OBJECTIVES:We aimed to identify a protocol with the lowest possible radiation dose for CT imaging of post-operative acetabular fractures without compromising intra- and inter-observer reliability. DESIGN:Ten fresh frozen cadavers with 20 acetabuli were used. Four common fracture patterns were created, and typical fixation constructs were placed. Intentional malreduction and joint penetration were performed in some of the specimens. Each specimen was scanned with decreasing radiation dose by varying a number of protocol factors such as current and exposure time (mAs), window filters, and others. The scans were then reviewed by five fellowship trained orthopaedic traumatologists comparing against the standard, full dose CT scan of each specimen. The following parameters were assessed for each specimen: 1) articular step-off 2) articular gap 3) intra-articular implant penetration and 4) surgeon confidence. Readings were noted to be in agreement if measurement was < 2 mm. RESULTS:Intra-observer reliability for step-off, gap, and intra-articular implants ranged from 80 to 100% (p < 0.001) across all raters. Inter-observer evaluation of a single, pre-determined slice was 100% (average difference in rater measurements between the full dose protocol and lowest radiation protocol was 0.42 mm). The lowest radiation dose with > 80% inter-observer reliability was a soft tissue algorithm viewed in a bone window with 1.25 mm slices at 0.0625 mm pixels, 40mAs and 516 pitch (ultra-low dose CT protocol), which represents 1/10th the radiation of a full dose pelvic CT scan. CONCLUSION:Utilizing the ultra-low dose CT protocol represents 1/10th of the radiation of a full dose CT scan, while still providing excellent intra- and inter-observer reliability.

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.

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.

Objective:This study examined fracture incidence in patients with bipolar disorder compared to those without and assessed fracture risk based on exclusive use of lithium, mood-stabilizing antiepileptics, antipsychotics, or antidepressants versus no medication use. Methods:Using TriNetX, patients aged 18 or older were divided into bipolar and non-bipolar cohorts. The bipolar cohort was subdivided into five sub-cohorts: no medication use, exclusive lithium use, exclusive atypical antipsychotic use, exclusive mood-stabilizing antiepileptics use, and exclusive antidepressant use. The incidence of central, upper extremity, lower extremity, and "any" skeletal fractures (encompassing the previous three groups) were compared between the bipolar and non-bipolar cohorts, between males and females with bipolar disorder, and between patients aged 18-64 and aged 65 or older with bipolar disorder. A second analysis was performed to determine the incidence and relative risk of different fracture types based on exclusive medication use compared to no medication use. Results:Patients with bipolar disorder had a higher fracture risk than patients without, with an increased risk ranging from 0.43 % for upper extremity fractures to 2.41 % for any fractures. Male patients and patients aged 65 or older had a significantly higher risk of fractures compared to female patients and patients aged 18-64 (p < 0.0001 for all outcomes). Lithium use was associated with a reduced risk of central fractures (p = 0.0065) and any fractures (p = 0.0037). Patients using mood-stabilizing antiepileptics exhibited a lower risk of lower extremity fractures (p = 0.0002) and any fractures (p = 0.0003). Antipsychotic use was linked to a decreased risk of all fracture types (p < 0.0001). Antidepressant use was associated with an increased risk of upper extremity fractures (p < 0.0001) and any fractures (p < 0.0001). Conclusions:Lithium, mood-stabilizing antiepileptics, and antipsychotics were associated with reduced fracture risk, while antidepressants increased fracture risk. Further research is needed to optimize bipolar disorder treatment strategies while minimizing fracture risk.

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.

