BACKGROUND:Diabetes mellitus (DM) is a major risk factor for adverse outcomes following orthopedic trauma. Although both type 1 (T1DM) and type 2 (T2DM) diabetes mellitus increase complication risk after lower extremity fracture fixation, their relative impacts remain poorly characterized. MATERIALS AND METHODS:We performed a retrospective cohort analysis to compare postoperative outcomes in patients with T1DM and T2DM who underwent surgical fixation of lower extremity fractures. Propensity score matching was performed within anatomical fracture subgroups based on age, sex, race, body mass index, hemoglobin A1c, and nicotine dependence. Outcomes were compared using appropriate statistical tests and survival analysis. RESULTS:A total of 10,464 patient-fracture encounters across 4 anatomic subgroups met inclusion criteria. After propensity score matching within each subgroup, 1,776 matched pairs (3,552 encounters) were analyzed. T1DM patients experienced higher rates of adverse outcomes compared to T2DM patients, with the greatest differences observed for infection (tibia: 7.3% vs 3.1%, P = .009; foot/ankle: 9.8% vs 1.8%, P < .001), amputation (femur: 2.9% vs 0.0%, P = .001; tibia: 2.6% vs 0.0%, P = .001), and mortality (hip: 21.8% vs 15.1%, P = .003; femur: 12.3% vs 4.4%, P < .001; tibia: 9.9% vs 2.5%, P < .001; foot/ankle: 7.5% vs 2.0%, P < .001). These risks appeared to increase distally, with the highest complication rates seen in the tibial and foot/ankle subgroups. CONCLUSIONS:T1DM confers a distinctly higher risk of infection, limb loss, and mortality following operative fixation of lower extremity fractures compared to T2DM, despite similar baseline characteristics after matching. These findings highlight the need for diabetes-subtype-specific perioperative management strategies to optimize outcomes in this high-risk population.

Marijuana use is rising in the United States, yet its impact on perioperative outcomes remains poorly understood, particularly in orthopaedic trauma where cessation is often not feasible. This study evaluates the risks associated with cannabis and nicotine use in patients undergoing fixation of upper extremity fractures. We performed a retrospective analysis of adult trauma patients with upper extremity fractures (2015–2023) identified using CPT codes for surgical fixation in the TriNetX database. Four cohorts were defined: cannabis-only users (n = 801), nicotine-only users (n = 14,310), concurrent users (n = 901), and non-users matched 1:1 to each exposure cohort. Propensity score matching was applied to each pairwise comparison. Primary outcomes were surgical and medical complications; secondary outcomes included new postoperative psychosocial diagnoses (anxiety, depression, opioid use disorder, and chronic pain) and coagulation parameters. Binary outcomes were compared using absolute risk differences, risk ratios, odds ratios, and 95

BACKGROUND:To investigate the effect of immediate weight-bearing (WB) status on mortality in geriatric distal femur patients. Secondary aims included determining the effect of WB status on surgical complications and ambulatory ability at 90 days. METHODS:This was a retrospective review of geriatric (age >60 years) patients with distal femur fracture (OTA/AO 33 A, 33C) from 9 level 1 trauma centers that underwent surgical fixation from 2012 to 2019. Mortality, ambulatory ability at 90 days, and surgical complications were compared between postoperative non-WB (NWB) versus WB (touch-down/partial/WB as tolerated) groups. A propensity-weighted regression model including demographics, tobacco-use, preinjury ambulatory status, injury mechanism, and American Society of Anesthesiologists classification was used to compare outcomes between the NWB and WB cohorts. RESULTS:Four hundred four patients were included where most of the patients (72%) underwent open reduction, internal fixation and most of the patients were NWB after surgery (63%). Most of the patients (328/404, 81%) were discharged to a nursing facility. Older patients, patients with ground-level fall, and American Society of Anesthesiologists I/II patients were more likely to be WB. Six-month mortality was 14%. Sixty-nine percentage of patients were able to ambulate without human assistance by 90 days. In the propensity-weighted analysis, there was no association with WB and mortality (hazard ratio [HR], 1.50; confidence interval [CI, 0.77, 2.92]; P = 0.24). No association was observed between WB and deep infections (HR, 2.86; [CI, 0.82, 9.93]; P = 0.10) or nonunion surgery (HR, 1.7; [CI, 0.71, 4.09]; P = 0.23). Finally, there was no association with WB and in ambulatory ability within 90 days (odds ratio [OR], 1.48; [CI, 0.65, 3.35]; P = 0.35). HRs/ORs >1 indicate higher risk/odds for the WB group. CONCLUSIONS:Based on this study, there was no association with prescribed postoperative WB and patient mortality, reoperations, or ambulatory ability within 90 days of surgery. LEVEL OF EVIDENCE:III PROGNOSTIC.

