Importance Previous research has suggested that intrawound vancomycin powder reduces deep surgical site infections among patients with periarticular tibial fractures at high risk of infection. It is unknown whether the addition of tobramycin powder further decreases infection rates. Objective To compare whether the combination of tobramycin plus vancomycin vs vancomycin alone delivered as intrawound powder at the time of definitive fixation reduces deep surgical site infections. Design, Setting, and Participants Open-label, assessor-masked, randomized clinical trial conducted at 39 US trauma centers. Eligible patients were adults with an operatively treated periarticular tibial fracture (either tibial plateau or pilon) who met 1 of 3 criteria for elevated infection risk. Enrollment occurred between June 18, 2021, and December 12, 2024 (final follow-up, July 15, 2025). Interventions Intrawound tobramycin (1.2 g) plus vancomycin (1.0 g) powder vs intrawound vancomycin (1.0 g) powder delivered at the time of definitive fixation. Main Outcomes and Measures The primary outcome was a deep surgical site infection requiring surgical management within 182 days of definitive fracture fixation. Secondary outcomes included deep surgical site infections with pathogens that were gram-negative only, deep surgical site infections with at least 1 pathogen that was gram-positive, deep surgical site infections with polymicrobial cultures, deep surgical site infections with negative culture results, and cellulitis or skin infections treated only with antibiotics. Results Among the 1660 participants randomized, 1528 (mean age, 47.0 [SD, 14.3] years; 603 female [39.5%]; 925 male [60.5%]) were included in the primary analysis. Deep surgical site infections occurred in 51 of 753 participants (182-day probability, 7.4%) in the tobramycin plus vancomycin group and 47 of 775 participants (182-day probability, 6.6%) in the vancomycin alone group (hazard ratio, 1.11; 95% bayesian credible interval, 0.75-1.66; posterior probability of superiority, 29.7%). The threshold required for superiority was not reached for any secondary outcome. Conclusions and Relevance Among patients with operatively treated periarticular tibial fractures at high risk of infection, adding intrawound tobramycin powder to vancomycin powder at the time of definitive fixation did not reduce deep surgical site infections compared with vancomycin powder alone. Trial Registration ClinicalTrials.gov Identifier: NCT02227446

BACKGROUND AND OBJECTIVE:Locked intramedullary (IM) nails are the primary treatment modality for femoral shaft fractures. This study aimed to determine the risk of developing a femur nonunion as a function of nail-to-bone diameter mismatch. MATERIALS AND METHODS:A retrospective case-control study was performed at a Level I trauma center. Adult patients with femoral shaft fractures (AO/OTA 32 classification) treated with IM nail fixation from 2016 to 2022 were identified from the institutional database. Cases required nonunion surgery. Controls were randomly selected in a 3:1 ratio and included only if fractures healed at final follow-up based on the modified Radiographic Union Score of the femur (mRUSF). The primary outcome was nonunion. The study compared the association of nonunion with nail diameter (range, 9 mm to 13 mm) relative to femur width (range, 12 mm to 36 mm) and adjusted for smoking status, open fracture, and the degree of comminution. RESULTS:In total, 203 patients were included: 50 cases and 153 controls. Patients with a femur anterior-to-posterior diameter >22 mm at the level of the lesser trochanter (11% of this sample) were at increased odds for nonunion when treated with a small diameter IM nail (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.7; P = .01). In patients with narrower femur diameters, the nail diameter was not associated with increased odds of nonunion surgery. CONCLUSION:Larger IM nails (≥11 mm) might have protected against nonunion in patients with wide femoral canals (≥22 mm) but likely conferred no significant benefit in patients with narrower femoral canals.

