = 0.45). The reoperation rate was 16.6% (95% CI, 11.7-23.0%) and the one-year mortality rate was 27.0% (95% CI, 20-35%). Slightly more than one half of patients returned to their baseline function at 54.6% (95% CI, 46.9-62.1%).
Conclusion: DFR for DFF was associated with a PJI rate of 5.8%. The one-year mortality rate was 27.0% and reoperation rate was 16.6%. Slightly more than one half of patients returned to their baseline function at 54.6%. DFR can be considered as a salvage option in cases of complex native and periprosthetic DFF, although surgeons should continue to counsel patients on the considerable risks, particularly mortality, associated with DFR when assessing treatment options for DFF.
Outcomes of Nonunion Repair for Distal Femur Fracture Nonunion
Erika Roddy, MD; Robert P Dunbar, MD; Conor P. Kleweno, MD; David P Barei, MD, FRCSC
Purpose: The purpose of this study was to report the outcomes of nonunion repair for aseptic distal femur nonunions in a large cohort of patients, in particular the rate of recalcitrant nonunion, defined as failure of the first nonunion repair. The secondary purpose was to identify patient, injury, and treatment factors associated with recalcitrant nonunion.
Methods: The retrospective cohort study at a Level I trauma center included all skeletally mature patients undergoing nonunion repair of a distal femur fracture (AO/OTA 33A or 33C) between 2005 and 2023. Patients with pathologic fractures or presumed septic nonunions were excluded. The primary outcome was the success of the first nonunion repair attempt, which was defined as obtaining clinical and radiographic union.
Results: The study included 102 patients; average age was 56 years (SD 15), and 64 patients (63%) were female. Open fractures were present in 47 patients (46%), and 60 patients (59%) had high-energy mechanism of injury. The average ISS was 17 (SD 9). 53 fractures were AO/OTA type 33A, while 49 were type 33C; 19 were periprosthetic fractures. The rate of recalcitrant nonunion (failure of the first nonunion repair) was 23%. Factors associated with development of recalcitrant nonunion included a diagnosis of fracture-related infection after the index nonunion repair procedure as well as the type of nonunion repair. Nonunion repair with a plate nail combination was significantly associated with decreased risk of recalcitrant nonunion (0 of 27, 0%) compared to nonunion repair with plate alone (8 of 28, 29%), nail alone (4 of 10, 40%), or graft alone (9 of 25, 36%), p = 0.006. Looking at dual-column fixation constructs as a whole (including nail-plate, plate plus endosteal plate, lateral plate plus medial allograft strut, dual-plate), fixation with a bicolumnar construct was again associated with a lower rate of recalcitrant nonunion (1 of 36, 3%) compared to nail alone (4 of 10, 40%), plate alone (8 of 28, 29%), or graft alone (9 of 25, 36%), p = 0.003.
Conclusion: A recalcitrant nonunion developed in one in four patients with a presumed aseptic distal femoral nonunion after attempted nonunion repair. Fixation with a nail-plate or dual-column construct may decrease the risk of recalcitrant nonunion.
Restoration of Normal Insall-Salvati Ratio Is Critical When Fixing Patella Fractures
Alexander M Lashgari, BA; Benjamin Hammond, BS; Benjamin William Padon, BA; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: The purpose of this study was to compare clinical outcomes of patients based on the immediate Insall-Salvati ratio (ISR) obtained following open reduction and internal fixation (ORIF).
Methods: Patients who were surgically treated for displaced patella fractures from 2012 to 2024 at a single multi-site urban academic institution were analyzed. All patients underwent repair with hardware or sutures. Final intraoperative fluoroscopic radiographs were measured for ISR. Patients were categorized into two groups based on intraoperative ISR measurements: normal ISR (NR), defined as between 0.8 and 1.2 and abnormal ISR (AR), outside of the 0.8 to 1.2 range. Demographic data, fracture classification (OTA classification), knee range of motion (ROM), postoperative complications, and fracture union were collected. Comparisons of statistics were performed using Pearson χ2 tests and independent t-tests. Statistical testing was performed using SPSS, version 29 (Armonk, NY).
Results: The analysis included 191 patients (163 NR and 28 AR). Of the 28 in the AR group, there were 23 tension band constructs, three plates, and two suture repairs. Demographically, the AR and NR groups were identical, and there was no difference in proportion of fracture type or fixation construct between groups (p = 0.611 and p = 0.563). Notably, the AR group exhibited higher complication rates (14.3% vs 4.3%, p = 0.037). The complications experienced by both groups included hardware failure (screw cut-out and inferior fragment distraction), fracture-related infections, and venous thromboembolism events. Of note, the AR group experienced a higher rate of hardware failure than the NR group (10.7% vs 1.2%, p = 0.004). Furthermore, knee ROM at 3 months was significantly greater in the NR group (117.22 ± 13.75 vs 105.13 ± 21.38, p<0.001) and at 6 months (127.37 ± 13.27 vs 119.25 ± 14.26, p = 0.020). No significant differences were found in the nonunion rates (p = 0.732).
Conclusion: Abnormal intraoperative ISRs following patella fracture repair are associated with poorer knee ROM and increased incidence of complications, specifically hardware failure following ORIF of the patella. This finding highlights the importance of the restoration of soft-tissue parameters along with anatomic fracture fixation in the setting of patella fractures.
Regional Anesthesia Is Safe and Effective for Patella Fracture Repair
Alexander M Lashgari, BA; David L Furgiuele, MD; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: Previous studies have demonstrated that regional anesthesia in orthopaedic fracture surgery is associated with decreased postoperative pain and decreased need for post-anesthesia care unit (PACU) analgesics when compared to general anesthesia. However, there is no evidence-based consensus on the optimal anesthesia modality for patella fracture repair. The purpose of this study was to evaluate the short-term postoperative outcomes of patients undergoing patella open reduction and internal fixation (ORIF) procedures based on the type of anesthesia administered.
Methods: A retrospective review was conducted of patients who were surgically treated for displaced patella fractures from 2012 to 2024 at a single multi-site urban academic institution. Fractures were classified according to the OTA system. Patients were included if they were older than age 18 years, sustained an isolated patella fracture, and had a minimum of 6-month follow up. Patients were divided into groups based on the anesthetic modality used during their surgery: regional anesthesia (RA) only, general/neuraxial anesthesia (NR), and a combination of these methods (CA). Data were retrospectively collected at regular follow-up intervals. Comparisons of statistics were performed using Pearson χ2 tests and multivariate linear regression tests as appropriate. Statistical testing was performed using SPSS, version 29 (Armonk, NY).
Results: Of the 263 patients that met inclusion criteria, 84 patients were in the RA group, 55 patients in the NR group, and 124 patients in the CA group. There were no complications associated with the administration of anesthesia within each cohort. There was no significant difference in fracture healing rates (p = 0.210) or complication rates between the anesthesia groups (p = 0.088). The RA and CA groups had significantly shorter operating room times than the NR group (p<0.001), significantly greater 3-month (p = 0.001) and 6-month (p = 0.016) knee range of motion (ROM) than the NR group when controlling for age, fracture pattern, and repair method.
Conclusion: This study demonstrates the efficacy of the use of regional anesthesia only for repair of a patella fracture. This technique is associated with greater early knee ROM in patients after surgery and a shorter surgical time with no increase in intra- or postoperative complications.
There’s Moore II It: Assessing Outcomes Following Tibial Plateau Fracture Dislocations
Alexander M Lashgari, BA; Benjamin William Padon, BA; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: The Moore type II fracture-dislocation of the knee (M2) represents a specific subset of tibial plateau injuries. The purpose of this study was twofold: first, to assess overall outcomes of this specific type of injury and second, to determine if surgical approach has any effect on outcome.
Methods: A consecutive series of patients who sustained tibial plateau fractures were classified by both the Schatzker and Moore systems over a 20-year period. Patients with an M2 fracture and ≥1-year of follow up were identified. Demographic, injury, and surgical information was collected. Clinical outcomes included knee range of motion (ROM), visual analog scale (VAS) pain scores, and patient-reported functional outcomes measured by the Short Musculoskeletal Function Assessment (SMFA). Patients were classified according to surgical approach: isolated medial (M), isolated lateral (L), and combined medial and lateral (C). Pearson χ2, t-tests, and ANOVA tests were conducted.
Results: A total of 595 patients was identified, 58 (10%) of whom sustained an M2 tibial plateau fracture (mean follow up = 28.34 months). The M2 cohort had a lower proportion of female patients compared to the non-M2 cohort (p = 0.048). Additionally, the M2 group trended toward a higher total complication rate (22.4 vs 14.0, p = 0.085). Functionally, the M2 group had poorer 6-month SMFA scores (p = 0.004), but by 1 year, this difference was not significant (p = 0.199). 13 (22.4%) patients experienced complications (knee contracture [3], fracture-related infection [2], wound complication [4], venous thromboembolism event [1], pulmonary embolism [1], and peroneal nerve complication [2]). When bifurcating by approach, the C group had a higher proportion of external fixation (50% vs 18.2% vs 5.6%, p = 0.006) placed initially. The C group had poorer outcomes with respect to pain and function than the isolated approaches (p = 0.004, p = 0.041). The lateral group had greater knee ROM than the combined group at 3 and 6 months (p = 0.029, p = 0.029), but were associated with both postoperative peroneal nerve injuries.
Conclusion: Moore II fractures represent a complex injury pattern with poor functional outcomes and increased complication rates when compared to all other tibial plateau fractures. With regard to surgical approach, the isolated medial approach was associated with better outcomes within the group.
Does Loss of Knee Extension Following Operative Treatment of Tibial Plateau Fractures Affect Outcome?
Abhishek Ganta, MD; Amaya Milan Contractor, BS; Kenneth A Egol, MD; Sanjit Reddy Konda, MD; Philipp Leucht, MD; Steven Rivero, MD; Nirmal C Tejwani, MD, FRCS
Purpose: The purpose of this study was to determine the effect that development of a knee extension contracture has on outcomes following surgical repair of tibial plateau fractures.
Methods: Patients in whom varying degrees of loss of terminal knee extension developed following surgical repair of a displaced tibial plateau fracture were identified. Patients were grouped into three cohorts: (1) full extension (FE), (2) 5° to 10° of extension contracture (Mild, ME), and (3) greater than 10° of extension contracture (Severe, SE) at 6 months postoperatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Outcomes were evaluated, including patient-reported pain levels, short musculoskeletal function assessment (SMFA) scores, complication rates, and reoperation rates.
Results: The cohorts consisted of three groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average age of patients among the three groups was 55.9 ± 15.6 years, and there were no differences in gender, body mass index (BMI), or Charlson Comorbidity Index (CCI). The average knee extension contracture for ME was 5°, and the average for SE was 12.7°. A total of 18 patients had external fixation prior to definitive fixation; seven (23%) were in the FE cohort and 11 (37%) were in the ME and SE cohorts (p = 0.443). Patients who experienced extension contracture had poorer SMFA scores at 6 months, and those in the severe cohort group had the poorest SMFA scores (112.6) compared to those with full extension (77.7) (p<0.001). Patients with an extension contracture experienced more pain at 6 months (p<0.001). A fracture-related infection (FRI) was more likely to develop in patients with extension contractures (p = 0.002). Finally, patients with extension contracture had higher rates of reoperation, with 36.7% of the ME cohort and 40% of the SE cohort undergoing reoperation compared to 13.3% in the FE cohort (p<0.001).
Conclusion: Patients in whom an extension contracture developed following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long-term follow up compared to those who achieved full knee extension.
Improving Visualization of the Articular Surface in Posterolateral Tibial Plateau Fractures
Ricardo R Tijerina, BS; Ryan D DeAngelis, MD; Adeet Amin, MD; Benjamin Kelley, MD; Sabir K Ismaily, BS; Patrick Kellam, MD; Timothy S Achor, MD; Stephen Warner, MD, PHD
Purpose: Tibial plateau fractures constitute roughly 1% to 2% of fractures. The position of the patient’s knee, direction of the force at the time of injury, and overall energy of the trauma determine the fracture pattern. Fractures may involve the medial and/or lateral tibial plateau, with a subset of these injuries involving the posterolateral tibial plateau. Using a standard anterolateral approach for treatment of these injuries does not allow for adequate visualization of the reduction of this posterolateral fragment. This study aimed to compare the visualization of the posterolateral tibial plateau articular surface using a standard anterolateral proximal tibia exposure versus a modified anterolateral proximal tibia exposure. We hypothesize that the modified anterolateral proximal tibia exposure will allow increased visualization of the lateral tibial plateau articular surface.
Methods: Seven adult cadaveric lower extremity specimens with no previous surgery were used for the study. The specimens were positioned with the knee flexed to 25°, and a standard anterolateral exposure to the proximal tibia was performed with a submeniscal arthrotomy. Standardized distraction was applied, and a probe digitizer was used to map the visible articular surface. After collection, all hardware was removed, and the knee was placed in 90° of flexion as per the “modified anterolateral approach.” Distraction and mapping were done similarly as previously described. The mapped data points were used to calculate the area of visualization of the articular surface in the standard and modified anterolateral exposure.
Results: Our study demonstrated that the modified anterolateral approach increased visualization of the articular surface by 54% (p<0.05) compared to the standard anterolateral exposure.
Conclusion: The modified anterolateral proximal tibia approach increases visualization of the articular surface in a safe and effective manner. The approach can serve as an alternative technique to address posterolateral tibial plateau fractures.
In Tibial Plateau Fracture Patients, the Contralateral Knee Serves as a Better Anatomical Template to Restore Articular Height and Width than Historical Norms
Heather Haeberle, MD ; Robert Bilodeau, BS; Alona Katzir, MD; Hallie Bradley, MD; Michael J Ricci, MD; William M Ricci, MD
Purpose: Restoration of pre-injury knee anatomy, ie, anatomic reduction, is a goal of tibial plateau fracture management. Condylar width and articular height are anatomic parameters commonly considered. Unscientific historical literature suggests that the lateral articular surface is higher than the medial surface, and tibial condylar width is typically equal to femoral condylar width. However, these anatomic relationships may not be true for all patients. This study assessed variation in articular height and tibial condylar width among patients and determined if the contralateral uninjured knee would be an accurate template for the injured knee.
Methods: Following Institutional Review Board (IRB) approval, calibrated bilateral whole-body standing anteroposterior (AP) radiographs from 2018 to 2022 were retrospectively reviewed. Patients with knee pathology or malrotated images were excluded. Relative heights of medial and lateral articular surfaces and relative width of the tibial plateau and femoral condyles were measured. Both patient-to-patient and side-to-side differences were evaluated.
Results: In total, 206 patients met eligibility. A random sample of 100 patients was analyzed (mean age: 53 years [SD = 16.6, 18–82]; female: 63%). Patient-to-Patient Variation: The lateral tibial articular surface averaged 3.1 mm higher (SD = 1.9 mm) than the ipsilateral medial surface, but there was substantial variability from patient to patient (range from lateral: 1.5 mm lower to 7.7 mm higher). The lateral tibial condyle width averaged 3.2 mm wider (SD = 1.7mm) than the femoral condyle (range: 1.4 mm narrower to 8.9 mm wider). The medial tibial condyle width averaged 0.9 mm narrower (SD = 1.9 mm) than the femoral condyle (range: 6.8 mm narrower to 3.3 mm wider). Side-to-Side Variation: The lateral tibial articular surface averaged only 0.7 mm different (lower) than the same patient’s opposite side (SD = 1.3 mm). The lateral tibial condyle averaged only 0.3 mm different (narrower) than the same patient’s opposite side (SD = 1.5 mm). The medial tibial condyle averaged only 0.03 mm different (narrower) than the same patient’s opposite side (SD = 1.5 mm).
Conclusion: Substantial patient-to-patient anatomic variation exists in the tibial plateau. The contralateral knee can serve as an accurate anatomic template for articular height and width restoration in patients with tibial plateau fractures.
Arthroscopic-Assisted Percutaneous Fixation Achieved Superior Clinical and Patient-Reported Outcomes Compared to Open Reduction and Internal Fixation for Lateral Tibial Plateau Fractures
Christopher John Chermside-Scabbo, MD, PhD; Jacob Samuel Wolf Borgida, B.S.; Sandy Vang, BA; Marc F Swiontkowski, MD, FIOTA; Mai Nguyen, MD
Purpose: The purpose of this study was to compare clinical and patient-reported outcomes from Schatzker I to III tibial plateau fractures treated with open reduction (ORIF) or arthroscopic-assisted percutaneous fixation (AAPF).
Methods: Adult patients who underwent surgical fixation for a tibial plateau fracture from 2020 to 2023 were identified from a database in one healthcare system. Patients with Schatzker I to III fractures treated with ORIF or AAPF were included and contacted to complete the International Knee Documentation Committee (IKDC) survey at a minimum of 4 months postoperatively (range: 4.8 months–3.9 years; median: 1.9 years; no difference between AAPF and ORIF, p = 0.23). Exclusion criteria included knee dislocations, open fractures, and periprosthetic fractures. Differences between surgical groups were assessed using a Pearson’s χ2 test or Fisher’s exact test for categorical variables and a Wilcoxon rank-sum test for continuous variables. A linear regression model was also used.
Results: In total, 64 patients met inclusion criteria (median age: 60 years, 78% female). Most patients had Schatzker II fractures (64%, N = 41). ORIF was performed in 37 (58%) patients and AAPF in 27 (42%). Baseline characteristics including age, sex, body mass index, ASA score, and fracture type did not differ between cohorts. The AAPF group had higher IKDC scores (81 vs 71, p = 0.005), better knee flexion (135° vs 130°, p = 0.023), and a shorter surgical time (35 minutes) compared to the ORIF group (p = 0.001). There was no difference in reoperations between the two groups (p = 0.4): eight hardware removals in ORIF versus four in AAPF, three manipulations under anesthesia for stiffness in ORIF versus one in AAPF, one chondroplasty in AAPF, and one conversion from AAPF to ORIF. Regression analysis found that positive predictors of higher IKDC scores are AAPF (β = 16, 95% CI: 5.6–26; p = 0.003) and longer follow up (β = 5.2, 95% CI: 0.06–10; p = 0.047).
Conclusion: Compared to ORIF, AAPF achieved superior patient-reported outcomes and knee flexion while requiring less surgical time.
Trimming the Fat: Can GLP-1 Receptor Agonist Therapy Impact Post-Traumatic Osteoarthritis Development After a Tibial Plateau Fracture?
Amelia R Goldstein, BS; Alexander M Lashgari, BA; Kenneth A Egol, MD
Purpose: Our objective was to evaluate the effect of prolonged GLP-1 usage on rates of posttraumatic osteoarthritis (PTOA) following surgical treatment of tibial plateau fractures across multiple body mass index (BMI) strata.
Methods: Between 2016 and 2023, 21 patients on long-term GLP-1 therapy for obesity (pretreatment BMI mean: 33.80 ± 5.61) who sustained a tibial plateau fracture requiring surgical fixation were identified (Group A). They were compared to three groups of patients with varying BMI who were not on GLP-1 therapy: Group B (BMI: 18.5–25, n = 150), Group C (BMI: 25–30, n = 150), and Group D (BMI: ≥30, n = 101) (see table). Demographics and clinical characteristics were analyzed. Analysis of variance (ANOVA) and χ2 tests, with standardized adjusted residuals, were used.
Results: In total, 422 patients were included in the analysis. Age and Charlson Comorbidity Index (CCI) were statistically similar across cohorts, except for Group A, which had a significantly higher CCI. As intended by study design, BMI differed significantly among groups (p<0.001). Group D (obese) exhibited a markedly higher incidence of PTOA (32.05%), with a standardized residual of approximately 2.79 (p ≈ 0.005). In contrast, Group A (GLP-1 therapy) demonstrated rates of PTOA comparable to Groups B and C (χ² ≈ 0.95, p ≈ 0.62).
Conclusion: Obese patients on GLP-1 receptor agonists demonstrated a significantly lower incidence of PTOA compared to untreated obese counterparts, with outcomes comparable to non-obese individuals.
Femoral Neck Fractures at an Urban, Pediatric Level I Trauma Center Are Primarily Low-Energy Fractures Associated With Poor Bone Health
Emily Louise DeMaio, MD; Ilona Lukina, BA; Samuel Allotey, BS; Romie Gibly, MD PhD
Purpose: Femoral neck fractures (FNF) are rare in children, representing less than 1% of pediatric fractures and are generally attributed to high-energy mechanisms. We investigated pediatric FNFs at our institution over a 17-year period to better understand epidemiology and mechanisms of injury.
Methods: With Institutional Review Board approval, we performed a data query using ICD and CPT codes to identify patients with femur fractures from 2007 to 2024. Demographic and clinical data were collected through chart review.
Results: We identified 1598 femur fractures, 105 (6.6%) of which were FNF, excluding slipped capital femoral epiphysis. Of the patients with FNFs, 18 (17.1%) had endocrine disorders, 14 (13.3%) had autism, 22 (21%) had metabolic bone disease, and 2 (1.9%) had muscular dystrophy. By mechanism, 54 (51.4%) patients had ground level falls, 3 (2.9%) were in motor vehicle crashes, 1 (1%) was a pedestrian versus auto, 4 (3.8%) fell from playground equipment, 8 (7.6%) fell from furniture, 5 (4.8%) fell from a height greater than 8 feet, and the remaining 30 (28.5%) were classified as “other.” There was one patient with a concurrent femoral shaft fracture, one with a distal femur fracture, and one in whom a deep venous thrombosis (DVT) developed. Most patients (98 patients, 93%) were treated surgically.
Conclusion: Contrary to previous assumptions that pediatric FNFs are due to high-energy mechanisms, most FNFs within our cohort were due to low-energy mechanisms compounded by coexisting metabolic and endocrine disorders and autism, which are associated with a restricted diet leading to micronutrient deficiencies. Therefore, a higher index of suspicion, education, and Vitamin D and calcium supplementation may decrease the incidence of FNF among these populations. Furthermore, despite 93% of patients having surgery, a DVT developed in only one patient. At our institution, no patients receive postoperative DVT chemoprophylaxis; thus, the very low incidence of DVT among our cohort supports that chemoprophylaxis is likely unnecessary in pediatric patients with FNF.
Are Classification Systems Predictive of Severity and Clinical Management in Pediatric Pelvic and Acetabular Fractures?
Mir Ibrahim Sajid, MD; Daniel D. Wang, M.D.; Jessica McGraw-Heinrich, MD; Omar Hammad Atassi, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA
Purpose: This study aims to assess whether existing classification systems to describe injury patterns are indicative of clinical management in pediatric pelvic ring and acetabular fractures.
Methods: This is a multicenter study that includes all pediatric and adolescent patients who were treated for pelvic ring and acetabular fractures at two Level I pediatric trauma centers between 2009 and 2024. We reviewed demographics, injury characteristics, and severity (measured using the pediatric trauma score), clinical management, and postoperative outcomes.
Results: In total, 177 patients with a mean age of 13.8 years were included and followed up for an average of 11 months (range: 1–91.7 months). Of these, 80 (45.2%) patients were Risser stage 4 (apophysis >75% of the iliac crest), and 116 (65.5%) had closure of their triradiate cartilage. An isolated pelvic ring injury was present in 111 (64.5%) patients, 52 (30.2%) had an isolated acetabular fracture, and 14 (8.1%) had combined pelvic ring and acetabular injuries. There was an even distribution of laterality (right: 35%, left: 35%, bilateral: 30%), and 18 (10.2%) had an open injury. The mean pediatric trauma score was 7.9 (range 1–11). Preoperative transfusion was given to 31 (17.5%) patients, and 143 (80.8%) underwent surgical fixation. In patients with pelvic ring injuries, a binary regression analysis demonstrated the pediatric trauma score (OR: 0.60, p = 0.02), Young and Burgess classification (OR: 2.10, p = 0.010) and Torode/Zieg classification (OR: 16.8, p<0.001) to be significant factors in determining surgical management. Similarly, the pediatric trauma score (OR: 0.38, p = 0.004) and the Young and Burgess classification (OR: 1.38, p = 0.021) were significant indicators of blood transfusion during the hospital course. The OTA classification was not predictive of either surgical management (OR: 3.2, p = 0.095) or blood transfusion (OR: 1.01, p = 0.962) in pelvic ring (OR: 0.99, p = 0.631) and acetabular injuries (OR: 11.5, p = 0.196).
Conclusion: Our study demonstrated that although Young and Burgess and Torode/Zieg classification may be indicative of severity and clinical management, the OTA’s classification for skeletally mature patients may not be helpful in the pediatric and adolescent population.
Clinical Outcomes of Operative Management of Acetabular Fractures in Pediatric and Adolescent Patients
Mir Ibrahim Sajid, MD; Daniel D. Wang, M.D.; Jessica McGraw-Heinrich, MD; Omar Hammad Atassi, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA
Purpose: This study aims to report outcomes on a large multicenter cohort of pediatric and adolescent patients with surgically managed acetabular fractures.