Abstract Cannabis use is rapidly increasing in the United States, yet its perioperative implications remain poorly understood, particularly in trauma populations. Despite expanding legalization, the perioperative effects of cannabis on surgical outcomes remain uncertain. This retrospective cohort study used electronic health record data to evaluate the association between cannabis use, with and without concurrent nicotine exposure, and postoperative outcomes following orthopedic lower extremity trauma fixation. We conducted a retrospective cohort study using the TriNetX Research Network, a global federated electronic health record platform that aggregates de-identified clinical data from more than 90 health systems. Adult patients who underwent surgical fixation of lower extremity fractures between 2015 and 2023 were stratified into four cohorts: cannabis only users (n = 2421), nicotine only users (n = 36,966), concurrent users (n = 2338), and non-users. Primary outcomes included surgical and medical postoperative complications; secondary outcomes included psychosocial outcomes and coagulation parameters (PT, aPTT). Binary outcomes were evaluated using absolute risk differences, risk ratios (RR), and 95% confidence intervals (CIs). Continuous variables were compared using independent samples t-tests assuming unequal variances. Cannabis-only users demonstrated higher rates of deep implant infection, nonunion or malunion, reoperation, transfusion, readmission, anxiety, and depression compared with matched non-users. Nicotine-only users showed higher rates of wound complications, infection, nonunion or malunion, reoperation, transfusion, pneumonia, myocardial infarction, death, opioid use, chronic pain, readmission, anxiety, and depression compared with matched non-users. Concurrent cannabis-and-nicotine users had higher rates of superficial wound infection, deep implant infection, reoperation, amputation, transfusion, pneumonia, respiratory failure, opioid use, chronic pain, readmission, and anxiety compared with matched cannabis-only users. Coagulation measures were not consistently different across exposure groups. Cannabis use was associated with surgical and psychosocial complications in this large retrospective cohort. Nicotine use was associated with broader adverse effects, and concurrent cannabis-and-nicotine exposure was associated with compounded perioperative risk. These findings support further prospective evaluation of perioperative substance use screening and counseling strategies in surgical populations. Prospective studies quantifying cannabis exposure are needed to define dose–response effects and mechanisms.

INTRODUCTION:Distal femur fractures are commonly treated with retrograde intramedullary nails or lateral locked plates. Although enthusiasm is growing for dual-implant constructs, most fractures are still treated with a single implant, though it remains unclear whether one implant type offers superior outcomes. This study compared revision surgery rates as well as clinical and radiographic outcomes between matched cohorts of distal femur fractures treated with intramedullary nails or lateral plates. METHODS:This multicenter retrospective study included adult patients with OTA/AO 33A or 33C distal femur fractures treated with isolated retrograde intramedullary nails or lateral locked plates with a minimum 3-month follow-up at 10 level-1 trauma centers. Outcomes were compared between propensity-matched nail and plate groups including all-cause revision surgery, unplanned revision surgery to promote union, revision surgery for deep surgical site infection, and modified Radiological Union Scale for Tibia scores. RESULTS:A total of 245 fractures treated with intramedullary nails were propensity score-matched 1:1 to 245 fractures treated with a single locked lateral plate. At a mean follow-up of 16 months, no significant differences were found in all-cause revision surgery (24% vs. 19%, P = 0.2), revision surgery to promote union (8.2% vs. 10%, P = 0.5), revision surgery for infection (5.7% vs. 5.7%, P > 0.9), or modified Radiological Union Scale for Tibia scores at 3 months (9 vs. 9, P = 0.6). No notable differences were observed in radiographic postoperative reduction parameters, surgical duration, follow-up duration, or qualitative clinical outcomes between the nail and plate groups. CONCLUSION:Distal femur fractures treated with retrograde intramedullary nails or lateral locked plates showed no notable differences in revision surgery rates, radiographic healing, or qualitative clinical outcomes. Surgeons should choose nails or plates based on experience, fracture type, and perceived ease of achieving a good reduction with the specific implant. LEVEL OF EVIDENCE:III.