Importance:Previous research has suggested that intrawound vancomycin powder reduces deep surgical site infections among patients with periarticular tibial fractures at high risk of infection. It is unknown whether the addition of tobramycin powder further decreases infection rates. Objective:To compare whether the combination of tobramycin plus vancomycin vs vancomycin alone delivered as intrawound powder at the time of definitive fixation reduces deep surgical site infections. Design, Setting, and Participants:Open-label, assessor-masked, randomized clinical trial conducted at 39 US trauma centers. Eligible patients were adults with an operatively treated periarticular tibial fracture (either tibial plateau or pilon) who met 1 of 3 criteria for elevated infection risk. Enrollment occurred between June 18, 2021, and December 12, 2024 (final follow-up, July 15, 2025). Interventions:Intrawound tobramycin (1.2 g) plus vancomycin (1.0 g) powder vs intrawound vancomycin (1.0 g) powder delivered at the time of definitive fixation. Main Outcomes and Measures:The primary outcome was a deep surgical site infection requiring surgical management within 182 days of definitive fracture fixation. Secondary outcomes included deep surgical site infections with pathogens that were gram-negative only, deep surgical site infections with at least 1 pathogen that was gram-positive, deep surgical site infections with polymicrobial cultures, deep surgical site infections with negative culture results, and cellulitis or skin infections treated only with antibiotics. Results:Among the 1660 participants randomized, 1528 (mean age, 47.0 [SD, 14.3] years; 603 female [39.5%]; 925 male [60.5%]) were included in the primary analysis. Deep surgical site infections occurred in 51 of 753 participants (182-day probability, 7.4%) in the tobramycin plus vancomycin group and 47 of 775 participants (182-day probability, 6.6%) in the vancomycin alone group (hazard ratio, 1.11; 95% bayesian credible interval, 0.75-1.66; posterior probability of superiority, 29.7%). The threshold required for superiority was not reached for any secondary outcome. Conclusions and Relevance:Among patients with operatively treated periarticular tibial fractures at high risk of infection, adding intrawound tobramycin powder to vancomycin powder at the time of definitive fixation did not reduce deep surgical site infections compared with vancomycin powder alone. Trial Registration:ClinicalTrials.gov Identifier: NCT02227446.

OBJECTIVE:To determine if 4-8-week radiographs are useful for predicting nonunions in patients with femoral shaft fractures treated with an intramedullary nail (IMN). METHODS:A retrospective case-control study; 1:2 ratio was conducted at a level I trauma center. Adult patients with a femoral shaft fracture (OTA/AO 32) treated with IMN between 2016 and 2022 were identified via Current Procedural Terminology code. The included cases underwent nonunion surgery a minimum of 3 months after the index procedure. The controls were randomly selected from the cohort and had a minimum of 6 months postoperative follow-up and evidence of radiographic union. The modified Radiographic Union Score of the Tibia (mRUST) applied to femur fractures was determined on radiographs obtained 4-8 weeks after the index surgery. RESULTS:One hundred forty-eight patients (mean age, 35 [SD, 15] years) were included. A significant difference was found between cases and controls relating to the distribution of mRUST scores at 4-8 weeks postoperatively (median, 6 versus 9; p < 0.0001). Logistic regression analysis demonstrated that the mRUST score at 4-8 weeks is a strong predictor of union with an area under the curve of 0.85 (95 % CI: 0.78-0.92). If the mRUST score at 4-8 weeks postoperatively is 9 or above, the probability of eventual union is 99 % (95 % CI: 94-100 %). CONCLUSION:The results suggest that healing on 4-8-week radiographs after IMN fixation for femoral shaft fractures may help identify patients at elevated risk of nonunion. Patients with mRUST scores 9 or above on the 4-8-week postoperative radiographs have a low likelihood of nonunion and less frequent radiographic follow-up may be needed.

