Justin M. Haller

OBJECTIVES: To compare nonunion surgery effectiveness for occult infected, aseptic, and septic nonunions in patients identified using the FRI criteria. METHODS: Design: Retrospective Review. Setting: Single Level I Tertiary Academic Center. Patients Selection Criteria: All skeletally mature patients over a 10-year period with nonunions and inflammatory laboratory findings at the time of index surgery were evaluated. Patients were classified using fracture-related infection (FRI) criteria as septic (SP) or aseptic. Aseptic patients were further stratified by intraoperative cultures into aseptic (AP, culture-negative) and occult infected (OP, culture-positive) groups. Exclusion criteria were pathologic fractures. Outcome Measure and Comparisons: Primary outcome measured was successful union after index nonunion surgery without need for additional surgical interventions. RESULTS: A total of 208 patients with nonunion fractures were included (OP: 29; AP: 125; SP: 54). Mean age was similar between groups (OP: 47.6 ± 21.2 years, range 19.9–79.9 years; AP: 54.5 ± 25.6 years, range 15.4–93.4; SP: 54.9 ± 23.5 years, range 16.5–81.3, P = 0.854). Male sex distribution in occult infected patients, aseptic patients, and septic patients was 65.5%, 66.4%, and 46.3%, respectively ( P = 0.035). Occult infected patients had the highest rate of successful union after index surgery without need for additional operative intervention (79.3%), followed by aseptic patients (72.8%) and septic patients (50.0%) ( P = 0.004). Postoperative infections after index nonunion surgery were significantly lower in aseptic patients (16.0%) and occult infected patients (10.3%) compared with septic patients (35.2%) ( P = 0.005). CONCLUSIONS: Index nonunion surgery in septic patients, as defined by FRI criteria, was associated with worse outcomes compared with aseptic and occult infected patients. The success of surgery in occult infected nonunion is comparable to aseptic cases, suggesting that subclinical fracture-related infection does not significantly compromise outcomes. LEVEL OF EVIDENCE: Prognostic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture-related infections (FRIs) remain a significant challenge in orthopaedic trauma, as they are a consistent source of poor patient outcomes and elevated health care costs. FRIs have traditionally been diagnosed using findings from physical examination, blood tests, and advanced imaging, and the mainstay of treatment has been bony debridement, removal of hardware, and local and systemic antibiotic therapy. Although patients with FRIs were historically treated with IV antibiotics, randomized clinical trials have since demonstrated that oral antibiotics can be just as effective while mitigating the risks associated with prolonged IV antibiotics. Emerging biomarkers for infection, including molecular methods such as transcriptomics, proteomics, metabolomics, and next-generation sequencing, offer the ability to more precisely identify infection from a wider range of microbes. Fluorescence-guided debridement surgery presents a strategy to better visualize infected tissue and decrease surgeon reliance on subjective intraoperative findings. The purpose of this review is to present emerging tools and treatment algorithms that might be able to increase the accuracy and precision with which FRIs are diagnosed and managed.

Polytrauma patients are a challenging cohort to treat because their multiple, potentially life-threatening injuries act synergistically with surgeries to affect cellular pathways necessary for survival. Current treatment algorithms and blood tests often fail to predict which patients will tolerate early fracture fixation and which patients will continue to deteriorate because of their injuries. Traditional laboratory tests in polytrauma patients have not been able to capture the nuances of cellular energy depletion, and lipidomics are now emerging as potential biomarkers to better categorize disease severity. Definitive treatment of fractures in polytrauma patients within 36 hours is recommended, but there is little consensus on the parameters necessitating “damage control” strategies. The IMPACT group recommends fixation within 24 hours and a dynamic treatment strategy rather than strict guideline adherence. In particular, patients with moderate to severe traumatic brain injury require cautious, individualized decision-making given their neurologic risks. The purpose of this review is to describe emerging diagnostic tools and treatment algorithms that are shifting the management of polytrauma patients from rigid protocols towards dynamic, individualized assessments.

OBJECTIVES: To compare a novel bicortical compression bolt to standard partially threaded transiliac-transsacral cannulated screws for fixation of Denis zone 2 sacral fractures in a biomechanical model. The hypothesis was that the compression bolt would demonstrate greater resistance to deforming forces, with less rotational displacement and reduced fracture gap formation. METHODS: Twelve standardized Sawbones pelvic models with zone 2 sacral fractures and ipsilateral superior and inferior pubic ramus fractures were randomized to cannulated screw (n=6) or compression bolt (n=6) fixation at S1 and S2. Both transiliac-transsacral constructs were placed with washers and tightened to a target of 1.13 N-m. Custom 3D-printed cutting jigs ensured identical fracture creation and implant placement across specimens. Models underwent cyclic loading to 250 N in a single-leg stance configuration for 10,000 cycles. Infrared optical tracking quantified rotational displacement in three planes and fracture gap formation. Construct completion rates, sacral fracture gap formation, rotational displacement in the sagittal, transverse, and coronal planes, and variance heterogeneity were compared between groups. RESULTS: Five of six cannulated screw constructs completed testing versus all six compression bolt constructs; the single screw failure resulted from S1 implant backout with synthetic-bone fracture at 6,277 cycles. At 10,000 cycles, the cannulated screw group demonstrated significantly greater sacral gap widening (3.5 mm vs. 0.6 mm, p=0.008) and rotational displacement in the sagittal (15.9° vs. 3.6°, p=0.002) and coronal planes (2.1° vs. 0.3°, p=0.018). The compression bolt group exhibited 51-fold less variance in fracture gap formation (95% CI: 4.3-382.1, p<0.001). CONCLUSION: In this synthetic biomechanical model of Denis zone 2 sacral fractures, compression bolts demonstrated greater resistance to sagittal and coronal deforming forces compared to cannulated screws, with significantly less fracture gap formation and greater fixation reliability. Bicortical fixation with adjustable compression represents an alternative approach for zone 2 sacral fracture stabilization.

