Diane Nam

Background: Loss of reduction during nonoperative management of distal radius fractures can lead to delayed operative treatment, malunion, and corrective osteotomy. This study aimed to systematically review and synthesize the available literature on predictors of loss of reduction of distal radius fractures for adult patients undergoing nonoperative treatment. Methods: MEDLINE, Embase, CINAHL, and Cochrane databases were searched from inception to June 9, 2025. Screening, data extraction, risk of bias assessment, and evidence grading were completed in duplicate. Data were pooled using random-effects models with inverse of variance weights to produce summary of effect odds ratios (ORs) with 95% confidence intervals (CIs). Bivariable prognostic factors and coefficients from multivariable models were pooled separately. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. Results: A total of 7,926 citations were screened, and 30 studies (7,495 fractures) met inclusion criteria. In bivariable analyses, 5 predictors demonstrated moderate certainty associations with loss of reduction: dorsal comminution (OR 2.69, 95% CI 1.67-4.32), failure to re-establish volar cortical alignment (OR 3.22, 95% CI 1.93-5.37), prereduction dorsal angulation >20° (OR 1.90, 95% CI 1.04-3.48), displacement beyond acceptable criteria vs minimally displaced fractures (OR 6.15, 95% CI 3.35-11.31), and age older than 60 years (OR 2.24, 95% CI 1.06-4.74, moderate certainty). In multivariable analyses, age older than 60 years (adjusted OR 3.80, 95% CI 1.59-9.10) and prereduction ulnar positive variance (adjusted OR 1.49 per 1-mm increase, 95% CI 1.09-2.06) demonstrated high certainty associations with loss of reduction. The weighted proportion of patients who lost reduction was 43.4% (95% CI 38.7-48.2). Conclusion: Age older than 60 years and increasing prereduction ulnar positive variance demonstrated high certainty associations with loss of distal radius reduction from available multivariable analyses. Further well-designed prognosis studies are needed to better delineate the predictors of loss of reduction with nonoperative management of distal radius fractures. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: Healing remains a clinical challenge in nonoperatively treated fragility fractures of the pelvis (FFPs). Modifying gut microbiota has been found to affect cytokine pathways involved in bone formation and resorption. This study examined the impact of probiotic treatment pre- and postunilateral pubic rami fracture on bone microstructure and load-to-failure of healing fractured and intact (unfractured) contralateral hemipelvises. METHODS: Twenty-one 6-month-old female Sprague Dawley rats were bilaterally ovariectomized and housed for 3 months to establish an osteoporotic phenotype. At 9 months old, stable unilateral fractures of the superior and inferior pubic rami of the left hemipelvis (type 1a FFP) were created. Before fracture creation, rats were randomly separated into control (phosphate-buffered saline administered for 12 weeks), prefracture treatment (probiotics administered for 12 weeks starting 6 weeks prefracture), and postfracture treatment (probiotics administered for 6 weeks postfracture) groups. At 6 weeks postfracture, rats were sacrificed, and their pelvises were harvested, microcomputed tomography imaged, and evaluated through microstructural analysis and biomechanical testing. RESULTS: On the intact hemipelvises, the prefracture treatment group (n = 5) had significantly higher bone volume (BV) ( P = 0.050), bone volume fraction (BV/TV) ( P = 0.019), bone mineral density ( P = 0.019), and tissue mineral density (TMD) ( P = 0.014) than those in the postfracture treatment group (n = 7). The intact hemipelvises of the prefracture treatment group also had significantly increased trabecular thickness (TbTh) ( P = 0.021) when compared with those in the control group (n = 6). On the fractured hemipelvises, the prefracture group had increased total volume (TV) ( P = 0.020), BV ( P = 0.011), and BV/TV ( P = 0.026) when compared with the control group (n = 4). Although load-to-failure was correlated with microstructural parameters (BV/TV (r = 0.42, P = 0.015), trabecular number (TbN) (r = 0.42, P = 0.014), bone mineral density (r = 0.55, P = 0.0008), TMD (r = 0.40, P = 0.019), and trabecular spacing (TbS) (r = −0.58, P = 0.0003), no significant differences in bone strength were found between groups. CONCLUSIONS: Probiotic treatment was shown to improve bone microstructure in osteoporotic rats; however, efficacy was related to treatment timing and duration. Administration of probiotics for 12 weeks beginning 6 weeks prefracture significantly enhanced bone quality in both the healing fractured and intact contralateral hemipelvises. This suggests a critical timing threshold exists for probiotic therapy to impact the gut microbiome, facilitating an alteration of the immune response postfracture and producing positive structural changes in osteoporotic pelvic bone.

OBJECTIVES: To compare reoperation rates of acute versus delayed reverse total shoulder arthroplasty (RTSA) following a period of nonoperative treatment for proximal humerus fractures (PHFs). We also aimed to identify an optimal time interval from PHF to RTSA before the risk of reoperation significantly increased. METHODS: Design: Database review. Setting: Ontario, Canada. Patient Selection Criteria: Adults aged 50 years and older who sustained a PHF (OTA/AO 11A-C) between 2004 and 2019 were included. Exclusion criteria included polytrauma, open fractures, non-Ontario residents, invalid health insurance, and any operative treatment before RTSA. Outcome Measures and Comparisons: The primary outcome measure was reoperation within 2 years following RTSA. A risk-adjusted, restricted cubic spline was used to model the probability of reoperation according to the time elapsed between PHF and RTSA to identify a time point at which the risk of reoperation significantly increased. A multivariate logistics regression was used to identify predictors. RESULTS: In total, 891 patients (685 acute, 206 delayed) underwent RTSA for PHF. The acute cohort had a significantly lower reoperation rate (3.9%) compared with the delayed cohort (8.3%) (P = 0.02). The odds of reoperation increased with a delay to RTSA greater than 28 days and continued to rise until 100 days after fracture. Patients who underwent RTSA 28 days after PHF were found to have a significantly higher odds of reoperation by 2 years (P = 0.03). CONCLUSIONS: Among patients undergoing RTSA for acute PHFs, a delay to surgery greater than 28 days is associated with a greater odds of reoperation and may be useful when counseling patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.