Background Cephalomedullary nails (CMNs) are frequently utilized for subtrochanteric femur fractures but a lack of cortical fit in proximal fractures may lead to varus deformity. We hypothesize that as the difference between fracture site canal width and diameter of the nail increases so will the risk of varus deformity. Methods A retrospective study of subtrochanteric femur fractures fixed with CMNs at an academic, level one trauma center over a 6.5-year period was performed. Patients were divided into two cohorts: CMN with sliding blade/screw (TFNA) or greater trochanteric entry recon nail (GTE). The primary outcome analyzed was the correlation between nail-canal mismatch with final neck shaft angle. Secondary outcomes analyzed included rates of nonunion and malunion. Results Seventy-one patients met the inclusion criteria (35 TFNA and 36 GTE). There was not a significant correlation between the nail-canal mismatch with final neck shaft angle for GTE nails (Pearson correlation coefficient r: -0.187, p=0.274). However, when TFNAs were subdivided into 125° and 130° cohorts, there was a stronger negative correlation for 125° (r: -0.678, p=0.001) compared to the 130° (r: -0.515, p=0.041). For 125° TFNAs, linear regression analysis demonstrated that for every 1 mm increase in nail-canal mismatch there was a decrease in final neck shaft angle by 0.757⁰. There was no difference in secondary outcomes. Conclusion GTE nails and TFNAs have similar rates of malunion and nonunion when managing subtrochanteric femur fractures. However, 125° TFNAs may be associated with increased varus neck shaft angles as the nail-canal mismatch increases.

Research into the applications of artificial intelligence (AI) within orthopedic trauma has undergone an exponential trajectory. While most studies focus primarily on radiographic fracture detection, the scope of AI has rapidly expanded to include preoperative planning, surgical education, and administrative optimization. This narrative review synthesizes evidence using PubMed, OpenEvidence, and Google Scholar to provide a comprehensive overview of AI's current utility and its future implications for the field. Current diagnostic applications represent the most established use of AI, with meta-analyses demonstrating that AI-assisted radiographic interpretation achieves a pooled sensitivity and specificity of 87% and 92%, respectively. Beyond 2D imaging, AI has revolutionized surgical preparation by generating patient-specific 3D anatomical models much faster than traditional manual methods. In the realm of surgical education, AI is transitioning resident assessment from subjective evaluation to a quantitative science by providing objective feedback on metrics like economy of motion. However, while AI can assist in manuscript development and research gap analysis, the risk of "hallucinations" and fabricated citations necessitates rigorous human oversight. Other non-surgical applications offer significant potential for enhancing healthcare equity and clinician well-being. AI-assisted diagnostics have been shown to reduce missed fractures, while "AI scribes" can save surgeons up to an hour of documentation daily. However, despite these advancements, a significant "validation gap" remains. Significant hurdles regarding professional liability, the "efficiency paradox" of increased patient workloads, and the need for multicenter testing must be addressed before AI can be fully integrated into the standard of care. Ultimately, AI represents a transformative shift in orthopedic trauma, moving the field toward a future where clinical decision-making and surgical technique are interwoven with AI assistance to improve patient outcomes and physician well-being.

Background:Level I trauma centers employ various orthopaedic call strategies based on resources and surgeon subspeciality availability. Objective:We hypothesize when surgeons fellowship trained in trauma are solely on call that patient outcomes will be improved compared to a combined plan. Methods:Retrospective cohort study from two 24-month time periods at an academic level one trauma center. The first cohort consisted of only trauma surgeons taking call. The second cohort consisted of a combination of trauma and other subspecialities taking call. The primary outcome analyzed was time from admission to operating room for hip, femoral shaft, distal femur, tibia shaft, pelvic ring and acetabulum fractures. Secondary outcomes analyzed included length of stay, 90 day incidence of reoperation, mortality, VTE and readmission. Results:Eight hundred and fifty seven patients in the trauma cohort and 992 patients in the combined cohort met the inclusion criteria. The time from admission to index surgical procedure was significantly shorter in the trauma cohort (1.7 vs 2.4). Length of stay (8.95 vs 11 days) and 90 day mortality (1.8% vs 3.8%) was improved in the trauma cohort. There was no difference in 90 day rate of VTE, readmission or reoperation. Length of stay and time to OR in pelvic ring injuries and acetabulum fractures were doubled compared to the hybrid group. Conclusions:Our findings suggest that when trauma fellowship trained surgeons are the only ones taking call patients have a shorter time from admission to index surgical procedure, length of stay and lower mortality rate.

