To evaluate for associations with loss or reduction (LOR) after fixation of Lisfranc joint injuries (LFJI). The secondary purpose was to compare 4.0 mm partially-threaded cannulated (4.0 PTC) and 3.5 mm fully-threaded solid (3.5 FTS) screw fixation. A retrospective comparative study at 2 level-one trauma centers was performed to evaluate patients with screw-only fixation of LFJI. Patient, injury, and screw fixation variables were collected. Associations with LOR were evaluated. Fixation with 4.0 PTC versus 3.5 FTS screws was compared in terms of LOR, screw breakage, and symptomatic screw removal. There were 78 patients included. The median age was 37.5 years (IQR 26.7–51.0) and 59.0

INTRODUCTION:Symptomatic interlocking screws are common after intramedullary nail fixation of tibia fractures. Low-profile headless interlocking screws recently became available and could potentially reduce the rate of symptomatic screws. The purpose of this study was to compare the rate of symptomatic screws and screw removals between these screw types. METHODS:A retrospective review identified patients with tibia shaft fractures treated with tibia intramedullary nails between August 1, 2018 to September 1, 2023 by 11 surgeons. Low-profile headless interlocking screws became available on June 28, 2021 and were routinely used thereafter. Patients treated with low-profile headless versus standard headed interlocking screws were compared in terms of symptomatic screws, defined as a patient reporting pain or discomfort at the site of a screw head in clinical documentation, symptomatic screw removals, screw failure (breakage or backout), and procedures to promote bone union. RESULTS:Overall, 79 patients were included in the analysis: 33 patients treated with 144 headless screws and 46 patients treated with 187 standard screws. The median patient age was 35 years, and a majority were male (68.4%, n = 54). The median follow-up length was 8.5 months (interquartile range 5.5 to 8.8 months). The headless screw group, compared with standard screw group, did not differ in age, injury mechanism severity, open fracture classification, tobacco use, American Society of Anesthesiologists classification >2, number of interlocking screws used, or follow-up time ( P > 0.05). The headless screw group was less likely to have symptomatic screws (0.0% vs. 23.9%; P = 0.002), less likely to have symptomatic screw removal (0.0% vs. 13.0%; P = 0.03), and had no difference in procedures to promote bone union (10.0% vs. 6.8%; P = 0.68) or screw backout (0.0% vs. 4.4%; P = 0.50). DISCUSSION:Standard headed interlocking screws were symptomatic in 23.9% of patients and 13.0% underwent symptomatic screw removal. In comparison, no patients treated with low-profile headless interlocking screws had symptomatic screws. LEVEL OF EVIDENCE:Level 3, diagnostic.