OBJECTIVES:To estimate representative outcomes of patients who underwent distal femur replacement (DFR) for distal femur fractures (DFFs). METHODS: DESIGN:Retrospective Cohort Study. SETTING:Twelve academic trauma centers in the United States. PATIENT SELECTION CRITERIA:Adult patients who underwent DFR for native or periprosthetic DFF (OTA/AO 33A1.1-33C3.3) from 2010 to 2022 were included. Patients who underwent DFR for infectious, oncologic, and/or other indications besides fracture fixation were excluded. OUTCOME MEASURES AND COMPARISONS:The primary outcome was periprosthetic joint infection (PJI). Secondary outcomes included reoperation, 1-year mortality, and function. Outcomes were estimated using proportions and Kaplan-Meier curves with 95% confidence intervals (CI) and stratified by periprosthetic fracture with Fisher exact testing. RESULTS:One hundred seventy-three patients were included, with 130 (75%) having a periprosthetic DFF. The median age was 77 [interquartile range, 70-84] and the median final follow-up was 6 months [interquartile range, 2-14], with 146 women (84%) and several medical comorbidities (63% American Society of Anesthesiologists class III and 24% American Society of Anesthesiologists class IV). The rate of PJI was 5.8% (95% CI, 3.1%-10.5%). PJI was 2.3% for native compared with 6.9% for periprosthetic DFF ( P = 0.45). The reoperation rate was 16.6% (95% CI, 11.7%-23.0%), and the 1-year mortality was 27% (95% CI, 20%-35%). Fifty-five percent of patients returned to their baseline function (95% CI, 46.9%-62.1%). CONCLUSIONS:DFR for native and periprosthetic DFF was associated with a PJI rate of 5.8%. The 1-year mortality rate was 27.0%, and the reoperation rate was 16.6%. Fifty-five percent of patients returned to their baseline function. DFR can be considered as an option in cases of complex native and periprosthetic DFF, although surgeons should continue to counsel patients on the considerable risks associated with DFR when assessing treatment options. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction:Prediction of nonhome discharge after open reduction internal fixation (ORIF) of distal femur fractures may facilitate earlier discharge planning, potentially decreasing costs and improving outcomes. We aim to develop algorithms predicting nonhome discharge and time to discharge after distal femur ORIF and identify features important for model performance. Methods:This is a retrospective cohort study of adults in the American College of Surgeons National Surgical Quality Improvement Program database who underwent distal femur ORIF between 2010 and 2019. The primary outcome was nonhome discharge, and the secondary outcome was time to nonhome discharge. We developed logistic regression and machine learning models for prediction of nonhome discharge. We developed an ensemble machine learning-driven survival model to predict discharge within 3, 5, and 7 days. Results:Of the 5330 patients included, 3772 patients were discharged to either a skilled nursing facility or rehabilitation hospital after index ORIF. Of all tested models, the logistic regression algorithm was the best-performing model and well calibrated. The ensemble model predicts discharge within 3, 5, and 7 days with fair discrimination. The following features were the most important for model performance: inpatient status, American Society of Anesthesiology classification, preoperative functional status, wound status, medical comorbidities, age, body mass index, and preoperative laboratory values. Conclusion:We report a well-calibrated algorithm that accurately predicts nonhome discharge after distal femur ORIF. In addition, we report an ensemble survival algorithm predicting time to nonhome discharge. Accurate preoperative prediction of discharge destination may facilitate earlier discharge, reducing the costs and complications associated with prolonged hospitalization.

(1) Use of orthobiologics within orthopaedic trauma should aim to address a specific issue using a specific material. (2) The so-called diamond concept can guide the surgeon’s choice of material, taking into consideration the need for osteogenic cells, an osteoconductive scaffold, osteoinductive mediators, further vascularized tissue, or improved mechanical stability. (3) Autologous bone graft remains the standard of treatment; however, consideration should be given to the potential donor site problems when deciding exactly which graft to use, with careful planning of the volume or size of graft required. (4) Synthetic grafts can be particularly valuable in cases with small defects, in large defects where graft expansion is required, or in potentially infected cases when an antibiotic-laden synthetic can be used. (5) For the management of recalcitrant nonunion, a number of stimuli may need to be provided to the nonunion site, and polytherapy should be considered.