OBJECTIVES:To determine the effect of external beam radiation (XRT) on preventing severe heterotopic ossification (HO) after acetabular surgery.Design:Randomized controlled trial.Setting:Two level I academic trauma centers.Patient Selection Criteria:Patients with an acetabular fracture (OTA/AO type 62) surgically treated through a posterior or combined anterior and posterior approach.Outcome Measures and Comparisons:Radiographic HO was determined using Brooker Classification at the last follow-up. The primary outcome was severe HO (Brooker classes III-IV). The secondary outcome was any HO (Brooker classes I-IV). The incidence of radiographic HO was compared between patients who did and did not undergo postoperative XRT. The results were analyzed in both an intention-to-treat (randomized to XRT) and as-treated (received XRT) basis.RESULTS:Severe HO occurred in 3 of 54 (6%) patients randomized to XRT and 9 of 50 (18%) patients randomized to no XRT (odds ratio 0.24, 95% confidence interval, 0.05 to 0.94; P = 0.05). Any HO occurred in 10 (19%) patients assigned to XRT and 17 (34%) patients in the no XRT control group (odds ratio 0.39; 95% confidence interval, 0.13 to 1.05; P = 0.07).CONCLUSIONS:The findings of this dual-center randomized controlled trial suggest that XRT after acetabular surgery significantly reduced the odds of severe HO compared with patients who did not receive XRT. These results can help guide shared decision making between surgeons and patients regarding the use of XRT for HO prophylaxis.LEVEL OF EVIDENCE:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE:To determine whether bone transport or Masquelet results in higher rates of major unplanned reoperations for the treatment of segmental tibial bone defects ≥4 cm in length. METHODS: DESIGN:Retrospective cohort. SETTING:Level I trauma center. PATIENT SELECTION CRITERIA:Adult patients with segmental tibial defects (OTA/AO 41, 42, 43) ≥4 cm who underwent surgical treatment with ring fixator bone transport or Masquelet between 2011 and 2022 with a minimum 1-year follow-up were included. OUTCOME MEASURES AND COMPARISONS:The primary outcome was a major unplanned reoperation after corticotomy (bone transport) or autografting (Masquelet), including below knee amputation, surgical debridement for deep infection, or surgical intervention for nonunion. Ring fixator bone transport and Masquelet were compared using multivariable logistic regression, adjusting for defect size as a potential confounder. RESULTS:Twenty-four patients treated with bone transport [mean age 40 years (18-66), 100% men] and 22 patients treated with Masquelet [mean age 42 years (22-71), 91% men] were included. Defect etiology was identified as acute traumatic in 25 patients (54%) and postinfectious in 21 patients (46%) ( P = 0.23). The median defect size was 7.2 cm (interquartile range 6.1-10.1) for transport and 5.8 cm for Masquelet (interquartile range 4.7-8.0) ( P = 0.08). Bone transport was associated with an 85% reduction in the odds of a major unplanned reoperation compared to treatment with the Masquelet technique (odds ratio, 0.15; 95% confidence interval, 0.03-0.58; P = 0.01). Bone transport patients underwent a mean of 0.38 major unplanned reoperations compared to 0.91 in the Masquelet group. Reoperation for deep infection occurred significantly less in the bone transport group (21%) compared to the Masquelet group (46%) (odds ratio, 0.18; 95% confidence interval, 0.03-0.76; P = 0.03). CONCLUSIONS:Bone transport was associated with a reduction in major reoperations compared to Masquelet for segmental tibial bone defects. This finding may have been driven by fewer surgeries for infection in the bone transport group. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Importance Fracture-related infection (FRI) is a serious complication following fracture fixation surgery. Current treatment of FRIs entails debridement and 6 weeks of intravenous (IV) antibiotics. Lab data and retrospective clinical studies support use of oral antibiotics, which are less expensive and may have fewer complications than IV antibiotics. Objective To evaluate the effectiveness of treatment of FRI with oral vs IV antibiotics. Design, Setting, and Participants The POvIV multicenter, prospective randomized clinical trial was conducted across 24 trauma centers in the US among patients aged 18 to 84 years who had fracture repair or arthrodesis with fixation with implants and developed an FRI without radiographic evidence of osteomyelitis. Patients were enrolled between March 2013 and September 2018 and followed up for 12 months after hospitalization for treatment of their FRI. InterventionOral vs IV antibiotics following FRI. Main Outcomes and Measures The primary outcome was number of surgical interventions, and the primary hypothesis was noninferiority of oral vs IV antibiotics with respect to the number of study injury-related surgical interventions by 1 year. Unadjusted modified intent-to-treat (mITT) and adjusted per-protocol (PP) analyses were prespecified. A post hoc adjusted mITT analysis was conducted to resolve discrepancies between the results of the prespecified mITT and PP analyses. Recurrence of a deep surgical site infection was a key secondary outcome. Results Among 233 total patients, mean (SD) age was 46.0 (13.9) years, and 53 patients were female (22.7%). The mean number of surgical interventions within 1 year was 1.3 and 1.1 for the oral and IV groups, respectively. The upper bound of the 95% confidence interval of the mean difference with unadjusted mITT analysis was 0.59, which was lower than the prespecified noninferiority margin of 0.67, indicating noninferiority of oral to IV antibiotics. Adjusted PP analysis did not support noninferiority of the number of reoperations. A post hoc adjusted mITT analysis also showed noninferiority. The treatment effects estimates for the key secondary outcome of reinfection showed a similar pattern as those for the primary outcome. Conclusions and Relevance In this prospective randomized clinical trial, oral antibiotic treatment was noninferior to IV treatment with respect to the primary outcome of number of surgical interventions based on mITT analysis. However, there is some uncertainty in these findings based on preplanned and post hoc secondary analyses. A similar pattern of treatment effect estimates was observed for the secondary outcome of recurrence of infection. Trial RegistrationClinicalTrials.gov Identifier: NCT01714596

