Christopher M. McAndrew

OBJECTIVES: To characterize injury patterns, treatment differences, and clinical outcomes associated with ballistic and blunt forearm fractures. METHODS: Design: Retrospective cohort study. Setting: Single Level 1 tertiary trauma center, 2018-2023. Patient Selection Criteria: The study included adults (≥18) who underwent operative fixation of diaphyseal radius and/or ulna fractures. Exclusion criteria were ipsilateral intraarticular or unstable elbow injuries, pathologic fractures, or fractures involving preexisting implants. Patients were stratified into 2 groups: ballistic and blunt injuries, which were further subclassified as blunt-closed or blunt-open. Outcome Measures and Comparisons: Primary outcomes included nerve deficit, complication rate, unplanned reoperation, nonunion, and postoperative infection. RESULTS: The study included 395 patients with 398 forearm fractures: 81 ballistic fractures in 78 patients [32 years (18–69), 88.9% male], 213 blunt-closed fractures [41 years (18–82), 59.2% male], and 104 blunt-open fractures [46 years (19–92), 71.2% male]. Ballistic fractures had significantly higher rates of nerve deficits (48.2% vs. 6.3%, P < 0.001), complications (38.5% vs. 21.1%, P = 0.020), and unplanned reoperation (30.8% vs. 14.2%, P = 0.012) compared with blunt injuries. Infection rates were similar between ballistic and blunt groups (10.3% vs. 5.8%, P = 0.294). Nonunion differed only between ballistic and blunt-closed fractures (18.0% vs. 5.6%, P = 0.042), not blunt-open fractures (18.0% vs. 9.2%, P = 0.228). On multivariable analysis, injury group remained an independent predictor of nerve deficit ( P < 0.001), complication ( P = 0.008), and unplanned reoperation ( P = 0.015), with ballistic injuries demonstrating the highest rates. CONCLUSIONS: Ballistic forearm fractures posed unique challenges compared with blunt injuries. They were associated with significantly higher rates of nerve deficit, unplanned reoperations, and overall complications, with higher nonunion observed when compared with blunt-closed injuries. These injuries warrant a high index of suspicion for nerve injury and close long-term follow-up to optimize patient outcomes and address the needs of a disproportionately affected, high-risk population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To evaluate whether a machine learning-based system can accurately measure coronal knee alignment parameters from routine postoperative radiographs following surgical fixation of distal femur fractures. Methods: Design : Retrospective cohort study. Setting: Single-center academic orthopedic trauma practice. Patient Selection Criteria: Adult patients 50 years of age or older who underwent surgical fixation of low-energy OTA/AO 33A and 33C distal femur fractures (including periprosthetic fractures) between November 2020 and December 2024 were retrospectively identified. Outcome Measures and Comparisons: A machine learning-based automated alignment assessment system was trained to identify standard radiographic landmarks, including the femoral intercondylar notch, femoral condyles, tibial spines, and tibial plateaus, and automatically calculate commonly used coronal alignment parameters including joint line convergence angle (JLCA), anatomic femorotibial angle (aFTA), anatomic lateral distal femoral angle (aLDFA), and anatomic medial proximal tibial angle (aMPTA). Automated measurements were compared with manual measurements annotated by a trained observer and validated by an orthopedic surgeon. Results: A total of 287 postoperative AP knee and distal femur radiographs were obtained as part of routine postoperative care and randomly divided into training and testing datasets for model development and validation. The cohort was 78.0% female with a mean age of 72.3 years (range: 50 to 97 years). Automated measurements demonstrated strong agreement with surgeon-validated measurements. Mean absolute error was 1.1° for JLCA (range: 0.0° to 3.5°), 1.5° for aFTA (range: 0.0° to 4.4°), 1.0° for aLDFA (range: 0.0° to 3.1°), and 2.3° for aMPTA (range: 0.1 to 6.4°). Pearson correlation coefficients ranged from 0.4 to 1.0, and Bland-Altman analysis demonstrated minimal systematic bias, with 95% of differences falling within a clinically acceptable range of ±5°. Conclusions: Automated alignment assessment utilizing a machine learning-based system using routine postoperative radiographs provided accurate measurements in distal femur fracture patients and may serve as a practical adjunct for longitudinal surveillance in orthopedic trauma practice. Level of Evidence: Level III