Background: This study aimed to characterize longitudinal 3-dimensional morphologic, alignment, and radiographic changes of the ankle and hindfoot following surgical fixation of tibial plafond fractures and to identify structural features associated with post-traumatic osteoarthritis (PTOA) severity. Methods: Thirty-two patients with surgically treated pilon fractures from 3 institutions underwent weightbearing computed tomography (WBCT) at 6, 12, and 18 months post-operatively. At 18 months, patients were grouped into low-grade and high-grade PTOA groups. Statistical shape modeling was used to quantify morphologic and alignment variation across the tibia, fibula, talus, and calcaneus. Joint distances at the talocrural and subtalar joints were calculated using correspondence-based metrics. Radiographic parameters were automatically derived from 3-dimensional bone models using a MATLAB toolbox. Cross-sectional and longitudinal statistical differences were assessed. Results: Patients who developed high-grade PTOA demonstrated progressive flattening of the calcaneal pitch, posterior and inferior translation of the tibia and fibula, and narrowing of the central tibiotalar joint. In contrast, the low-grade group exhibited greater valgus hindfoot alignment, mild widening of the medial and posterior tibiotalar joint, and greater alignment variation over time. Radiographically, the high-grade group displayed a significant increase in tibiocalcaneal angle over time ( P = .03) and a trend toward a more varus hindfoot configuration. Conclusion: Distinct longitudinal alignment and morphologic trajectories differentiate low-grade and high-grade PTOA development following pilon fracture fixation. Preservation of coronal alignment and subtalar adaptability may provide a protective mechanism against rapid PTOA progression. These findings highlight the clinical potential of WBCT and shape-based 3-dimensional analysis for early detection of malalignment patterns associated with post-traumatic degeneration. Level of Evidence: Level III, prognostic study.

OBJECTIVES: To investigate whether preoperative muscle characteristics measured on CT scans could predict early ambulation capacity after hip fracture surgery. METHODS: Design: Retrospective cohort study. Setting: Single level I academic trauma center. Patient Selection Criteria: Patients aged ≥55 years who underwent surgical fixation for hip fractures (OTA/AO types 31A, 31B) between January 2015 and December 2024 were included. Inclusion required preoperative CT imaging and documented ambulation assessments at postoperative day 1 (POD1) and discharge. Patients with neuromuscular disorders affecting muscle mass were excluded. Outcome Measures and Comparisons: The primary outcome was distance walked (feet) during physical therapy at POD1 and discharge. Preoperative CT scans were opportunistically analyzed for muscle quality (Hounsfield units) and size (cross-sectional area) in psoas, gluteal, and quadriceps muscles. Associations were analyzed using linear mixed-effects models adjusted for body mass index, Charlson Comorbidity Index, preinjury wheelchair use, time to surgery, and fixation method. RESULTS: A total of 140 patients (mean age 75 ± 8 years, 59% female) contributed 210 ambulation observations. Ambulation improved from 0 (IQR 0–20) feet at POD1 to 20 (IQR 0–86) feet at discharge ( P < 0.001). In the fully adjusted mixed-effects model, quadriceps quality was the only muscle metric that independently predicted ambulation (β = 0.042, 95% CI: 0.012–0.072, P = 0.007; marginal R ² = 0.272). Among clinical covariates, higher body mass index was associated with reduced ambulation (β = −0.060, P = 0.029); Charlson Index was not significant (β = −0.062, P = 0.189). No other muscle quality (gluteus medius, gluteus maximus, psoas; all P > 0.16) or size metric (all P > 0.33) reached significance. CONCLUSION: In patients after hip fracture surgery, preoperative quadriceps muscle quality was the primary muscle–based predictor of early postoperative ambulation. Muscle quality outperformed size in predicting early functional recovery. Opportunistic CT-based Hounsfield units assessment identified patients at risk of limited early mobilization. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Geriatric distal femur fractures are associated with mortality rates exceeding 20%, comparable to hip fractures. Traditional single implant fixation often requires weight-bearing restrictions that delay recovery. This pilot study aims to assess the feasibility of conducting a multicentre randomised controlled trial comparing dual vs single implant fixation for geriatric distal femur fractures. Methods and analysis: This multicentre, prospective, randomised controlled pilot trial will enrol 80 participants aged 60 years or older with displaced distal femur fractures at five US level 1 trauma centres. Patients will be randomly allocated 1:1 to receive either single implant (lateral plate or retrograde nail) or dual implant (nail-plate or dual plate) fixation. All patients will be permitted immediate weight-bearing. The primary outcome is feasibility assessed through enrolment rate (80 patients in 12 months), protocol adherence (≥90%) and follow-up retention (≥85% at 12 months). Secondary outcomes include post-surgical mobility (AM-PAC, TUG), patient-reported outcomes (PROMIS-PF, PROMIS-29), mortality (90-day and 1 year) and complication rates. Analyses will be on an intention-to-treat basis. Ethics and dissemination: The protocol was approved by the University of Utah Institutional Review Board (IRB_00149119) and IRBs at all participating centres. Written informed consent will be obtained from participants or legally authorised representatives. Findings will be disseminated through peer-reviewed publications and conference presentations. Trial registration number: NCT05292313 .