Methods: All patients between the ages of 1 and 17 years who underwent surgical fixation of acetabular fractures at two Level I pediatric trauma centers from 2009 to 2024 were included in this study. Patient and injury demographics, surgical implants, and complications were recorded.
Results: In total, 44 patients with a mean age of 14.4 years (range: 1.1–17) and body mass index (BMI) of 23.9 ± 5.3 kg/m2 were included and followed for an average of 7.8 months (range: 1–65). Most of the patients were male (n = 31), Risser Stage 4 (n = 21), and had closure of their triradiate cartilage (n = 30). A right acetabulum fracture occurred in 24 patients, 18 had a left-sided injury, and two had a bilateral acetabular fracture. The mean pediatric trauma score was 8.9 (range: 1–11). Fracture patterns included posterior wall (n = 28), T-type (n = 4), anterior column (n = 3), transverse (n = 3), transverse/posterior wall (n = 3), posterior column (n = 2), and posterior column/wall (n = 1). All fractures were fixed acutely. Mean surgical time was 2.6 ± 1.4 hours, and mean blood loss was 350 mL. A Kocher-Langenbeck approach was used in most patients (n = 36); an anterior intrapelvic approach was used in four patients and a lateral window approach was used in four. Plate fixation was used in 38 patients, cannulated column screws in 11, independent lag screws in four, and suture-anchors in 10. Of the patients who had radiographic follow up to union (n = 38, 86.4%), all patients had union at an average of 11.8 ± 4.4 weeks postoperatively and were fully weightbearing at 11 ± 6.8 weeks. At final follow up, pelvic pain, lower-back pain, and limp was present in three patients each. Acetabular dysplasia occurred in two patients, and leg-length discrepancy in one. One patient reported symptomatic implants that were removed surgically.
Conclusion: Surgical fixation of acetabular fractures in children and adolescents results in favorable outcomes with low rates of complication.
Variables Associated With Loss of Reduction After Fixation of Traumatic Pubic Symphysis Disruptions
Benjamin Pesante, MS; Tom Giles Pollard, MD; Keenan Masami Onodera, Md; Nicholas Jerome Tucker, MD; Raveesh Daniel Richard, MD; Cyril Mauffrey, MD, FACS, FRCS; Joshua Parry, MD
Purpose: Our objective was to determine what variables are associated with loss of reduction of pubic symphysis injuries after plate fixation.
Methods: A retrospective review of patients treated with plate fixation of traumatic pubic symphysis injuries was performed. Symphysis diastasis on injury, postoperative, and follow-up radiographs was measured. Associations among patient, fracture, and fixation characteristics and a loss of reduction ≥10 mm were analyzed.
Results: The review included 50 patients. The median age was 38.5 years (interquartile range [IQR] 27.7 to 48.5), and a majority were male (80.0%, n = 40). A loss of reduction ≥10 mm occurred in 18% (n = 9), and revision fixation occurred in 6.0% (n = 3). On univariate analysis, patients with a loss of reduction, compared to patients without, had a greater BMI (32.2 vs 26.5, p = 0.001), increased symphysis diastasis on injury radiographs (46.0 vs 24.0 mm, p = 0.0001), and more anterior pelvic space infections (55.6% vs 14.6%, p = 0.01). There were no associations among loss of reduction and age, AO/OTA classification, Young Burgess classification, 4-screw vs >4-screw plate fixation, number of posterior screws, or residual postfixation symphyseal diastasis (p>0.05). On multivariate analysis, initial symphysis diastasis was the only variable associated with loss of reduction ≥10 mm (p = 0.03). A symphysis diastasis of ≥35.0 mm was found to maximize the sensitivity (88.9%) and specificity (75.7%) for identifying patients who had a loss of reduction.
Conclusion: The severity of initial symphysis diastasis was associated with loss of reduction. A threshold of 35.0 mm of symphysis diastasis maximized the sensitivity and specificity for identifying patients who experienced a loss of reduction.
Iliosacral Screw Fixation Entrance Points and Their Relationship With Superior Gluteal Artery Branches. Are There Differences Between Normal and Dysmorphic Sacrum?
Alberto Telias, MD; Jose Rojas, MD; Valentina Herrera, MD; Sergio Bruna, MD; Aleksandar Munjin, MD
Purpose: Vascular damage of the superior gluteal artery (GSA) after percutaneous iliosacral (IS) screw fixation is low (0.6% to 1.2%), with cadaveric and imaging studies showing a close relationship between IS pelvic bone entry points (BEPs) and GSA branches (deep superior branch). There are no data regarding the GSA relationship in the pelvis with sacral dysmorphism (SD). Our study seeks to describe and compare the BEPs of IS screws and their distance to GSA in normal (NS) and SD pelvis.
Methods: CT angiography of 100 hemipelves in 50 healthy adults (matched male:female, 1:1) was performed with 128-slice spiral CT. Normal sacrum (NS) and dysmorphic sacrum (DS) were identified using Routt criteria. GSA vascular imaging was performed, and the volumetric reconstruction (VR) of iliosacral bone pathways of S1 iliosacral (S1-IS), S2 transiliac-transsacral (S2-transsacral screw [TTS]) in NS and DS, and S1 transiliac-transsacral (S1-TTS) in NS was performed with a CT software program. The VR was performed by measuring the anterior and posterior edges of the respective sacral bone on axial reconstruction, considering a safe IS bone pathway with a minimum of 10 mm width and >1cm2 in 3D VR for safe bone pathway. After creating BEPs, the closest distance to the GSA was measured (GSA–BEPs, mm). Univariate analysis of GSA–BEPs distance between NS and DS was performed with a p<0.5 significance.
Results: There were 40% SD cases. The main GSA-BEPs distances in S1-IS were DS:15.3 mm (IQR 11.5), NS:13.7 mm (IQR 10.8), P = 0.75; S1-TTS NS: 7.6 mm; S2-TTS DS: 9.9 mm (IQR 13.5), NS: 7.5 mm (IQR 17.0), p = 0.02, respectively. 24% of BEPs contacts GSA (DS:20%, NS:27%, p = 0.58). Regarding IS bone pathways, S1-IS:6%; S1-TS:26%; S2-TS:9% had contact with GSA (p = 0.03).
Conclusion: There is a small distance between BEP and GSAb. The S1-TTS was the closest, with a more direct contact with GSAb. In NS, the entry point S2-TTS was closer than in DS. Considering the sacral characteristics, there is protective anatomy in DS that minimizes the risk of damaging GSAb with IS screws.
Does malreduction of the sacroiliac joint affect the clinical outcomes in unstable pelvic ring injuries after internal fixation?
Hu Wang, MD; Yan Zhuang, MD
Purpose: To evaluate the effects with malreduction of the sacroiliac joint on the clinical outcomes in unstable pelvic ring injuries after internal fixation
Methods: A retrospective analysis the data of patients with unstable pelvic ring injury after internal fixation, all patients with disruption of the sacroiliac joint. All patients were grouped according to the maximum residual displacement of the sacroiliac joint（d）after operation. According to the post-operative Computer Tomography（CT）scan, d≤5mm were classified as anatomical reduction group, and d＞5mm were classified as malreduction reduction group. The majeed pelvic fracture scoring system was used to evaluate the postoperative functional outcomes. Re-displacement of the sacroiliac joint, or loosening and breakage of the internal plants, or re-displacement of the fracture were defined as the failure of internal fixation. Compare the failure rate of internal fixation between the two groups.
Results: A total of 86 patients were included in this study, including 48 males and 38 females. The average follow-up time was 37.7±6.6 months, ranging from 25 to 51 months. According the measurement of postoperative CT, there were 36 cases with the sacroiliac joint anatomical reduction and 50 cases with the malreduction. There was no statistically significant difference in the general data of patients between the anatomical reduction group and the malreduction group (P>0.05). The excellent and good rate of majeed score, anatomical reduction group was more than (86.1%, 31/36) malreduction group (54.0%, 27/50), the difference was statistically significant (c2=13.242, P<0.05). VAS score with anatomical reduction group was less than malreduction group, the difference was statistically significant (c2=13.285, P<0.05). A total of 15 cases with internal fixation failure. The failure rate in the anatomical reduction group (2.8%, 1/36) was lower than the malreduction group (20.0%, 10/50), and the difference was statistically significant (c2=4.129, P＜0.05).
Conclusion: Reduction and internal fixation of pelvic fractures with involving sacroiliac joint disruption, the functional outcomes with malreduction of sacroiliac joint is significantly worse than anatomical reduction. The malreduction group has a higher failure rate of internal fixation.
A Predictive Scoring System for Late Displacement and Deformity Following Non-operative Treatment of Young-Burgess Lateral Compression Type 1 (OTA 61-B1/B2) Pelvic Ring Injuries
Rown Parola, MD; Wayne Hoskins, PhD, FRACS; Charles Gusho, MD; Daniel Allen Bravin, MD; Brett Duane Crist, MD; Joshua Neill Milby, DO; Gregory J Della Rocca, MD, PhD; Kyle Schweser, MD; James P Stannard, MD; Jaime Lyn Bellamy, DO; Douglas Haase, MD
Purpose: The purpose of this study was to identify risk factors and develop a scoring system based on static radiographs that can predict late displacement and deformity of Young-Burgess lateral compression type 1 (LC1) pelvic ring injuries treated nonoperatively.
Methods: A retrospective analysis of two Level I trauma centers was performed. All LC1 (AO/OTA 61-B2/B3) pelvic ring injuries treated nonoperatively with minimum 3-month follow-up from January 2019 through January 2024 were reviewed. Exclusion criteria were nonacute presentations, nonunions, pathologic fractures, and nonambulatory patients. The primary outcome measure for this study was greater than 1 cm of pelvic ring displacement from initial to final radiographs showing fracture healing. Patient demographic and radiologic risk factors were identified on univariate analysis. Statistically significant variables (p<0.05) entered a multivariable logarithmic regression to develop a scoring system via stepwise elimination of noncorrelative factors, which was assessed via receiver operator characteristic (ROC) curve analysis.
Results: Included for analysis were 213 LC1 injuries managed nonoperatively. Female sex, age, initial anterior ring displacement, bilateral anterior ring involvement, superior ramus fracture angle, superior ramus comminution, Nakatani zone of fracture, and complete sacral fracture were univariately correlated with development of pelvic deformity. After multivariate analysis with stepwise elimination, only superior ramus fracture angle, initial anterior ring displacement, and superior ramus comminution remained significant. The scoring system developed scored 4 points for a longitudinal fracture angle, 2 points for anterior ring displacement, and 1 point each for superior ramus comminution or oblique fracture angle. Deformities developed in 88% of patients with a total score greater than or equal to five. The area under the ROC curve for the scoring system was 0.86 with a 95% CI of 0.81 to 0.91.
Conclusion: Superior ramus fracture angle, comminution, and anterior ring displacement correlate most with late displacement and deformity of LC1 fracture patterns. A combination of these factors in a developed scoring system increases the risk of displacement.
Does ipsilateral sacroiliac joint dislocation with poor radiological outcomes of acetabular fractures treated with open reduction and internal fixation via anterior approach
chun-gui liu, MD; Hu Wang, MD
Purpose: To evaluate the effect of ipsilateral sacroiliac joint dislocation on the radiological outcomes of acetabular fractures treated with open reduction and internal fixation via anterior approach.
Methods: The data of patients with acetabular fracture who underwent open reduction and internal fixation via anterior approach from January 2014 to December 2022 were retrospectively analyzed. According to whether with ipsilateral sacroiliac joint dislocation, divided into group 1 (acetabular fracture group) and group 2 (acetabular fracture combined with ipsilateral sacroiliac joint dislocation group).
Results: According to the inclusion and exclusion criteria, a total of 195 patients were included, with 127 cases in group 1 and 38 cases in group 2. Letournel-Judet classification in the Group 1, 8 cases were anterior wall fracture, 17 cases of anterior column fracture, 19 cases of transverse fracture, 48 cases of both column fracture, 10 cases of T-shaped fracture, 25 cases of anterior column + posterior hemi transverse fracture. In the Group 2, 3 cases were anterior column, 18 cases of transverse fracture, 6 cases of both column fracture, 9 cases of T-shaped fracture, and 2 cases of anterior column + posterior hemi transverse fracture. Postoperative Matta score results, the excellent and good rate in group 1 was 76.4%, while the excellent and good rate in group 2 was only 47.4%. In the group 2, a total of 18 cases with congruence hip joint, and 20 cases (52.6%) with incongruence hip joint. The difference between the two groups was statistically significant. The postoperative sacroiliac joint separation distance was 4.48±0.3mm in group 1 and 8.86±2.16mm in group 2, the difference between the two groups was statistically significant.
Conclusion: When ipsilateral sacroiliac joint dislocation is combined with acetabular fracture, the most common types of acetabular fractures are transverse fractures and T-shaped fractures. Ipsilateral sacroiliac joint dislocation significantly reduces the reduction results of acetabular fractures. Poor reduction is mainly manifested by the failure to restore the concentric hip joint and the residual separation displacement of the sacroiliac joint.
Acute Total Hip Arthroplasty Versus Open Reduction Internal Fixation for Geriatric Acetabular Fractures? Patients Prefer Whichever Method Returns Them to Function Fastest: A Discrete Choice Experiment
Elizabeth Partridge Wellings, MD, MS, MEng; Nathan O'Hara, PhD, MHA; Emilie Collins, BS; Michael Maceroli, MD; Adam Boissonneault, MD
Purpose: Certain geriatric acetabular fracture patterns have been associated with higher rates of conversion to total hip arthroplasty (THA), and there has been a trend to perform acute THA on such patients. This study seeks to quantify and compare the relative importance of outcomes and treatment options following acetabular fracture from a patient perspective.
Methods: The study was designed as a discrete choice experiment at a Level I academic trauma center. Adult patients ≥50 years who sustained an acetabular fracture were included in the study. In a series of eight questions, respondents chose between two hypothetical scenarios, defined by six attributes: joint replacement, discharge disposition, weightbearing status, assistive devices use, return to driving, and future surgery. Multinomial logit modeling was used to assess the attribute’s relative importance, ranging from 0 to 100%, with high values indicating greater importance.
Results: A total of 63 study participants (median age, 62 years [IQR, 54–70]) completed the survey. The strongest patient preference was for joint preservation (relative importance, 26%; 95% CI, 22%–30% ), followed by discharge disposition (relative importance, 19%; 95% CI, 15%–22%) and timeline to another surgery (relative importance, 17%; 95% CI, 14%–21%). Patients generally preferred joint preservation but were willing to undergo joint replacement for better clinical outcomes. Specifically, hip replacement was the preferred treatment if it provided at least two of the following benefits: discharge directly home instead of short-term rehabilitation, avoidance of another surgery by 10 years, immediate instead of delayed weightbearing, or return to driving in 1 month instead of 4 months.
Conclusion: Following acetabular fracture, patients ≥50 years prioritized joint preservation but were willing to undergo joint replacement if it provided multiple clinical benefits related to discharge, revision surgery, weightbearing, and return to driving. These findings may help guide surgeon and patient decision-making, and for those surgeons that do perform acute THA, it may help guide patient-centric protocols.
Impact and Incidence of Unnecessary Interfacility Transfer of Patients With Pelvic Injuries
Lauren Luther, MD; Ridge Maxson, MD; Jake Fox, MD; Andres Fidel Moreno, MD; Cade Morris, MD; Anoop Chandrashekar, BS; Phillip M Mitchell, MD; Robert Hunter Boyce, MD
Purpose: Patients presenting to lower-level hospitals with complex orthopaedic trauma commonly undergo interfacility transfer (IFT) to a regional trauma center for further evaluation and care. This study assessed the incidence, patient characteristics, and costs associated with unnecessary IFT of patients with isolated pelvic, acetabular, or sacral injuries.
Methods: A retrospective chart review was performed to identify adults (age ≥ 18 years) with isolated pelvic, acetabular, and/or sacral trauma who were transferred to a Level I trauma center between 2022 and 2023. Unnecessary IFT was defined as transfer occurring for patients who were managed nonoperatively without an examination under anesthesia or who failed a trial of nonoperative management. Bivariate and subsequent multivariate logistic regression analyses were performed to generate odds ratios (OR) and 95% confidence intervals (CI) evaluating the relationship between unnecessary IFT and certain patient and injury characteristics. Cost of care at the receiving institution (RI) was calculated using hospital financial records.
Results: Among 171 patients identified, the median age was 62 years (range, 18 to 94), and most patients were men (53%). Unnecessary IFT occurred in 91 cases (53%). The unnecessary IFT cohort was older (72 years versus 46 years, P< 0.001) and had a larger proportion of isolated injuries involving the pelvis (22% vs 1%, P< 0.001) or sacrum (12% vs 4%, P = 0.49). Low functional demand (OR 20.05; 95% CI, 3.28 – infinity) and hip dislocation (OR 0.01; 95% CI, 0.00–0.05) were associated with unnecessary IFT on bivariate analysis. Multivariate analysis revealed that age ≥ 72 years (OR 2.92; 95% CI, 1.26–6.77), low-energy mechanism (OR 3.52; 95% CI, 1.57–7.89), and ambulation after injury (OR 3.98; 95% CI, 1.70–9.41) were also independently associated with unnecessary IFT. The total cost of care received at the RI by patients in the unnecessary IFT cohort was $1,199,609.37, with a median of $9018.16 per patient (IQR, $3916.04–$14,483.62).
Conclusion: Most IFTs for patients with isolated pelvic, acetabular, or sacral injuries appear to be unnecessary and result in considerable direct and indirect costs to patients and regional trauma centers.
Intra-articular Air – A Novel Predictor of Posterior Wall Acetabulum Fracture Instability
Jonathan David Ellis, MD; Jacob Meyer, B.S.; Joseph Johnson, MD; Clay Spitler, MD; Michael J Beltran, MD; Michael T Archdeacon, MD, FIOTA; H Claude Sagi, MD
Purpose: The presence of intra-articular air can be indicative of a recent hip dislocation event because of a negative pressure phenomenon. Intra-articular air may be a marker of hip instability in patients with a posterior wall acetabulum fracture (AO/OTA 62-A1), especially patients with hip dislocations that auto reduced prior to presentation. The purpose of this study is to determine if intra-articular air correlates with fracture instability on examination under anesthesia (EUA).
Methods: This was a retrospective study of patients with posterior wall fracture who underwent an EUA from 2014 to 2024 at two Level I trauma centers. Chart review was performed to record demographic, injury, and management information. Radiographs and CT scans were reviewed to evaluate fracture size (Calkins, Keith, and Moed methods), distance from dome, displacement, and intra-articular air. EUA positive and negative groups were compared using Fisher’s exact and Mann-Whitney U tests for categorical and nominal variables, respectively.
Results: In the study, 73 patients underwent EUA, resulting in 40 positive (unstable) and 33 negative (stable) EUAs. EUA positive and negative groups had similar mean age (28 vs 34 years, p = 0.148) and body mass index (31 vs 30 kg/cm2, p = 0.322). The EUA positive group had a higher rate of intra-articular air (80 vs 9%, p<0.001), hip dislocation on injury radiograph (58 vs 18%, p<0.001), and increased fracture displacement (>5 mm, 75 vs 30%, p<0.001). The EUA negative group had more patients with smaller fracture size (<20% with Calkins method, 49 vs 13%, p = 0.002). Otherwise, there was no significant difference between groups with regard to fracture size measurements. In the 35 patients without a hip dislocation on injury radiograph, EUA positive patients had a higher rate of intra-articular air (71 vs 7%, p<0.001), and increased fracture displacement (71 vs 22%, p = 0.005).
Conclusion: Posterior wall acetabulum fracture instability is significantly higher in patients with intra-articular air or increased fracture displacement (>5 mm) regardless of presence or absence of hip dislocation history. EUA should be performed in posterior wall acetabulum fractures that have intra-articular air or increased fracture displacement.
Prolonged Hypercoagulability Exists Following Pelvic and Acetabular Fractures Regardless of Surgical Management or Non-Operative Treatment
Ahmed Negm, MD, PhD; Christoff Lee, BSc; Lisa Yamaura, PhD; Jessica Duong, PhD; Andrew Dodd, MD; Paul Duffy, MD; Herman Singh Johal, MD MPH; Robert Korley, MDCM; Prism Schneider, MD, PHD, FRCSC
Purpose: Venous thromboembolism (VTE) is a potentially life-threatening blood clotting complication, occurring in up to 27% of patients with pelvic or acetabular (PA) fractures. Thrombelastography (TEG) is a point-of-care tool that evaluates real-time viscoelastic changes in whole blood throughout the clotting process. TEG has been used to quantify hypercoagulability and identify those at increased risk for VTE. Duration of post-injury hypercoagulability in patients with PA fractures is undefined; therefore, the optimal duration of thromboprophylaxis to prevent VTE remains unknown. We aimed to evaluate the duration of post-injury hypercoagulability in PA fractures using serial TEG analysis.
Methods: In this study of adults with PA fractures, patients who underwent nonoperative treatment were prospectively enrolled and compared with age- and sex-matched patients with PA fracture who underwent surgery from a prior prospective cohort study. Whole blood samples were collected upon hospital admission, on post-admission days (PAD) one and three for nonoperative (or postoperative days [POD]) one and three in surgically treated PA patients, and at 2- and 4-weeks post-admission. Samples were analyzed using the TEG®6s Hemostasis Analyzer (Haemonetics Corporation) to quantify maximal amplitude (MA), which indicates clot strength. Hypercoagulability was defined as MA ≥65 mm based on current literature. Descriptive statistics were used to determine the duration of the hypercoagulable state and increased VTE risk.
Results: A total of 18 participants (age: 51 ± 21years; 44.4% female) were included, half of whom were treated surgically. There were no statistically significant differences between the groups in age (p = 0.95), sex (p = 1.0), body mass index (p = 0.44), or admission MA values (p = 0.09). However, MA was significantly elevated in surgically treated participants on POD1 (67.1 ± 2.7 mm) and POD3 (71.2 ± 1.8 mm) compared with MA in nonoperatively treated patients on PAD1 (61.6 ± 3.2 mm; p<0.01) and PAD3 (63.8 ± 3.2 mm; p<0.01). Participants in both groups remained hypercoagulable (mean MA = 67.5 mm; p = 1.0) at 4 weeks post-injury.
Conclusion: Major orthopaedic injuries, such as PA fractures, induces a hypercoagulable state. Regardless of surgical or nonsurgical management, patients with PA fractures remained hypercoagulable based on serial TEG analysis until 4 weeks post-injury. Consideration for prolonged thromboprophylaxis is warranted for patients with pelvic and acetabular fractures, regardless of surgical intervention or not.
Fracture Characteristics Predicting Displacement in 438 Stress-Examined Lateral Compression Type-1 Pelvic Fractures
Dane Brodke, MD, MPH; Orthopaedic Trauma Research Group
Purpose: Stress examination of lateral compression pelvic ring fractures can contribute to treatment decision-making. However, resource constraints may preclude immediate testing. This study investigated which fracture characteristics and scoring systems best predict stress positivity in lateral compression type-1 (LC1) pelvic ring fractures.
Methods: A multicenter retrospective cohort study included adult LC1 pelvic fractures treated at eight Level I centers over 10 years. Nine fracture characteristics were assessed, with Beckmann and Bruce scores calculated. The primary outcome was a positive stress examination, defined as a 1-cm change in linear measurement between the medial femoral heads. To account for nonlinear relationships and interactions, each fracture characteristic’s predictive importance was analyzed with Random Forest machine learning. Beckmann and Bruce scores were compared using receiver operating characteristic (ROC) analysis.
Results: A stress examination was performed on 438 LC1 pelvic fractures; 193 (44%) were positive. Superior and inferior ramus displacement as well as the sacral zone (with zone 2 predicting stress positive) were the characteristics that most predicted stress positivity (see figure). The Beckmann score is significantly more predictive of stress positivity than the Bruce score (area under the curve [AUC] 0.70 vs AUC 0.63, p = 0.02).
Conclusion: Ramus displacement was the most important factor in predicting stress positivity of LC1 pelvic fractures. Many important fracture characteristics that influence pelvic ring stability were not captured in the traditional Bruce scoring system.
A Multicenter Assessment of Ballistic Pelvic Fractures: Does Bullet Trajectory Through Bowel Prior to Bone Result in Higher Deep Infection Rates?
Andrew P. Collins, MD; Nolan Farrell, MD ; Zachary E Zeller, MD; Jennifer Eurich, MD; Ibrahim Sajid, BS; Christian Gabriel Falgons, MD; Nigel Blackwood, BS; Michael Jason Beebe, MD; Mary Kate Erdman, MD; Hassan Riaz Mir, MD, MBA, FACS, FIOTA; Jonathan G Eastman, MD; Clay Spitler, MD; Paul Tornetta, MD, PhD, FIOTA; Reza Firoozabadi, MD
Purpose: Gunshots that enter the bowel prior to bone may implicate gastrointestinal flora seeding of the pelvis, increasing the risk for osteomyelitis or hardware infection. The objective of this study was to compare deep infection rates among bullets that travel through bowel then bone versus bone then bowel.