Orthopaedic infections remain challenging complications to treat, with profound economic impact in addition to patient morbidity. The overall rate of infection following orthopaedic surgery with internal fixation devices has been estimated at 5%, with hospital costs 8 times that of those without fracture-related infections and with significantly poorer outcomes regarding function and pain. Fracture-related infections (FRIs) occur in approximately 20% of all trauma cases, and treatment has evolved very little over the years. While union can be achieved 70%–89% of the time, long-term recurrence rates vary between 9% and 58% and retention of implants is only around 30%–40%. This is underscored by the financial, psychosocial, and physical burden placed on the patients. The difficult management of FRIs is multifactorial; however, a major contributor is biofilm. Alternative treatment strategies to combat biofilm have come in the form of photodynamic therapy and bacteriophage therapy. Use of local antibiotic therapy in the form of powder and dissolvable antibiotic beads has continued to be expanded, with new applications explored. Systemic antibiotic use has continued to be optimized, with new treatment protocols calling for per os (PO) administration as opposed to intravenous. In conclusion, orthopaedic infections remain difficult clinical dilemmas, although evolving prevention and treatment modalities continue to emerge.

Background Lateral lumbar interbody fusion may be performed through lateral decubitus (LD-LLIF) or prone transpsoas (PTP) approaches. While PTP offers theoretical advantages related to single-position access and sagittal alignment, comparative data evaluating perioperative outcomes, complication profiles, and radiographic parameters remain limited. This study compares clinical outcomes, complications, and radiographic alignment between LD-LLIF and PTP, with additional subgroup analysis of staged versus single-stage LD-LLIF procedures. Methods A retrospective observational study was conducted at a single academic center. Adult patients undergoing LD-LLIF or PTP between August 2021 and March 2024 by fellowship-trained orthopaedic spine surgeons were identified. Demographics, comorbidities, operative parameters, radiographic measurements, and perioperative outcomes were collected. Subgroup analysis compared staged and single-stage LD-LLIF procedures. Statistical analysis utilized two-sided t-tests and chi-squared tests with significance set at p < 0.05. Results A total of 82 patients were included (LD-LLIF: 54; PTP: 28). Operative time was significantly longer in PTP compared to LD-LLIF (472.5 ± 204.5 vs. 266.8 ± 91.0 minutes, p < 0.001). PTP was associated with higher estimated blood loss (p = 0.056), shorter hospital stay (p = 0.050), and increased rates of dural tear (14.3% vs. 0%, p = 0.012) and transient postoperative hip flexor weakness (21.4% vs. 0%, p = 0.001). Radiographically, PTP demonstrated greater postoperative segmental lordosis (12.4 ± 4.5° vs. 10.4 ± 4.0°, p = 0.041) and Cobb angle correction (−0.8 ± 5.0° vs. −4.3 ± 5.9°, p = 0.009), with no significant differences in global lumbar or L4-S1 lordosis. In the LD-LLIF subgroup, staged procedures (n = 18) demonstrated longer operative time (292.9 ± 46.6 vs. 231.0 ± 123.7 minutes, p = 0.013), but complication rates were not significantly different compared to single-stage procedures (27.8% vs. 21.1%, p = 0.736). Conclusion Both LD-LLIF and PTP achieved effective radiographic correction with acceptable complication profiles. LD-LLIF and PTP may be used in the treatment of primary and revision lumbar spinal pathology. In our series, PTP was associated with longer operative time and higher neurologic complication rates. Staged LD-LLIF procedures increased operative duration without increasing complication rates. Further prospective investigation is warranted to optimize patient selection and evaluate long-term outcomes.

