Masquelet's induced membrane technique (MIMT) is a staged surgical procedure that leverages the foreign body induced membrane (IM) that forms around a cement spacer placed into a segmental bone defect to support subsequent bone grafting. The mechanisms by which the IM supports bone consolidation are not fully understood. We present an indirect coculture system for studying IM-MSC interactions using a rat model of MIMT. Compared to control cells, MSC Tnap (alkaline phosphatase) was induced by 4- but not 8-week IM. MSC Spp1 (Osteopontin) was attenuated by both 4- and 8-week IM. Although Tnfrsf11b (osteoprotegrin) in MSC exposed to IM was not different from control cells, it was induced by 8-week IM compared to 4-week IM. MSC Tnfsf11 (RANKL) was reduced by 4-week and 8-week IM. MSC Thbs2 (Tsp2) was induced by 8-week but not 4-week IM. Ablation of macrophages in IM blocked the induction of Thbs2 by 8-week IM. MSC Col1a1 expression was not affected under any condition tested. TMT proteomics analysis of IM-conditioned medium revealed 150 unique secreted proteins, 7 of which were differentially abundant (fold change ≥ 2 and FDR corrected p ≤ 0.05) in 8-week versus 4-week IM secretomes. All differentially abundant proteins were elevated in medium conditioned by 8-week IM. Our data suggest that factor(s) secreted by IM resident cells affect MSC gene expression, and that duration of IM development influences the potency and nature of this paracrine effect. Patient-specific factors including age and interval between MIMT surgeries may affect IM biological potency and graft to bone consolidation.

SUMMARY:Lateral compression (LC) 3 pelvic ring injuries are high energy, complex patterns that may include a "crescent fracture," which is an important consideration when determining the appropriate fixation tactic. This review discusses the reduction and fixation of a pediatric LC3 pelvic ring injury with particular focus on the open and percutaneous techniques for treatment of a crescent fracture.

Disuse osteopenia is a well-recognized consequence of prolonged physical inactivity, but its rate after orthopaedic injuries necessitating non-weight-bearing is not well studied. The purpose of this study was to estimate the rate of disuse osteopenia at the lumbar spine and proximal femur in patients with lower extremity trauma admitted to the hospital. We performed a retrospective chart review of patients with lower extremity trauma with a period of strict non-weight-bearing between completion of two computed tomography (CT) scans. The radiodensity of the proximal femur or lumbar vertebrae was measured from the earliest and latest available CT scans within the non-weight-bearing timeframe. The change in estimated bone mineral density (eBMD) was calculated as a proxy for disuse osteopenia. A total of 189,111 patients were screened, with 17 patients in the proximal femur group and 15 patients in the lumbar spine group meeting inclusion and exclusion criteria. The average rate of change in eBMD of the proximal femur was a decrease of 7.54 HU/day, 95% confidence interval (CI) [3.65, 11.43]. The average rate of change in eBMD of the lumbar spine was an increase of 1.45 HU/day, 95% CI [-3.15, 6.06]. In admitted, non-weight-bearing orthopaedic trauma patients, our novel study suggests that the proximal femur experiences disuse osteopenia during periods of non-weight-bearing, although this finding was not observed at the lumbar spine. The clinical significance of this data underscores the important consideration of disuse osteopenia by all physicians when caring for patients that may require non-weight-bearing restrictions.

Distal femur fractures (DFF) are frequently treated surgically with single traditional constructs (STC), such as with a lateral plate or intramedullary nail, although nail-plate combination constructs (NPCC) are gaining attention. The purpose of this study is to compare outcomes between NPCC and STC for surgical fixation of DFF to guide surgeon decision-making. Data Sources: This study is a systematic review and meta-analysis using PubMed, CINAHL, MEDLINE, Web of Science, Science Direct, and SPORTDiscus from database inception until January 10th, 2024. Study Selection: Inclusion criteria were comparative studies that examined clinical outcomes and complications for NPCC versus STC for DFF in adult patients. Data Extraction: Data included operative time, estimated blood loss (EBL), length of stay (LOS), as well as likelihood of total complications, total unplanned reoperations, and malunion. Data Synthesis: Statistical analysis included a random-effects model using unstandardized mean difference or odds ratio (OR). Five retrospective comparative studies (n = 1,368 patients; mean age: 52.3 ± 8.1 years; 134 patients in the NPCC group) were included. There was no statistically significant difference in operative time (p = 0.696), EBL (p = 0.408), or LOS (p = 0.963) between patients in the NPCC group as compared to patients in the STC group after DFF. Patients in the NPCC group had a statistically significant lower number of total complications (p = 0.009; OR: 0.31; 10.6