Methods: This was a retrospective cohort study from seven Level I trauma centers. Patients 18 years and older with gunshot wounds (GSW) resulting in ballistic iliac fractures presenting between 2018 and 2024 with a minimum of 6-month follow up were included. Deep infection was characterized by any patient who required repeat or delayed irrigation and debridement of the pelvis after initial operative or nonoperative management. Analyses determined from CT scans were conducted among patients with gunshot wounds that went from the abdominal cavity first then through bone (GSWG) versus those that went through bone first then the abdominal cavity (GSWB).
Results: In total, 128 patients with ilium fractures from GSWs were included. There were 42 (32.8%) patients in the GSWG cohort, 49 (38.3%) in the GSWB cohort, and 37 (28.9%) with an unclear bullet trajectory or one that did not involve the abdominal cavity. In the GSWG cohort, six (14.3%) patients subsequently underwent irrigation and debridement of the bony pelvis for deep infection compared to one (2.0%) patient in the GSWB cohort (p = 0.029). Initial irrigation and debridement were performed in 10 (23.8%) GSWG patients within 1 week of injury versus six (12.2%) GSWB patients (p = 0.091). Each cohort had three (7.1% GSWG, 6.1% GSWB) patients with superficial infection that resolved with antibiotics (p = 0.847).
Conclusion: Prior literature has not assessed the impact of the theoretical risk of bony pelvis bacterial contamination for projectiles that travel from the abdominal cavity into bone. This multicentered study demonstrates that bullets that traverse the abdominal cavity prior to entering the bony pelvis are at higher risk of a deep infection developing that requires subsequent irrigation and debridement.
Prognostic Value of Preoperative Radiographic Parameters for Sexual and Functional Outcomes in Young Women With Pelvic Fractures
Amelia R Goldstein, BS; Chloe Cecile Fong, BA; Danielle M Olson, MS; Michael Coons, B.S.; Abhishek Ganta, MD; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: This study aimed to determine the prognostic value of preoperative radiographic measures—specifically pubic symphyseal diastasis, sacroiliac (SI) joint congruity, and/or concomitant sacral fracture—in predicting long-term sexual and functional outcomes in young women with pelvic fractures.
Methods: A retrospective cohort analysis was conducted on 35 female patients age 45 years or younger who were treated both surgically and nonsurgically for pelvic fractures. Inclusion criteria required that patients had a minimum follow-up duration of 1 year and a complete pelvic injury radiographic series. Pubic symphyseal diastasis was measured on injury plain radiographs (AP, inlet, and outlet) as the minimum distance between the pubic superior cortical surface of one pubic bone to the corresponding edge of the contralateral side. SI joint congruity was assessed by comparing the joint space between the sacral and iliac surfaces on each side of the pelvis; an SI joint was classified as incongruous if the joint space width difference was greater than 1.5 mm. Concomitant sacral fractures were identified on imaging and recorded. Long-term outcomes were evaluated using two validated questionnaires: the Female Sexual Function Index (FSFI) for sexual outcomes and the Short Musculoskeletal Function Assessment (SMFA) for overall functional status. Patients were stratified based on an FSFI threshold of 26.55 or less, indicating sexual dysfunction. Welch’s t-tests and χ2 tests were used.
Results: The mean age at time of injury was 33.1 ± 8.7 years, and the average follow up was 4.1 ± 2.6 years. Overall, 54.2% (19 of 35 patients) demonstrated FSFI scores of 26.55 or less, outside the normal sexual function range. Mean SMFA score across the cohort was 16.4 ± 22.3. Patients with SI joint incongruity experienced higher rates of sexual dysfunction (52.8% vs 18.8% [p = 0.01]). Patients with joint symmetry had significantly higher FSFI scores (mean: 24.2 ± 3.1 vs 13.9 ± 2.4 [p = 0.01]). Sacral fractures occurred in 25 patients (71.4%). This subgroup demonstrated a trend toward lower sexual function (mean FSFI: 18.45 ± 5.61 vs 25.84 ± 12.09 [p = 0.09]). The dysfunction group had a higher mean pubic symphyseal diastasis (10.0 ± 2.1 cm vs 5.28 ± 13.6 cm); however, this difference was nonsignificant (p = 0.18).
Conclusion: Initial injury radiographic parameters, specifically SI joint incongruity, demonstrate significant prognostic potential for long-term sexual outcomes in young women with pelvic fractures.
The Ability to Perform an Active Straight Leg Raise May Screen to Conservatively Treat Minimally Displaced Pelvic Fractures
Regis Louis Renard, MD, MS; Jason P Eckels, MD; Taylor Barnhart, BA
Purpose: The ideal treatment for minimally displaced pelvic fractures is evolving. Early surgical treatment may improve acute pain, decrease time to mobilization, and decrease hospitalization compared to conservative treatment in select cases. Anecdotally, we observed that patients with minimally displaced pelvic fractures who could actively straight leg raise (aSLR) on examination within 24 to 48 hours of presentation seemed to be able to be treated conservatively. Our goal was to examine the ability to aSLR to help determine potential surgical treatment, association to pain, and relationship to length of hospitalization.
Methods: An institutional review board (IRB)-approved prospective cohort was performed at a Level I rural trauma center on 30 patients with CT-scan–identified minimally displaced pelvic fractures (less than 10 mm) without additional lower extremity injuries. Patients were skeletally mature and had minimally displaced pelvic fractures. Patient demographics, aSLR, injury characteristics, treatment provided, length of stay (LOS), Brief Pain Inventory–Short Form (BPI–SF), Majeed Scoring (MS), and PROMIS29 at presentation were recorded. A statistical evaluation was performed.
Results: In total, eight of 30 patients were able to perform aSLR (age: 65.5 ± 16.63 years; females: 100%). All patients who could perform aSLR were treated conservatively. Patients who could not perform aSLR were age 54.81 ± 20.21 years (female: 58.14%). Of the 21 patients who could not perform a straight leg raise, 17 elected percutaneous treatment of their pelvic injury. LOS of aSLR patients was 3.88 ± 2.9 days; LOS for those who could not aSLR was 5.14 ± 4.49 days (p = 0.19). The BPI-SF pain severity index for aSLR patients was 6.714 ± 1.65 versus 6.81 ± 1.64 for non-aSLR patients. The BPI-SP pain interference index for aSLR patients was 7.63 ± 1.61 versus 6.80 ± 1.39 for non-aSLR patients. MS for aSLR patients was 28.71 ± 11.79 versus 21.91 ± 7.83 (p = 0.095) for non-aSLR patients. PROMIS pain intensity scores for aSLR patients was 7.17 ± 1.33 versus 6.32 ± 2.66 (p = 0.14) for non-aSLR patients.
Conclusion: Patients who could aSLR were treated conservatively with decreased LOS compared to patients who could not aSLR, who often chose surgical stabilization of their pelvic ring injury. All patients experienced similar significant pain after injury on pain and PROMIS scores. The aSLR may help with screening pelvic ring injuries that can be treated conservatively.
A Comparison of Opioid Prescription in Operatively and Non-Operatively Treated Isolated LC1 Pelvis Fractures
Makoa Mau, BS; Tyler Thorne, MD; Lucas S Marchand, MD; David L Rothberg, MD; Thomas F Higgins, MD; Justin Haller, MD
Purpose: Much controversy exists surrounding the operative indications of lateral compression type 1 (LC1) pelvic fractures. However, a presumed benefit of surgery is less early pain and improved function. The purpose of this study was to compare and predict the opioid consumption, clinical, and patient reported outcomes of operative (OP) and nonoperative (NOP) isolated LC1 pelvic fractures.
Methods: Skeletally mature patients with pelvic fracture at a single Level I trauma center between 2015 and 2023 were retrospectively reviewed. Patients with an isolated LC1 (OTA 61-B2.1) pelvic fracture with at least 6 weeks of follow up were included. Demographics, surgical outcomes, Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Pain Interference (PI), Anxiety, and Depression were recorded. Narcotic prescriptions in morphine equivalents (ME) 3 months pre-fracture through 6 months post-fracture were obtained through the state prescription drug monitoring program (PDMP). Gamma log link general linear models controlling age and gender were used to estimate prescribed MEs at the initial post-injury visit, any subsequent refills, and over the total observation period.
Results: In total, 135 patients were included in the analysis: 81 NOP and 54 OP. OP patients were significantly younger (41.3 vs 54.7 years, p<0.001) and more likely to be current tobacco users (24.0% vs 8.1%, p = 0.033). Although there were no differences in prescribed ME prior to injury, OP patients were prescribed significantly more total ME over the 9-month period of observation (4002 ME vs 1318 ME, p = 0.009). The linear model estimated OP patients were prescribed significantly more initial ME after fracture/surgery (480 ME vs 260 ME, p = 0.002). There were no differences in nonunion rates or PROMIS PF, PI, Anxiety, or Depression up to 6 months post-fracture.
Conclusion: Patients with operatively treated LC1 fractures are prescribed significantly more opiates than those treated nonoperatively, despite having similar PROMIS PI. Assuming comparable functional results, operative treatment of these injuries resulted in the use of significantly more opiate analgesics, which is very surprising because the stated benefit of the operation is improved pain control.
Impact of Finite Element Analysis Studies on Reducing Mechanical Failure in Surgical Fixation of Pelvic Ring Injuries: A Retrospective Analysis
Jose Miguel Rojas, Orthopaedic surgeon; Tania Liz Rojas, MD; Claudio Rojas, MD
Purpose: Finite element analysis (FEA) simulates the mechanical behavior of different fixation strategies, guiding surgical decisions for anterior and posterior pelvic arches. However, clinical validation of FEA recommendations remains limited. Our purpose was to evaluate whether adequate fixation based on FEA can reduce mechanical failure in patients with AO type B and C pelvic ring injuries (PRI).
Methods: A retrospective study of patients treated for PRI at a Level I trauma center between December 2022 and March 2024 was performed. Exclusion criteria included AO type A fractures, acetabular fractures, surgery at another center, less than 6 months of follow up, delayed surgery, or paraplegia from spinal cord injury. Adequate fixation was defined based on FEA findings and categorized by pelvic arch: for ligamentous injuries in the posterior arch, one iliosacral screw (ISS) in S1 for type B injuries and two ISS for type C injuries; in sacral ala fractures, one transiliac-transsacral screw (TITS) in S1 for type B injuries, and two TITS or lumbopelvic fixation for type C injuries; for the anterior arch, a four‐hole plate for ligamentous type B injuries, and a double plate or a combination device (a plate with a supra‐acetabular external fixator) for type C injuries. Mechanical failure was defined as pubic symphysis diastasis, pubic plate breakage, internal rotation of the hemipelvis, or nonunion of the fracture, with screw loosening also evaluated.
Results: Of 155 patients with PRI, 98 met inclusion criteria (median age: 44.5 years [range, 32–60 years], female: 20%, high-energy trauma: 96%); 62% of fractures were AO type B and 38% were type C. Overall, mechanical failure occurred in 56.1% of patients (27.6% when excluding screw loosening). Notably, no posterior arch failures were observed. Adequate fixation was associated with a significantly lower failure rate (10.3% vs 39% in patients with inadequate fixation; p = 0.004).
Conclusion: Integrating FEA insights into surgical planning can reduce mechanical failures by nearly 50%. These results underscore the importance of optimal fixation in both arches to improve outcomes in the management of pelvic ring injuries.
Asymmetric Sacral Dysmorphism: Prevalence and Impact on Surgical Planning
Adeet Amin, MD; Kathryn Barth, MD; Erik Norman Mayer, M.D.; Ryan D DeAngelis, MD; Gregory Vincent Schimizzi, MD PhD; Avrey Novak, MD; Christian Gabriel Falgons, MD; Colin Ward, BS; Connor Park, BS; Milton L Routt, MD; Stephen Warner, MD, PHD; Patrick Kellam, MD; Jonathan G Eastman, MD
Purpose: Proper iliosacral screw placement requires an understanding of sacral morphology and recognition of sacral dysmorphism. Although the characteristics of sacral dysmorphism have been well-described, the presence and relevance of asymmetric dysmorphic features have not been previously characterized. This study aims to determine the prevalence and surgical relevance of asymmetric sacral dysmorphism.
Methods: A retrospective review was conducted of patients presenting to an academic Level I trauma center between January 2023 and July 2024. Inclusion criteria were patients between age 18 and 85 years with a surgical pelvic ring injury and a thin-cut pelvis CT (≤2.0 mm) with 3D reformats. Sacral dysmorphism was defined by the inability to place a transiliac-transsacral screw in the upper sacral segment. Asymmetry was assessed by evaluating side-to-side differences in neuroforaminal height, upper sacral segment pathway obliquity, and anterior-posterior pathway width.
Results: Of 228 patients evaluated, 118 (51.7%) demonstrated sacral dysmorphism. Among patients with dysmorphism, 35 (29.6%) exhibited at least one feature of asymmetry. The asymmetric group included 19 females and 16 males, with an average age of 42.1 years (range: 16–91 years). Asymmetric features included differences in neuroforaminal height, upper sacral segment pathway obliquity, and pathway width (see figure).
Conclusion: Nearly 30% of patients with sacral dysmorphism demonstrate asymmetric features, which can impact surgical planning. Recognition of asymmetric sacral dysmorphism is important for proper execution of posterior pelvic fixation.
Intraoperative Multidimensional (3D) Fluoroscopy Leads to Surgeon Modification of Reduction and Implant Fixation
Umar Abbas Khan, MD; Michael Anthony Holzman, MD; Robert A Hymes, MD; A. Stephen Malekzadeh, MD; Jeff E Schulman, MD; Abraham Goch, MD; Jonathan Hayes Wills, MD; Caitlin Quigley, MPH; Grace Phillips, BS; Greg Gaski, MD
Purpose: Conventional fluoroscopy is the current standard for measuring reduction during pelvis and acetabular surgery, but it has limited ability to quantify small fracture displacements, identify intraarticular fragments, and permit safe insertion of implants in narrow bone corridors. Most complications are identified on postoperative CT scans, potentially leading to unplanned reoperation. Recent studies have highlighted potential advantages of intraoperative multidimensional fluoroscopy (IMF; 3D), which may resemble CT. This prospective study hypothesized that a provisional IMF "spin" would lead to intraoperative surgeon decision to improve reduction and/or implant fixation in more than 10% of cases.
Methods: This is a prospective observational study of patients older than age 17 years undergoing pelvis and/or acetabular fracture surgery from 2023 to 2025. Seven fellowship-trained trauma surgeons participated. A provisional IMF spin was performed at least once after reduction was achieved with temporary and/or partial definitive fixation, and a final spin was performed after final implant insertion. All patients had a postoperative CT scan. The primary outcome was incidence of surgeon modification of fracture malreduction or implant malposition (prospectively recorded) based on provisional IMF spin. Secondary outcomes included final spin reduction/implant modification and radiation dosage of fluoroscopy, IMF, and CT.
Results: In total, 62 patients with 67 surgeries were enrolled (mean age: 65.7 years, body mass index [BMI]: 28.0, injury severity score [ISS]: 20.2, male: 48). There were 26 pelvis fractures, 36 acetabular fractures, and five combined injuries. After the provisional spin, the surgeon chose to improve the reduction (n = 13), modify fixation (n = 23), or both (n = 10) in 36 of 67 surgeries (53.7%). Implant fixation was modified in seven cases (10.4%) and reduction in zero after the final IMF spin. The mean fluoroscopy total dose-area-product (DAP) was 21,263 mGy-cm2 and mean air kerma dose was 62.6 mGy, which was significantly less than IMF DAP 40,560 mGy-cm2 and air kerma 217.4 mGy (p<0.001). Mean postoperative CT dose-length-product was 803.9 mGy-cm.
Conclusion: This prospective study demonstrated that IMF utilization resulted in the surgeon decision to improve pelvis/acetabular fracture reduction or modify fixation in more than half of all surgeries. Overall patient radiation dose may be decreased if postoperative CT was not obtained in lieu of IMF.
Fifty Percent Reduction of Intraoperative Radiation in Orthopedics: Impact of Using the C-arm’s Lowest Possible Radiation Settings
Antoine Arsenault, BSc; Dominique Rouleau, MD, MSc; Julien Chapleau, MD, MSc, FRCSC
Purpose: C-arm fluoroscopy is frequently used in orthopaedic trauma surgery and repeatedly exposes operating room personnel to ionizing radiation, which poses documented long-term health risks. Radiation safety strategies include the use of personal protective equipment and variations in C-arm use. This study aimed to determine whether the lowest possible radiation (LPR) setting on the C-arm could reduce the total radiation exposure compared to the standard method while maintaining sufficient image quality. The LPR options are quarter-dose mode (Low-dose [LD] versus standard dose) and pulsed images (four images per second versus 24 images per second).
Methods: A retrospective study of patient records between March 2022 and August 2024 was undertaken to retrieve information on imaging and type of surgery. The cumulative radiation dose (CD, in milliGray [mGy]) and exposure duration (d, in seconds) were retrieved from the report automatically generated by the C-arm console. The relative radiation dose (RD = CD/d, in mGy/sec) was calculated to compare results across different groups, which included four anatomic regions: distal lower limb (dLL)—tibia, ankle, and foot; proximal lower limb (pLL)—hip, femur, and patella; distal upper limb (dUL)—forearm and wrist; and proximal upper limb (pUL)—shoulder and humerus.
Results: A total of 432 cases was reviewed, 193 in LPR and 239 in standard dose. The four groups included 226 dLL, 100 pLL, 56 dUL, and 50 pUL. Using LPR settings resulted in significant RD reductions across all groups, with an overall average reduction of 55% (p<0.01) and individual group reductions of 44% (p<0.01), 68% (p<0.01), 41% (p<0.01), and 58% (p<0.01), respectively. LPR mode did not show an overall increase in total radiation exposure duration, which reflects the number of images taken. This absence of duration increase (ie, images), suggests that image quality in LPR mode was adequate for orthopaedic surgery.
Conclusion: Using the C-arm with the LPR settings for orthopaedic surgery allows a significant mean reduction of 55% in radiation exposure for operating room personnel, without sufficiently affecting image quality to impact the number of images required.
Perfectionism and Burnout in Orthopaedics
Mahant Malempati, BS; Bonnie Y Chien, MD; Justin K Greisberg, MD; Nicholas Danford, MD
Purpose: Anecdotal observation has noted the presence of perfectionist tendencies among orthopaedic surgeons. Some studies have linked perfectionism to burnout among physicians, but no studies have looked specifically at orthopaedic surgeons. We hypothesized that perfectionism is strongly associated with orthopaedic surgeon burnout.
Methods: We performed a survey study of orthopaedic residents and faculty at both academic and non-academic institutions. The survey collected demographic data, perfectionist tendencies as measured by the validated Perfectionism Questionnaire used by Terry-Short et al and levels of burnout as measured by the validated Patient Health Questionnaire-9 (PHQ-9) and Burnout Assessment Tool (BAT). Associations among demographics, perfectionism, and burnout were analyzed using a multivariable logistic regression model.
Results: There were 71 respondents (11 residents/fellows and 60 attending physicians; average age: 47.0 years [SD: 12.5]; male: 59). Of these respondents, 56 were married, and 54 had children. The race distribution was 48 White, 14 Asian, 3 Black, 3 Non-White Hispanic, and 3 Others. Higher perfectionism was significantly associated with increased burnout risk (OR = 4.96, 95% CI: 1.78–13.78, p = 0.002). Having children significantly reduced perfectionist tendencies (OR = 0.22, 95% CI: 0.06–0.72, p = 0.012) and risk of burnout (OR = 0.24, 95% CI: 0.07–0.83, p = 0.025).
Conclusion: Our findings suggest that higher perfectionist tendencies are strongly associated with an increased risk of burnout among orthopaedic surgeons. Conversely, having children appears to be a protective factor against both perfectionism and burnout. These results highlight the importance of understanding perfection within orthopaedic surgery.
Inflammation Biomarker Clusters are Associated With Organ Dysfunction in Polytrauma Patients With Fractures
Greg Gaski, MD; Simon Tallowin, BMBS, Mac; Prism Schneider, MD, PHD, FRCSC; Katherine Frey, PhD; Renan Castillo, PhD; Seth Schobel, PhD; Felipe A. Lisboa, MD; Henry Robertson, PhD; Timothy R Billiar, MD; Eric Elster, MD; Laurence B Kempton, MD; Reza Firoozabadi, MD; Joshua Layne Gary, MD; Stephen Warner, MD, PHD; William T Obremskey, MD, MPH, FIOTA; Robert V O'Toole, MD; Arun Aneja, MD, PhD; Todd O. McKinley, MD; METRC
Purpose: The immune response following polytrauma is complex, dynamic, and thought to play a fundamental role in organ dysfunction and resolution after injury. Organ dysfunction trajectories after major trauma are highly variable even in demographically similar patients with comparable injury profiles. The post-injury immunologic response likely influences clinical outcomes. This investigation aimed to identify groups (latent classes) of short-term organ dysfunction trajectories in polytrauma patients with major orthopaedic injuries. We hypothesized there would be differential expression of immunologic mediators among the groups.
Methods: This is an a priori planned secondary analysis of a multicenter prospective observational trial of polytrauma patients age 18 to 55 years (ISS>15) with pelvis, acetabulum, femur, and/or diaphyseal tibia fractures. Organ dysfunction trajectories were identified using latent process modelling, classifying patients into three groups based on the dynamic evolution of their total multiple organ dysfunction score (MODS) over the first five days post-injury: low, intermediate, and high organ dysfunction. A panel of 33 trauma-relevant immunologic mediators were measured at 0 hour, 1 hour, 12 hours, 24 hours, and 48 hours post-admission. The primary outcome was variation in mean log transformed immunologic mediator concentrations among groups. A mixed analysis of variance (ANOVA) model with repeated measures was used to assess differences in mediator concentrations between groups and temporal changes.
Results: A total of 322 polytrauma patients was enrolled. Nine mediators differed significantly at multiple time points between the low, intermediate, and high organ dysfunction groups, dominated by five mediators belonging to the inflammation cluster: MCP-1 (24-hour low: 2.71 ± 0.31, intermediate: 2.89 ± 0.30, high: 3.14 ± 0.35); IL-6 (low: 1.96 ± 0.41, intermediate: 2.28 ± 0.44, high: 2.60 ± 0.46); IL-8 (low: 1.26 ± 0.43, intermediate: 1.42 ± 0.47, high: 1.74 ± 0.47); IL-10 (low: 1.89 ± 0.56, intermediate: 2.16 ± 0.60, high: 2.49 ± 0.49; all p<0.001); and MIG (p = 0.039). Over time, 25 immune mediators fluctuated significantly, with IL-10, IL-1Ra, and IL-8 (p<0.001) exhibiting the most pronounced temporal changes.
Conclusion: Notable differences in the inflammation biomarker cluster were observed among orthopaedic polytrauma patients in three distinct groups of patients that had varied levels of organ dysfunction. Characterization of the early and dynamic immune response after trauma may aid clinicians in identifying patients at risk of a sustained organ dysfunction trajectory.
Early Total Care Associates With Improved Organ Function in Polytraumatized Patients Presenting in Hemorrhagic Shock
Greg Gaski, MD; Prism Schneider, MD, PHD, FRCSC; Katherine Frey, PhD; Renan Castillo, MS; Timothy R Billiar, MD; Robert V O'Toole, MD; Reza Firoozabadi, MD; Laurence B Kempton, MD; Stephen Warner, MD, PHD; William T Obremskey, MD, MPH, FIOTA; Arun Aneja, MD, PhD; Todd O McKinley, MD; METRC
Purpose: Titration of orthopaedic interventions for patients with polytrauma affects outcomes. Early total care ([ETC]; definitive fixation <36 hours after injury) is typically beneficial but can be detrimental in under-resuscitated patients. Here we report clinical outcomes in patients who presented in hemorrhagic shock (maximum Day 1 [D1] lactate >4) who were treated with ETC or damage control orthopaedics (DCO).
Methods: In total, 322 patients with polytrauma admitted to the ICU with a Glasgow coma scale (GCS) >8 who sustained surgical injuries to the pelvis, acetabulum, femur, or diaphyseal tibia were prospectively enrolled. We measured Marshall Organ Dysfunction Scores (MODS) daily from D1 to D7 for clinical outcomes. We have shown that an average MODS from days 2 to 5 (aMODSD2-D5) >3 had significantly worse outcomes (ventilation days; complications) and aMODSD2-D5 was our primary outcome. Daily MODS and aMODSD2-D5 were compared (t-tests) between patients treated with ETC versus DCO in those with D1 lactate >4 (n = 93; 24 ETC vs 69 DCO); D1 lactate >4 and injury severity score (ISS) >25 (n = 56; 12 ETC vs 44 DCO); and D1 lactate >4 and total transfusion volume (packed red blood cells, plasma, platelets) <3000 mL (n = 69; 21 ETC vs 48 DCO).