Early weight bearing is frequently allowed and encouraged following fixation of hip and femoral and tibial shaft fractures, while pelvis, acetabulum, and lower extremity periarticular fractures are often prescribed 6–12 weeks of restricted weight bearing. Our objective was to perform a feasibility randomized trial of immediate versus delayed weight bearing as tolerated (WBAT) for fractures of the pelvis, acetabulum, distal femur, and proximal and distal tibia. A parallel two-arm pilot feasibility trial was performed at one academic level I trauma center in the United States. Patients with a fracture of the pelvis, acetabulum, distal femur, proximal tibia, or distal tibia were eligible. Patients were randomized to either immediate WBAT or delayed (≥ 6 weeks) weight bearing after surgery. Our feasibility criteria included the following: (1) 25

Importance:Fracture-related infection (FRI) is a serious complication following fracture fixation surgery. Current treatment of FRIs entails debridement and 6 weeks of intravenous (IV) antibiotics. Lab data and retrospective clinical studies support use of oral antibiotics, which are less expensive and may have fewer complications than IV antibiotics. Objective:To evaluate the effectiveness of treatment of FRI with oral vs IV antibiotics. Design, Setting, and Participants:The POvIV multicenter, prospective randomized clinical trial was conducted across 24 trauma centers in the US among patients aged 18 to 84 years who had fracture repair or arthrodesis with fixation with implants and developed an FRI without radiographic evidence of osteomyelitis. Patients were enrolled between March 2013 and September 2018 and followed up for 12 months after hospitalization for treatment of their FRI. Intervention:Oral vs IV antibiotics following FRI. Main Outcomes and Measures:The primary outcome was number of surgical interventions, and the primary hypothesis was noninferiority of oral vs IV antibiotics with respect to the number of study injury-related surgical interventions by 1 year. Unadjusted modified intent-to-treat (mITT) and adjusted per-protocol (PP) analyses were prespecified. A post hoc adjusted mITT analysis was conducted to resolve discrepancies between the results of the prespecified mITT and PP analyses. Recurrence of a deep surgical site infection was a key secondary outcome. Results:Among 233 total patients, mean (SD) age was 46.0 (13.9) years, and 53 patients were female (22.7%). The mean number of surgical interventions within 1 year was 1.3 and 1.1 for the oral and IV groups, respectively. The upper bound of the 95% confidence interval of the mean difference with unadjusted mITT analysis was 0.59, which was lower than the prespecified noninferiority margin of 0.67, indicating noninferiority of oral to IV antibiotics. Adjusted PP analysis did not support noninferiority of the number of reoperations. A post hoc adjusted mITT analysis also showed noninferiority. The treatment effects estimates for the key secondary outcome of reinfection showed a similar pattern as those for the primary outcome. Conclusions and Relevance:In this prospective randomized clinical trial, oral antibiotic treatment was noninferior to IV treatment with respect to the primary outcome of number of surgical interventions based on mITT analysis. However, there is some uncertainty in these findings based on preplanned and post hoc secondary analyses. A similar pattern of treatment effect estimates was observed for the secondary outcome of recurrence of infection. Trial Registration:ClinicalTrials.gov Identifier: NCT01714596.