OBJECTIVES:The optimal treatment of acetabulum fractures in elderly patients is unknown. The purpose of this study was to review outcomes of open reduction and internal fixation (ORIF) or acute total hip arthroplasty (aTHA) and to determine the age threshold based on treatment using a cost-effectiveness decision model. METHODS:The PubMed database was queried for clinical English language studies from 2002 to 2022 (N > 10), of acetabular fracture patients age >50 years treated with either ORIF or aTHA. Revision surgery and mortality rates were collected. Costs were obtained from the National Inpatient Sample database. Health state utilities were converted to quality-adjusted life years, and a Markov decision analysis model was constructed. Sensitivity analyses were done with regard to the quality of life and cost variables. RESULTS:Thirty studies met inclusion criteria, including 16 ORIF studies (N = 909) and 18 aTHA studies (N = 403). The ORIF cohort had a mean age of 71 years, follow-up of 3.5 years, mortality rate of 11.7%, and a conversion arthroplasty rate of 19.6%. The aTHA cohort had a mean age of 73 years, follow-up of 3.2 years, mortality rate of 10.7%, and a revision rate of 4.5%. Our model demonstrated that ORIF was a more cost-effective treatment for patients aged 67 years or younger and that aTHA was more cost-effective for patients aged 68 years and older. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost of ORIF and aTHA but highly sensitive to functional outcome variables in the model. CONCLUSION:A review of 30 studies demonstrated a conversion arthroplasty rate of 19.6% for patients older than 60 years compared with a revision rate of 4.5% for patients treated with aTHA. Without considering fracture pattern or patient factors, we found that aTHA is a more cost-effective treatment than ORIF for treatment of acetabulum fractures in patients aged 68 years and older. LEVEL OF EVIDENCE:Economic Level III.

INTRODUCTION:Distal femur fractures are complex injuries that often present with multiple fragments, posing notable challenges to fixation. This study aimed to (1) use preoperative CT scans to graphically display fracture lines in intra-articular distal femur fractures and (2) identify common fracture patterns in these injuries. METHODS:All skeletally mature patients that underwent surgical fixation of Orthopaedic Trauma Association type 33C distal femur fractures between 2012 and 2022 were identified across two level 1 trauma centers (n = 63). Preoperative axial, sagittal, and coronal computed tomography scans were obtained. Fracture lines in each plane were traced out and superimposed on standardized distal femur cross-sections, generating a fracture map for each plane. Injury and fracture characteristics were summarized and compared between fracture patterns. RESULTS:On axial scans, 59 of 63 fractures contained a central intercondylar split from the intercondylar notch to the trochlea. On coronal scans, fracture lines originated at the notch and exited laterally and medially in the supracondylar region, creating a Y-shape. One-third of all fractures contained coronal fracture lines, with most involving the lateral condyle. Based on fracture line orientation and location, fractures were divided into four main fracture pattern types. Type 4 fractures (central split and medial coronal fracture line) were associated with lower average medial fracture height and a lower rate of medial metaphyseal comminution. DISCUSSION:We found that C-type distal femur fractures can present with four main fracture patterns. Most fractures contain a central sagittal intercondylar split, and a high proportion of fractures contain either medial or lateral coronal fracture lines. Fracture pattern was associated with mechanism of injury, presence of medial comminution, and medial fracture line height. Future studies should focus on clinical outcomes and surgical management of these distinct fracture patterns. LEVEL OF EVIDENCE:IV.

OBJECTIVES:To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). METHODS: DESIGN:Multicenter retrospective cohort study. SETTING:Ten level-I trauma centers. PATIENT SELECTION CRITERIA:Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS:To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS:There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS:8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE:Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:The aim of this study was to profile modified Radiographic Union Scale for Tibia (mRUST) scores over time in distal femur fractures treated with intramedullary nails and identify predictors of radiographic union timing and delayed progression. METHODS: DESIGN:Multicenter retrospective cohort study. SETTING:Ten Level I Trauma Centers. PATIENT SELECTION CRITERIA:The inclusion criteria were patients with distal femur fractures (OTA/AO 33A and 33 C) treated with intramedullary nails, with a minimum follow-up of 1 year or until radiographic union or reoperation. The exclusion criteria were fractures treated with combination nail-plate constructs, pathologic fractures, and patients younger than 18 years old. OUTCOME MEASURES AND COMPARISONS:The primary outcome was the mRUST score at 3, 6, and 12 months postoperatively. Receiver operating characteristic curve analysis identified the optimal 3-month mRUST score predicting reoperation. Multivariable models were used to identify predictors of radiographic union timing and delayed progression. RESULTS:The study included 155 fractures in 152 patients, with a mean patient age of 51 and a mean follow-up of 17 months. A 3-month mRUST score of ≤8 predicted reoperation with a PPV of 25% and a NPV of 99%. The timing of radiographic union was associated with tobacco use (1.2 months later; P = 0.04), open fracture (1.4 months later; P = 0.04), and the use of topical antibiotics (2.1 months longer; 95% CI, 0.33-3.84; P = 0.02); however, topical antibiotics were at high risk of being confounded by injury severity. Delayed progression to fracture healing, wherein the most rapid radiographic healing occurs more than 3 months postoperatively, was predicted by chronic kidney disease ( P < 0.01). CONCLUSIONS:A 3-month mRUST score >8 suggests a very high likelihood of avoiding reoperation for nonunion. Tobacco use and open fractures were associated with a longer time to radiographic union. Chronic kidney disease is associated with a delayed radiographic progression, suggesting a need for adjusted expectations and management strategies in these patients. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating.Design: Retrospective cohort study.Setting: Ten Level I trauma centers.Patient Selection Criteria:Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019.Outcome Measures and Comparisons:Surgery for nonunion stratified by risk for nonunion.RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. (P > 0.05).CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures.LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA. METHODS:The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA. RESULTS:A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22). CONCLUSIONS:No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively. LEVEL OF EVIDENCE:III.