PURPOSE:To evaluate outcomes and complications after fixation of distal radius fractures performed by a fellowship-trained trauma versus hand orthopaedic surgeons. METHODS:A retrospective review of operative distal radius fractures between 8/2022 and 8/2024 at a single academic, level I trauma center was performed. The primary outcome was unplanned reoperations. Secondary outcomes included reduction quality and complications. RESULTS:A total of 134 distal radius fractures (86 trauma and 48 hand) were included with a mean follow-up of 5.8 and 5.4 months, respectively. No notable differences were found in baseline characteristics or initial injury radiograph measurements except for open injuries and fixation method. The trauma group had significantly more open injuries (20% vs/ 6%, P-value = 0.03) and used a volar plate alone (74% vs. 65%, P-value = 0.01) more than the hand group. No differences were found in unplanned revision surgeries between the trauma (10%) and hand (13%) surgeons. A significant difference was found in final radiograph measurements in radial inclination (21.9 vs/ 19.5, P-value = 0.04) and radial height (11.5 vs/ 9.9, P-value = 0.05) for the trauma and hand groups, respectively. No differences were found in any of the other complications recorded for the trauma and hand groups: nonunion (1% vs 2%), superficial infection (5% vs. 6%), deep infection (2% vs. 0%), chronic pain (20% vs. 27%), and tendon rupture (1% vs. 0%). CONCLUSION:No notable differences were found in unplanned revision surgeries or complications in surgically treated distal radius fractures between fellowship-trained trauma versus hand surgeons.

Penicillin is a frequently reported medication allergy. The beta-lactam ring shared between cephalosporins and penicillin often leads to the use of alternative antibiotics for surgical prophylaxis due to concern for cross-reactivity, despite a true IgE-mediated hypersensitivity being very rare. This misconception leads to the use of less effective second line antibiotics, such as clindamycin or vancomycin, for penicillin-allergic patients which has been shown to increase odds of postoperative infection in elective knee arthroplasty, shoulder arthroplasty and spine surgery. Preoperative penicillin allergy testing has been demonstrated to be a cost-effective measure in the prevention of prosthetic joint infection and is suggested for all penicillin-allergic patients in the peri-operative setting. This review highlights and summaries the outcomes of orthopaedic procedures in patients with reported penicillin allergies and discusses potential solutions to the perioperative challenges of patients with reported penicillin allergies.

Introduction: Orthopedic surgeons are the third highest prescribers of narcotics. Previous work demonstrated that surgeons prescribe three times the narcotics required, and most patients do not properly dispose of leftover medication following surgery. This has prompted the creation of multimodal pain regimens to reduce reliance on narcotics. It is unknown if these pathways can effectively eliminate opioids following total knee arthroplasty (TKA). Our purpose was to evaluate a multimodal regimen without schedule II narcotics following TKA, in a randomized, blinded fashion. We hypothesized that there would be no difference in pain scores between groups. Methods: A total of 43 narcotic-naïve patients participated in a randomized, double-blinded, placebo-controlled trial. Postoperative protocols were identical between cohorts, except for the study medication. The narcotic group received an encapsulated 5 mg oxycodone, whereas the control group received an encapsulated placebo. Perioperative outcomes were compared with routine statistical analysis. Results: Four patients withdrew early secondary to pain: three in the placebo group and one in the narcotic group (p=1.00). We found no difference in hospital length of stay (p=0.09) or pain scores at all time points between cohorts (all p>0.05). There was a higher proportion of patients using a narcotic in the opioid treatment arm at day 30 (40% vs. 21.4%, p=0.29) and day 60 (20% vs. 7.1%, p=0.32), although this was not statistically significant. Conclusion: A multimodal regimen without schedule II narcotics demonstrates equivalent pain scores and may reduce the risk of long-term opioid dependence following TKA.