Objectives: To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. Design: Multicenter retrospective cohort study. Setting: Ten Level-I trauma centers. Patients/Participants: Patients with OTA/AO 33A or C distal femur fractures (n = 1107). Intervention: Surgical fixation of distal femur fracture. Main Outcome Measurement: The outcome of interest was deep surgical site infection. Results: There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17–4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01–3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63–8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25–0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01–1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94–3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95–2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%). Conclusions: Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pelvic osteochondromas are relatively rare, representing 5% of all osteochondromas.1 Although otherwise a benign lesion, axial location and the presence of a cartilage cap more than 2-cms at the time of skeletal maturity are risk factors for malignant transformation.1 Osteochondromas arising from the superior pubic ramus are rarely described in the literature. Resection of benign bone tumors in this location is historically described through the ilioinguinal approach with varying skin incisions. One of the earliest reports of resection of an osteochondroma from the superior ramus is a 1951 report in which the author describes making a U-shaped incision from the anterior superior iliac spine, curving down to the thigh and up over the pubic crest.2 A fascia lata flap is fashioned, and the inguinal ligament is detached along with the rectus sheath to expose the superior ramus. The osteochondroma is then resected, working around the external iliac vessels and femoral nerve. A more recent case report describes the resection of a similar superior ramus osteochondroma through an extended ilioinguinal approach.1 Another case series of patients with benign or malignant pubic rami tumors undergoing resection reports that tumors were resected using 1 of 2 approaches—an anterior approach directly over the superior ramus between the inguinal ligament inferiorly while retracting the rectus insertion off the ramus superiorly or using an inner-thigh approach used to access the inferior pubic ramus.3 Rene Stoppa described his approach to hernia repairs in 1975 (Stoppa).4 The Stoppa approach for hernia surgery was later adapted for the treatment of pelvis fractures by Hirvensalo, who described their ilioanterior approach to the pelvis in 1993 and Cole, who described the modified Stoppa anterior intrapelvic approach in 1994. (Hirvensalo, Cole)5,6 The modified Stoppa approach has not been described for the resection of tumors originating from the superior pubic ramus. We report our technique of using the modified Stoppa approach to resect an osteochondroma arising from the superior ramus. Our patient presented to the clinic with a prominent left groin mass and workup, including preoperative radiographs and CT scan (Fig. 1A-D) as well as MRI that were consistent with a benign-appearing osteochondroma. The patient was indicated for surgery due to the prominence of the mass and concern for future malignant transformation, which would require wide resection if this were to occur.FIGURE 1: Preoperative AP pelvis (A), inlet CT-reconstruction (B), outlet CT-reconstruction (C), and obturator oblique CT-reconstruction (D) showing an osteochondroma arising from the left superior ramus.TECHNIQUE The patient is placed supine on a radiolucent flat-top operating table and general anesthesia is induced. A lumbar epidural can be placed to aid postoperative pain control. A foley catheter is placed to empty the bladder and prevent distention into the surgical field. The entire pelvis and ipsilateral lower extremity is prepped in standard fashion. The surgeon stands opposite the side of the pelvis with the bone pathology. A curvi-linear Pfannenstiel incision is made, and dissection is carried through subcutaneous tissue down to the rectus abdominus fascia, which is split longitudinally along the linea alba. A malleable retractor and moist lap are placed in the space of Retzius to protect the bladder. The origin of the rectus abdominus is partially released off the pubic tubercle, and a Hohmann retractor is placed over the anterior portion of the pubic tubercle to retract the rectus anteriorly. The periosteum along the posterior aspect of the superior ramus is opened, and subperiosteal dissection around the ramus is performed and extended laterally. The hip is flexed and placed on a triangle to relax the iliopsoas and femoral neurovascular bundle, which can then be subperiosteally elevated to aid exposure of the pelvic brim. Subperiosteal dissection is carried laterally towards the iliopectineal fascia, which can be released to enter the true pelvis and expose the quadrilateral surface if needed. Care should be taken during the subperiosteal dissection of the posterior pubic ramus to identify and ligate the corona mortis with vascular clips if present. The obturator neurovascular bundle should be identified and protected if more inferior exposure is necessary for the obturator foramen. Resection of the osteochondroma on the superior ramus can then be performed. Fluoroscopy is used to identify the planned resection, ensuring that the hip joint and pubic symphysis are not violated. A Misonix bone scalpel (Bioventus Inc., Durham, NC) is used to start the osteotomies of the superior ramus, which are then completed with an osteotome. (Fig. 2A-B). The resected osteochondroma is then removed in its entirety, as confirmed by direct visualization, palpation, and fluoroscopy (Fig. 3A-B). The surgical site is irrigated. The rectus abdominus is then repaired, starting distally at the pubic symphysis, and advancing proximally. A sub-fascial hemovac drain can be placed before the closure of the rectus abdominus if desired. Layered skin closure is performed, and a sterile dressing is applied. The patient is awoken from anesthesia. Postoperatively the patient is allowed to be full weight-bearing to the bilateral lower extremities with no heavy lifting for 6 weeks postoperatively.FIGURE 2: A, Intra-operative view of the modified Stoppa approach showing resection of the osteochondroma with a portion of the superior ramus. B, The resected osteochondroma with a multi-lobulated large cartilage cap.FIGURE 3: Intra-operative fluoroscopy AP pelvis (A) and outlet pelvis (B) views showing resection of the osteochondroma and a portion of the left superior ramus. Vascular clips are seen after ligation of the corona mortis.Expected Outcomes Both the ilioinguinal and the modified Stoppa approaches are frequently used for treating fractures of the acetabulum and anterior pelvic ring. Compared with the ilioinguinal approach, the modified Stoppa has lower rates of approach-related complications, such as inguinal hernia, thrombosis, hematoma, and injury to the femoral nerve and external iliac vessels, which can occur in up to 10% of cases utilizing the ilioinguinal approach.7 The modified Stoppa does not have as steep a learning curve effect and has quicker operative times compared with the ilioinguinal approach.8 Using a less invasive approach, we were able to directly expose the pubic symphysis, superior ramus, and quadrilateral surface and safely excise the superior pubic ramus osteochondroma. We propose that the approach can be utilized in other non-traumatic pathologies, such as the resection of bone tumors. Complications Care should be taken when utilizing the modified Stoppa approach for resection of tumors of the anterior pelvic ring to avoid inadvertent injury to nearby structures. During the split of the rectus abdominis, the urinary bladder can be injured distally, and the peritoneum can be injured in the proximal extent of the dissection if carried too proximal. These structures can be protected with a moist lap and malleable retractor during the approach. A Foley catheter should be placed before starting the procedure to decompress the bladder. Lateral subperiosteal dissection of the posterior-superior surface of the superior ramus exposes the corona mortis, which is often present and traversing perpendicular to the superior ramus. The vessels should be identified and ligated before dissection of the surrounding fascia and periosteum to prevent injury to the vessels and retraction of an injured vessel before ligation. The obturator neurovascular bundle can be identified inferiorly before coursing through the obturator foramen, and judicious use of the Hohmann retractors can be used to protect the bundle during bone resection. Maintaining gentle hip and knee flexion over a triangle relaxes the femoral neurovascular bundle and prevents inadvertent traction injury to the femoral nerve from prolonged retractor use. If additional exposure of the iliac crest, internal iliac fossa, or sacral ala is required, a lateral window can be performed in addition to the modified Stoppa. If extension along the inferior ramus is needed, a vertical limb following the base of the thigh towards the ischium can be added to T the incision, such as has been described for Enneking type III pelvis resections.9 Broad prepping and draping of the entire pelvis should be performed initially to allow the addition of these extensions if needed.