OBJECTIVES:To assess the biomechanical differences between linked and unlinked constructs in young and osteoporotic cadavers in addition to osteoporotic sawbones. METHODS:Intraarticular distal femur fractures with comminuted metaphyseal regions were created in three young matched pair cadavers, three osteoporotic matched pair cadavers, and six osteoporotic sawbones. Precontoured distal femur locking plates were placed in addition to a standardized retrograde nail, with unitized constructs having one 4.5 mm locking screw placed distally through the nail. Nonunitized constructs had seven 4.5 mm locking screws placed through the plate around the nail, with one 5 mm distal interlock placed through the nail alone. Cadaveric specimens were subjected to axial fatigue loads between 150 and 1500 N (R Ratio = 10) with 1 Hx frequency for 10,000 cycles. Sawbones were axially loaded at 50% of the ultimate load for fatigue testing to achieve runout, with testing performed with 30 and 300 N (R Ratio = 10) loads with 1 Hz frequency for 10,000 cycles. RESULTS:In young cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (1.51 ± 0.62mm) compared to the non-unitized constructs (1.34 ± 0.47mm) (Figure 4A), (p = 0.722). In osteoporotic cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (2.46 ± 0.47mm) compared to the non-unitized constructs (2.91 ± 1.49mm) (p =0.639). There was statistically no significant difference in cyclic displacement between the unitized and non-unitized groups in osteoporotic sawbones(p = 0.181). CONCLUSIONS:Linked constructs did not demonstrate increased axial stiffness or decreased cyclical displacement in comparison to unlinked constructs in young cadaveric specimens, osteoporotic cadaveric specimens, or osteoporotic sawbones.

BACKGROUND:The American College of Surgeons recommends operative debridement of open tibial fractures within 24 h of presentation. It is unknown what the compliance rates are with this recommendation and what factors contribute to delays to operation. METHODS:To determine the characteristics associated with delays to operation for open tibial fractures, we conducted a retrospective cohort study utilizing American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2021. Individuals aged 18 and older presenting to a trauma center with an open tibial fracture were included. Associations were determined with a hierarchal regression model nesting patients within facilities. RESULTS:Of the 24,102 patients presenting to 491 trauma centers, 66.3 % identified as White, 21.7 % as Black, 1.5 % as Asian, 1.1 % as American Indian, and 10.6 % as Other race. In total, 15.8 % identified as Hispanic. Patients were most often men (75.9 %) and privately insured (47.6 %). The median time to OR was 10.2 h (IQR 4.4-17.7) with 84.6 % receiving surgery within 24 h. In adjusted analyses, Black and American Indian patients had 5.5 % (CI 1.3 %-9.9 %) and 17.8 % (CI 2.2 %-35.8 %) longer wait times, respectively, and a decreased odds of receiving surgery within 24 h (AOR 0.85, CI 0.8-0.9; AOR 0.69, CI 0.5-0.9) when compared to White patients. Female patients had 6.5 % (CI 3.0 %-10.2 %) longer wait times than men. Patients with Medicaid had 5.5 % (CI 1.2 %-9.9 %) longer wait times than those with private insurance. Greater time to OR was associated with increasing age (p < 0.001), increasing injury severity (p < 0.001), and the presence of altered mentation (p < 0.001). CONCLUSION:We identified longer wait times to operative irrigation and debridement of open tibial fractures for Black and American Indian patients, women, and those with Medicaid. The implementation of health equity focused quality metrics may be necessary to achieve equity in trauma care.