Results: In patients with D1 lactate >4, aMODSD2-D5 was 3.9 in DCO patients versus 1.9 in ETC patients (p<0.001). Likewise, aMODSD2-D5 was 4.4 in DCO versus 2.6 in ETC patients with D1 lactate >4 and ISS >25 (p = 0.023). In patients with D1 lactate >4 with <3000 mL transfusion volume, aMODSD2-D5 was 3.3 in DCO versus 1.8 in ETC patients (p = 0.003). Daily MODS demonstrated that divergence in organ dysfunction trajectories between ETC and DCO patients occurred between 24 hours and 72 hours after injury and primarily resulted from improvements in pulmonary and hematologic function in ETC patients.
Conclusion: In patients with polytrauma with D1 lactate >4, ETC was associated with distinct improvements in pulmonary and hematologic function that led to improvements in overall organ function.
Cumulative Radiation Exposure in Orthopaedic Trauma Patients: How Much is too Much?
Alexa Pius, MD; Christopher Lin, MS; Christopher Jin, MS; Carina Tedesco, BS; Sandhya Chandar, BS; Jia Wang, PhD; Nicole Pham, MPH; Henry Goodnough, MD, PhD; Michael J Gardner, MD; Julius A Bishop, MD
Purpose: Utilization of medical imaging continues to rise, with an almost 2000% increase over the past several decades in the number of CT scans performed. Although orthopaedic patients are known to have significant radiation exposure around the time of their injuries, the current levels of exposure are unknown. The purpose of this study was to estimate the amount of radiation exposure from imaging studies among orthopaedic patients presenting to the emergency department (ED) at an academic, tertiary care, Level I trauma center.
Methods: An institutional database was used to identify patients who presented to the ED from 2015 to 2023 with an orthopaedic injury. Records were reviewed to assess exposures to radiation (excluding fluoroscopy) in the 12 months following injury. The type and frequency of each study, the radiation dose of each study (mSv), and the cumulative dose of radiation (mSv) per patient was calculated.
Results: In total, 4203 patients were included, and 53,592 imaging studies were performed. The average age was 58 years (median: 60, [IQR 39–75]) and the number of radiologic studies per patient was 13 (median: 8, [IQR 4–16]). The most common study was chest radiograph (11,400), followed by CT scan of the abdomen and pelvis (2126), and pelvis radiograph (1702). The average total effective dose of radiation per patient was 12.052 mSv (median: 1.607, [IQR 0.010–13.44]), which is classified as moderate per the International Commission on Radiological Protection (ICRP, 2007) guidelines and is associated with increased cancer risk. Fifty-nine patients had >100 mSv of radiation associated with their ED visit, which is classified as high-dose and is associated with acute organ effects and a significant cancer risk. Of the patients who received high-dose radiation amounts (>100 mSv), the average number of studies was 65 (median: 49, [IQR 29–88.5]).
Conclusion: Orthopaedic patients presenting to the ED at an academic Level I trauma center are exposed to high levels of radiation during their evaluation and treatment. Orthopaedic surgeons should be mindful of the potential associated risks and be judicious in obtaining diagnostic studies. Additional research is underway to model the risk of development of fatal cancer based on this exposure.
Outcomes and Final Amputation Level in Patients Presenting With Traumatic Lower Extremity Amputations
Jaquelyn Kakalecik, MD; Konstantin Brnjos, MD; Ayman Habib, BS; Terrie Vasilopoulos, PhD; Jennifer Elizabeth Hagen, MD, MS; Thomas Krupko, M.D.
Purpose: Patients presenting with traumatic lower extremity amputations frequently undergo amputation more proximal than the initial injury because of contamination or to achieve soft-tissue coverage. This study aims to define risk factors for more proximal amputation and for infection following definitive closure.
Methods: A retrospective chart review was performed of patients presenting with a traumatic lower extremity amputation at a single Level I trauma hospital between January 2005 and April 2024. Patients younger than 18 years or without an acute fracture in the amputated limb were excluded. Mechanism of injury, time to antibiotics, time to debridement, and final amputation level were recorded. Computed tomography angiography (CTA) abnormalities, tourniquet present on arrival, gross contamination, ISS, and body mass index (BMI) were compared using Fisher’s exact and Mann-Whitney non-parametric tests. Statistical significance was defined as p<0.05.
Results: In the final analysis, 86 patients with an average age of 44.9 ± 16.9 years were included. Higher rates of above-knee amputation (53%) versus below-knee amputation (30%) were associated with tourniquet present on arrival (p = 0.022). There was no significant difference in requirement for revision amputation or subsequent surgical debridement between above- and below-knee amputations (p = 1.0). Patients requiring subsequent debridement were more likely to have higher mean BMI (31.5 ± 7.5) compared to those not requiring it (27.2 ± 6.7 ; p = 0.007), but the number of vessels present on CTA, time to debridement, time to antibiotics, and the presence of gross contamination did not significantly increase the need following final closure. Patients with a below-knee amputation (74%) were more likely to be ambulatory at final follow up compared to those with above-knee amputations (50%; p = 0.033).
Conclusion: These results suggest a tourniquet present on arrival is the only risk factor for a more proximal level of amputation. Increased BMI was the only significant risk factor for subsequent debridement, suggesting the quality of surgical debridement may have a greater impact on outcomes than injury characteristics.
Outcomes of Aseptic, Septic, and Occult Infected Index Nonunion Repair: A Retrospective Comparative Study
Kai Rossbach, MD Candidate, MS; Makoa Mau, MD; Lucas S Marchand, MD; David L Rothberg, MD; Thomas F Higgins, MD; Justin Haller, MD
Purpose: Our objective was to compare the effectiveness of index nonunion surgery for occult-infected nonunion (ON) with aseptic nonunion (AN) and septic nonunion (SN) in patients identified using fracture-related infection (FRI) criteria. This study also compared the success rate of achieving union with bone grafting versus no bone grafting in the treatment of ON.
Methods: Skeletally mature patients diagnosed with nonunion at a single Level I trauma center between 2013 and 2023 were retrospectively reviewed. Patients with incomplete culture data, missing inflammatory labs, or lack of 6-month follow up were excluded. Patients were categorized into AN, SN, or ON groups using FRI criteria. Successful union after nonunion surgery without need for additional surgical interventions was evaluated. ON patients were organized into bone graft (ONBG) and no bone graft (ONNBG) groups to compare successful nonunion surgery. Multivariate regression was used to compare outcomes while controlling for gender, ASA classification, and diabetes.
Results: In total, 208 patients with nonunion fractures were included in the analysis: 125 AN, 54 SN, and 29 ON. Most patients had either a femoral nonunion (34%) or a tibial nonunion (49%). ON patients were significantly more likely to be infected by a low virulence organism (82.8% vs 9.3%, p<0.001). The overall success rate of index nonunion surgery was 67.8%. Patients in the ON group had the highest success rate (79.3%), followed by those in the AN group (72.8%) and the SN group (50.0%) (p = 0.004). Recurrent infections were significantly lower in the AN (16.0%) and ON (10.3%) groups compared to the SN group (35.2%) (p = 0.005). Regression analysis demonstrated that surgery success was significantly lower in SN patients (OR = 0.38, p = 0.009); ON and AN patients had similar success (OR = 1.58, p = 0.4). Bone graft use did not significantly affect successful union in ON patients (ONBG [16 of 21] 76.2% vs ONNBG [7of 8] 87.5%; p = 0.65).
Conclusion: Index nonunion surgery in SN patients is associated with worse outcomes compared to AN and ON patients identified with the FRI criteria. Surgery success in ON patients is comparable to AN patients, suggesting that low-virulence infections do not significantly compromise effectiveness of nonunion surgery. Further, in this sample, bone grafting in occult infections did not impair nonunion surgery success.
Proton Pump Inhibitors vs H2 Receptor Antagonists for Gastrointestinal Prophylaxis in Lower Extremity Fractures Procedures: A Comparative Retrospective Study
Rafael Madera, BS, MD canditate ; Uttsav Patel, BS, MD canditate ; Brian Lynch, MD
Purpose: A gap exists in the literature comparing different gastrointestinal prophylaxis modalities after lower extremity fracture procedures. Herein, we compared the use of proton pump inhibitors (PPI) and H2 receptor antagonists after fracture and/or dislocation procedures on the leg (tibia and fibula) and ankle joint.
Methods: The data used in this retrospective cohort study were collected from the TriNetX Research Network. Using the CPT code 1005246, we screened for patients in the network with no history of H2 antagonist and PPI use who underwent fracture and/or dislocation procedures on the leg and ankle joint and segregated them based on those who were prescribed PPI and those who were prescribed H2 antagonist within 30 days following their procedure. Each cohort was matched based on age, sex, race, obesity, chronic lower respiratory disease, hyperlipidemia, hypertension, nicotine dependence, alcohol disorders, chronic kidney disease, diabetes mellitus type 2, and ischemic heart diseases. After propensity score matching, 7866 patients were assigned to each cohort, all of whom underwent their procedure between 2009 and 2024. Subsequently, we compared each cohort's risk of experiencing selected outcomes using ICD-10 and CPT codes within a 2-year postoperative period.
Results: Complications that the PPI group was at a statistically significant greater risk for include repair, revision, and/or reconstruction procedures on the leg (tibia and fibula) and ankle joint (3.661% vs 2.568%, RR: 1.426, 95% CI: 1.194–1.702, p<0.0001), osteomyelitis (4.272% vs 3%, RR: 1.424, 95% CI: 1.209–1.677, p<0.0001), osteonecrosis (0.572% vs 0.331%, RR: 1.731, 95% CI: 1.069–2.802, p = 0.0238), repair of nonunion or malunion of the tibia or fibula (2.428% vs 1.615%, RR: 1.504, 95% CI: 1.204–1.878, p = 0.0003), ankle pain (24.345% vs 22.883%, RR: 1.064, 95% CI: 1.006–1.125, p = 0.0309).
Conclusion: Our findings demonstrate that patients who have undergone procedures on the leg and ankle experience a greater risk of postoperative orthopaedic complications with the use of PPI as GI prophylaxis as compared to patients who were given H2 antagonists. Our findings suggest that H2 antagonists are preferable for GI prophylaxis when considering orthopaedic complications after these procedures.
Plate vs. Nail: Is there a More Effective Implant for Extreme Tibia Fractures?
Abhishek Ganta, MD; Fiona Cherry, BA; Nirmal C Tejwani, MD, FRCS; Sanjit Reddy Konda, MD; Kenneth A Egol, MD
Purpose: Our objective was to determine differences in outcomes among “extreme” tibial metaphyseal fractures treated with intramedullary nailing (IMN) or plate osteosynthesis.
Methods: Two board-certified orthopaedic trauma surgeons reviewed 545 prospectively collected patients to identify extreme tibial shaft fractures (defined as most proximal or distal segments that involved or would have involved the area encompassed by the nail locking bolts). 51 patients were identified; 25 patients treated with an intramedullary nail were compared to 26 patients treated with plate and screws for similar patterns. Data collected included patient demographics, surgical details, and outcomes. Cohorts were compared using Fisher’s exact test, independent T tests, and multivariable linear regression.
Results: The mean age of all patients was 46.73 years. There were no differences in American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI) score, age, male/female composition, or body mass index (BMI) between cohorts. There were no differences in low- versus high-energy mechanism of injury between cohorts; however, the IMN cohort had a greater proportion of open fractures (p = 0.007). When controlling for covariates, patients who underwent IMN were allowed earlier weightbearing on the operated extremity. There were no differences in ankle or knee range of motion at latest follow up. There was a greater incidence of total complications among IMN (p = 0.029). Single variable analysis revealed an association between IMN and nonunion (p = 0.025). IMN trended toward greater need for reoperation (p = 0.084).
Conclusion: Intramedullary nailing of “extreme tibia fractures” was associated with higher rates of total complications compared to plate osteosynthesis and trended with greater need for reoperation. However, it should be noted that there was a higher incidence of open fractures in this cohort. There were no differences in the rate of malalignment, range of motion, or time to healing between cohorts. Intramedullary nailing is associated with earlier weightbearing, which can allow patients to more readily return to pre-injury function.
Early Routine Radiographic Follow-up at 2-3 Weeks for Operatively Treated Tibia, Fibula or Ankle Fractures Does Not Contribute to Identification of Complications: A Two Center Case Series of 628 Patients.
Derek van Duuren, MD; Robert Kaspar Wagner, MD; Jacob Samuel Wolf Borgida, B.S.; Maaz Muhammad, MD; Carlos Sierra-Arce, MS; Austin Taylor Gregg, BS; Adam Musick, BS; Derek S Stenquist, MD; Mitchel B Harris, MD; Thuan V Ly, MD; Arun Aneja, MD, PhD
Purpose: Our objective was to determine if early routine radiographic follow up at 2 to 3 weeks for patients with surgically treated tibia, fibula, or ankle fractures identified complications (ie, complications only visible on radiographs and not associated with symptoms on history taking or clinical examination) and whether these complications were clinically relevant (ie, resulting in treatment change).
Methods: All adult patients from two Level I trauma centers who underwent surgical treatment for a tibia, fibula, or ankle fracture between January 2021 and January 2023 and who received early routine radiographic follow up between 10 and 30 days postoperatively were included. Routine radiographs were defined as radiographs that were scheduled and obtained as part of the institution’s standardized follow-up protocol. The primary outcome was the rate of complications detected on early routine radiographs, stratified by the presence of associated symptoms based on history taking and/or findings on physical examination. The secondary outcome was any documented treatment change for complications.
Results: The study included 628 patients (median age 47 years, 42% male). A total of five complications in 628 patients (0.8%) were seen on early routine radiographs, of which three complications (0.5%) were exclusively identified on radiographs (ie, not associated with symptoms). None of the three complications resulted in a change in treatment strategy. The remaining two complications were visible on radiographs but were accompanied by symptoms on history taking or physical examination.
Conclusion: The results of the current study suggest that obtaining early routine radiographs at 2 to 3 weeks after surgical treatment of tibia, fibula, or ankle fractures may not be necessary and that obtaining radiographs based on clinical indication is feasible. These findings should be considered in light of the increasing healthcare expenditures and time investment from patients and healthcare professionals.
Surprise IIIB Open Tibia Fractures: Can We Predict Wound Healing Failures in Primary Closure of Open Tibia Fractures?
Elliott Joseph Druten, B.S.; Chirag Soni, M.S.; Faith K Darden, BS; Adam Zhuang, BS; Dillon O’Neill, MD; Jan P Szatkowski, MD; Roman M Natoli, MD, PHD; Yohan Jang, DO; LUKE A LOPAS, MD
Purpose: Despite appearing amenable to primary closure at definitive fixation, Gustilo-Anderson (GA) type I–IIIA injuries may result in wound healing failure requiring a subsequent rotational or free flap. The purpose of this study is to investigate the rate and characteristics of GA type I–IIIA tibia fractures requiring soft-tissue coverage in a delayed fashion secondary to wound healing complications.
Methods: A retrospective review of patients age 18 years and older with open tibia fractures (AO/OTA 41A-C, 42A-C, and 43A-C) was conducted at an academic Level I trauma center from 2013 to 2023. Patients initially treated at another facility and those with less than 3 months of follow up were excluded. Patient demographics, injury characteristics, and medical and surgical treatments were recorded. The primary outcome of interest was the rate of conversion from GA types I–IIIA to IIIB postoperatively.
Results: A total of 258 patients with open tibia fractures was included, 186 (72%) were male, and the average age was 44.8 years (range 18–88). 31 patients were initially type IIIB or IIIC, and therefore were ineligible for conversion. Of the remaining 227 patients, 37 (16.3%) were ultimately converted to a IIIB. 22 (60%) of conversions occurred in AO/OTA 42 injuries; 12 (32%) occurred in AO/OTA 43 injuries. 21 (57%) conversions occurred in AO/OTA C type fractures (41C:2, 42C:10, 43C:9); 23 (62%) conversions were GA type IIIA, and 10 (27%) were GA type II. Increased age was a risk factor for conversion to a IIIB (average 44.1 years vs 49.1 years, p = 0.018). Polytrauma status, AO/OTA 43B injuries, and Gustilo-Anderson type approached significance (p = 0.053, 0.058, and 0.056 respectively). No relationship between type of antibiotic administered and conversion risk was identified (p>0.24 for all). No medical comorbidities (diabetes, chronic kidney disease, organ transplant, inflammatory arthropathy) or social factors (alcohol abuse, drug use, tobacco abuse) were identified as risk factors (p>0.35 for all).
Conclusion: Flap coverage because of wound healing failure was ultimately required in 16.3% of open tibia fractures primarily closed at definitive fixation. Further work to develop predictive risk algorithms and mitigation strategies is warranted.
Risk Factors for Failure of Repair of Diaphyseal Tibial Nonunions: A Retrospective Cohort Study of 109 Patients
Sikun Fan, Bsc, MD candidate; Robert K. Wagner, MD; Carla Lehle, MD; Austin Taylor Gregg, BS; Adam Musick, BS; Maaz Muhammad, MD; Thomas Policicchio, BA; Stein Jasper Janssen, MD PhD; Mathieu Wijffels, MD PhD; Derek S Stenquist, MD; Thuan V Ly, MD; Arun Aneja, MD, PhD
Purpose: Our objective was to identify factors associated with the need for additional nonunion surgery following diaphyseal tibial nonunion repair with (exchange) intramedullary nailing or plate fixation.
Methods: All consecutive patients age 18 years or older who underwent surgical repair for a diaphyseal tibial nonunion with (exchange) nailing or plating at two Level I trauma centers between March 2004 and January 2024 were retrospectively identified. A minimum follow up of 6 months was required. The primary outcome was the need for additional surgery for persistent nonunion. Bivariate analysis and multivariable logistic regression were performed to identify patient, nonunion, and treatment factors associated with additional nonunion surgery.
Results: A total of 109 patients (median age 42 years [IQR: 28─52], 72% male) with a median follow up of 18 months [IQR: 8─44] was included. Revision fixation was performed with (exchange) intramedullary nailing in 60 patients (55%) and plate fixation in 49 (45%). Autologous bone grafting was used in 40 patients (37%). Overall, 31 patients (28%, 95% CI: 20%–38%) required additional nonunion surgery. In multivariable logistic regression, female sex (OR: 3.57, 95% CI: 1.23–10.4, p = 0.020), current smoking (OR: 4.11, 95% CI: 1.43–11.8, p = 0.009), and an initial open fracture (OR: 4.52, 95% CI: 1.40–14.5, p = 0.012) were associated with increased odds for additional nonunion surgery. No treatment variables (including fixation type and bone graft use) were associated with additional nonunion surgery in bivariate analysis. Amputation was ultimately performed in five patients (4.6%) because of persistent nonunion.
Conclusion: More than one in four patients undergoing diaphyseal nonunion repair require additional surgery for persistent nonunion. Smoking was the only modifiable factor that was associated with additional nonunion surgery, and emphasis needs to be placed on smoking cessation. Overall, the association of female sex and an initial open fracture with additional nonunion surgery provides insight for prognostication and risk stratification.
Soft Tissue Healing in Type II and IIIa Tibial Fractures: A Retrospective, Multi-Institutional Comparison of Factors Affecting Bony Union
Walter Sobba, BS; Garrett William Esper, MD ; Jon Bekisz, MD; Sallie Yassin, MS; Owen Marecic, MD; Max Durtschi, BA; Christopher Lin, BA; Michael J Gardner, MD; Kenneth A Egol, MD; Jacques Hacquebord, MD
Purpose: Open tibia fractures are challenging orthopaedic injuries considering their high risk of infection and nonunion. Past research has focused on Gustilo-Anderson type IIIB injuries with studies showing that more aggressive initial soft-tissue reconstruction with free tissue transfer leads to shorter time to soft-tissue healing and bony union. We hypothesize that more rapid soft-tissue healing among Gustilo-Anderson type II and IIIA tibia fractures is associated with shorter time to union.
Methods: We conducted a multicenter retrospective review of type II and IIIA open tibial shaft and plafond fractures. Chart review identified patient baseline demographics, comorbidities, injury severity, and surgical outcome data. The primary analysis used Cox proportional-hazards models to assess the association between time to soft-tissue healing and the hazard of achieving bony union.
Results: Overall, 144 patients were identified and 105 completed follow up and were included in our survival analysis. Bony union was achieved in 92 (87.6%) patients while 13 (12.4%) experienced nonunion. Patients with nonunion were more likely to have a larger area soft-tissue defect (p = 0.018) and experience deep-space infection (p<0.001). The hazard of achieving bony union with complete soft-tissue healing at 90, 120, 180, and 360 days was 96%, 81%, 67%, and 24%, respectively.
Conclusion: Delayed soft-tissue healing and increased soft-tissue injury severity are associated with increased risk of nonunion in open tibia fractures. Our results support more aggressive soft-tissue coverage in certain fractures, likely resulting in increased recategorization of IIIA fractures as IIIB following free tissue transfer.
Increased Risk of Deep Infection and Reoperation in Low-Energy Gunshot Tibial Shaft Fractures
Divya Jeyasingh, MS; David Hunter Campbell, MD; Christopher Wedwick, MD; Niloofar Dehghan, MD, MSc, FRCSC
Purpose: Gunshot-related injuries represent a significant public health concern. Despite the high frequency of fractures resulting from ballistic injuries, there remains a lack of a well-defined, standardized classification and perioperative treatment protocol. This study investigates the deep infection and reoperation rates associated with low-energy gunshot (LE-GS) tibial shaft fractures, comparing outcomes to fractures caused by blunt-force mechanisms. A secondary objective was to analyze the microbial profile of infections in these cases.
Methods: A retrospective cohort study was conducted at three Level I trauma centers from 2014 to 2024. Patients ages 16 to 65 years with tibial shaft fractures (OTA/AO 41A2-3, 42A-C, 43A) treated with intramedullary nailing (IMN) following LE-GS or blunt-force trauma were included. Patients were categorized into four groups: closed fractures, LE-GS, Type I/II open fractures, and Type III open fractures. Primary outcomes were deep infection and unplanned reoperations. Statistical analyses included χ2, Fisher’s exact tests, ANOVA, and multivariable logistic regression.
Results: A total of 195 patients who underwent IMN fixation of tibial shaft fractures were included: closed (n = 68), open Type I/II (n = 55), open Type III (n = 37), and LE-GS (n = 35). The LE-GS group had the highest infection rate (34.3%), followed by Type III fractures (16.2%), Type I/II fractures (12.7%), and closed fractures (1.5%). LE-GS fractures had significantly higher deep infection (34.3%) and reoperation rates (57.1%) compared to closed fractures (1.5% and 13.2%, respectively, p<0.001). Multivariable analysis confirmed LE-GS as a significant risk factor for infection (OR 4.26, p = 0.003) and reoperation (OR 3.51, p = 0.002). Infections in LE-GS fractures were predominantly polymicrobial and Gram positive, with 58.9% of isolates resistant to first-generation cephalosporins.
Conclusion: Tibial fractures caused by low-energy gunshot injuries exhibit deep infection and reoperation rates comparable to Type III open fractures, challenging the traditional classification of these injuries. Treating these injuries as closed fractures may be suboptimal, and a proper debridement and irrigation may be warranted. Current antibiotic prophylaxis may be inadequate, warranting further investigation into optimized treatment protocols.
Comparing the Effects of Age, Biological Sex, and Extremity Fracture Location on Continuous ICP Measurements in Trauma Patients
Yasser Bouklouch, PharmD MPH; Justin Matta, Bsc Ms; William T Obremskey, MD, MPH, FIOTA; Ross Kenneth Leighton, MD, FIOTA; Mitchell Bernstein, MD; Edward J Harvey, MD, FIOTA, FAAOS, FRCSC
Purpose: Baseline data for extremity compartment pressure after trauma have only been looked at in small cohorts with historically inaccurate technology. Newer technology has allowed accurate continuous pressure monitoring specifically for diagnosis of acute compartment syndrome (ACS). This study used data from prospective cohort trials using modern pressure sensors to look at baseline pressure values. Particularly, there was a comparison of the effects of age, sex, and fracture location on continuous trend behaviors in patients with extremity trauma.
Methods: 18 hours of intracompartmental pressures (ICP) from 129 non-ACS trauma patients with lower extremity fractures were examined. The trends in patients were analyzed with respect to age, biological sex, and anatomic fracture location.