Atypical femur fractures represent a distinct clinical entity from other geriatric and fragility fractures. Cephalomedullary nailing is the preferred means of fixation. Anatomic reduction is key to avoiding delayed healing and nonunion.

OBJECTIVES: A novel protocol was previously presented for nonoperative management of Weber B (OTA/AO 44B) ankle fractures with criteria of medial clear space <7 mm on gravity stress (GS) radiographs and ipsilateral superior clear space and contralateral GS medial clear space within 2 mm. This study recruited an operative cohort for comparison of outcomes. METHODS: Design: Retrospective cohort study. Setting: Level 1 academic center. Patient Selection Criteria: The recruited operative cohort consisted of patients who may have been considered for the nonoperative protocol, but underwent surgery instead. Outcome Measures and Comparisons: Kellgren-Lawrence scale for evaluation of arthritis, American Orthopedic Foot and Ankle Society Hindfoot, Olerud Molander Ankle, Lower Extremity Functional Scale (LEFS), and PROMIS (physical function, depression, pain interference) scores for the current operative cohort were compared with that of the original nonoperative cohort. RESULTS: There were 20 patients in the operative cohort and 29 in the original nonoperative cohort. Mean follow-up was 6.9 and 6.7 years, respectively. The following outcome scores were better for the nonoperative cohort compared with the operative, respectively: LEFS, 75.2 and 68.1 (P = 0.009); Olerud Molander Ankle, 94.1 and 89.0 (P = 0.05); American Orthopedic Foot and Ankle Society, 98.5 and 91.7 (P = 0.0003); PROMIS Physical Function, 58.2 and 50.4 (P = 0.01); PROMIS Pain Interference, 42.2 and 49.7 (P = 0.004). The PROMIS Depression, 42.8 and 45.4 (P = 0.29), was not different between groups. All patients achieved union of their fracture. Surgical complications included implant removal (15%), SPN neurapraxia (5%), and delayed wound healing (5%). CONCLUSIONS: In carefully selected patients with isolated Weber B fractures, nonoperative management may be considered because it can lead to equivalent or superior outcomes with none of the risks typically associated with surgical intervention. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Case: A 45-year-old man who sustained an open tibial shaft fracture treated with intramedullary (IM) nailing 9 years earlier presented with persistent pain and concern for occult infection. He underwent tibial nail removal and debridement with reamer-irrigator-aspirator. Postoperative course was complicated by acute compartment syndrome. Conclusion: This is a unique case of postoperative compartment syndrome after IM debridement and tibial hardware removal. A high index of suspicion should be prioritized in patients who complain of severe or unexpected pain to mitigate delays in diagnosis and aid in early treatment.

OBJECTIVE:Multiple comorbidities in hip fracture patients are associated with increased mortality and complications. The goal of this study was to characterize the relationship between specific patient factors including comorbidities and outcomes in geriatric hip fractures, including length of stay, unplanned ICU admission, discharge disposition, complications, and mortality. METHODS:This is a retrospective review of a trauma database from five Level 1 and Level 2 trauma centers of patients with hip fractures of the femoral neck and intertrochanteric region who underwent treatment using hip pinning, hemiarthroplasty, total hip arthroplasty, cephalomedullary nailing, or dynamic hip screw fixation. Mortality was the primary outcome variable (including in-hospital mortality, 30-day mortality, 60-day mortality, and 90-day mortality). Secondary outcome variables included in-hospital adverse events, unplanned transfer to the ICU, postoperative length of stay, and discharge disposition. Regression analyses were used for evaluation of relationships between comorbidities as independent variables and primary and secondary outcomes as dependent variables. RESULTS:Two thousand three hundred patients were included. The mortality was 1.8%, 7.0%, 10.9%, and 14.1% for in-hospital, 30-day, 60-day, and 90-day mortality, respectively. Diabetes and cognitive impairment present on admission were associated with mortality at all-time intervals. COPD was the only comorbidity that signaled in-hospital adverse event with an odds ratio of 1.67 (P = 0.012). No patient factors, time to surgery, or comorbidities signaled unplanned ICU transfer. Patients with renal failure and COPD had longer hospital stays after surgery. CONCLUSION:Geriatric hip fractures continue to have high short-term morbidity and mortality. Identifying patients with increased odds of early mortality and adverse events can help teams optimize care and outcomes. Patients with diabetes, cognitive impairment, renal failure, and COPD may benefit from continued and improved medical optimization during the perioperative period as well as being more closely managed by a medicine team without delaying time to the operating room.