OBJECTIVES: To evaluate variables associated with loss of fixation of retrograde rami screws in the treatment of stress-positive minimally displaced lateral compression type 1 (LC1) injuries. METHODS: Design: Retrospective comparative study. Setting: Level 1 trauma center Patient Selection Criteria: Stress-positive minimally displaced (<1 cm) LC1 pelvic ring injuries treated with retrograde rami screws. Outcome Measures and Comparisons: Loss of fixation, defined as >5 mm of pelvic fracture displacement based on the radiographic tear-drop distance or >5 mm of implant displacement on follow-up radiographs; revision surgery for loss of fixation. RESULTS: Thirty-eight patients with 40 retrograde rami screws were analyzed. Median patient age was 64 years (interquartile range 42.5-73.3 years), 71.1% (n = 27/38) were female, and 52.6% (n = 20/38) of injuries were secondary to low-energy mechanisms. Loss of fixation occurred in 17.5% (n = 7/40) of screws with 10% (n = 4/40) requiring revision surgery. On univariate analysis, patients who had a loss of fixation were more likely to have greater dynamic displacement on stress radiographs (22.0 vs. 15.2 mm; median difference 5.6 mm, confidence interval [CI] -19.2 to 10.3; P = 0.04), unicortical rami screws (71.4% vs. 9.1%; proportional difference 62.3%, CI 8.8%-22.6%; P = 0.001), and partially threaded rami screws (71.4% vs. 21.2%; proportional difference 50.2%, CI 10.0%-77.6%; P = 0.01). The remaining variables had no observed association (P >= 0.05) with loss of fixation, including age, sex, body mass index, energy of injury mechanism, tobacco use, American Society of Anesthesiologist score, sacral fracture type, distal rami fractures, rami comminution, number of sacral screws, fully threaded sacral screws, transsacral screws, or rami screw diameter. On multivariate analysis, only unicortical rami screws (P = 0.01) remained associated with loss of fixation. CONCLUSIONS: Retrograde rami screws had a high rate of loss of fixation in minimally displaced LC1 pelvic ring injuries, and this was associated with unicortical screws. These screws should be avoided when possible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION:A recovery without adverse events is a top priority of orthopaedic trauma patients, however many randomized controlled trials (RCTs) are only powered to detect a difference in patient-reported outcome measures (PROMs). While it may be assumed that differences in major adverse event rates between treatment groups will result in differences in PROMs, this has not been established. The purpose of this study was to perform a systematic review of RCTs to evaluate if differences in these outcomes were correlated. METHODS:A systematic search was conducted of online databases to identify RCTs in orthopaedic trauma fracture management that reported both major adverse events and PROMs. Adverse events included secondary surgeries or complications that could negatively affect long-term outcomes (nonunion, chronic regional pain syndrome, etc.). The correlation between a difference (p < 0.05) in adverse events and a difference in PROMs was assessed. RESULTS:The systematic review yielded 30 RCTs involving 6,769 patients. The primary outcome was a continuous PROM in 70.0 % (21/30). A difference in major adverse events was reported in 23.3 % (7/30) and a difference in PROMs was reported in 6.7 % (2/30). Studies reporting a difference in adverse events, compared to those that did not, were not more likely to report a difference in PROMs (14.3 % (1/7) vs. 4.3 % (1/23); p = 0.42). CONCLUSIONS:There was no correlation between differences in adverse event rates and differences in PROMs in orthopaedic trauma RCTs. Investigators should consider powering studies to detect differences in the major adverse events that both patients and surgeons wish to avoid. LEVEL OF EVIDENCE:Level I.