Results: Younger patients exhibited higher mean ICPs compared to older patients at all time points. Both groups experienced the same rates of decline in pressure over time from trauma. Both older and younger patient groups experienced a steady linear decrease in pressure over the course of monitoring. The younger age group had a decrease of 0.202 mmHg/hour (y = 26.4 – 0.202 x); the older age group had a decrease of 0.202 mmHg/hour (у = 23.9 – 0.202 x). Males and females initially had similar ICPs, but females showed a steeper decline over time, with the pressure in the female group decreasing at a mean rate of 0.303 mmHg/hour compared to 0.163 mmHg/hour in the male group. Tibia fractures were associated with a higher initial pressure and steeper declines in ICP compared to forearm fractures.
Conclusion: There are variances for continuous ICP measurements associated with age, sex, and fracture location in trauma patients in whom ACS does not develop. Continuous ICP monitoring offers a better understanding of pressure trends, allowing for more accurate and individualized assessments. Recognizing these trends are crucial in ACS assessment.
Modern External Ring Fixation Versus Internal Fixation for Treatment of Severe Open Tibial Fractures: An Observational Trial
Chris Renninger, MD; Jefferson Lansford, MD; Robert V O'Toole, MD; Lisa Reider, PhD; Julio Rivera, PhD; Renan Castillo, MS; Joshua Layne Gary, MD; J. Spence Reid, MD; Stephen M Quinnan, MD; Madhav A Karunakar, MD; William T Obremskey, MD, MPH, FIOTA; Greg Gaski, MD; METRC
Purpose: Previous results of a randomized controlled trial evaluating the 1-year probability of major limb complication in severe open tibial shaft fractures treated by either modern ring external fixation (MREF) or internal fixation (IF) have been reported. The current study reports results of the observational arm of the same study protocol.
Methods: This prospective observational study included patients aged 18 to 64 with severe open tibial shaft fractures and candidates for a randomized trial comparing MREF and IF, who refused randomization and consented to enrollment in an observational arm. The primary outcome was major limb complication within 365 days after randomization refusal, including amputation, infection, soft-tissue problems, nonunion, malunion, and loss of reduction/implant failure. Analyses were performed for the observational cohort alone (MREF: n = 53, IF: n = 123) and combined randomized and observational cohorts (MREF: n = 174, IF: n = 249). Analyses were performed unadjusted with Fisher Exact tests and then using generalized linear models (GLM) to control for patient and injury factors.
Results: In the observational cohort, MREF patients were younger (31.3 vs 36.6 years, p = 0.01), had a lower body mass index (BMI) (26.7 vs 28.8, p = 0.04), and were more likely to have planned bone defect treatment (62.3% vs 32.5%, p<0.001). One year postoperatively, MREF patients had higher rates of major limb complication (55.7% vs 37.1%, p = 0.005), nonunion (33.6% vs 18.6%, p = 0.001), and pin-tract infection (15.1% vs 0.8%, p = 0.004). In the combined cohorts, MREF patients had higher rates of major limb complication (59.3% vs 40.3%, p<0.001), implant failure (14.6% vs 1.3%, p<0.001), and pin-tract infection (18.9% vs 0.8%, p<0.001). These findings remained significant both before and after adjusting (p-values for GLMs reported). Across all analyses, no significant difference was detected in rate of deep infection (MREF 17.3% vs 19.0%, p = 0.75, observational; MREF 23.6% vs 24.1%, p = 0.78, combined).
Conclusion: Similar to previously reported randomized results, the current study suggests severe open tibial shaft fractures treated with MREF have a higher risk of limb complications without reduction in deep infection risk.
Zone of Injury Determined by Free Air on Computed Tomography Scans of Open OTA 42A-C Tibial Fractures Correlates With Nonunion and Hardware Removal
Amelia R Goldstein, BS; Nathaniel P Mercer, MD; Bradley Austin Lezak, MD, MPH; Alexander M Lashgari, BA; Kenneth A Egol, MD; Abhishek Ganta, MD; Sanjit Reddy Konda, MD
Purpose: Our objective was to evaluate a novel CT metric—the ratio of soft-tissue zone of injury (ZOISoft) to fracture zone of injury (ZOIFX)—as a predictor of clinical outcomes in open tibia fractures.
Methods: A retrospective review of patients in a tibia fracture registry from 2014 to 2024 at a single institution was performed. Inclusion criteria were age 18 years or older, open fracture, OTA 42A-C fracture, availability of preoperative CT imaging of the injured tibia, and a minimum follow up of 6 months. Demographic data, Charlson Comorbidity Index (CCI), injury characteristics, and clinical outcomes (fracture-related infection, amputation, nonunion, hardware removal, and total number of reoperations) were recorded. The ZOISoft was defined as the distance (mm) between the proximal and distal extents of soft-tissue air, while the ZOIFX represented the distance (mm) of the proximal and distal extent of the fracture. The ratio of ZOISoft/ZOIFX was calculated for each case, and patients were cohorted into two groups based on the ratio: ZOISoft/ZOIFX <3 (Group A) and ZOISoft/ZOIFX ≥3 (Group B). Univariate analyses were conducted using two-tailed Student’s t-tests and χ2 tests.
Results: In total, 55 patients (mean age: 39.2 ± 20.6 years; mean follow up: 16.9 ± 9.5 months) met the inclusion criteria and were divided into two groups: 33 patients (60.0%) in Group A and 22 patients (40.0%) in Group B. Demographic characteristics were similar between groups, except that Group A had a higher proportion of men (90.9% vs 68.2%, p = 0.03). Gustilo-Anderson classifications did not differ significantly between groups (Group A: 1 [n = 4], 2 [n = 9], 3 [n = 11]; Group B: 1 [n = 10], 2 [n = 12], 3 [n = 12]; p = 0.51). Group B experienced a higher incidence of nonunion (40.91% vs 18.18%; p = 0.05) and hardware removal (40.91% vs 18.18%; p = 0.03). Rates of other complications—including infection (22.73% vs 24.24%), amputation (4.55% vs 9.09%), and overall complication rates (50.00% vs 36.36%)—and the average number of reoperations (1.19 ± 1.95 vs 1.33 ± 2.95) did not differ between groups.
Conclusion: A ZOISoft/ZOIFX ratio of 3 or more was associated with an increased risk of nonunion and the need for hardware removal.
Do Computed Tomography Angiography Findings Correlate With Postoperative Complications for Tibial Fractures?
Grace Hernandez, MD; Joseph Morrison, BS; Chiara Anna Giordani, MS; Frank J Sierra, BS; Shannon Tse, BMBS; Noah Lyndall, BS; Jingyanshan Li, BS; Ellen Fitzpatrick, MD; Gillian Soles, MD; Mark Lee, MD; Sean Thomas Campbell, MD; Augustine Mark Saiz, M.D.
Purpose: Computed tomography angiography (CTA) can be used to assess vascular injury in tibia fractures. Prior investigations discourage routine use of CTA for fractures without at least one hard or soft sign of vascular injury. However, studies have shown that fracture and wound healing are related to perfusion. This study aims to evaluate the association between CTA abnormalities and postoperative complications for tibial fractures.
Methods: A retrospective review was conducted on patients with tibial fracture (AO/OTA 41–44) who underwent CTA and fixation at a Level I trauma center between 2014 and 2023 with more than 6-week follow up. Demographics, injury, and surgical characteristics were collected. CTA reports were analyzed for vessel abnormalities. Patients were stratified based on whether surgical approach overlapped with injured angiosome. Univariate regressions assessed associations with clinical outcomes (unplanned return to the operating room [UROR], nonunion, infection).
Results: Among 177 tibia fractures (167 patients, mean age: 43.8 years, male: 74.9% ), CTA revealed 97 (58.1%) had zero, 33 (19.8%) one, 17 (10.2%) two, and 20 (12.0%) three abnormal vessels. Open fractures (p = 0.003), nerve deficit (p = 0.003), and non-palpable dorsalis pedis (p<0.001) on initial examination correlated with increased likelihood of vessel injury. High-energy mechanism of injury had higher incidence of vascular injury, while penetrating injuries had a higher proportion of three-vessel injury (p = 0.035). Approach/angiosome overlap did not correlate with postoperative outcomes. Predictors of UROR included open fracture (OR: 2.71, 95% CI: 1.34–5.52), two abnormal vessels (OR: 3.09, 95% CI: 1.12–8.52), and nerve deficit (OR: 4.10, 95% CI: 1.03–16.3). Deep infection was associated with open fracture (OR: 2.56, 95% CI: 1.04–6.29), and three abnormal vessels (OR: 3.94, 95% CI: 1.24–12.55). Nonunion was predicted by open fracture (OR: 5.76, 95% CI: 1.86–17.80) and nerve deficit (OR: 8.23, 95% CI: 1.92–35.15).
Conclusion: Multivessel abnormality on CTA and open injury are both predictors of UROR and postoperative infection for patients with tibia fracture. However, vessel injury on CTA is not associated with fracture nonunion, and surgical approach overlap with injured angiosome is not correlated with postoperative complication. Surgeons should feel confident using the approaches deemed necessary for the fracture without concern for a second hit to angiosome.
Low-Dose Aspirin Provides Safe Thromboprophylaxis After Tibial or Femoral Shaft Surgery
Ariel Kesick, BS, MPP; Jackson Durbin, BS; Keli Doe, MD; Rachel Ranson, DO; Robert Sterling, MD; James N DeBritz, MD
Purpose: Recent literature supports the use of low-dose (81 mg) aspirin for venous thromboembolism (VTE) prophylaxis following joint arthroplasty; however, its efficacy in high-risk patients after long bone fractures has not been evaluated. This study investigates trends in aspirin use in patients undergoing open reduction and internal fixation (ORIF) of femoral or tibial shaft fractures. We evaluate VTE risk and 90-day postoperative outcomes among patients receiving low-dose aspirin compared with alternative chemoprophylaxis.
Methods: The TriNetX Research Network database was used. CPT, ICD-10, and RxNorm codes were used to determine the proportion of patients undergoing ORIF for femoral or tibial shaft fractures who received low-dose aspirin versus other chemoprophylaxis (high-dose aspirin, warfarin, heparin, direct oral anticoagulants) between 2012 and 2023. VTE risk was determined by the 2022 ICM-VTE guidelines and 90-day postoperative outcomes (deep vein thrombosis, pulmonary embolism, mortality, infection, and hospital readmissions) were assessed. All statistical analysis was conducted in TriNetX, and outcomes were assessed using odds ratios (ORs).
Results: Between 2012 and 2023, we identified 27,342 patients who underwent ORIF for femoral or tibial shaft fractures and received VTE prophylaxis. Of these, 14,947 were classified as high VTE risk and 12,370 were classified as normal VTE risk. The use of low-dose aspirin increased from 2.9% to 24.9%; high-dose aspirin use decreased from 9.6% to 8.1%; warfarin use decreased from 5.5% to 0.6%, and low molecular weight heparin use decreased from 88.7% to 77.4%. High-risk VTE patients receiving low-dose aspirin had lower odds of VTE events 90 days postoperatively compared to other prophylaxis groups. Both low-risk and high-risk patients in the low-dose aspirin cohorts had similar risk of 90-day postoperative complications compared to those on alternative thromboprophylaxis.
Conclusion: This large cohort study demonstrates that low-dose aspirin is a safe and effective method of VTE chemoprophylaxis for patients undergoing ORIF for femoral or tibial shaft fractures.
Acute Alcohol Intoxication and Chronic Alcohol Use Increase Risk of Infection After Open Tibia Fractures
Chirag Soni, MS; Elliott Joseph Druten, BS; Michael Orcutt, DO; James Slaven, MS; Luke A Lopas, MD; Yohan Jang, DO
Purpose: Alcohol use is recognized as a risk factor for impaired wound healing. This study sought to evaluate the impact of acute and chronic alcohol use on the incidence of surgical site infection (SSI) in patients with open tibia fractures.
Methods: A retrospective review of skeletally mature patients with open tibia fractures at an academic Level I trauma center from 2017 to 2021 was conducted. Minimum of 6-months follow up was required. Patients missing blood toxicology labs were excluded. Ethanol levels exceeding 10 mg/dL were considered ethanol positive. Daily alcohol consumption or documentation of chronic alcohol use was defined as chronic alcohol use. The primary outcome was the incidence of superficial and deep SSIs. Bivariate and multivariate analyses were performed to identify associations between alcohol use and infection rates.
Results: In total, 187 patients with 190 AO/OTA 41, 42, 43 A-C fractures met inclusion criteria; 70 patients (36.8%) had SSIs: 15 isolated superficial infections, 43 isolated deep infections, and 12 had both superficial and then a subsequent deep infection. Both acute intoxication (p = 0.033) and chronic alcohol use (p = 0.005) were associated with superficial SSI in bivariate (p = 0.044, OR: 2.96, 95% CI: 1.03–8.50) and multivariate (p = 0.022, OR: 4.70, 95% CI: 1.25–17.70) analysis. In patients with chronic alcohol use, acute intoxication further increased the risk of superficial SSI (p = 0.036, OR: 11.05 95% CI: 1.85–65.86). Significant risk factors for overall infection in multivariate analysis also included smoking (p = 0.007, OR: 2.30, 95% CI: 1.26–4.20), compartment syndrome (p = 0.023, OR: 2.75, 95% CI: 1.15–6.58), and severity of open fracture (p = 0.003, OR: 1.57, 95% CI: 1.16–2.12).
Conclusion: Alcohol intoxication and chronic alcohol use were significant risk factors for superficial SSI in patients with open tibia fractures, with compounded risk when both were present. These findings highlight the increased risk of superficial SSI and delayed wound healing in this high-risk population. To the authors’ knowledge, this study presents the first investigation into the relationship between acute alcohol intoxication and SSI in orthopaedic trauma.
Fixation of Glenoid Fractures Results in Low Rates of Conversion to Arthroplasty and Excellent Patient Reported Shoulder Outcomes
Patrick McGlone, MD; Michael Ambrose, BS; Austin Chiu, BA; Asher Gruver-Williams, MS; Alexander Wise, BS, MS; Karli Marie Funk, PT, DPT, MS; Brian Shear, MD; Nathan O'Hara, PhD, MHA; Robert V O'Toole, MD; Andrew Eglseder, MD
Purpose: Few studies have examined the outcomes of glenoid fractures after open reduction and internal fixation (ORIF). We hypothesized that the fixation of glenoid fractures would result in infrequent secondary surgeries and acceptable shoulder function scores.
Methods: This case series identified all surgical intra-articular glenoid fractures treated at a single tertiary trauma institution from 2007 to 2024. The primary outcome was an unplanned reoperation. A subset of patients was contacted for a secondary measure of shoulder function (the Single Assessment Numeric Evaluation [SANE] score, a validated outcome scoring from 0 [worst] to 100 [best]). We used descriptive statistics for the outcomes and assessed demographic differences between shoulder function respondents and nonrespondents.
Results: The study included 113 patients (mean age, 40 years, 78% male) with a median follow up of 9.5 years. The risk of unplanned reoperation in our study population was 15.9% (95% CI: 10.3%–23.8%), with 18 patients undergoing unplanned secondary surgery related to the first surgery. The most common secondary procedure was the removal of hardware (n = 6). Only two patients (1%) required eventual shoulder arthroplasty, one for rotator cuff arthropathy, and one with an associated proximal humerus fracture-dislocation from the initial injury. The median SANE score was 95 (interquartile range, 75–100), with no significant difference in the demographics of respondents versus nonrespondents.
Conclusion: To our knowledge, this is the largest series reported of intra-articular glenoid fractures treated surgically. The risk of reoperation was only 15.9%, consistent with previous small case series reporting complication rates of 9% to 18%, and only 1% of patients at midterm had been converted to total joint arthroplasty for arthritis. Long-term patient-reported outcome scores are excellent (median 95) and better than elective arthroplasty (median 78), arguing that attempted fixation of these complex fractures results in favorable outcomes with a low complication profile.
Radiographic Union Scoring for Humeral Shaft Fracture (OTA/AO 12) Predicts Non-Operative Treatment Failure
Don T Li, MD, PhD; Joseph Kahan, MD; Kristin Yu, MD; Rodney Arthur, MD; Erin Stockwell, MD; Laurence B Kempton, MD; Brad J Yoo, MD; Christopher Schneble, MD
Purpose: The purpose of this study is to develop a model that calculates the probability of nonoperative treatment failure in humeral shaft fractures (OTA/AO 12) based on 6- and 12-week modified Radiographic Union Scores (mRUS) and assess predictive capabilities of risk factors for failure of nonoperative treatment of these fractures.
Methods: This is a retrospective review of all patients ≥18 years with isolated OTA/AO 12 fractures treated nonoperatively for at least 12 weeks at two Level I trauma centers from 2011 to 2018. Nonoperative management was considered successful if both clinical and radiographic union was documented. Nonoperative treatment failure was defined as concurrent fracture site mobility and lack of interval callus formation on radiographs beyond 12-week follow up. Patient, fracture, and treatment characteristics were collected. Blinded mRUS values were calculated at 6- and 12-week follow up. Inter- and intraobserver reliability was assessed via Intraclass Correlation Coefficients (ICC). All variables were tested for multicollinearity, with mRUS scores indicating a strong correlation necessitating individual models for each time point. A bootstrapped backward selection binary logistic regression analysis was performed individually for both 6- and 12-week mRUS values. This was then used to calculate predicted outcome probabilities based on score magnitudes.
Results: A total of 102 patients was included in final analyses; nonoperative treatment failed in 26 patients. Excellent interobserver (ICC = 0.85) and intraobserver (ICC = 0.94) agreement of mRUS values was demonstrated. In multivariate analysis, mRUS was the only predictor for failure of nonoperative management. Age (p = 0.956), body mass index (BMI, p = 0.908), tobacco use (p = 0.305), diabetes (p = 0.389), and fracture type (p = 0.181) did not correlate with nonoperative fracture union. At 6-week follow up, mRUS<7.5 demonstrated increased risk of nonoperative failure (OR = 3.3; CI: 1.9–5.6; p<0.001) with sensitivity 72.3%, specificity 83.8%, positive predictive value (PPV) 58.6%, negative predictive value (NPV) 92.5%, and 82.3% accuracy. At 12-week follow up, mRUS<9.5 demonstrated increased risk of nonoperative failure (OR = 18.2; CI: 2.8–111.4; p<0.001) with sensitivity 96.2%, specificity 93.0%, PPV 83.3%, NPV 98.5%, and 93.8% accuracy.
Conclusion: 6- and 12-week mRUS scores are predictive of nonoperative treatment failure in patients with isolated OTA/AO 12 fractures, with 12-week scores being more discriminative.
Primary Versus Salvage Total Elbow Arthroplasty for Treatment of Distal Humerus Fractures
Niloofar Dehghan, MD, MSc, FRCSC; Divya Jeyasingh, BSc; Tony Hyunh, MD; James Moore Dunwoody, MD, FRCSC; Laura schemitsch, JD; Michael D McKee, MD
Purpose: Distal humerus fractures in the elderly can be treated with open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA). TEA is a viable option for elderly patients with comminuted intra-articular distal humerus fractures; however, there are concerns regarding longevity and complications, bringing up the question of whether there is any benefit or harm in attempting ORIF first and performing a salvage TEA later in case of ORIF failure. The aim of this study is to investigate differences in reoperation rates between primary TEA for distal humerus fractures compared to salvage TEA following a failed ORIF.
Methods: This is a retrospective study conducted at two large health systems. Patients were included if they underwent TEA for treatment of an acute distal humerus fracture (<40 days from time of injury) or TEA for treatment of a failed ORIF. Data were retrospectively collected and analyzed. We hypothesized that salvage TEA would be associated with a higher rate of revision surgery.
Results: A total of 116 patients was identified: 68 underwent primary acute TEA for treatment of their distal humerus fracture, while 48 had salvage TEA after a failed ORIF (mean age: 73 years, 81% female). The mean age in the primary TEA group was 76 years, which was significantly higher than the mean age of 68 in the salvage group (p<0.001). The rate of revision TEA was significantly higher in the salvage TEA group (11 of 48, 23%) compared to the primary TEA group (4 of 68, 6%, p = 0.007). There were also more subsequent unplanned surgeries in the salvage group compared to the primary TEA group (29 vs 14, p = 0.04). The rate of aseptic loosening requiring revision TEA trended toward significance in the salvage group (13% vs 3%, p = 0.11).
Conclusion: To our knowledge, this is the largest study comparing primary acute TEA to salvage TEA for the treatment of distal humerus fractures. Patients undergoing salvage TEA had significantly higher rates of revision arthroplasty as well as total unplanned reoperation procedures. In these elderly patients, a primary TEA may be a better approach than an attempt at ORIF and later conversion to TEA.
Do We Need Such Large Implants on the Diaphyseal Ulna? Outcomes of 2.7 mm Versus 3.5 mm Plating
Jody Law, MD; Christopher Lin, MS, BS; Kenneth Brinson, BS; Lawrence Henry Goodnough, MD, PhD; Michael J Gardner, MD; Julius A Bishop, MD
Purpose: Diaphyseal ulna fractures comprise a significant proportion of traumatic injuries to the upper extremity. Traditionally, these fractures have been treated with 3.5-mm plates; however, these are often symptomatic and can lead to large stress risers after implant removal. The purpose of this study was to compare 2.7-mm plating to 3.5-mm plating for open reduction and internal fixation of diaphyseal ulna fractures.
Methods: A retrospective review of consecutive patients treated surgically for a displaced diaphyseal ulna fracture using either 2.7-mm or 3.5-mm dynamic compression style plates over a 10-year period was conducted. Patients who had a minimum 12 weeks of clinical follow up were evaluated for union outcomes, complications, and need for reoperation.
Results: A total of 135 patients met criteria for inclusion, with 61 patients treated with 2.7-mm plate fixation and 74 patients treated with 3.5-mm plate fixation. The overall rate of union was 94%. When comparing 2.7-mm and 3.5-mm plating, there was no significant difference in rates of union (2.7 mm: 96.7%; 3.5 mm: 91.2%) or rate of elective implant removal (2.7 mm: 6.6%; 3.5 mm: 12.2%). However, the 3.5-mm plate group had a significantly higher rate of total postoperative complications (2.7 mm: 3.3%; 3.5 mm: 18.9%; p = 0.005), more superficial infections (2.7 mm: 0%; 3.5 mm: 6.8%; p = 0.0386), and more unplanned returns to the operating room (2.7 mm: 0%; 3.5 mm: 6.8%; p = 0.0386). In regression analysis, 3.5-mm plating, vascular injury, AO/OTA C fractures, and open fractures were all associated with increased complication rates.
Conclusion: In the treatment of diaphyseal ulna fractures, 2.7-mm plating was associated with equivalent union rates, lower complication rates, and a decreased incidence of additional surgery when compared to 3.5-mm plating. Surgeons should consider 2.7-mm plating to be a safe and efficacious alternative to the historical gold standard of 3.5-mm plating.
Contemporary Analysis of Revision and Resection Rates in Radial Head Arthroplasty Used in Elbow Trauma
Amelia R Goldstein, BS; Benjamin William Padon, BA; Chloe Cecile Fong, BA; Benjamin Hammond, B.S.; Sanjit Reddy Konda, MD; Abhishek Ganta, MD; Kenneth A Egol, MD; Nirmal C Tejwani, MD, FRCS
Purpose: Radial head arthroplasty (RHA) is a widely accepted treatment of complex radial head fractures and associated injuries. Despite extensive use, combined rates of radial head prosthetic removal/revision have been reported to be near 22.7%. This study aimed to report rates based on the use of modern implants and techniques.
Methods: A retrospective analysis was conducted on patients undergoing radial head replacement for isolated, comminuted radial head fractures or those in association with a terrible triad injury or Monteggia fracture variant with press-fit modular impacts between 2012 and 2024. Inclusion criteria included 6 months or more of follow up. Demographic variables and surgical outcomes (fracture-related infection (FRI), nerve injury, periprosthetic fracture, removal of hardware (ROH)/revision surgery) were collected and analyzed. Elbow range of motion (ROM) and patient-reported measures were documented at last follow up.
Results: In total, 281 patients with 281 RHAs were analyzed. The cohort demonstrated an overall ROH/revision surgery rate of 6.70% (mean follow up: 11.9 ± 13.8 months). Postoperative nerve injuries were documented in 21 patients (7.4%), comprising 12 ulnar nerve neuropathies, five posterior interosseous nerve neuropathies, and four radial nerve neuropathies. Additional complications included FRI in 2.69%(n = 8) and periprosthetic fracture in 0.53% (n = 2). Table 1 shows patient-reported measures and ROM data.
Conclusion: This study, representing the largest individual analysis of RHA to date, indicates a relatively low rate of ROH/revision surgery at 6 months or more postoperatively.
Mid-Term Patient-Reported Outcomes Following Use of the Internal Joint Stabilizer for Unstable Injuries of the Elbow
Mitchell K. Ng, MD; Paul G. Mastrokostas, BA; Jake Schwartz, MD; Kevin Kang, MD
Purpose: This study aims to evaluate the midterm functional outcomes and complications associated with the Internal Joint Stabilizer of the Elbow (IJS-E) for managing elbow instability, particularly in patients with terrible triad injuries.