OBJECTIVES:To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates.DESIGN:Multicenter retrospective cohort study.SETTING:Ten Level 1 trauma centers.PATIENTS/PARTICIPANTS:Patients with OTA/AO 33A or 33C fractures.INTERVENTION:Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867).MAIN OUTCOME MEASUREMENTS:The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up.RESULTS:One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069).CONCLUSIONS:Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF.LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

CASE:One week after receiving a COVID-19 vaccine in his left deltoid, a 34-year-old man developed severe right periscapular pain that lasted 2 weeks and was followed by profound right shoulder girdle atrophy and weakness. Both the pain and motor deficits resolved over the subsequent 4 months. CONCLUSION:Parsonage-Turner syndrome (PTS) is an idiopathic brachial plexopathy that can develop in the setting of recent vaccination and lead to significant shoulder pain and weakness. Given the worldwide increase in newly vaccinated patients, orthopaedic surgeons should take detailed histories to identify potential triggers (recent vaccination or illness) that point toward PTS rather than musculoskeletal pathology.

Background: The purpose of this study was to assess the impact of social distancing orders on ambulatory orthopaedic fracture care at a level 1 trauma center during the Coronavirus Disease 2019 (COVID-19) pandemic. Methods: All ambulatory orthopaedic fractures that presented to the author’s Level 1 trauma center were analyzed retrospectively between December 2019 and June 2020. Patients were divided into prepandemic (n=377) and pandemic (n=224) groups based on the date of presentation. Primary outcomes included new ambulatory fracture volume, and time to presentation and surgery. Secondary outcomes included fracture type and clinic no-show rates. Results: In the first 8 wk after the pandemic began, there was a 60.8% decrease in new patients with ambulatory fractures (24.6/week pre-pandemic, 9.63/week during the first 8 wk, P=0.001). The presentation rate of patients with new ambulatory fractures returned to the prepandemic baseline after the first 8 wk of the pandemic. No significant difference in time to presentation or surgery was noted between groups. There was no statistically significant difference in the presentation rate of the most commonly treated fracture types (ankle, distal radius, hand, or foot) between groups. There was a statistically significant increase in overall clinic no-show rate during the pandemic period. Conclusions: An initial decrease in ambulatory fracture volume was seen during the first 8 wk of the COVID-19 pandemic. No delay in time to presentation or time to surgery was seen between groups. After the first 8 wk of the pandemic, a return to normal ambulatory fracture volume was seen. Level of Evidence: Level III.