OBJECTIVES:To explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. METHODS:A retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. RESULTS:We identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2-4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1-4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3-3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8-2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). CONCLUSION:Low SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

OBJECTIVE: This study was undertaken to evaluate hip fracture simulator training and orthopedic resident skill attainment. We hypothesized that after 6 training sessions, improvement in post -training scores in junior residents would exceed that of senior residents and that senior residents would attain expert level proficiency sooner. DESIGN: Thirty orthopedic residents from a single institution completed 6 training sessions. Sessions included a pretest, 9 training modules, and post-test. An expert score was obtained from the average scores of 8 trauma fellows and attending orthopedic traumatologists. The primary outcome measure was overall score. SETTING: A single academic institution. PARTICIPANTS: Orthopedic residents (postgraduate years [PGYs] 1-5). RESULTS: Twenty-six residents completed the study. The mean overall post -training score was 87% of the expert level. Factors associated with post -training score changes were additional training sessions (4.2% improvement [p < 0.01]), time between training sessions (0.3% decrease [p = 0.05]) and PGY5 class (12.1% improvement [p = 0.03]). Fifty-four percent of residents attained the expert overall score. Expert score attainment was not associated with an additional year of training or case log volume. Post -training scores plateaued for the PGY1s and showed linear improvement for the PGY5s. CONCLUSIONS: Differences in trends between training levels suggest this simulator is a useful adjunct to a 5 -year orthopedic residency training program. (J Surg Ed 81:288-294. (c) 2023 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture. Materials and Methods We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling. Results The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively). Discussion After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes. Conclusions Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

OBJECTIVE:To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared. METHODS: DESIGN:Secondary analysis of a prospective, multicenter trial. SETTING:Two level I academic trauma centers. PATIENT SELECTION CRITERIA:Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury. OUTCOME MEASURES AND COMPARISONS:Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared. RESULTS:Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management. CONCLUSIONS:Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden. LEVEL OF EVIDENCE:Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Our treatment of tibial plateau fractures involves three distinct phases. First, preoperative evaluation involves a complete history and physical exam to identify mechanism of injury, patient comorbidities, and the presence of associated neurovascular injury or compartment syndrome. Radiographic assessment during this phase of treatment routinely includes plain radiographs and computed tomography (CT) scan to accurately define the fracture pattern, degree of intra-articular involvement, and to aid in preoperative planning. The second phase consists of the surgery itself and may include temporizing knee-spanning external fixation in bicondylar fractures or those with excessive soft-tissue swelling and/or fracture blisters. The goals of definitive surgical treatment are to anatomically reduce the articular surface, repair any concomitant meniscal pathology, and provide stable fixation to allow for immediate range of motion (ROM) of the knee. The third phase of treatment is the postoperative therapy and immobilization protocol, which is designed to maximize functional recovery while protecting the soft tissue and internal fixation construct during bony healing. The most common postoperative problems we encounter in treating these injuries are knee stiffness, loss of reduction, flexion contractures, and wound or soft-tissue problems. This postoperative protocol is designed to minimize the occurrence of these problems.