Case: An obturator hip dislocation with an associated open book pelvic ring injury is an extremely rare injury pattern. This case report will discuss challenges to closed reduction, acute management strategies and review the literature on combined hip dislocations and open book pelvic ring injuries. Conclusion: This injury pattern presents unique reduction challenges that should be recognized early in order to provide effective resuscitation and preserve the femoral head blood supply. Failing to close reduce the hip delays reducing the pelvic ring volume because sheets and binders are precluded from working effectively.

Background:Patient specific implants (PSI) represent a novel innovation aimed to improve patient satisfaction and function after total knee arthroplasty (TKA); however, longitudinal patient reported outcome measures (PROMs) for PSI are not well described. We sought to primarily evaluate PROMs of patients undergoing TKA with either PSI or off-the-shelf (OTS) implants at mid-term follow-up. Methods:A retrospective review was performed on a prospectively collected cohort of 43 primary, cruciate-retaining TKAs performed with PSI (n = 23) and OTS implants (n = 20) by a single surgeon. Patient demographics, operative characteristics, range of motion (ROM) return, reoperations, and outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) T-score, Knee Injury and Osteoarthritis outcome score (KOOS), and Knee Society Score-Function (KSS-F)] were compared. Mean follow-up was 5 years. Results:TKA performed with either PSI and OTS implants demonstrated no difference in obtaining ROM by 3 months (extension 3° short of full extension vs. 0°, p = 0.16) or flexion (114° vs. 115°, p = 0.99) and final ROM was identical [0° extension to 120° flexion (p = 1)]. Although not significant (p = 0.42), 5 (22%) PSI TKA and 2 (10%) OTS implant patients required manipulation under anesthesia. KSS-F and PROMIS T-scores were higher in the PSI versus OTS TKA patients, respectively (90 vs. 73, p = 0.002; 51.6 vs. 44.5, p = 0.01). However, after multivariable analysis, none of these continuous outcome measures were significantly different (p = 0.28 for KSS and p = 0.45 for PROMIS T-score) between the groups. Conclusion:In a series of TKAs performed with PSI, no difference existed in postoperative ROM, reoperations, or patient-reported outcomes compared to OTS implants at 5 years. Surgeons may utilize the equivocal midterm results during TKA preoperative patient discussion of implant technologies.

OBJECTIVE Opiate consumption in the United States has reached alarming levels. As a result, the state of Florida enacted House Bill 21 (HB21) in July 2018. Following HB21, we hypothesized total opioids prescribed would decrease, with a resulting increase in phone calls, unscheduled visits for pain control, and refills dispensed. DESIGN Retrospective cohort study comparing opiate usage 6 months before and after HB21 enactment. SETTING Single Level I academic trauma center. PARTICIPANTS Patients with isolated lower extremity fractures who were treated with a single surgery. INTERVENTION Opioid prescription limitations according to Florida's HB21. MAIN OUTCOME MEASURES We compared morphine milligram equivalents (MMEs) dispensed at discharge, length of stay (LOS), readmissions, emergency room (ER) visits, calls for pain control, refills, and total MMEs dispensed for 3 months postoperatively. RESULTS A total of 116 patients met inclusion criteria. Our results demonstrated a decrease in the median MMEs provided at discharge (288 vs. 184, p 0.005) and total MMEs dispensed (375 vs. 225, p 0.0003). There was no significant difference in LOS (2 vs. 2.5 days, p 0.979), unscheduled clinic visits for pain (two per group), ER visits for pain (eight per group), or phone calls for pain (13 vs. 9, p 0.344). There were no readmissions for pain control pre-HB21 and one post-HB21. The percentage of patients obtaining >1 refill decreased from 22.4 to 1.7 percent (p 0.002). CONCLUSIONS Legislation restricting opioid pain medications may be effective in decreasing opiate use in orthopedic trauma patients while decreasing provider burden.