OBJECTIVES:To analyze the impact of switching from single-use reamer shafts to reusable reamer shafts for intramedullary nail fixation (IMN) of femur and tibia fractures at a single Level 1 trauma center, regarding cost, metal waste, and infection rates. DESIGN:Retrospective comparison study. SETTING:Level 1 trauma center. PATIENTS/PARTICIPANTS:Patients with operative femur and tibia fractures treated before and after adoption of a reusable reamer shaft were enrolled. INTERVENTION:Reamed IMN fixation. MAIN OUTCOME MEASUREMENTS:Reductions in cost ($292 per shaft) and metal waste (0.44 pounds [lbs]) per reamer shaft, reamer shaft failure (breakage and/or incarceration), superficial and deep infections. RESULTS:A single surgeon treated 125 and 135 fractures before and after adoption of a reusable reamer shaft. No reamer shaft failures were identified. The before and after groups did not differ in age, OTA/AO classification, or infection rates. By adopting reusable reamer shafts, the surgeon avoided an estimated 54 single-use reamer shafts per year for an estimated cost and metal waste savings per year of $15,643 USD and 24 lbs. Over the same period that the surgeon switched to using reusable reamer shafts, a total of 283 single-use reamer shafts were used by 12 surgeons in the same department. If the entire department had adopted reusable reamer shafts during that period, an estimated 164 reamer shafts per year would have been avoided for a total cost and metal waste savings per year of $47,763 USD and 72 lbs. CONCLUSION:Single-use reamer shafts represent an easily addressable source of extraneous cost and metal waste in orthopaedic surgery. LEVEL OF EVIDENCE:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To compare the hospital course of patients with minimally displaced (<1 cm) lateral compression type 1 injuries treated before and after implementation of lateral stress radiographs (LSRs) to determine management. Design: Retrospective comparative cohort. Setting: Urban level 1 trauma center. Patients/Participants: Isolated lateral compression type 1 injuries managed before (n = 33) and after implementation of LSRs (n = 40) to determine management. Intervention: Patients in a prestress cohort managed nonoperatively versus patients in an LSR cohort managed operatively if stress positive (≥1 cm displacement on LSRs). Main Outcome Measurements: Physical therapy clearance before discharge, discharge location, hospital length of stay, and inpatient opioid morphine milligram equivalents were measured. Results: The prestress and LSR protocol groups were similar in demographic/injury characteristics (age, sex, mechanism, American Society of Anesthesiologists score, Nakatani classification, bilateral/unilateral injury, Denis zone, sacral fracture completeness, and sacral comminution). Forty-five percent of LSR protocol patients were stress-positive (n = 18) and managed operatively. The LSR protocol group was more likely to clear physical therapy by discharge (97.5% vs. 75.8%, PD: 21.7%, 95% CI: 5.1%–36.8%, P = 0.009), less likely to discharge to a rehabilitation facility (2.5% vs. 18.2%, PD: −15.7%, CI: −30.0% to −0.5%, P = 0.04), and had no difference in length of stay (MD: 0.0, CI:-1.0 to 1.0, P = 0.57) or inpatient opioid morphine milligram equivalents (MD: 9.0, CI: −60.0 to 101.0, P = 0.71). Conclusion: Implementation of an LSR protocol to determine management of minimally displaced stress-positive lateral compression type 1 injuries was associated with increased rates of operative management, physical therapy clearance by discharge, and a reduction in the number of patients discharging to rehabilitation facilities. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose To describe the construction and use of a percutaneous pelvic fixation model, evaluate its translational validity among fellowship-trained orthopedic trauma surgeons, and investigate the importance of specific criteria for effective competency-based assessment of pelvic fixation techniques. Methods Five orthopedic trauma surgeons were asked to place percutaneous wires on a pelvic fixation model, including anterior column (antegrade/retrograde), posterior column (antegrade/retrograde), supra-acetabular, transsacral, and iliosacral. Evaluation criteria included successful wire placement, redirections, cortical breaches, procedure duration, radiation exposure, and quality of fluoroscopic views. Following completion, participants were provided a survey to rate the model. Results There were no differences between approaches on successful screw placement, wire redirections, or fluoroscopic quality. Antegrade approaches to the anterior and posterior columns took longer ( p = 0.008) and used more radiation ( p = 0.02). There was also a trend toward more cortical breaches with the antegrade anterior column approach ( p = 0.07). Median ratings among surgeons were 4 out of 5 for their overall impression and its accuracy in tactile response, positioning constraints, and fluoroscopic projections. Learning parameters considered most important to the progression of trainees (most to least important) were successful screw placement, corridor breaches, wire redirections, quality of fluoroscopic views, radiation exposure, and procedure duration. Conclusion In being affordable, accessible, and realistic, this percutaneous pelvic fixation model represents an opportunity to advance orthopedic surgery education globally. Future research is needed to validate the findings of this pilot study and to expand upon how trainees should be evaluated within simulations and the operating room to optimize skill progression.