INTRODUCTION The purpose of this study was to evaluate whether intramedullary nail contact with physeal scar improves construct mechanics when treating distal tibial shaft fractures. METHODS Axially unstable extra-articular distal tibia fractures were created in 30 fresh frozen cadaveric specimens (15 pairs, mean age 79 years). Specimens underwent intramedullary nailing to the level of the physeal scar locked with one or two interlocks or short of the physeal scar locked with two interlocks (reference group). Specimens were subjected to 800N of axial load for 25,000 cycles. Primary outcomes were stiffness before and after cyclic loading. Secondary outcomes were load to failure, load at 3 mm displacement, plastic deformation, and total deformation. RESULTS The physeal scar with one interlock cohort demonstrated 3.8% greater stiffness before cycling (P = 0.75) and 1.7% greater stiffness after cycling (P = 0.86) compared with the reference group. The physeal scar with two interlocks group exhibited 0.3% greater stiffness before cycling (P = 0.98) and 8.4% greater stiffness after cycling (P = 0.41) in relation to the reference group. No differences were identified regarding load to failure or load at 3 mm displacement. In specimens with two interlocks, those in contact with the physeal scar demonstrated significantly less plastic (P = 0.02) and total (P = 0.04) deformation. CONCLUSIONS Constructs ending at the physeal scar demonstrated stiffness and load to failure similar to those without physeal scar contact. Less plastic and total deformation was noted in two-interlock constructs with physeal scar contact, suggesting a possible protective effect provided by the physeal scar. These data argue that physeal scar contact may offer a small mechanical benefit in nailing distal tibia fractures, but clinical relevance remains unknown.

Background: This cadaveric study seeks to determine whether skills acquired on the simulator translate to improved performance of the clinical task. We hypothesized that completion of simulator training modules would improve performance of percutaneous hip pinning. Methods: Eighteen right-handed medical students from two academic institutions were randomized: trained (n = 9) and untrained (n = 9). The trained group completed nine simulator-based modules of increasing difficulty, designed to teach techniques of placing wires in an inverted triangle construct in a valgus-impacted femoral neck fracture. The untrained group had a brief simulator introduction but did not complete the modules. Both groups received a hip fracture lecture, an explanation and pictorial reference of an inverted triangle construct, and instruction on using the wire driver. Participants then placed three 3.2 mm guidewires in cadaveric hips in an inverted triangle construct under fluoroscopy. Wire placement was evaluated with CT at 0.5 mm sections. Results: The trained group significantly outperformed the untrained group in most parameters (P ≤ 0.05). Conclusions: The results suggest that a force feedback simulation platform with simulated fluoroscopic imaging using an established, increasingly difficult series of motor skills training modules has potential to improve clinical performance and might offer an important adjunct to traditional orthopaedic training.

Fixation of humeral shaft fractures is frequently performed with large-fragment (4.5 mm) plates to accommodate immediate weight bearing. Use of small-fragment (3.5 mm) plates as an alternative carries theoretical benefits. We examined nonunion rates and postoperative radial nerve palsy (RNP) rates in a retrospective cohort of patients undergoing open reduction and internal fixation of humeral shaft fractures with 3.5-mm or 4.5-mm plates. Two hundred thirty-six patients with 241 humeral shaft fractures were included. Small 3.5-mm plates were used in 83% of the patients, and large 4.5-mm plates were used in 17% of the patients. Fifty-three percent were made weight bearing as tolerated following surgical fixation. There was a 7% incidence of nonunion and a 10% incidence of RNP in the 3.5-mm plate group. There was a 7% incidence of nonunion and a 15% incidence of RNP in the 4.5-mm plate group. No statistically significant relationship was shown between nonunion or RNP and plate size ( P =.74 and P =.39). No relationship was shown between nonunion and postoperative weight-bearing status ( P =.45). Subgroup analysis according to plate size additionally showed no association of nonunion with postoperative weight bearing in both the 4.5-mm ( P =.55) and the 3.5-mm ( P =.25) cohorts. Small-fragment and large-fragment plating of humeral shaft fractures resulted in comparable union and RNP rates, regardless of postoperative weight-bearing status. Our findings suggest that 3.5-mm plate fixation of humeral shaft fractures is a safe alternative to 4.5-mm plate fixation. [ Orthopedics . 2023;46(4):198–204.]