A 32-year-old woman with bipolar patellofemoral chondral lesions caused by traumatic patella dislocation underwent autologous chondrocyte implantation with concomitant tibial tubercle osteotomy and MPFL reconstruction. At 1- and 2-year follow-ups, the patient had returned to all previous activities with considerable improvement in all patient-reported outcome scores. This is an encouraging treatment option for a historically difficult therapeutic problem.

INTRODUCTION More than 90% of orthopaedic surgery graduates pursue fellowship training after residency. Previous investigations have examined factors considered important by orthopaedic sports medicine and hand surgery fellowship program directors (PDs). This study sought to identify which factors orthopaedic trauma fellowship PDs deem most important when evaluating applicants. METHODS A web-based survey was sent to all 59 orthopaedic trauma fellowship PDs. PDs were given a list of 12 factors, which they ranked in order of importance. A weighted score for each factor was calculated. PDs could also write-in additional factors they considered important when ranking applicants. RESULTS The overall response rate was 83% (49/59 PDs). Forty-five percent of responding PDs listed the interview as the most important factor when ranking applicants. Other factors considered most important included letters of recommendation, personal connections to the applicant and/or letter writers, and the applicant's background in trauma. Results of the weighted score calculation again identified the interview as the most important factor when ranking applicants, followed by letters of recommendation, personal connections to the applicant/letter writers, the applicant's residency program, strength of the applicant's background in trauma, and research experience. DISCUSSION Orthopaedic trauma fellowship PDs consider the interview, letters of recommendation, and personal connections to the applicant/letter writers to be the most important factors when ranking fellowship applicants.

Infection after anterior cruciate ligament reconstruction and Nocardia infection in immunocompetent hosts are rare events in isolation. This case report highlights the rare combination of these events in a 46-year-old healthy man who acquired a Nocardia nova infection of the tibia tunnel site after an anterior cruciate ligament reconstruction with peroneus allograft. He was successfully treated with tibial tenodesis screw removal, two surgical debridements, and 4 weeks of trimethoprim-sulfamethoxazole and meropenem, followed by 6 months of clarithromycin and original graft retention. This report will review the current antibiotic recommendations and surgical management of this challenging situation. Our case is unique in that the infection was isolated to the distal aspect of the tibial tunnel and did not spread into the entire knee joint, highlighting the importance of early debridement and irrigation in the operative suite when graft site infection is suspected.

Biplanar fluoroscopy allows for the simultaneous acquisition of x-ray images in 2 planes without needing to move the extremity or C-arm. It is advantageous in cases such as pinning supracondylar humerus fractures or slipped capital femoral epiphyses where frequently alternating between 2 planes under fluoroscopic imaging is required. However, literature describing the technique is lacking. Therefore, the purpose of our article is to discuss room setup, advantages, and disadvantages of using biplanar fluoroscopy in cases involving the elbow, shoulder, hip, and knee.

INTRODUCTION:Gustilo-Anderson type IIIB open fractures are severe injuries associated with multiple complications and threaten the viability of the limb. In addition, large segmental bone defects pose reconstructive challenges when treating open fractures and outcomes can be unpredictable. This case report highlights a good outcome in a patient with a type IIIB open tibia fracture with segmental bone loss that was successfully treated with a staged induced membrane technique and latissimus dorsi free flap.CASE REPORT:A 17-year-old female sustained a Gustilo-Anderson type IIIB open tibia fracture with segmental bone loss after a motor vehicle collision. While amputation seemed inevitable, her extremity was able to be salvaged using the staged induced membrane technique and free flap coverage. She made an exceptional recovery and at 24-month follow-up, her short form-12 scores and foot and ankle outcome scores were close to the average for a healthy adult.CONCLUSION:Our patient's outcome represents the benefits of a shared decision-making process with a multidisciplinary approach and highlights the benefit of limb salvage in a healthy patient.