Objectives: To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior–posterior versus posterior-only fixation. Design: Retrospective comparative cohort. Setting: Urban level-one trauma center. Patients/Participants: LC1 injuries managed operatively. Intervention: Anterior–posterior versus posterior-only fixation; Main Outcome Measurements: Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up. Results: Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior–posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior–posterior fixation required less inpatient MEDs (MD: −180.0, CI: −341.2 to −15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%–57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%–57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: −1, CI: −2 to 0, P = 0.09) and decreased LOS (MD: −1, CI: −4 to 1, P = 0.17). Late fracture displacement did not differ between groups. Conclusion: Anterior–posterior fixation of LC1 injuries was associated with an improved early hospital course—specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To compare the early outcomes of patients with stress-positive minimally displaced lateral compression type 1 (LC1b) pelvic ring injuries managed with or without operative fixation. Design: Retrospective comparison study. Setting: Level 1 trauma center. Patients/Participants: Forty-three patients with LC1b injuries. Intervention: Operative versus nonoperative. Main Outcome Measurements: Discharge to subacute rehabilitation (SAR); 2- and 6-week pain visual analog score, opioid use, assistive device use, percentage of normal single assessment numerical evaluation, SAR status; fracture displacement; and complications. Results: The operative group did not differ in age, gender, body mass index, high-energy mechanism, dynamic displacement stress radiographs, complete sacral fractures, Denis sacral fracture classification, Nakatani rami fracture classification, follow-up length, or American Society of Anesthesiologists classification. The operative group was less likely to be using an assistive device at 6 weeks [observed difference (OD) −53.9%, 95% confidence interval (CI) −74.3% to −20.6%, OD/CI 1.00, P = 0.0005], less likely to remain in an SAR at 2 weeks (OD −27.5%, CI, −50.0% to −2.7%, OD/CI 0.58, P = 0.02), and had less fracture displacement at follow-up radiographs (OD −5.0 mm, CI, −9.2 to −1.0 mm, OD/CI 0.61, P = 0.02). There were no other differences in outcomes between treatment groups. Complications occurred in 29.6% (n = 8/27) of the operative group compared with 25.0% (n = 4/16) of the nonoperative group resulting in 7 and 1 additional procedures, respectively. Conclusions: Operative treatment was associated with early benefits over nonoperative management, including shorter time using assistive devices, less SAR use, and less fracture displacement at follow-up. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm. As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: −3.0 mm, CI: −4.8 to −1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: −33.9

The purpose of this study was to determine the effect of rotation and tilt on the radiographic teardrop distance (TD) on anteroposterior (AP) pelvis radiographs. Radiographic examination of a pelvis models was conducted utilizing increasing degrees of beam rotation and tilt on portable C-arm fluoroscopy. The TD, x-plane rotation (symphyseal-mid-sacrum distance (SMS)), and y-plane tilt (sacroiliac joint-symphysis distance (SIS)) were measured by four independent observers. Interobserver reliability was assessed using intraclass correlations. TD was altered by less than 2 mm with up to 7.5° fluoroscopic rotation (SMS: 3 cm) and up to 30° of inlet and 15° of outlet (SIS: ± 3.3 cm). SMS distance effectively corresponded to the degree of rotation present (r = 1.00, CI: 0.97 to 1.00, p < 0.0001) and was strongly correlated to TD (r = −0.95, CI: −0.99 to −0.67, p = 0.001). SIS distance effectively corresponded to the degree of tilt present (r = −0.97, CI: −0.99 to −0.88, p < 0.0001) and was correlated to TD (r = 0.94, CI: 0.75 to 0.99, p = 0.0001). Linear regression models determined that, with every degree of rotation and tilt, TD was altered by 0.4 mm and 0.09 mm, respectively (p = 0.0004, r2 = 0.93 and p < 0.0001, r2 = 0.94, respectively). Interobserver reliability among observers was excellent (0.92). The TD has excellent interobserver reliability and is minimally impacted by up to 7.5° of rotation, 30° inlet tilt, and 15° of outlet tilt. Utilization of these thresholds may ensure reliability of TD measurements when assessing pelvis stress radiographs.

Objectives: To determine the association of pelvic fracture displacement on lateral stress radiographs (LSRs) with the hospital course of patients with minimally displaced lateral compression type 1 (LC1) pelvic injuries. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: Twenty-eight adult patients with minimally displaced (<1 cm) LC1 injuries. Intervention: Nonoperative management. Main Outcome Measurements: Delayed operative fixation, days to clear physical therapy, mobilization, hospital length of stay, and total hospital opioid morphine equivalent dose. Results: LSR displacement was correlated with delayed operative fixation [r = 0.23, 95% confidence interval (CI) 0.05–1.11; P = 0.01], days to clear PT (r = 0.13, CI 0.01–0.28; P = 0.02), length of stay (r = 0.13, CI 0.006–0.26; P = 0.02), and opioid morphine equivalent dose (r = 19.4, CI 1.5–38.1; P = 0.03). A receiver operating characteristic curve for delayed operative fixation over LSR displacement had an area under the curve of 0.87. The LSR displacement threshold that maximized sensitivity and specificity for detecting patients who required delayed fixation was 10 mm (100% sensitivity and 78% specificity). Ten of the 15 patients with ≥10 mm of displacement on LSRs underwent delayed operative fixation for pain with mobilization at a median of 6 days (interquartile range 3.7–7.5). Patients with ≥10 mm of displacement on LSRs took longer to clear PT, took longer to walk 15 feet, had longer hospital stays, and used more opioids. Conclusions: LC1 fracture displacement on LSRs is associated with delayed operative fixation, difficulty mobilizing secondary to pain, longer hospital stays, and opioid use. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Summary: Small posterior wall rim fractures are typically stable; however, if incarcerated in the joint, they must be removed. It is possible to reduce the morbidity associated with open approaches by addressing these incarcerated fragments in a percutaneous manner. This allows the restoration of joint congruity and removal of the osteochondral fragment from the joint space. The following report details the surgical technique to accomplish this, and the results of a case series of patients who underwent this technique. The advantages include limiting the morbidity of an open approach. However, the surgeon must be prepared to convert to an open approach if percutaneous removal does not accomplish the goals of surgery—a concentric, stable hip joint.