Existing literature is discrepant on the differences in blood loss and need for transfusion between short and long cephalomedullary nails used for extracapsular geriatric hip fractures. However, prior studies used the inaccurate estimated rather than the more accurate ‘calculated’ blood loss based on hematocrit dilution (Gibon in IO 37:735–739, 2013, Mercuriali in CMRO 13:465–478, 1996). This study sought to clarify whether use of short nails is associated with clinically meaningful reductions in calculated blood loss and resultant need for transfusion. A retrospective cohort study using bivariate and propensity score-weighted linear regression analyses was conducted examining 1442 geriatric (ages 60–105) patients undergoing cephalomedullary fixation of extracapsular hip fractures over 10 years at two trauma centers. Implant dimensions, pre and postoperative laboratory values, preoperative medications, and comorbidities were recorded. Two groups were compared based on nail length (greater or less than 235 mm). Short nails were associated with a 26

Although the efficacy of ketorolac in pain management and the short duration of use align well with current clinical practice guidelines, few studies have specifically evaluated the impact of ketorolac on bony union after fracture or surgery. The purpose of this study was to review the current basic science and clinical literature on the use of ketorolac for pain management after fracture and surgery and the subsequent risk of delayed union or nonunion. Animal studies demonstrate a dose-dependent risk of delayed union in rodents treated with high doses of ketorolac for 4 weeks or greater; however, with treatment for 7 days or low doses, there is no evidence of risk of delayed union or nonunion. Current clinical evidence has also shown a dose-dependent increased risk of pseudoarthrosis and nonunion after post-operative ketorolac administration in orthopedic spine surgery. However, other orthopedic subspecialities have not demonstrated increased risk of delayed union or nonunion with the use of peri-operative ketorolac administration. While evidence exists that long-term ketorolac use may represent risks with regard to fracture healing, insufficient evidence currently exists to recommend against short-term ketorolac use that is limited to the peri-operative period. Level of evidence V Narrative Review

Case: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. Conclusion: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.

Objectives:To examine the relationship between anticoagulant and antiplatelet drugs and surgical blood loss for geriatric patients undergoing cephalomedullary nail fixation of extracapsular proximal femur fractures.Design:Multicenter, retrospective, cohort study using bivariate and multivariable regression analyses.Setting:Two Level-1 trauma centers.Patients:One thousand four hundred forty-two geriatric (ages 60-105 years) patients undergoing isolated primary intramedullary fixation of nonpathologic extracapsular hip fractures from 2009 to 2018 including 657 taking an antiplatelet drug alone (including aspirin), 99 taking warfarin alone, 37 taking a direct oral anticoagulant (DOAC) alone, 59 taking an antiplatelet drug and an anticoagulant, and 590 taking neither.Intervention:Cephalomedullary nail fixation.Main Outcome Measurements:Blood transfusion and calculated blood loss.Results:More patients taking antiplatelet drugs required a transfusion than controls (43% vs. 33%, P < 0.001), whereas patients taking warfarin or DOACs did not (35% or 32% vs. 33%). Median calculated blood loss was increased in patients taking antiplatelet drugs (1275 mL vs. 1059 mL, P < 0.001) but not in patients taking warfarin or DOACs (913 mL or 859 mL vs. 1059 mL). Antiplatelet drugs were independently associated with an odds ratio of transfusion of 1.45 [95% confidence interval (CI), 1.1-1.9] in contrast with 0.76 (95% CI, 0.5-1.2) for warfarin and 0.67 (95% CI, 0.3-1.4) for DOACs.Conclusions:Geriatric patients taking warfarin (incompletely reversed) or DOACs lose less blood during cephalomedullary nail fixation of hip fractures than those taking aspirin. Delaying surgery to mitigate anticoagulant-related surgical blood loss may be unwarranted.