Objectives:To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture.Design:Multicenter retrospective cohort study.Setting:Ten Level-I trauma centers.Patients/Participants:Patients with OTA/AO 33A or C distal femur fractures (n = 1111).Intervention:Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination.Main Outcome Measurements:The outcome of interest was unplanned reoperation to promote union.Results:There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive.Conclusions:Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups.

Background: Socioeconomic status is known to influence outcomes in healthcare. This study compares hip fracture care in patients of different socioeconomic status. Methods: A retrospective study of hip fracture patients over the age 65 with hip fracture who received operative care by a single surgeon was undertaken at an academic level 1 trauma center (county group, n=47) and two private tertiary care hospitals (private group, n=78). A standardized hip fracture protocol was initiated for all patients upon admission with the goal of operative management in less than 48 hr. Time-to-surgery, length of stay, and short-term postoperative complications were compared between groups. Results: Patients from the county hospital, which serves a low socioeconomic population, were largely nonwhite (93.6%) with 12.8% uninsured, whereas 32.1% of private patients were nonwhite, and all were insured. County patients had a longer time from presentation to surgery compared with private patients (30.5 hr vs 21.7 hr, respectively, P=0.003). Length of stay was equivalent between county and private patients (8.0 days vs 7.2 days, respectively, P=0.060). There was no significant difference in the rate of complications between county versus private groups (21.3% vs. 21.8%, respectively, P=0.946). Difference in 30-day mortality was not statistically significant (8.5% county vs. 3.9% private, respectively, P=0.424). No risk factors were associated with significantly increased risk of complications with logistic regression analysis. Conclusions: There was a similar length of stay, complication rate, and mortality rate after hip fracture surgery despite demographic differences between the groups. A fragility fracture protocol can lead to similar outcomes in patients of differing demographics and insurance payor mixes. Level of Evidence: Level III.

Clavicular reconstruction is typically managed conservatively. Despite demonstrating improving outcomes, including range of motion and pain, there are currently no published reports of acute reconstruction with vascularized free fibula flaps (VFFF) or vascularized periosteal extensions in adult patients with clavicular defects. VFFFs have been utilized to correct critical bony defects of the clavicle and chronic nonunions; however, descriptions following acute trauma are rare. Bony union enhancement with periosteal extension has been described in both pediatric and adult populations, but never in the case of clavicular reconstruction. Herein, we seek to fill this gap in the literature by describing the acute reconstruction of a 6.5 cm bony gap in a 29-year-old male following a gunshot wound to the chest, utilizing a 6.5 cm VFFF with periosteal extension, and inset to the internal mammary vessels. The postoperative course was uncomplicated, with bony consolidation noted by 10 weeks, and full, pain-free range of motion at 8 months, showing this technique may be a viable option following acute trauma.

Objective: The objective of this study was to report on the early clinical results of a novel moldable calcium phosphate putty in managing metaphyseal voids associated with periarticular fractures. Design: This was a retrospective cohort study. Setting: Level I Academic Trauma Center. Patients/Participants: A total of 41 patients with periarticular fractures treated from June 2017 to June 2018 were included in the study. Intervention: Open reduction internal fixation. Main Outcome Measurement: Articular subsidence, bone void filler incorporation and resorption, calcium phosphate extravasation into soft tissue and joint, nonunion, infection. Results: Fracture distribution was as follows: 23 plateau, 6 pilon, 5 acetabulum, 4 calcaneus, 1 midfoot, 1 olecranon, 1 distal radius. Twenty-six patients had >6-month follow-up at the time of publication. All fractures have united. There were no instances in which the Montage extravasated into the soft tissue or joint. In all, 23/26 (88%) patients went on to union without articular subsidence. Overall, 25/26 (96%) showed radiographic evidence of incorporation and partial resorption. There were 2 unplanned surgeries (8%). One patient had an open pilon fracture that underwent debridement and implant removal at 4 months for deep infection; 1 patient with a tibial plateau fracture underwent debridement with implant retention at 4 weeks for deep infection. Both went on to clinical and radiographic union. Conclusions: Montage shows excellent efficacy in preventing articular subsidence when used as a metaphyseal void filler with fixation of periarticular fractures. There is strong radiographic evidence of incorporation and partial resorption at early clinical follow-up. The handling characteristics during its application showed no soft tissue or intra-articular extravasation. Early clinical results are promising, and further study is warranted. Level of Evidence: Level IV.