To evaluate the value of three-dimensional (3D) computed tomography (CT) scans on the interobserver and intraobserver reliability of AO/Orthopaedic Trauma Association (OTA) and Young and Burgess (YB) classifications for pelvic ring injuries. Seven reviewers (four fellowship-trained orthopaedic trauma surgeons and three fellows) independently classified 36 pelvic ring injuries using radiographs and axial two-dimensional (2D) CT scan images and then repeated this process 2 months later with the addition of 3D CT images. Interobserver and intraobserver reliability was assessed. The interobserver reliability of the AO/OTA classification using 2D vs. 3D CT scans was considered fair (k 0.23, CI 0.17–0.29) vs. slight (k 0.16, CI 0.09–0.22), with no observed difference [mean difference (MD) − 0.07, CI 0.16–0.01]. The interobserver reliability of the YB classification using 2D vs. 3D CT scans was considered fair for both (k 0.37, CI 0.32–0.42, vs. 0.37, CI 0.30–0.45), with no observed difference (MD − 0.0005, CI − 0.08 to 0.08). The intraobserver reliability of the AO/OTA vs. YB classifications was considered fair (k 0.35, CI 0.26–0.44) vs. moderate (k 0.49, CI 0.40–0.57), with the YB classification having higher kappa value (MD 0.13, CI 0.01–0.26, p = 0.03). The addition of 3D CT scan reconstructions to radiographs and 2D CT did not improve the interobserver reliability of AO/OTA and YB classifications for pelvic ring injuries.

Objectives: To evaluate the interobserver reliability of measured displacement and occult instability of minimally displaced lateral compression type 1 (LC1) fractures on lateral stress radiographs (LSRs) and to compare differences in displacement between LSR with the injured side down (ID) and up (IU). Design: Retrospective review. Setting: Urban Level 1 trauma center. Patients/Participants: Twenty-three adult patients with minimally displaced (<1 cm) LC1 injuries. Intervention: None. Main Outcome Measurements: Three orthopaedic surgeons measured the distance between the radiographic teardrops on LSR and supine anteroposterior pelvic radiographs to calculate dynamic fracture displacement. The interobserver reliability of the measured displacement, a continuous variable, was assessed by calculating the intraclass correlation coefficient. The interobserver reliability of occult instability (≥10 mm of displacement on LSR), a categorical variable, was assessed by calculating the kappa value. Matched-pairs analysis was performed to calculate the mean difference of measurements between observers and between ID and IU LSR. Results: The interobserver reliability of the measured displacement was excellent (intraclass correlation coefficient 0.93). The mean difference in measurements between observers ranged from −1.8 to 0.96 mm. The mean difference in the measured displacement between ID and IU LSRs for each observer ranged from −0.6 to 0.3 mm. There was 83% (19/23 cases) agreement on the presence of occult instability (≥10 mm of displacement on LSR) on both ID and IU LSRs. The interobserver reliability of occult instability was moderate (kappa 0.76). Conclusions: Measured fracture displacement and occult instability of minimally displaced LC1 injuries were reliably measured and identified on LSR, regardless of the laterality.