Surgical fixation of distal femur fractures in geriatric patients is an evolving topic. Unlike hip fractures, treatment strategies for distal femur fractures are ill-defined and lack substantive high-quality evidence. With an increasing incidence and an association with significant morbidity and mortality, it is essential to understand existing treatment options and their supporting evidence. Current fixation methods include the use of either retrograde intramedullary nails, or plate and screw constructs. Due to the variability in fracture patterns, the unique anatomy of the distal femur, and the presence or absence or pre-existing implants, decision-making as to which method to use can be challenging. Recent literature has sought to describe the advantages and disadvantages of each, however, there is currently no consensus on a standard of care, and little randomized evidence is available that directly compares intramedullary nails with plating. Future randomized studies comparing intramedullary nails with plating constructs are necessary in order to develop a standard of care based on injury characteristics.

Category: Trauma; Other Introduction/Purpose: Disuse osteopenia develops in individuals with decrease lower limb use especially after injury necessitating non-weightbearing, hospitalization or both. However, the nature of this change is not well characterized and, therefore, cannot be appropriately addressed. Conventional CT produces a reliable evaluation of bone quality as Hounsfield Units (HU) and offers the opportunity to longitudinally study bone density in activity-altered patients. The purpose of this study is to estimate the degree of osteopenia in non-weightbearing hospitalized patients and to identify patient-related factors associated with this loss. Methods: Initial screening criteria included patients who presented to the emergency department between January 1, 2010 to August 1, 2020; baseline lower extremity orthopaedic trauma evaluated by CT. Further criteria included CT imaging capturing the ipsilateral hip at the time of admission; a second CT scan, for any indication (eg, small bowel obstruction, diverticulitis, etc) that include that same hip; strict non-weightbearing in between scans. Exclusion criteria included change in weightbearing status and CT imaging changes that would not allow eBMD analysis (eg, intervention). Estimated BMD (eBMD) was measured at baseline and and at the secondary time point via HU approximation 12mm inferior to superior aspect of femoral neck on axial CT. The change in eBMD was calculated as a proxy for disuse osteopenia and the relationship between relative bone loss (as a nominal rate of osteopenia, eBMD loss/time) and patient-specific factors was explored. Results: Of 200,000 patients who received CT evaluation including their hip during the targeted timeframe, seventeen patients met our inclusion and exclusion criteria. There was an average of 7.3 days (median = 6 days; mode = 4 days; interquartile range: 4 - 8.5 days) between CT scans. The average rate of disuse osteopenia in the cohort was a net average decrease of 7.5 +- 5.8 HU/day. To place in a standardized clinical context, this change is estimated to correlate linearly with respect to change in DEXA BMD T-Score and may be clinically relevant when HU approach values <100. Associated patient factors that may further precipitate osteopenia whilst non-weightbearing are smoking, female gender, and diabetes. Conclusion: We report novel, preliminary data estimating the rate of disuse osteopenia in admitted, non-weightbearing orthopaedic trauma patients. This data underscores an important consideration all physicians should make when non- weightbearing status is being considered or required after injury or admission.