Methods: This retrospective cohort study was conducted at a single Level I trauma center. Patients treated with the IJS-E for elbow instability between June 2016 and July 2024 were identified through a review of institutional medical records. Inclusion criteria consisted of traumatic elbow injuries requiring stabilization with the IJS-E, while exclusion criteria included incomplete clinical records and prior stabilization with external fixators. The primary outcomes assessed were Disabilities of the Arm, Shoulder, and Hand (DASH) scores, IJS-E implantation duration, and the incidence of subsequent surgical procedures. Descriptive statistical analyses were performed to summarize patient characteristics and outcome measures.
Results: The study included 24 patients with a mean age of 51.7 years (range: 19–79 years) at the time of surgery. The median IJS-E implantation duration was 96 days, with a mean of 97.6 days (range: 41–171 days). The median follow-up period was 46.8 months, with a mean of 50.3 months (range: 5.0–93.2 months). Functional outcomes assessed using DASH scores showed a mean of 18.8 and a median of 6.3. One patient experienced complications requiring two additional procedures, including hardware removal with joint debridement and interposition arthroplasty. Another patient underwent elbow arthrotomy with capsular excision at 212 days.
Conclusion: The IJS-E offers an effective treatment option for managing elbow instability, particularly in complex injuries such as terrible triad patterns. Functional outcomes, as demonstrated by DASH scores, indicate a reduction in disability compared to traditional methods, while the low rate of reoperations and complications underscores the safety and reliability of the device. These findings highlight the potential of the IJS-E as a viable alternative to external fixation, supporting its broader application in orthopaedic trauma care.
Does Indomethacin Cause Nonunion When Used for HO Prophylaxis After ORIF of Distal Humerus Fractures?
Utku Kandemir, MD; Chloe Dlott, MD
Purpose: Open reduction and internal fixation (ORIF) is the standard of care for displaced distal humerus fractures in adults. One of the common problems associated with distal humerus fractures is heterotopic ossification (HO), and it is reported to occur in up to 49% of patients. HO is commonly associated with decreased range of motion (ROM). Indomethacin can be used after surgical treatment of distal humerus fractures; however, as a nonsteroidal anti-inflammatory medication, it may complicate fracture healing and may cause nonunion of the fracture. The effect of indomethacin on fracture union in distal humerus fractures has not been reported previously. The purpose of the study was to report the radiographic and clinical outcomes of patients with distal humerus fractures treated with ORIF and indomethacin postoperatively.
Methods: Patients older than age 18 years treated for distal humerus fracture with ORIF with a minimum follow up of 6 months were included in the study. All patients were placed on 75 mg of indomethacin PO once a day postoperatively for 6 weeks. The arm was placed in a sling for comfort postoperatively. Full active and active-assisted ROM was started on postoperative day 1. Weightbearing was started after fracture union. All patients were followed at 2, 6, and 12 weeks, 6 months, 1 year, and annually afterward. A retrospective review was performed and the following data were collected: age, gender, history of HO, associated injuries, fracture type per OTA classification, type of surgical exposure, union at 3 and 6 months, time to union, loss of reduction, failure of fixation, wound healing problems, infection, and ROM of elbow and forearm.
Results: The study included 87 patients (mean age: 48 years [range: 24–74 years]). Most fractures were intraarticular (OTA classification: six patients, Type 13A; 15 patients, Type 13B; and 44 patients, Type 13C). Mean follow up was 19 months (range 12–56 months). A posterior paratricipital approach with olecranon osteotomy was used in 42 patients, a posterior paratricipital approach (without osteotomy) in 36 patients, and a lateral approach in nine patients. There was no nonunion of the distal humerus or osteotomy site. Type I HO occurred in nine patients and Type II HO in 6 patients. Osteotomy fixation failed in one patient in 2 weeks, requiring revision. There were no infection or wound-healing problems. The mean elbow extension was 8°; mean elbow flexion was 132°. Mean forearm supination was 69° and mean forearm pronation 77°.
Conclusion: Nonunion did not occur when indomethacin was used for prophylaxis against HO after ORIF of distal humerus fractures. Good to excellent ROM of elbow and forearm was also achieved using a standard aggressive protocol.
Single Mini-Fragment Plate Fixation for Displaced Midshaft Clavicle Fractures May Be Associated With Higher Rates of Reoperation
Andrew J Laychur, MD; Sean Cannizzaro, MD; Timothy J Hartman, MD; Michael Flood, MD; Rohan Patel, BS; Matthew Patrick Sullivan, MD
Purpose: Displaced midshaft clavicle fractures are common injuries. Questions remain regarding the optimal method of surgical fixation. Previous studies have shown a possible reduction in reoperation rate with the use of dual plate fixation compared to single plate fixation. The goal of this study was to assess risk for reoperation based primarily on fixation method including use of single or double plating techniques and/or mini or small fragment plates.
Methods: A retrospective query of all adult patients who sustained displaced midshaft clavicle fractures from 2016 to 2020 at a single Level I trauma center was performed. Patients with a minimum follow up less than 1 year were excluded. Remaining patients were stratified into two groups based on presence or absence of reoperation as indicated for either symptomatic hardware or mechanical failure. Demographics, fracture characteristics, and fixation method including plate number and configuration were compared between groups in the form of a retrospective case control study.
Results: A cohort of 173 patients (mean age: 42.6 ± 15.7 years) was identified with mean follow up of 54.5 ± 22.7 months. A total of 24 patients underwent reoperation. Patients who underwent fixation with a single plate neared significance for increased risk of reoperation compared to dual plate configurations (OR: 3.46; 95% CI: 0.99–12.2; p = 0.053). On subgroup analysis, patients who underwent fixation with a single anterior mini-fragment 2.7 mm plate compared to dual mini-fragment plates had 6.70 times increased odds of reoperation (95% CI: 18.4–24.4; p = 0.004). Of patients (n = 16) who underwent reoperation with index surgery including a single mini-fragment plate, 50% underwent revision for symptomatic hardware while the other 50% underwent revision for mechanical failure.
Conclusion: Patients who sustain displaced midshaft clavicle fractures and undergo surgical fixation with a single mini-fragment plate (2.7 mm) may be at an increased risk for return to the operating room for revision surgery. Indications for revision surgery may include both symptomatic hardware and mechanical failure. Further study of these findings may guide both surgeons and patients in surgical management of these injuries.
Cost Comparison Between Open Reduction and Internal Fixation and Non-Operative Management for Ulnar Diaphyseal Fractures
Herman Singh Johal, MD MPH; Paul Duffy, MD; Andrew Dodd, MD; Robert Korley, MDCM; Kim Rondeau, MSc; Prism Schneider, MD, PHD, FRCSC; Canadian Orthopaedic Trauma Society
Purpose: Providing value-based care has become increasingly important; therefore, there is a need for cost-benefit assessments to inform surgical decision-making. Prior studies have reported on earlier functional recovery and reduced complication rates for patients with ulnar diaphyseal fractures treated with open reduction and internal fixation (ORIF) compared to nonoperative treatment. This study aimed to complete a cost analysis comparing the differences in direct and indirect costs between ORIF and nonoperative treatment relative to the improvement in functional outcome scores for patients with isolated ulnar diaphyseal fractures.
Methods: This is an a priori planned secondary analysis from a large randomized controlled trial comparing ORIF (plate and screws) with nonoperative treatment (below-elbow casting) for ulnar diaphyseal fractures. A cost analysis was completed using data on costs and outcomes from the trial, including both direct costs of care (implant costs, hospital stay, readmissions, complications) as well as indirect costs (time off of work). Change in the Disabilities of the Arm, Shoulder, and Hand (DASH) functional outcome scores was used to quantify effectiveness, with a minimal clinically important difference (MCID) of 10 used as a threshold for clinically significant improvement. Costs and outcomes were captured over a 1-year period. A Monte Carlo model was used to generate incremental cost-effectiveness ratios, using a probabilistic sampling strategy.
Results: In total, 99 participants were included across 11 participating sites (mean age: 41.0 years; male: 73% ). Overall average direct and indirect costs for the ORIF group were $21,332.95, while overall average costs for the nonoperative group were $23,470.19. Overall change in the DASH score for the ORIF group was 13.8, while the overall change for the nonoperative group was 6.9 points. When combined, this resulted in an incremental cost-effectiveness ratio of $325.05 per point improvement in DASH, or $3,250.51 less costly to obtain a clinically important improvement in a DASH functional outcome score with ORIF.
Conclusion: Using traditional thresholds, ORIF of isolated ulnar diaphyseal fractures would be considered a cost-effective treatment option. This study supports a shared decision-making approach that includes consideration for early functional benefit and cost savings with ORIF.
Rotator Cuff Tears Between Various Treatment Groups for Those Patients With A Humeral Shaft Fracture
Neil Werthmann, MD; John Riehl, MD; Mason Poffenbarger, MD; Kyle Patrick O'Connor, MD
Purpose: Humeral shaft fractures are commonly treated nonsurgically, with open reduction and internal fixation (ORIF), and with intramedullary nailing (IMN). Each of these treatments has advantages and disadvantages. One concern surgeons have raised with IMN is its effect on the rotator cuff (RC). The aim of this study is to compare rates of rotator cuff tear (RCT) among nonsurgical (NS), ORIF, and IMN within 24 months of treatment.
Methods: Data were collected retrospectively through an institutional database, and 4117 patients age 18 years and older with humeral shaft fractures were identified. Patients were categorized into NS, ORIF, and IMN treatment groups. The primary outcome of the study was RCT within 24 months as well as infection, radial nerve injury, and nonunion. Demographic information, smoking status, and open fracture status were recorded.
Results: In total, 3008 ORIF patients, 627 IMN patients, and 482 NS patients were identified. RCT within 24 months was not significantly associated with the treatment modality (p = 0.8993). The ORIF group experienced RCT in 20 (0.67%) patients, 4 (0.64%) in the IMN group, and 2 (0.42%) in the NS group. Infection was statistically significant and occurred at a rate of 0.83% (4/482) in the NS group, 1.66% (50/3008) in the ORIF group, and 0.48% (3/627) in the IMN group (p = 0.0354). Radial nerve injury occurred at a rate of 0.02% (1/482) in the NS group, 1.33% (40/3008) in the ORIF group, and 0.96% (6/627) in the IMN group (p = 0.0673). The nonunion rate was 2.28% (11/482) in the NS group, 2.03% (61/3008) in the ORIF group, and 2.87% (18/627) in the IMN group (p = 0.4174).
Conclusion: The findings of the current study suggest there is no increased incidence of RCT with humeral IMN compared to ORIF and NS treatment of humeral shaft fractures at 24 months postoperatively. The IMN treatment group also demonstrated lower rates of complications including infection and radial nerve palsy compared to ORIF. The IMN treatment group experienced a similar rate of nonunion compared to the other treatment groups. IMN is a safe and effective treatment option in humeral shaft fractures.
Quality of Surgical Technique in Patients With a Humeral Shaft Fracture in the HUMMER Study: An International Survey Among Expert Surgeons
Dennis Den Hartog, MD PHD; Leendert HT Nugteren, BSc; Esther MM Van Lieshout, PhD MSc; Michael Verhofstad, MD, PhD, FIOTA; HUMMER Expert panel
Purpose: Operative treatment for a humeral shaft fracture is superior over nonoperative treatment. It is undetermined whether quality of surgical technique affects outcomes. The aim of this study was to evaluate quality of surgical technique performed in patients with a humeral shaft fracture and to assess if quality was associated with complications and (functional) outcomes.
Methods: Upper extremity experts assessed surgical technique in patients who participated in the HUMMER study. The surgical technique was well performed if the expert considered that it (at least) adhered to the AO principles. Consensus on quality of surgical technique was achieved through a structured survey. When consensus was not reached, patients were discussed in an expert panel discussion. Surgical technique (good, sufficient, or poor) was linked to functional outcomes, complications, and reoperations. Outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH), CMS, pain (VAS), quality of life (SF-36, EQ-5D), and range of motion (ROM).
Results: Among 245 surgically treated patients, a panel of 16 orthopaedic trauma surgeons from seven countries classified 81.6% of plate cases and 59.8% of intramedullary nailing (IMN) cases as well-performed or sufficient-performed. Compared to a poor-performed technique, CMS, shoulder abduction, forward flexion, external rotation, and elbow pronation-supination displayed a significant treatment effect (ptreatment<0.05) and faster improvement of the DASH score (pinteraction = 0.014) and pain levels (pinteraction = 0.034), in favor of a well-performed technique. Performance of the surgical technique seemed unrelated to quality of life, complication rates, reoperations, and nonunion. Compared to nonoperative treatment, well-performed surgery had superior functional outcomes and lower complication (16.0% vs 34.5%, p = 0.019) and nonunion rates (2.5% vs 26.3%, p<0.001). These differences were less emphasized for poor-performed operations.
Conclusion: Well-performed surgical technique leads to faster functional recovery, improvement of ROM, and fewer complications than poor technique. Although operative treatment is superior to nonoperative treatment, this is particularly demonstrated when the surgery is performed well after assessment of the experts. In cases of poor-performed surgical technique, the benefits of operative treatment over nonoperative treatment are less pronounced, emphasizing the crucial role of the quality of surgical technique in achieving optimal outcomes.
Regional vs General Anesthesia Outcomes in Reverse Total Shoulder Arthroplasty
Michael Coons, BA; Benjamin William Padon, BA; Kenneth A Egol, MD
Purpose: The purpose of this study is to evaluate the efficacy of a regional block compared with general anesthesia for reverse total shoulder arthroplasty (RTSA) procedures.
Methods: This retrospective study evaluated 527 RTSA cases performed at a single academic center over the last 10 years. Patients were grouped into one of two cohorts: ‘Regional’ or ‘General’, based on the anesthesia type used in their operation. Outcomes included intraoperative complications, postoperative pain levels, postoperative nausea and vomiting (PONV), length of surgery, length of admission, and need for readmission and revision surgery.
Results: All regional anesthesia cases were completed successfully without conversion to general anesthesia. There was no significant difference in intraoperative complication rates between regional and general groups (1.2% vs 0%, p = 0.35). Additionally, there was no group difference with regard to postoperative pain (p>0.5), PONV (p>0.5), readmission (p = 0.5), or need for revision (p = 0.5). The regional group did experience significantly shorter average length of surgery (112 min vs 141 min, p<0.001) and average length of admission (49.1 hr vs 54.3 hr, p = 0.02) than the general anesthesia group.
Conclusion: Our study demonstrates that the use of regional anesthesia in RTSA is safe and confers similar outcomes to the use of general anesthesia while decreasing length of surgery and length of admission. These results may be interpreted as a higher quality approach.
Comparison of Dynamic Hip Screw and Proximal Femoral Nail in Cases of Unstable Intertrochanteric Fractures of the Femur, in terms of Blood Loss and Operative Time: Experience in a Tertiary Care Hospital
Syed Faraz Anwar, MBBS,FCPS (Surg), FCPS (Ortho)
Purpose: Our objective was to compare the dynamic hip screw with the proximal femoral nail in unstable intertrochanteric femur fractures.
Methods: A quasi-experimental study by the Department of Orthopaedic Surgery, Combined Military Hospital, Malir Cantonment, Pakistan, was held from December 2020 to August 2021. This study comprised patients age 40 to 80 years with unstable intertrochanteric proximal femoral fractures (AO Classification 31A2, 31A3). Patients were randomized into two groups: group A patients underwent dynamic hip screw fixation and group B patients underwent proximal femoral nailing. Follow up was done at 2, 6, and 12 weeks postoperatively. Two variables, surgical time and blood loss, were evaluated.
Results: In total, 36 patients were recruited in this study with 18 patients in each group. The average blood loss for group A was 193.3 ± 29.10 mL and for group B 79.44 ± 17.98 mL (p<0.001). Average surgical time for group A was 51.56 ± 7.76 minutes and for group B 36.89 ± 3.66 minutes (p<0.001).
Conclusion: Proximal femoral nailing is a better choice in unstable proximal femoral fractures regarding surgerical time and blood loss.
Low Middle-Income Country (LMIC) Setting: Is Low Vitamin D Associated With Fracture Risk in Children Younger Than 18 Years?
Shahryar Noordin, MBBS, FCPS, FACS; Mohammad Khozema Safri, MBBS; Andrew Howard, MD, FRCSC; Zulfiqar Bhutta, MD
Purpose: The purpose of this study was to assess the relationship between low vitamin D and fracture risk in children younger than age 18 years.
Methods: A matched case-control study was conducted, recruiting patients from Jinnah Postgraduate Medical Centre and controls from the National Institute of Child Health, Karachi, Pakistan. Patients included were children with lower or upper extremity fractures, while controls were pediatric outpatients with non-orthopaedic complaints, matched by age, gender, and nutritional status.
Results: In total, 287 patients were matched to 204 controls from April 2024 to January 2025. Serum 25(OH)D levels were significantly lower in the patients with fractures (20.1 vs 13.3 nmol/L), with an adjusted odds ratio (AOR) of 0.93 (95% CI: 0.88–0.99, p = 0.031). Dietary analysis showed no significant link between buffalo milk consumption and fracture risk. Single vitamin D supplementation lowered the fracture risk (AOR: 0.27, 95% CI: 0.12–0.58, p<0.001), while multivitamin use was associated with a higher fracture risk (AOR: 43.2, 95% CI: 13.3–140, p<0.001). Low serum calcium (AOR: 0.16, 95% CI: 0.09–0.29, p<0.001) and low serum creatinine (AOR: 0.02, 95% CI: 0.00–0.18, p<0.001) were associated with fractures.
Conclusion: Vitamin D deficiency is significantly associated with pediatric fractures in LMICs, and single-vitamin D supplementation reduces fracture risk.
Clinical and Radiological Outcome of Lumbopelvic Fixation in Unstable Isler Class II and III Sacral Fractures
Umair Nadeem, FCPS Orthopedic Surgery
Purpose: Many sacral fractures can be treated nonoperatively. Unstable sacral fractures, usually as part of a pelvic ring injury and those with neurologic involvement, need surgical fixation. Iliosacral screws, tension band ilio-iliac plating, and transiliac bars can be used in sacral fractures not compromising the lumbosacral articulation (Isler I). Fractures entering the L5–S1 facets (Isler II) and those entering the lumbosacral spinal canal (Isler III) need lumbopelvic fixation for proper biomechanical stability. The purpose of this study was to evaluate clinical and radiologic outcomes of lumbopelvic fixation in unstable Isler class II and III sacral fractures.
Methods: A prospective cohort study was held at Ghurki Trust Teaching Hospital Lahore from January 2019 to December 2020. All patients with unstable Isler II and III sacral fractures were recruited for this study. Lumbopelvic fixation using a posterior triangular osteosynthesis (PTO) construct was performed in all patients. Patients were evaluated clinically and radiologically, including full lumbopelvic radiographs and 3D CT scans during the pre- and postoperative periods. Clinical parameters included a full neurologic examination, visual analog scale (VAS), and oxygen desaturation index (ODI).
Results: In total, 13 (8 males, mean age: 26 ± 9.4 years) patients were recruited for this study. All patients had unstable sacral fractures; seven had Isler II and six had Isler III fractures. Sacral fracture was part of a pelvic ring injury complex in 10 patients. Neurology was disturbed in nine patients. The mean follow up period was 20.1 ± 9.6 months. The mean preoperative VAS improved from 9.2 ± 2.4 to 2.2 ± 1.3 postoperatively, while the mean preoperative ODI improved from 86.5 ± 5.6 to 14.5 ± 5.1 postoperatively. Fracture healing was radiologically complete in all patients and none needed revision. Residual deformity was present in 33% of patients with no clinical import. Superficial surgical site infections (SSI) occurred in two patients who were treated uneventfully with antibiotics.
Conclusion: Lumbopelvic fixation is a useful procedure in the treatment of unstable Isler II and III sacral fractures with satisfactory clinical and radiologic outcomes.
A Retrospective Cohort Study of Holosight Robot-Assisted Percutaneous Minimally Invasive Surgery in the Treatment of Pelvic Fractures
Changchun Fan
Purpose: Our objective was to compare the curative effects of Holosight robot-assisted percutaneous minimally invasive surgery and traditional closed reduction and fixation surgery for pelvic fractures.
Methods: This retrospective cohort study includes 31 cases of Holosight robot-assisted percutaneous minimally invasive surgery and 21 cases of traditional closed reduction and fixation surgery for pelvic fractures at the department of traumatic orthopaedics in Jinan Third People's Hospital. The patients were divided into two groups: the robot group and the traditional group. Follow up was conducted from February to December 2023. The Majeed score, a quantitative evaluation system for fractures, was used to compare postoperative functions in pain, sitting, standing, walking, and daily life between the two groups.
Results: The differences in operation time, intraoperative bleeding, the number of guide pin implantations, and the number of fluoroscopies between the two groups were statistically significant (P<0.01). However, there was no statistically significant difference in fracture healing time and Majeed scores at the last follow up.
Conclusion: Holosight robot-assisted percutaneous minimally invasive fixation surgery can independently plan the surgical path. Compared to the traditional method, it requires fewer adjustments of the guide pin, has a shorter operation time, and results in less intraoperative bleeding. There is no significant difference in postoperative functional recovery and fracture healing time, indicating a satisfactory clinical effect.
Fractures of the Diaphysis of the Humerus: Our Therapeutic Vision
Horacio Tabares, MD; Horacio Tabares Saez, MD
Purpose: Fractures of the humeral shaft are relatively common, accounting for approximately 1% to 5% of all fractures. The annual incidence ranges between 13 and 20 per 100,000 people and is higher with age. The purpose of this work is to show the results obtained in fractures of the humeral shaft through minimally invasive fixation with a fine intramedullary nail (Steinmann) and a monopolar external fixator.
Methods: In a prospective descriptive study from January 2018 to August 2023, patients with humerus fractures were treated by osteosynthesis with a fine intramedullary nail (Steinmann) and a monopolar external fixator. Patients were followed up 6-months postoperatively.
Results: In total, 103 humeral shaft fractures were treated. AO/OTA classifications were as follows: 47 type A (21 were 12A1, 15 were 12A2, and 11 were 12A3); 31 type B (19 were 12B2 and 12 were 12B3). The remaining 25 fractures were type C (14 were 12C2 and 11 were 12C3). In some cases, basically in groups 12B and 12C, increased interfragmentary compression was required after 6 to 8 weeks because little bone callus was visible on radiographs. Consolidation was achieved in 98% of patients between 12 and 16 weeks without presence of neurologic injury (radial nerve); functional recovery of the scapulohumeral joint was complete in all patients.
Conclusion: Minimally invasive osteosynthesis of humeral shaft fractures with a closed fine intramedullary nail and a monopolar external fixator produces good results related to bone consolidation and scapulohumeral functional recovery in a relatively short time.
Continuous Local Antibiotics Perfusion (CLAP) on Treatment Efficacy in Fracture-Related Infections: A Multi-Center Study
Shunsuke Takahara, MD, PhD; Yukichi Zenke, PhD.; Daisuke Himeno, MD, PhD; Shinnosuke Yamashita, MD, PhD; Masahiro Matsumoto, MD; Yasuaki Yamakawa, PhD, MD; Hokuto Morii, MD, PhD; Keisuke Oe, MD, PhD; Takahiro Niikura, MD, PhD; Akihiro Maruo, MD, PhD
Purpose: Fracture-related infections (FRI) remain a challenging problem in orthopaedic trauma surgery. In recent years, continuous local antibiotic perfusion (CLAP), which involves the direct infusion of a highly concentrated gentamicin solution into infected intramedullary canals and/or soft tissues, has emerged as a promising treatment that offers potential advantages over traditional local antibiotic delivery. This study aimed to evaluate the efficacy of CLAP in patients with FRI.
Methods: This retrospective cohort study was conducted at ten institutions and included 169 patients who underwent surgical treatment for FRI between 2019 and 2022 with a follow-up period of at least 1 year. The mean age of the patients was 53.1 years (range: 13–90 years). The primary outcome was the success rate of infection control, and the secondary outcomes included the recurrence rate and incidence of acute kidney injury (AKI). Patients were divided into two groups based on whether CLAP was performed: the CLAP group and the non-CLAP group. Univariate analysis was conducted to compare variables between the two groups. Multivariate analysis was performed with primary and secondary outcomes as dependent variables.
Results: The success rate was significantly higher in the CLAP group than that in the non-CLAP group (86% vs 71%, p = 0.03). The recurrence rate was significantly higher in the non-CLAP group (13% vs 32%, p = 0.003). There was no significant difference in the incidence of AKI between the two groups (p = 0.6). In multivariate analysis, CLAP was significantly associated with the success rate of infection control (OR: 3.6, 95% CI: 1.37–9.42, p = 0.01). Furthermore, CLAP was associated with a lower rate of recurrence (OR: 3.4, 95% CI: 1.47–7.77, p = 0.004). Regarding adverse effects, CLAP was not significantly associated with AKI (OR: 1.76, 95% CI: 0.513–6.030, p = 0.37).