Summary: The use of antibiotic-impregnated cement as a local antibiotic delivery system is well-established as an adjunctive treatment for chronic osteomyelitis. Because the elution of antibiotics is a surface area phenomenon, the geometry of the cement is an important consideration. The antibiotic cement bead rouleaux technique is a simple and efficient method of bead fabrication that requires only 10 minutes of preparation time and readily available operating room supplies. The discoid structure of the beads provides 3 times the surface-area-to-volume ratio of a spherical bead, which facilitates antibiotic elution. Given the speed and ease of fabrication, along with optimized geometry, the antibiotic cement bead rouleaux is a useful addition to the surgeon's repertoire.

A ratio of observed difference (OD) over the 95% confidence interval (CI) has been shown to be strongly associated with the perceived clinical relevance (CR) of medical research results. The purpose of this study was to evaluate the association between the OD/CI ratio and perceived CR in orthopaedic research. Sixty-seven orthopaedic surgeons completed a survey with 15 study outcomes (mean difference and CI) and were asked if they perceived the findings as clinically relevant. The interobserver reliability of perceived CR and the association between CR and the OD/CI ratio and p-value were assessed. The interobserver reliability of CR between respondents was moderate (kappa = 0.46, CI 0.45 to 0.48). P-values did not differ between results with and without CR (median difference (MD) − 0.12, CI − 0.74 to 0.0009, p = 0.07). The OD/CI ratio, however, was greater for results with CR (MD 1.01, CI 0.3 to 3.9, p = 0.004). The area under the curve (AUC) for the p-value and OD/CI ratio receiver operating characteristic (ROC) curves was 0.80 (p = 0.01) and 0.97 (p = 0.0003). The cutoff p -value and OD/CI ratio that maximized the sensitivity (SN) and specificity (SP) for CR were 0.001 (SN 80%, SP 80%) and 0.84 (SN 100%, SP 90%). The SN and SP of a p-value cutoff of 0.05 was 100% and 50%. The interobserver reliability of the perceived CR of orthopaedic research findings was moderate. The OD/CI ratio, in contrast to the p-value, was strongly associated with perceived CR making it a potentially useful measure to evaluate research results.

Background:Increasingly, total hip and total knee replacements are being performed at outpatient ambulatory surgery centers. The purpose of this study was to investigate the feasibility and safety of instituting a same-day surgery program for hip and knee replacement at an urban, safety net hospital. Methods:Retrospective review of a prospectively collected registry for all patients scheduled for same-day total joint replacement at a safety net hospital was performed. Medical records were reviewed for patient demographics, same-day hospital admissions, and 30-day emergency room/hospital admissions. Results:131 same-day total joint replacements were identified, including 76 knees and 55 hips. Median ASA was 3, and median Charlson comorbidity score was 2. Rate of same-day surgery for total joint replacements increased from 4.5% in September 2020 to 100% in September 2021. On major patient outcomes, 3.8% of patients (n = 5) required conversion to inpatient admission. Rate of 30-Day Emergency Department (ED) visits was 13.0% (n = 17). Most common complaints included postoperative pain (n = 10), incision drainage/edema/hematoma (n = 9), and cellulitis (n = 2). 30-Day Hospital Readmissions occurred in 1.5% of patients (n = 2). Conclusion:Same-day hip and knee replacement can be performed safely at a safety net hospital. Unlike dedicated high-volume orthopedic hospitals or outpatient surgery centers, urban safety net hospitals face a different set of challenges and must care for a wide variety of patients who do not plan for their illness and/or may not be able to pay for their care. Outpatient total joint replacement may extend total joint replacement to patients who might not have access otherwise.

Summary: Complex traumatic and/or infected wounds and their sequelae are a significant burden for high-volume trauma centers. Local or free flap coverage options are well described; however, they may be high risk in poor hosts with multiple comorbidities and active infections. In addition, flap coverage can result in delays in wound coverage depending on specialist availability. Porcine urinary bladder matrix grafting has been shown to be a simple definitive wound coverage option that can be performed without delay in multiple patient populations for wounds that would otherwise require flap coverage. The purpose of this article was to describe a technique for urinary bladder matrix grafting and report on a series of orthopaedic trauma patients treated with this technique.