Objectives: (1) To evaluate adequacy and reproducibility of the gravity and manual stress imaging in the diagnosis of unstable ankle fractures and (2) to evaluate the diagnostic utility of lateral talar displacement ratio (LTDR) derived in relation to the talar body width on ankle stress imaging. Design: Retrospective cohort study. Setting: Level 1 Trauma Center. Patients: One hundred seventy consecutive patients who presented with supination-external rotation 2 ankle fractures (OTA/AO 44-B2.1) requiring dynamic stress testing. Intervention: Dynamic stress imaging to determine ankle stability. Main Outcome Measure: Ankle instability and subsequent need for surgical fixation as determined by dynamic stress imaging. Results: No statistical significant difference was found between the adequacy of gravity stress radiographs and manual stress images in regards to surgical decision-making (P = 0.595). Using manual and gravity stress images, receiver operating characteristic curves were generated for medial clear space (MCS) (area under the curve = 0.793, 0.901) and LTDR (0.849, 0.850), corresponding to thresholds of 10.5% and 10.2% for manual and gravity, respectively. Seventy-three of 105 patients (69.5%) with MCS > 5 mm and 62 of 75 patients (82.7%) with LTDR > 10% were offered surgical intervention. Sixty-two of the 77 patients (80.5%) offered surgery had both MCS > 5 mm and LTDR > 10%. Conclusion: This study shows that manual stress radiographs are just as effective as gravity stress radiographs in making an assessment of ankle fracture stability as there was no difference in diagnostic value between gravity and manual stress imaging in regards to surgical decision-making. Use of additional radiographic measurements such as the LTDR can provide additional information in determining stability when MCS is within a clinical gray area. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. Design: Retrospective cohort study. Setting: One Level 1 and One Level 2 academic trauma centers. Patients/Participants: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. Main Outcome Measurement: Major and minor complications. Results: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). Conclusion: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable."

Objective: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). Design: Retrospective. Setting: Level 1 and level 2 academic centers. Patients: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. Methods: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1–3 mm step, 5–10 mm gap, and/or 5–15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation. Results: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18–74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). Conclusions: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Hip dislocations are highly morbid injuries necessitating prompt reduction and postreduction assessment for fracture and incarcerated fragments. Recent literature has questioned the need for initial pelvic radiographs for acute trauma patients, resulting in computed tomography (CT) scans as the initial evaluation. This study investigates the relationship between choice of pre-reduction imaging and treatment of acute hip dislocations. Design: Retrospective Case-Control. Setting: Single Academic Level I Trauma Center. Methods: All acute hip dislocations from 2011 to 2016 were reviewed. Exclusion criteria were diagnosis of dislocation at another facility, death prior to reduction, emergent surgical or ICU intervention, and periprosthetic dislocation. Patients were grouped by those with only a radiograph prior to reduction, Group I, versus those with a pre-reduction CT scan, Group II. The primary outcomes were time to reduction and the acquisition of a second CT scan. Results: Of the 123 hip dislocations identified, 35 patients were excluded, mostly for transfer with a known dislocation. Group I included 29 patients and Group II included 59 patients. The mean time to reduction was 74 min in Group I and 129 min in Group II for a difference of 55 min (p <0.001). The rate of repeat CT scan was 0 in Group I versus 48 (81%) in Group II (p <0.001). Conclusion: Initial trauma pelvic radiography prior to CT is still important in the setting of suspected hip pathology to decrease time to hip reduction and unnecessary radiation exposure. Level of evidence: Prognostic Level III. (C) 2019 Published by Elsevier Ltd.