Aim To determine (1) frequency of resident research projects being in the same orthopaedic subspecialty that they ultimately choose for fellowship and practice; (2) percentage of research projects that were published. Methods Resident Thesis Day programs were independently assessed by two reviewers from 2010 to 2020. Reviewers classified projects based on orthopaedic subspecialty: Spine, Joints, Trauma, Hand, Foot and Ankle, Sports, Pediatrics, Oncology, and Shoulder Elbow. Presenting residents' fellowship subspecialty, current practice specialty, and geographic state of current practice were collected using internet searches. Correlation of residents who completed a thesis day project in the same subspecialty as their fellowship and current practice was calculated. Results A total of 81 resident physicians, 11 (13.6%) female, were included. In the entire cohort, 50.6% did a thesis day project in a different field than their current or projected subspecialty. Of those who completed, or are currently completing fellowship, 33 (52.4%) did their thesis day project in the same subspecialty as their fellowship. Of the current residents who have matched into fellowship, 46.7% did a thesis day project in the same subspecialty. A total of 51 (63.0%) projects were published. Conclusion The majority of resident research projects were published, and about 50% of orthopaedic residents went on to complete a fellowship and practice in the same subspecialty as their research project. As residents often spend a considerable amount of time and effort on their projects, these findings may help tailor resident education and research curriculums to focus more on research principles than specific orthopedic content.

Summary: Distal femur fractures are common in the elderly population. The risk of sustaining a distal femur fracture is increased with the presence of total knee arthroplasty components. Fixation with a retrograde intramedullary nail is a viable option for treatment of these injuries. This case-based video demonstrates the preoperative planning, techniques, and potential technical pitfalls to performing a retrograde intramedullary nail through a total knee arthroplasty in patients with a distal femur fracture.

Summary: Open segmental tibial fractures are difficult injuries fraught with potential for complications. Delays or missteps in treatment and soft tissue coverage can lead to disastrous outcomes. This article and the accompanying video demonstrate an example of a timely, team-based approach for management of an open segmental tibial shaft fracture with complex osseous fixation and soft tissue reconstruction.

Masquelet's induced membrane technique (MIMT) is a relatively new, two-stage surgical procedure to reconstruct segmental bone defects. First performed by Dr. Masquelet in the mid-1980s, MIMT has shown great promise to revolutionize critical-sized bone defect repair and has several advantages over its alternative, distraction osteogenesis (DO). Also, its success in extremely challenging cases (defects > 15 cm) suggests that its study could lead to discovery of novel biological mechanisms that might be at play during segmental defect healing and fracture non-union. MIMT's advantages over DO have led to a world-wide increase in MIMT procedures over the past decades. However, MIMT often needs to be repeated and so the average initial success rate in adults lags significantly behind that of DO (86% vs 95%, respectively). The autologous foreign-body membrane created during the first stage by the immune system's response to a polymethyl methacrylate bone cement spacer is critical to supporting the morselized bone graft implanted in the second stage. However, the biological and/or physical mechanisms by which the membrane supports graft to bone union are unclear. This lack of knowledge makes refining MIMT and improving the success rates through technique improvements and patient selection a significant challenge and hinders wider adoption. In this review, current knowledge from basic, translational, and clinical studies is summarized. The dynamics of both stages under normal conditions as well as with drug or material perturbations is discussed along with perspectives on high-priority future research directions.

Abstract. Objectives:. There is no definitive evidence to guide clinicians in their decision-making for implant choice regarding long or short intramedullary nails for unstable fracture patterns. Historically short nails were associated with higher rates of perisprothetic fractures which seem to have improved with newer designs. Long intramedullary nails have higher blood loss and time under anesthesia. The purpose of this study was to assess stability of long and short intramedullary nail constructs in unstable intertrochanteric fracture patterns to better elucidate if unstable intertrochanteric fractures are amenable to treatment with short intramedullary nails. Methods:. This study utilized composite model femurs which were assigned to either a comminuted or reverse obliquity fracture pattern, then subsequently assigned to implantation with either a long or short intramedullary nail. All the samples were reamed to the level of the distal femur and instrumented with the appropriate nail. Axial and torsional stiffness as well as axial load to failure values were determined using a servohydraulic loading system. Results:. Short nail constructs exhibited significantly greater axial stiffness in A1 fractures and torsional stiffness in A3 fractures when compared with long nails. There was no significant difference between axial load to failure between long nails and short nails. Discussion:. We found no significant difference in axial load to failure values between long and short intramedullary nail fixation in 2 unstable intertrochanteric fracture patterns in a composite femur model. Short nails exhibited greater stiffness in axial loads in the A1 pattern and torsional stiffness in the A3 pattern. This suggests short or long intramedullary nails could be appropriately employed for fixation of unstable intertrochanteric hip fracture patterns.