Conclusion: In this multi-center study of 169 FRI patients, CLAP was associated with a higher success rate of infection control and a lower recurrence rate without increasing adverse events.
Innovative Treatment for Rescue of Femoral Neck Fractures: Comparison of Two Systems
Ricardo Madrigal, MD
Purpose: The aim of this study was to compare the results of transcervical fractures treated with a dynamic system: femoral neck system (FNS), and a static system: proximal mini femoral plate (MPFP) in the preservation of the femoral head.
Methods: A prospective, randomized, comparative study was carried out in patients with intracapsular fracture (31B1, 31B2, and 31B3 OTA/AO) who underwent surgery from May 2021 through February 2024. Two groups were randomly formed for treatment: group A was treated with the FNS system and group B with the MPFP system. Clinical information (age, gender, history, type of injury mechanism, type of fracture, surgical time, surgical bleeding, initiation of partial or complete load, infections, and successful outcome or complications) was recorded in an Excel database; variables were compared between groups by means of a descriptive and inferential analysis in the SPSS statistical program. A value of p<0.05 was considered significant.
Results: Of 32 patients (19 women), 14 were treated with MPFP, and 18 with FNS. The average postfracture surgery time in the FNS group was 3 days; in the MPFP group, it was 3.5 days. Radiographs were taken to assess evolution on different occasions. There was no infection in either group. The mean time of support onset was 4 weeks in both groups. In MPFP, results were good in 65% of patients, and in FNS, results were good in 78% of patients. Patients' mean age was 71 years in the FNS group and 56 years in the MPFP group. In the FNS group, four patients had bad results (three patients with diabetes mellitus [DM] and one with depression and hypothyroidism). In the MPFP group, five patients had bad results (two with DM, two with depression, and one with obesity and who was a Jehovah’s Witness).
Conclusion: Significant differences were found between the groups with better results in the FNS group. Both systems used a minimally invasive technique with minimal physiologic stress for the patient. Average bleeding was 50mL, and average surgery time was 30 minutes. A common factor in implant failure was uncontrolled concomitant diseases and depression. Both systems demonstrated adequate results regardless of the time elapsed from surgery and the patient's age. The FNS system presented similar results to those found in the literature, and the MPFP system presented better results than those found in the literature.
Aftercare Following Fatal Traumatic Injuries, Needs and Questions: A Scoping Review
Nadia AG Hakkenbrak, NH; Johan G.H. Van den Brand, JH; Sohaib Jaddi, SJ; Linda Schoonmade, LS; Frank Willem Bloemers, MD, PHD, MSc
Purpose: Fatalities due to trauma account for nearly 8% of all deaths worldwide. In the Netherlands, approximately 2000 people die each year in hospitals as a result of their injuries. The death of a loved one has tremendous emotional and socioeconomic impact. Recommendations on adequate aftercare for relatives are lacking, as there are no specific studies focusing on traumatic fatalities.
Methods: A search was conducted in Medline/Ovid, Embase.com, PsycINFO (Ebsco), and Web of Science Core Collection. Studies regarding trauma, death, aftercare, and relatives, published before February 16, 2024, were included. The studies were assessed on three topics: participants, intervention, and recommendations.
Results: In total, 1131 articles were identified, and 10 articles were selected for analysis. Eight studies included relatives, one included close friends, and another included intensive care nurses and managers. The majority of the participants were female, with a mean age, reported in four studies, ranging from 21 to 47 years. Three studies reported on suicide, three on homicide, and six did not specify the type of trauma. In four studies, a questionnaire was sent, and in six, an (in-depth) interview was conducted. The duration of the interview sessions was reported as approximately 1 hour in five studies. In four studies, the involved caregiver was a social worker, in two a bereavement consultant, in one a psychotherapist, and in two a member of the supportive care team. The time interval between death and aftercare ranged from 4 to 6 weeks (by phone) up to 1 year. In two studies that reported on bereavement support provided, support was not offered in more than one half of the cases. Support should be provided after the loss of a loved one; two studies reported this should preferably occur within 2 weeks. Implementing bereavement services led by trained professionals is recommended.
Conclusion: Structured aftercare following trauma-related deaths is advised in the current literature. Aftercare, whether by phone or face-to-face, provided by a trained professional 4 to 6 weeks after death, and repeated upon request, is recommended.
Comparative Analysis of Tibial Plateau Fractures: Ilizarov Fixator Versus Posteromedial Lobenhoffer Approach
Mohammad Sohail Rafi, FCPS; Shahzaib Riaz Baloch, MBBS, FCPS
Purpose: Our objective was to compare clinical and functional outcomes between Ilizarov circular external fixation and open reduction and internal fixation (ORIF) using the direct posteromedial Lobenhoffer approach.
Methods: In total, 88 patients with tibial plateau fractures were prospectively enrolled. Based on fracture morphology, 39 patients with isolated posteromedial/posterocentral fragments underwent ORIF via the Lobenhoffer approach; 49 patients were managed with Ilizarov external fixation. Key parameters assessed included surgical time, intraoperative blood loss, hospital length of stay, complication rates, radiographic fracture healing time, postoperative pain visual analog scale (VAS), range of motion (ROM), and functional outcomes by the Hospital for Special Surgery (HSS), Knee Society Score (KSS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 and 12 months.
Results: The Lobenhoffer approach group demonstrated significantly shorter mean surgical times (p<0.05) and more blood loss compared to the Ilizarov group. Direct visualization facilitated superior anatomic reduction of posterior fragments. Consequently, patients treated with the Lobenhoffer approach exhibited significantly improved early postoperative knee ROM (p<0.01) and superior functional outcomes at both 6 and 12 months (higher HSS, KSS, and KOOS scores; p<0.05). Pain reduction (VAS) was also significantly faster in the Lobenhoffer group. Complication rates were slightly higher in the Lobenhoffer cohort (primarily superficial wound issues versus Ilizarov pin-tract infections). Final union times were comparable.
Conclusion: The posteromedial Lobenhoffer approach offers substantial advantages for tibial plateau fractures with isolated posteromedial/posterocentral involvement, including reduced surgical time and enhanced fracture reduction, accelerated restoration of knee mobility, and superior early-to-medium term functional outcomes compared to Ilizarov fixation. Limitations and Recommendations: The Lobenhoffer approach is strongly recommended as the primary surgical strategy for managing these specific complex posterior fracture patterns. Its effectiveness in achieving direct reduction and stable fixation translates to improved patient recovery and function. Further multicenter, prospective studies with longer-term follow up are warranted to confirm durability and osteoarthritis progression.
Lateral vs Posterolateral Approach for Ankle Fracture: A Comparative Analysis of Infection Rates
Mireia Gomez Masdeu, Orthopaedic Trauma Consultant; Sara Wahab Zuriarrain, Orthopaedic Trauma Consultant; Julio De Caso Rodriguez, Orthopaedic Trauma Consultant; Angelica Millan Billi, Orthopaedic Trauma Consultant; Jorge Pilco Inga, Orthopaedic Trauma Resident; Jorge Eduardo Acha Baldelomar, Orthopaedic Trauma Resident; Ion Carrera Fernandez, Orthopaedic Trauma Surgeon
Purpose: The aim of this study was to compare the incidence of fracture-related infections (FRI) of 44B AO ankle fractures following open reduction and internal fixation (ORIF) synthesis, examining the impact of the surgical approach used (lateral versus posterolateral). Secondary objectives included assessing the impact of comorbidities and surgical duration on outcomes.
Methods: We conducted a comparative, retrospective, single-center cohort study of patients who underwent ORIF for 44B AO ankle fractures between 2019 and 2024 with a minimum follow up of 3 months. Demographic, clinical, and surgical data, history of smoking, and corticosteroid therapy, as well as comorbidities such as diabetes, renal failure, or vasculopathy were obtained from the patients' clinical history. FRI was classified according to the 2018 AO Foundation/European Bone and Joint Infection Society criteria. Statistical analysis compared infection rates between approaches and evaluated associations with comorbidities using appropriate tests (χ2 tests, Mann-Whitney Test).
Results: In total, 427 patients (288 women, mean age 52 years) were included. The FRI rate was 3.3%, similar to current literature (1.4–9). For the lateral approach, the incidence of infection was 2.9% and for the posterolateral approach, it was 3.2%, a nonstatistically significant difference (p = 0.92). No significant associations were found between FRI and comorbidities: corticosteroid therapy (p = 0.2), comorbidities such as diabetes (p = 0.9), vascular disease (p = 0.4), or renal insufficiency (p = 0.2) could increase the risk of infection, which has not been demonstrated in any group. Surgical time was longer in the posterolateral approach (96 min) versus the lateral approach (75 min), which was statistically significant (p<0.05).
Conclusion: No statistically significant differences were found between the lateral and posterolateral approaches regarding the incidence of FRI in 44B AO fractures in our cohort although the posterolateral approach required longer surgical time. Comorbidities and corticosteroid use were not predictive of infection.
Determining the Impact of UK NIHR Trauma Trials Over 17 years: A Retrospective Review
Lynn Hutchings, MB BChir MSc DPhil FRCS; Caroline B Hing, FRCS MD; Xavier Griffin, FRCS PhD; Matt Costa, FRCS PhD
Purpose: The National Institute for Health and Care Research (NIHR) together with the Royal College of Surgeons of England (RCSE) research initiatives have facilitated trial delivery in orthopaedic trauma, providing funding and infrastructure to support trial development and delivery. Emphasis on conducting high-quality research to advance patient care is now well established in the United Kingdom (UK). A collaborative authorship model enabling engagement from surgeons and trainees across the UK has embedded trial recruitment within standard care.
Methods: To determine the number of NIHR trauma trials delivered, their epidemiology, and the impact from a retrospective review of 17 years of trauma trials in the UK, Clinical Trials Units delivering NIHR trauma trials were contacted to participate and results were collated across the trials.
Results: From 2008 to 2025, there were 25 national trauma trials registered for recruitment; 18 trials were completed and their results were published. Of the 18 studies published, 1330 participating collaborating authors were cited on the final publication. Completed trials included a study population ranging from the mean age of 3 to 86 years, and 24,079 patients were screened with 13,372 recruited to participate. Out of the 18 studies, all but one study, which closed early, successfully recruited to target. Studies included both upper limb (7) and lower limb (11). An additional seven trauma studies are in recruitment and follow up.
Conclusion: A culture shift in the UK has supported the successful participation of National Health Service (NHS) UK trauma surgeons in the delivery of trials with a collaborative authorship model and patient participation, including both trainees and established surgeons in the successful delivery of national trials. Support from Clinical Trials Units with regional principal investigators and associate principal investigators comprising trainees provides a network for rapid set up and delivery of interventional trauma trials.
Breakout
Traditional Fixation versus Arthroplasty for Geriatric Acetabulum Fractures: Tips and Techniques to Optimize Success
Paul William Perdue1, David Zuelzer1, Aaron J Johnson2, Jibanananda Satpathy1
1Virginia Commonwealth University Health System, 2University of Maryland
Objective 1: Identify geriatric acetabulum fracture patterns amenable to traditional open reduction and internal fixation and demonstrate techniques for successful fixation
Objective 2: Identify geriatric acetabulum fracture patterns and characteristics that may be problematic and challenging for traditional open reduction and internal fixation techniques
Objective 3: Demonstrate two different arthroplasty reconstructive strategies for management of geriatric acetabulum fractures
Management of geriatric acetabulum fractures continues to be a frequently debated topic, especially when considering traditional ORIF versus arthroplasty reconstruction. In addition to traditional low energy mechanisms, high energy injuries are becoming more common and strategies for successful treatment are vital. Despite this increasing importance, we have not had much in terms of breakout sessions on this topic at past meetings and I believe a case-based breakout session would be beneficial to the OTA membership and audience. Furthermore, with arthroplasty practices transitioning to outpatient surgery centers, arthroplasty reconstruction of these injuries is falling to the orthopaedic trauma surgeon making it even more important. To have a balanced discussion we will have one panelist focus on tips and strategies for successful traditional ORIF. Two other panelists, who are fellowship trained in both trauma and arthroplasty, will review their experiences and strategies with two different arthroplasty-based reconstruction methods.
Paul Perdue MD - introduction and eventual questions/further cases at conclusion if time allows
David Zuelzer MD - Strategies and tips/techniques for traditional ORIF of geriatric acetabulum fractures
Aaron Johnson MD, MS - Experience with Acute FAR method and tips/strategies
Jibanananda Satpathy MD - Will review experiences of "fix and replace" strategies and current cup/cage reconstruction method
Breakout
Orthopaedic Trauma Advances in the Pipeline
Arun Aneja1, Benjamin Kyle Potter2, Ida Leah Gitajn3, Roman M Natoli4, Mark Lee5, Andrew H Schmidt6
1Massachusettes General Hospital, 2University of Pennsylvania, 3Dartmouth Health, 4Indiana University, 5University of California Davis, 6Hennepin Healthcare
Objective 1: Understand Emerging Technologies: Gain familiarity with innovative approaches such as osseointegration and biphasic plating, and their potential impact on surgical outcomes.
Objective 2: Explore Diagnostic Innovations: Learn about next-generation sequencing and biomarkers for infection detection, as well as fluorescence-guided techniques for intraoperative decision-making
Objective 3: Evaluate the Translation of Innovation to Practice: Examine new tools and technologies for diagnosing and treating compartment syndrome to optimize patient care.
Orthopaedic trauma continues to present persistent clinical challenges particularly around prevention, diagnosis and treatment of mangled extremities, infection, nonunion, and compartment syndrome. While current practices have advanced, significant gaps remain in achieving consistent, optimal outcomes, particularly in cases involving severe trauma or high-risk patients. This breakout is designed to equip surgeons with critical insights into innovative solutions that are either newly available or on the horizon that address these persistent challenges. Understanding these innovations will enable surgeons to anticipate how emerging technologies can improve patient care, reduce complications, and enhance recovery. This breakout will not only provide a glimpse into the future of orthopaedic trauma care but also facilitate critical discussions on how to bridge the gap between current limitations and upcoming advancements.
Arun Aneja MD, PhD - Moderator
Benjamin Potter MD - Osseointegrated prostheses
Ida Leah Gitajn MD - Fluorescence Guided Surgical applications in Orthopaedic Trauma
Roman Natoli MD, PHD - Nex Generation Sequencing and Infection Biomarkers
Mark Lee MD - Biphasic Plates
Andrew Schmidt MD, FIOTA - New Technology in Compartment Syndrome
Breakout
Pilon Fractures: Current Controversies and Fixation Pearls
Christopher Lee1, Stephen Warner2, Lucas S Marchand3, Marcus F Sciadini4
1UCLA, 2UT Houston, 3University of Utah, 4Shock Trauma
Objective 1: Identify the advantages and disadvantages of a single versus combined approaches in the treatment of complex pilon fractures.
Objective 2: Provide tips and tricks and various surgical strategies to address complex pilon fractures and associated fibula fractures.
Objective 3: Understand the role of the hind foot fusion nail in the acute treatment of pilon fractures, and illuminate some limitations in their use.
Complex tibial plafond fractures and their associated fibula fractures remain challenging fractures to address, with complications ranging from hardware failure to infection and to end stage osteoarthritis. Although various surgical exposures have been described, the ability to address these fractures through a single versus dual approach remains nuanced. Furthermore, the advancement in implant design with respect to nails, including increased interlock options, has allowed for the expanded use of IMNs when treating these injuries. However, results with open reduction internal fixation for these challenging injuries remains somewhat poor. The recent use of hind foot fusion nails to acutely address these injuries has recently gained popularity, though their optimal use remains somewhat unclear and the long term implications with their use not entirely understood. The purpose of this symposium is to provide a case-based discussion on these topics, and provide the audience with tools to optimize success.
Christopher Lee MD - A case-based discussion highlighting the benefits and disadvantages of using a front only versus combined approach to complex pilon fractures.
Stephen Warner MD, PHD - A case-based discussion on which pilon fractures are amenable for antegrade nailing, and tips/tricks to optimize outcomes.
Lucas Marchand MD - A case-based discussion on ideal treatment strategies to address the fibula, and when to leave them alone.
Marcus Sciadini MD - A case-based discussion highlighting the use of the TTC nail in the treatment of pilon fractures, and also addressing the calamities that can occur with their use.
Breakout
Complex Elbow Fracture-Dislocations: Tip and Tricks for How to Get it Right the First Time
Jennifer Tangtiphaiboontana1, Andrew M Choo2, Jonah Hebert-Davies3, Utku Kandemir4
1Mayo Clinic, 2UT Houston, 3Harborview, 4UCSF
Objective 1: Review the various surgical approaches to address complex elbow fracture-dislocations
Objective 2: Discuss patterns of injuries and how to detect subtle nuisances of complex elbow fracture-dislocations through a case based discussion
Objective 3: Discuss surgical tips and tricks for fixing complex elbow fracture-dislocations and how to optimize success
Complex elbow-fracture dislocations are fraught with challenges such as persistent instability and/or stiffness and can be daunting to treat, especially for those who are less familiar with elbow. As a joint that requires a balance of bony and soft tissue stability, several questions often arise. Does the radial head need to be fixed or replaced? Which implant should be used? It is necessary to fix the coronoid or repair the MCL? What approach should I use to fix the coronoid? The purpose of this breakout is to provide a clear and simple way to analyze and treat these injuries. The session will also cover how to recognize associated injury patterns and nuisances that can be detected preoperatively and intraoperatively to optimize success. Through a series of short lectures and interactive case base discussions, the participants will gain more confidence and learn surgical pearls to enable them to treat these fractures.
Jennifer Tangtiphaiboontana MD - Tips and tricks for radial head fixation and radial head arthroplasty. Will also discuss how to know with a revision radial arthroplasty implant may be need in the primary setting and how to avoid missing a clinically relevant MCL injury
Andrew Choo MD - Review the various approaches to the elbow including posterior, medial, and lateral and how to decide which to use to optimize access to the fractures
Jonah Hebert-Davies MD - Discuss surgical tips and tricks on managing proximal trans-ulnar fracture, classically knowns as transolecranon or monteggia varients
Utku Kandemir MD - Discuss how to manage the persistently unstable triad including when and how to reconstruct an irreparable coronoid fracture, ligament repair/reconstruction, and when to use an ex-fx or IJS
Breakout
Strategies and Techniques in Management of Geriatric Ankle Fractures: Lets get them up and walking!
Abhishek Ganta1, Sanjit Reddy Konda1, Richard S Yoon2, David H Chafey3, Samantha Nino4
1NYU Langone Health, 2Jersey City Medical Center, 3UNM, 4IU
Objective 1: Understanding the nuances in geriatric ankle fractures with regards to fracture pattern, patient specific factors that drive treatment, and deciding when and when not to operate
Objective 2: Understanding when to modify traditional fixation methods: i.e. fusion nails, percutaneous techniques for fracture fixation, and to modify fixation to allow for early weight bearing
Objective 3: What to do in patients with bad soft tissue injury, when to formally fuse, and when to amputate.
The goal of this breakout session is to take a deeper dive into the literature as well as utilize a case based approach to address the increasing prevalence of geriatric ankle fractures. Presentations will focus on the spectrum of injury characteristics in this patient cohort and various fixation options that can be utilized to minimize complications and allow earlier weight bearing.
Abhishek Ganta MD - This portion of the breakout will address concepts in treating open geriatric fractures to minimize soft tissue complications
Sanjit Konda MD - Various percutaneous techniques in geriatric ankle fractures to minimize surgical incision size
Richard Yoon MD, FIOTA - Treatment of complex posterior malleolus fractures in the geriatric ankle population
David Chafey MD - Indications and strategies for immediate TTC fusion nailing of geriatric ankle fractures
Samantha Nino MD - This topic will address various methods for salvage in geriatric ankle fractures when fixation has failed
Breakout
Lateral Compression Pelvic Ring Injuries: Questions, Controversies and Clinical Pearls
Cyril Mauffrey1, Brandon Yuan2, Adam Boissonneault3, Michael Maceroli3, Sarah N Pierrie4
1Denver Health, 2Mayo Clinic, 3Northside Gwinnett Medical Center, 4Carolinas Medical Center
Objective 1: Provide a comprehensive discussion on current trends in decision making for Type 1 Lateral compression pelvic ring injuries.
Objective 2: Demonstrate effective surgical treatment strategies for LC2 and LC3 patterns through an in depth examination of the underlying pathology.
Objective 3: Develop strategies and indications for Spino-Pelvic supplementation in complex sacral fractures.
This breakout session will offer an interactive, case-based update on decision making and treatment strategies for Lateral Compression pelvic ring injuries. The included lectures will provide thought provoking debate centered around current controversies within this broad constellation of injuries. Despite significant advances in pelvic fracture management, many controversial topics remain including operative indications and ideal fixation constructs for lateral compression type injuries. Furthermore, the wide variety of subtypes within this classification, and ever changing literature, can be overwhelming for treating surgeons who are often left with more questions than answers. This breakout session will highlight these challenging topics, summarize current research, and demonstrate effective tips and techniques to help navigate the broad constellation lateral compression pelvic fractures.
Cyril Mauffrey MD, FACS, FRCS - This topic will cover relevant literature on preoperative and intraoperative stress examination in LC 1 patterns as well as how to properly select operative patients
Brandon Yuan MD - Thorough discussion of the many controversial fixation options available for LC1 fractures
Adam Boissonneault MD - Spotlight on LC2 fractures including when to use a sacroiliac screw, when to use an LC2 channel lag screw and when to use both.
Michael Maceroli MD - In depth discussion of LC3 pattern pelvic ring injuries relating to the reduction, fixation, and surgical exposure
Sarah Pierrie MD - An in-depth look at lumbo-pelvic fixation for complex sacral fractures including indications, technical considerations and post operative weight bearing protocols
Breakout
UK experience of managing of bone loss
Enis Guryel1, Michael Kelly2, Alex Trompeter3, Alastair Robertson1, Alex Vris4
1University Hospitals Sussex NHS Trust, 2Bristol, 3St George's Hospital, 4Barts
Objective 1: The registrant will learn about various methods of managing bone defects
Objective 2: The registrant will formulate an algorithim for the management of bone defect
Objective 3: The registrant will learn about the use of 3D printed implants and earlier results
The managment of bone defects has evolved and this breakout will provide an opportunity to discuss the various methods available. We will include synthetic void fillers, Masquelet, frame transport, plate assisted bone segment transport, bone transport nails and 3D printed implants.
The colloborative working with plastic surgeons has meant that limb salvage options have expanded which has meant early complex decisions are required. We believe there is a need for this to be taught as many of these options are often discussed in isolation.
During the breakout we will discuss our results and share tips and tricks. The registrant will learn how to make decisions and we will propose an algorithm for the management of bony defects.
Enis Guryel FRCS - The use of synthetic bone grafts, masquelet for bone loss
Michael Kelly FRCS - Retention of fragments
Alex Trompeter MD - 3D printed cages
Alastair Robertson FRCS - Bone transport
Alex Vris FRCS - plate assisted bone segment transport
Breakout
My life as an orthopaedic trauma surgeon: What has been worthwhile (and what has not)?
Derek J Donegan1, Mark R Adams2, Thomas F Higgins3, Timothy G Weber4, Keith A Mayo5
1University of Pennsylvania, 2Rutgers New Jersey Medical School, 3Utah, 4OrthoIndy, 5Swedish Medical Center
Objective 1: To discuss how to deliberately develop your life so that you can have a fulfilling career and life as an Orthopaedic Trauma Surgeon.
Objective 2: To identify patterns of what makes for a healthy, well-balanced life as an orthopaedic trauma surgeon.
Objective 3: To recognize unhealthy habits and poor life choices that occur in the life of an orthopaedic trauma surgeon.
The high suicide rate in our profession was the impetus to discuss the suffering inherent in our lives as surgeons, as well as to introduce content on how to live a better life. This was the intention of two previous breakout sessions: "Orthopaedic Trauma Surgeons Thriving (and Not Dying)" and “It’s Not About the Hardware, It’s About the Marrow! Life as an Orthopaedic Trauma Surgeon: Mind, Body, and Soul”.
This session is a thematic continuation but approaches the problem from a different perspective. A question that weighs on many of us is “Am I spending my time and effort wisely?”. As the panel has three senior surgeons, their reflection is an opportunity to “begin with the end in mind” for the audience. Ideally, as the panel describes what has gone well and what they would have done differently, the audience will compare their experiences and honestly evaluate their personal direction.
Derek Donegan MD - Many surgeons are unsure as to whether or not they are doing it “right”. To address that uncertainty, we will hear from four surgeons that reflect on their lives as orthopaedic trauma surgeons and identify what has been worthwhile.