Objective: To determine the outcomes of high-risk patients treated with tibiotalocalcaneal hindfoot fusion nails. Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between January 2007 and December 2016, 50 patients with significant medical comorbidities treated with a tibiotalocalcaneal hindfoot fusion nail in the setting of acute distal tibia and ankle trauma considered to be limb-threatening. Intervention: Tibiotalocalcaneal hindfoot fusion nail. Main Outcome Measurements: Two-year cumulative incidence of unplanned reoperation and estimated survival with limb salvage at 2 years. Results: Of the 50 patients, 20 (38%) had an unplanned reoperation (mean: 2.5 reoperations), including 19 for implant removal, 11 for irrigation and debridement and/or placement of an antibiotic delivery device, and 4 for revision fusion. Three patients required amputation and 3 patients died within 2 years of injury, resulting in an estimated survival with limb salvage at 2 years of 79% (95% confidence interval: 67%–91%). After accounting for the competing risk of death and incomplete follow-up, the 2-year cumulative incidence of unplanned reoperation was 64% (95% confidence interval: 62%–67%). Conclusions: Patients in this series experienced a high rate of return to the operating room but a relatively low rate of amputation. Because patients were indicated for this course of treatment on the basis of comorbidities felt to put them at high risk of loss of limb with traditional treatment, acute hindfoot fusion nailing might represent a viable option in select high-risk patients and injuries. Clinicians should be aware that complications are still common. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Discrete choice experiments are a robust technique for quantifying preferences. With this method, respondents are presented with a series of hypothetical comparisons described by attributes with varying levels. The aggregated choices from respondents can be used to infer the relative importance of the described attributes and acceptable trade-offs between attributes. The data generated from discrete choice experiments can aid surgeons in aligning patient values with treatment decisions and support the design of research that is responsive to patient preferences. This article summarizes the application of discrete choice experiments to orthopaedics. We share best practices for designing discrete choice experiments and options for reporting study results. Finally, we suggest opportunities for this method within our field.

Objectives: Describe patient-reported pain and function within 24 months of a pelvic fracture treated with posterior screw fixation and identify factors associated with increased pain. Design: Prospective case series. Setting: Academic trauma center. Patients/Intervention: Eighty-eight patients with adult pelvic fracture treated with sacroiliac or transiliac screws. Main Outcome Measures: Average pain measured with the Brief Pain Inventory (BPI); function measured with the Majeed Pelvic Outcome Score from 6 to 24 months postinjury. Results: The mean pain from 6 to 24 months postinjury was 2.22 on the 10-point BPI scale (95% CI, 0.64-3.81). Sixty-nine patients (78.4%) reported mild to no pain at 6 months; 12 (13.6%) patients had severe pain. Two years after injury, 71 patients (80.6%) exhibited mild to no pain. Within 24 months of injury, the mean pelvic function was 71 on the 100-point Majeed scale (95% CI, 60-82). Half of the sample (n = 44) had good to excellent pelvis function by 6 months postinjury; 55 patients (62.5%) attained this level of function by 24 months. A history of chronic pain (1.31; 95% CI, 0.26-2.37; P = 0.02), initial fracture displacement (>= 5 mm) (0.99; 95% CI, 0.23-1.69; P = 0.01), and socioeconomic deprivation (0.28; 95% CI, 0.11-0.44; P < 0.01) were significantly associated with increased pain. Conclusion: Our findings suggest that most patients with unstable pelvic ring fractures treated with posterior screw fixation achieve minimal to no pelvis pain and good to excellent pelvic function 6-24 months after injury.