Mark Adams MD - Dr. Adams will describe how he is currently using his time and efforts as a mid-career orthopaedic trauma surgeon, as well as his uncertainty as to where they are leading him. This is intended to set up the following three talks from senior surgeons who have a long-term perspective.
Thomas Higgins MD - Dr. Higgins’ reflection is an opportunity to “begin with the end in mind” for the audience. Ideally, as he describes what has gone well and what they would have done differently, the audience will compare their experiences and honestly evaluate their personal direction.
Timothy Weber MD - Dr. Weber’s reflection is an opportunity to “begin with the end in mind” for the audience. Ideally, as he describes what has gone well and what they would have done differently, the audience will compare their experiences and honestly evaluate their personal direction.
Keith Mayo MD - Dr. Mayo's reflection is an opportunity to “begin with the end in mind” for the audience. Ideally, as he describes what has gone well and what they would have done differently, the audience will compare their experiences and honestly evaluate their personal direction.
Breakout
What went wrong in pelvic and acetabular fracture management and how can I fix it?
Reza Firoozabadi1, Thomas M Large2, Adam J Starr3, Michael T Archdeacon4, Javier Del Rio5, Xavier Griffin6
1University of Washington, 2Grady Medical Center, 3UT Southwestern, 4University of Cincinnati COM, 5Hospital Clinico Mutual de Seguridad CChC, 6Oxford
Objective 1: Determine how much anterior and/or posterior fixation is required to maintain reduction of a variety of pelvic ring injuries.
Objective 2: Determine how to assess and treat patients with posterior wall acetabular fractures with recurrent instability.
Objective 3: Determine an appropriate sequence of fixation for patients with combined acetabular and pelvic ring injuries.
The purpose of this breakout session to provide healthy discussion around the topic of pelvic ring and acetabular injuries that went bad. This will be a case-based discussion reviewing failed non-operative and operative management. The discussion will be centered around the following; what could have been done differently at the index procedure, potential reasons for failure, and how to address deformity/and or instability post-surgery. Anterior and posterior pelvic ring fixation options will be examined in the setting of a non-union/mal-union surgery. Treatment modalities in the setting of infection will also be discussed. Lastly, we will discuss special considerations in the pediatric and elderly patient population.
Reza Firoozabadi MD - The purpose of this breakout session to provide healthy discussion around the topic of pelvic ring and acetabular injuries that went bad. This will be a case-based discussion reviewing failed non-operative and operative management. The discussion will be centered around the following; what could have been done differently at the index procedure, potential reasons for failure, and how to address deformity post-surgery. Anterior and posterior pelvic ring fixation options will be examined in the setting of a non-union/mal-union surgery. Treatment modalities in the setting of infection will also be discussed. Lastly, we will discuss special considerations in the pediatric and elderly patient population.
Thomas Large MD - Will present a complex pelvic case that went onto non-union.
Adam Starr MD - Will present a pediatric pelvic ring injury that was treated non-operatively which resulted in deformity.
Michael Archdeacon MD, FIOTA - Will present an elderly patient with a sacral U type fracture that displaced in over time, resulting in neurologic injury.
Javier Del Rio MD - Will present a complex combination pelvic ring and acetabulum case.
Xavier Griffin MD - Present a complex involving an a patient with a small posterior wall with recurrent dislocations.
Breakout
The Use of Internal Lengthening Nails in Post Traumatic Reconstruction
Mitchell Bernstein1, Geoffrey Marecek2, Mani Kahn3, Stephen M Quinnan4
1McGill, 2Cedars Sinai, 3Montefiore Einstein, 4Paley Institute
Objective 1: Basics of internal lengthening nails and their range of applications in the post traumatic deformity patient
Objective 2: Patient assessment and surgical planning for the use of internal lengthening nails in post traumatic reconstruction
Objective 3: Use of internal lengthening nails for post traumatic reconstruction in the treatment of isolated limb length discrepancy, fracture nonunion, bone defects and the treatment of combined malunion with limb length discrepancy.
1. Patient Assessment and Surgical Planning – Bernstein (5 min)
2. Basics of Internal Lengthening Nails and use in the treatment of Isolated LLD - Bernstein (10 min)
3. The use of ILN for nonunion – Marecek (10 min)
4. ILN in the treatment of bone defects – Kahn (10 min)
5. The treatment of the combined malunion and LLD – Quinnan (10 min)
6. Cases/Questions/Discussion – all (15 min)
This session will make the use of internal lengthening nails more accessible to trauma surgeons interested in embracing this technology with a mix of tips from the experts and example cases. Using the skills all trauma surgeons possess, patients can benefit widely from using internal hardware to solve what in the past has required ring fixators or staged treatments.
Mitchell Bernstein MD - Patient assessment is critical in the management of post traumatic deformity, and understanding when and how internal lengthening nails can be applied and the basics of their application is essential to embracing this technology into ones practice
Geoffrey Marecek MD - When fractures with nonunion are combined with other deformity or recalcitrant to other treatments, ILN can be used to aid in salvage
Mani Kahn MD, MPH, MS - The use of internal lengthening nails to treat bone defects
Stephen Quinnan MD - The use of a combination of techniques coupled with internal lengthening nails can be used to treat malunion and nonunion and leg length discrepency simultaneously
Breakout
Transitioning Towards Retirement: Challenges, Opportunities, and Strategies
Jeffrey Mark Smith1, Thomas A DeCoster2, Carla S Smith3, Ranjan Gupta4, Heather A Vallier5
1Orthopaedic Trauma & Fracture Specialists, 2UNM, 3St. Lukes Health System, 4UCI, 5Metro Health
Objective 1: Create a reflective practice to create awareness and next steps for transition into retirement.
Objective 2: Identify strategies to support a smooth transition to retirement.
Objective 3: Prepare mentally, emotionally, and create a strategic plan for retirement.
Retirement need not be about losing your identity as a surgeon. Too many surgeons transition into retirement without awareness of the challenges nor opportunities of this phase of their career. It can be about embracing the next challenge in your life and career. It can arrive as planned or out of the blue. Orthopaedic trauma surgeons in academic and private practice environments transitioning to retirement have ways to leverage their knowledge and experience, if they choose. This session will help mid-to-late career surgeons develop some thoughtful transition plans for the next phase of their life and careers.
Jeffrey Smith MD - The breakout will discuss many of the most common issues, and a few of the uncommon ones, that come up as Orthopaedic Trauma surgeons transition into retirement.
Thomas DeCoster MD - Focus on the challenges, opportunities and strategies for transitioning into retirement in an academic setting.
Carla Smith MD - Discussing the many mental and emotional opportunities as one transitions into retirement
Ranjan Gupta MD - Discussion of what others want from you versus how to best leverage what you bring to the table
Heather Vallier MD, FIOTA - Volunteer and Paid Opportunities to Give and Receive Fulfillment
Breakout
Thriving at a Traditionally Non-Academic Trauma Center
Erin Hofer1, Peter Althausen2, Jason M Evans1, Timothy G Weber3, Clifford B Jones4
1TriStar Skyline Medical Center, 2Reno Orthopedic Center, 3Ortho Indy, 4Dignity Health
Objective 1: Recognize crucial pieces of a successful practice and life (business and clinical)
Objective 2: Understand the importance of staying connected and ways to do so
Objective 3: Identify common pitfalls and opportunities
Orthopedic surgeons spend the first 5+ years of their orthopedic life training in academic centers. After training, however, a large number of orthopaedic trauma surgeons establish their practices outside of academic centers. This panel of established surgeons will help those in all career stages learn to thrive in a career outside of academics.
The session will be split into 4 sections as follows -
1. Set yourself up for success (business): faculty will discuss important parts of practice from the business side, including establishing and fostering community, hospital alignment, and private practice investments.
2. Building your team (clinical): faculty will discuss establishing your team's workflow, integrating your team with other teams, and resident replacements in practice.
3. Staying connected: faculty will discuss mentorship, involvement in national/regional organizations, and research and quality control
4. Pitfalls to avoid: faculty will discuss common pitfalls related to business, clinical practice, and family life
Erin Hofer MD - Moderator
Peter Althausen MD, MBA - Faculty will discuss important parts of practice from the business side, including establishing and fostering community, hospital alignment, and private practice investments.
Jason Evans MD - Faculty will discuss establishing your team's workflow, integrating your team with other teams, and resident replacements in practice.
Timothy Weber MD - Faculty will discuss mentorship, involvement in national/regional organizations, and research and quality control
Clifford Jones MD, FACS, FIOTA - Faculty will discuss common pitfalls related to business, clinical practice, and family life
Breakout
Driving Innovation: Which Pathway is Ideal and How to Succeed in Taking Your Idea From Conception to Bedside?
Paul Edward Matuszewski1, Thomas A (Toney) Russell2, Samuel Sterrett3, Dan Gruppo4, Edward J Harvey5, Erik Kubiak6
1Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, 2PBC Biomed, 3Rimon Law, 4Conextions Medical, Inc, 5McGill University, 6University of Nevada
Objective 1: Understand the various pathways to driving innovation, including independent development, working with industry and academic institutions.
Objective 2: Gain insight into which pathway may be most appropriate for your idea.
Objective 3: Learn some of the common mistakes and ways to succeed in development.
The individuals most qualified to conceptualize innovative ideas which can lead to practice changing devices and products are orthopaedic trauma surgeons. Unfortunately, most surgeons are not equipped with the knowledge, experience and understanding of how to navigate and succeed in fully developing an idea, which prevents beneficial ideas from becoming reality. The goal of this symposium will be to introduce participants to the different pathways of development, including working independently, with industry and academic institutions. The panel consists of highly experienced individuals who will discuss these pathways, their insights including pitfalls and pearls with each strategy.
Paul Matuszewski MD - Dr. Matuszewski will outline the goals and organization of the symposium.
Thomas Russell MD, FIOTA - Dr. Russell is a pioneer in innovation. From products developed as a resident in his garage shop to working with industry, Dr. Russell has a wealth of experience. Dr. Russell will share his experience and discuss how the process has changed over the years and what mistakes to avoid in the process.
Samuel Sterrett JD - Sandy Sterrett is a lawyer from the law firm of Ramon Law, Washington DC which works companies throughout the country and globe. Sandy has extensive experience working with surgeons (including orthopaedic trauma surgeons), focusing on protection of intellectual property, product development consulting, joint ventures and collaborations. Sandy will discuss key aspects of working with industry, academia, negotiating contracts, conflict management, protection of intellectual property and how to improve your chances of success.
Dan Gruppo BA - President and CEO of Connections Inc, a soft tissue repair device company, has a vast experience working with surgeons from multiple perspectives including private equity and large publicly traded entities. He was the prior vice president of marketing of a large orthopaedic implant company. These experiences give him a unique insight into understanding what industry partners are looking for when you have an idea, concept or even product that you may be looking to develop further. He will discuss and share these insights with the audience.
Edward Harvey MD, FIOTA, FAAOS, FRCSC - Dr. Harvey has a wealth of experience developing a product and company from the benchtop to bedside. Dr. Harvey will share his experience and discuss navigating product development in the context of academia, managing these conflicts, and some of the lessons he learned along the way.
Erik Kubiak MD - Dr. Kubiak has tremendous experience in developing products, commercialization, developing a company surrounding a product and successfully negotiating the large sale of a product company. Dr. Kubiak will discuss his experience in this arena, share lessons learned and insights into what pathway is best for your particular endeavor and situation.
Breakout
Reverse shoulder arthroplasty for the trauma surgeon
Dominique Rouleau1, Niloofar Dehghan2, Michael D McKee3, Armodios Hatzidakis4
1University of Montreal, 2Banner University Medical Center, 3University of Arizona College of Medicine Phoenix, 4Western Othopaedics
Objective 1: Indications for reverse shoulder arthroplasty in trauma
Objective 2: Intra-operative techniques: exposure, how to handle the tuberosities, what implants to use
Objective 3: How to lower complications such as infection and dislocation
Reverse shoulder arthroplasty is commonly used for treatment of proximal humerus fractures in elderly. Many trauma surgeons may not have the training or be comfortable in performing reverse shoulder arthroplasty. However, they may find themselves in a situation where they are expected to perform these procedures for treatment of a proximal humeral fracture. Lack of expertise can increase the risk of complications with this procedure. This session will provide guidance on how to perform the procedure to obtain the best outcomes and limit complications.
This breakout session will be a combination of lectures as well as a case discussion at the end.
Dominique Rouleau MD - Discussing the best approach and best implants to use for the humerus and glenoid
Niloofar Dehghan MD, MSc, FRCSC - Discuss how to lower infection and dislocation risks with reverse shoulder arthroplasty
Michael McKee MD - How to handle the tuberosities intra-op
Armodios Hatzidakis MD - What are the indication and who benefits from a reverse shoulder arthroplasty?
Breakout
Mistakes I’ve Made and Lessons Learned: A Research Perspective
Ida Leah Gitajn1, Joseph R Hsu2, Hassan Riaz Mir3, Robert V O'Toole4, Gerard P Slobogean5
1Dartmouth Health, 2Carolinas Medical Center, 3Florida Orthoapedic Institute, 4University of Maryland, 5University of Maryland School of Medicine
Objective 1: Describe common mistakes in clinical and translational science research—recognize frequent mistakes in study design, data collection, management and analysis that clinician-researchers may encounter
Objective 2: Analyze real-world research missteps—examine candid examples of mistakes, understanding what went wrong and the impact these missteps had on study outcomes and progress,
Objective 3: Discuss lessons learned and ways to avoid pitfalls in research.
Conducting clinical and basic science research presents numerous challenges, and many clinician-researchers enter the field with limited formal research training. Even the most distinguished among us have fallen into pitfalls in all stages of research including study design, data collection, data management and analysis. Some of these are minor speed bump and others feel like sinkholes. Unfortunately, these lessons are often learned the hard way and are rarely shared with the broader orthopaedic community. This session aims to change that. Through candid examples, we’ll highlight mistakes research luminaries have made, discuss what went wrong and share how to avoid them. Attendees will leave with practical insights and a better roadmap for conducting rigorous, impactful research without repeating errors that have kept us up at night.
Ida Leah Gitajn MD - Introduction/moderator
Joseph Hsu MD - Examples of mistakes and lessons learned
Hassan Mir MD, MBA, FACS, FIOTA - Examples of mistakes and lessons learned
Robert O'Toole MD - Examples of mistakes and lessons learned
Gerard Slobogean MD, MPH, FRCSC - Examples of mistakes and lessons learned
Main Symposium
Wellness, Moral Resilience, and Longevity in Orthopaedic Trauma: A Focus on Surgeon Wellbeing and Career Sustainability
Samir Mehta1, Derek J Donegan1, Matthew R. Garner, Milton Thomas Michael Little2, Karen Reivich1
1University of Pennsylvania, 2Cedars-Sinai Medical Center
Objective 1: To examine the societal, structural, and professional factors that affect the wellbeing of orthopaedic trauma surgeons, and discuss ways to improve their work environment and career satisfaction.
Objective 2: To address the issue of moral injury within the trauma surgery field, offering strategies to manage ethical dilemmas and mitigate psychological harm.
To explore how mental resilience and fortitude contribute to the sustainability of a long and successful career in orthopaedic trauma surgery.
Objective 3: To provide practical tools and strategies for trauma surgeons to safeguard their mental health, build resilience, and promote long-term career longevity.
Orthopaedic trauma surgery is a rewarding yet challenging profession, and ensuring the mental and physical wellbeing of surgeons is critical to the sustainability of both their careers and the quality of patient care they provide. This symposium offers a unique opportunity to address the broader societal, emotional, and psychological factors that affect trauma surgeons, with a focus on fostering long-term wellness, moral resilience, and career satisfaction. By integrating these strategies into the fabric of trauma surgery practice, we can support a healthier, more sustainable career trajectory for our surgeons, ultimately benefiting both providers and patients alike. The symposia will be highlighted by Dr. Karen Reivich, an internationally recognized expert in the fields of resilience, depression prevention, and Positive Psychology and experience with the US Army, professional sports teams, and health care professionals.
Samir Mehta MD - Introduction and Q&A
Derek Donegan MD - Addressing the Broader Context Derek Donegan will discuss the overall wellbeing of the orthopaedic trauma surgeon community, exploring the societal and structural factors that influence their health and career satisfaction. He will delve into the systemic pressures facing trauma surgeons today, including increasing work hours, administrative burdens, financial stressors, and the growing complexity of patient care. Donegan will provide a broad overview of how the external healthcare environment impacts surgeons' mental, physical, and emotional health, and offer suggestions for changes in workplace culture and policy that can help mitigate these challenges. His presentation will emphasize the need for a supportive, sustainable work environment to enhance the wellbeing of trauma surgeons, ultimately contributing to better career longevity and personal fulfillment.
Matthew Garner MD - N/A
Milton Little MD - Navigating Ethical Dilemmas and Emotional Toll on Trauma Surgeons Milton Little will explore the concept of moral injury among orthopaedic trauma surgeons—a term that refers to the psychological distress resulting from having to make difficult decisions that conflict with personal values or professional ethics. Trauma surgeons often face life-and-death situations, moral quandaries, and the pressure of limited resources or time constraints, all of which can contribute to moral injury. Little’s session will examine the psychological impact of moral injury, including feelings of guilt, shame, and disillusionment, and how these emotions can affect job satisfaction and mental health. He will provide strategies for recognizing and addressing moral injury, offering guidance on how trauma surgeons can find emotional resolution, manage ethical stressors, and ultimately protect their mental health from the negative effects of these experiences.
Karen Reivich PhD - Dr. Reivich will focus on the importance of mental fortitude in ensuring a sustainable and fulfilling career in orthopaedic trauma surgery. Drawing on her expertise in psychology and resilience training, Foster will discuss the tools and strategies needed to build emotional resilience and mental strength in the face of a demanding profession. She will highlight approaches such as mindfulness, cognitive-behavioral strategies, and self-compassion, which can help trauma surgeons manage stress, avoid burnout, and maintain a balanced life. Foster’s presentation will provide practical, evidence-based techniques for improving mental wellbeing, fostering long-term career satisfaction, and ensuring the longevity of trauma surgeons in a challenging and often high-pressure environment.
Main Symposium
IOTA Symposium: Orthopaedic Trauma Care in the Geriatric Patient: Challenges and Controversies
Zsolt J Balogh1, Kees Jan Ponsen2, Theodore Miclau3, Zsolt J Balogh1, Masanori Yorimitsu4, Michiel Herteleer5, Hector Jose Aguado6, Pieter Joosse2, Andrew C Gray7, Zsolt J Balogh8, Andrew Oppy9
1Australian Orthopaedic Association, 2Dutch Trauma Society, 3Orthopaedic Trauma Association, 4Japanese Orthopaedic Trauma Association, 5Belgium Orthopaedic Trauma Society, 6Spanish Orthopaedic Trauma Association, 7British Orthopaedic Trauma Society, 8Australian Orthopaedic Associatiohn, 9Royal Melbourne Hospital
Objective 1: To understand critical issues in the care of geriatric trauma patients who sustain orthopaedic injuries.
Objective 2: To discuss specific global controversies surrounding aspects of fracture care in the polytraumatized geriatric patient.
Objective 3: To review evolving treatment approaches to the geriatric orthopaedic trauma patient, including international standards for and differences in care.
As the world’s population ages, the number of traumatic injuries in older adults continues to increase. Older adults are at greater risk of morbidity and mortality following trauma, being more likely to have cognitive impairment, underlying chronic conditions, and baseline frailty that decrease their ability to recover physiologically. This symposium seeks to examine major aspects of care in the geriatric orthopaedic trauma patient facing providers globally, including systematic approaches, patient factors, and surgical decision-making.
Zsolt Balogh MD, PhD, FIOTA - Orthopaedic Trauma Care in the Geriatric Patient: Challenges and Controversies
Kees Ponsen MD, FIOTA - Orthopaedic Trauma Care in the Geriatric Patient: Challenges and Controversies
Theodore Miclau MD, FIOTA - Orthopaedic Trauma Care in the Geriatric Patient: Challenges and Controversies
Zsolt Balogh MD, PhD, FIOTA - Symposium Introduction: Injury Triage: Can We Get It Right?
Masanori Yorimitsu FIOTA - Geriatric triage effectiveness
Michiel Herteleer MD PhD FEBS - Effects of a multidisciplinary team on geriatric orthopaedic trauma patient recovery
Hector Aguado PhD Prof - Refinement of age at which patients are considered elderly
Pieter Joosse MD - End of life decision-making for orthopaedic trauma interventions
Andrew Gray MD - Changing indications of surgical interventions in geriatric orthopaedic trauma patients
Zsolt Balogh MD, PhD, FIOTA - Considerations for selecting appropriate interventions in geriatric orthopaedic patient populations
Andrew Oppy MBBS FRACS - N/A
Main Symposium
Which Papers Should I Believe? Keys for Interpreting Our Underpowered Retrospective Orthopaedic Trauma Literature
Robert V. O'Toole1, Nathan O'Hara2, Renan Castillo3, Saam Morshed4, Gerard P Slobogean5
1RAC Shock Trauma Center, University of Maryland School of Medicine, 2RAC Shock Trauma Center, University Of Maryland School of Medicine, 3JHU, 4UCSF, 5University of Maryland School of Medicine
Objective 1: Clarify the rationale why clinicians need to better understand methodology for reviewing papers.
Objective 2: Highlight the pitfalls in interpreting retrospective research.
Objective 3: Improve understanding of what conclusion should and should not be drawn from modern analysis techniques for retrospective studies.
Orthopaedic trauma research is challenging as randomized trials are rare due to the expense, difficulty, and time needed to complete. Therefore, most research in our field is retrospective and often underpowered for the primary question. Clinicians want to practice evidence-based medicine but often find it difficult to determine which papers should influence their practice.
Gaps and Need for the Symposium:
Although the quality of orthopaedic trauma is improving, most research in our field is still retrospective. The study design and statistical approaches for these studies are evolving and often difficult for clinicians to understand. The knowledge gap is problematic as it prevents the clinicians from adequately evaluating the validity of findings from many research papers. This symposium will be aimed at the practicing orthopaedic trauma surgeon with no specialized research training and attempt to provide basic knowledge to better evaluate modern retrospective research papers.
Robert O'Toole MD - Common errors in interpreting retrospective orthopaedic trauma papers
Nathan O'Hara PhD, MHA - “Speaking truth to power”: why sample size really matters
Renan Castillo PhD - Modern options to look at the retrospective data
Saam Morshed MD, PhD - Fatal analysis errors
Gerard Slobogean MD, MPH, FRCSC - Should this paper influence my practice?
Main Symposium
Limb Salvage vs Amputation: What Have We Learned in the Last 20 Years, and Have Things Changed?
Paul Edward Matuszewski1, James Alan Blair2, Stephen M Quinnan3, Joseph R Hsu4, Kevin Tetsworth5
1Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky College of Medicine, 2Grady Memorial Hospital, 3Paley Institute, 4Carolinas Medical Center, 5Royal Brisbane Hospital
Objective 1: Learn how our understanding regarding the outcomes of limb salvage or amputation have changed over the last 20 years.
Objective 2: Learn how techniques in limb salvage, amputation, orthotics, prosthetics have improved outcomes in these patients.
Objective 3: Understand how osseointegration has evolved and changed our perspective of limb salvage versus amputation.
Thought leaders in limb salvage, rehabilitation and osseointegration will discuss how our understanding has changed since the LEAP study, including advancements in techniques, and how osseointegration has modified the landscape. Understanding how our knowledge has changed, and the availability of new techniques is important to surgeons as it drastically changes the discussion of these two pathways when caring for patients. A discussion with thought leaders and overarching perspective will give context and help orthopaedic traumatologists synthesize this information and apply it to their practice and ultimately improve outcome.
Paul Matuszewski MD - Introduction and Goals of the Symposium
James Blair MD, FACS - Several studies and follow-up studies have been completed since the landmark LEAP study. Dr. Blair will explore and give context to the evidence that has been developed over the past 20 years to give us our current understanding of limb salvage versus amputation.
Stephen Quinnan MD - It’s not just prolonged treatment with pins and wires these days. Dr. Quinnan will broadly discuss how improvements in techniques, including all-internal methods, cable transport, bone void fillers and soft tissue techniques that have improved our ability to manage complex limb salvage cases.
Joseph Hsu MD - Advances in orthotics, prosthetics and rehabilitation techniques have enabled both limb salvage and amputation patients to have improved outcomes. Dr. Hsu will discuss these advances and how they can be implemented in your practice to help improve these patients experiences and functional outcomes.
Kevin Tetsworth MD, FRACS, FIOTA - Over the last 10 years, osseointegration has advanced tremendously to benefit thousands of amputees. Does this change our perspective of amputation? Dr. Tetsworth will discuss these advances and how these have changed the landscape of Amputation vs Limb Salvage.