Purpose: Distal femur fractures occur in older, osteoporotic patients and carry a measurable risk of subsequent ipsilateral hip fracture. Prophylactic femoral neck screw placement is believed by many to mitigate this risk, but clinical evidence is limited. This study evaluates the association between prophylactic femoral neck fixation after distal femur fracture and future ipsilateral hip fracture. Methods: A retrospective cohort study was conducted at a single Level 1 tertiary trauma center between 2018 and 2024. Adult patients (≥ 18 years) with AO 33A/B/C fractures and Su type 1–3 periprosthetic fractures of the distal femur fracture treated with operative fixation were included. Patients with pathologic fractures, prior hip arthroplasty, or isolated antegrade intramedullary nailing were excluded. Treatment was classified by the presence or absence of ipsilateral prophylactic femoral neck screw fixation. The primary outcome of interest was the incidence of subsequent ipsilateral hip fracture. Results: Of 395 patients, 163 (41%) received prophylactic femoral neck fixation. The prophylactic screw (PS +) cohort included more female patients (81.0% vs. 68.5%, p = 0.006) and more periprosthetic fractures (65.0% vs. 35.8%, p < 0.001). Fixation constructs differed significantly, with nail-plate combinations predominating in the PS + group (69.1% vs 26.4%, p < 0.001). Six patients (1.5%) sustained an ipsilateral hip fracture. No difference was observed in the incidence of ipsilateral hip fracture by prophylactic femoral neck fixation (1.2% vs 1.7%, p = 0.691) or fracture-free survival ( p = 0.802). Conclusion: Prophylactic femoral neck screw placement was not associated with a reduced rate of ipsilateral hip fracture after distal femur ORIF. Hip fractures occurred in both groups, suggesting that screw placement alone may not be independently protective.

Purpose: Body mass index (BMI) is a recognized risk factor for infection in distal femur fracture management, but the role of local subcutaneous fat thickness at incision sites remains unclear. This study evaluated whether local adiposity independently predicts surgical site infection (SSI) after open reduction internal fixation (ORIF) and compared its predictive value to BMI. Methods: We conducted a retrospective case–control study of 302 adults who underwent ORIF for distal femur fractures at a Level 1 trauma center (2021–2024). Subcutaneous fat depth was measured at lateral, prepatellar, and, when available, medial sites on plain radiographs. The primary outcome was SSI requiring irrigation and debridement within 1 year. Logistic regression assessed the predictive value of fat thickness and BMI, with subgroup analysis of periprosthetic fractures. Results: Nineteen patients (6.3%) developed SSI. On univariate analysis, greater lateral, prepatellar, medial fat, and BMI were significantly associated with infection. Logistic regression showed lateral and prepatellar fat predicted SSI, but these effects were lost once BMI was included, confirming BMI as the stronger independent predictor. In the periprosthetic subgroup, neither BMI nor adiposity predicted infection. Conclusion: In distal femur fractures, BMI outperformed local fat thickness as a predictor of SSI, supporting its use as a practical risk stratification tool. While greater local adiposity correlated with reoperation, these associations diminished when BMI was considered. In periprosthetic fractures, no predictors were identified, highlighting the need for larger studies to clarify whether implants alter infection risk.

Surgical treatment of unicondylar distal femur fractures remains a challenge. Achieving stable fixation to allow early range of motion and weightbearing is complicated by poor bone quality and articular surface comminution, commonly leading to poor outcomes. Multiple treatment strategies have been previously described including small fragment, large fragment, and anatomical plate fixation. However, given the variability of fracture patterns, anatomical implants often lack the appropriate geometry and fixation options required to provide adequate stabilization. With knowledge and application of the principles of fracture fixation, these injuries can be effectively treated with standard non-anatomically shaped, contourable implants. The objective of this report was to describe a technique that provides effective fixation in these cases and report on outcomes of a small series. This technique utilizes a dual-implant construct that includes a small or large fragment plate positioned to buttress the metaphyseal apex of the fracture, and a small fragment reconstruction plate contoured in the shape of a “J” (J-plate) that wraps around the femoral condyle and onto the anterior cortex of the femur. There are advantages to this technique compared to anatomically contoured plates, including precise placement of implants in biomechanically advantageous locations, orthogonal fixation, and decreased implant costs.

Introduction: Patella fractures are articular injuries that can alter knee biomechanics, disrupt joint contact forces, and promote cartilage degeneration. However, progression to reconstructive surgery is not fully characterized. This study investigates the risk of progression to total knee arthroplasty (TKA) following patella fractures and assesses whether initial operative versus nonoperative management impacts this risk. Methods: We retrospectively analyzed TKA progression in patients with patella fractures using synthetic data from a large Level I academic trauma center (1996–2024). Patients were identified by historic diagnostic codes for patella fractures and TKA. Age-stratified TKA rates were compared to published national data, and indirect standardization was used to calculate the age-adjusted standardized incidence ratio (SIR), risk difference (RD), and attributable risk percent (AR%). Results: Among 3212 native patella fractures, 263 patients (8.2%) later underwent TKA. The mean age at fracture was 58.1 years (SD 17.5) with a mean time to TKA of 4.1 years (SD 4.9). The SIR for TKA was 1.6 (95% CI 1.3–1.9), RD 3.1%, and AR% 37.2%. In the 406 operatively treated fractures (mean age 55.3 years, SD 18.6; 60.8% female), TKA occurred in 5.4% (SIR 1.4, 95% CI 0.9–2.2), compared to 8.6% in the 2,806 nonoperatively treated fractures (mean age 58.5 years, SD 17.4; 61.8% female; SIR 2.1, 95% CI 1.8–2.3) ( p = 0.04). Conclusion: Individuals with patella fractures face an increased lifetime risk of advanced joint degeneration and subsequent TKA compared to the general population, with nonoperative treatment linked to a higher risk than operative management. Further analysis of initial injury patterns, radiographic findings, and patient factors are in need for further research to understand and validate these findings.

Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity orthopaedic injuries. Skeletal traction has proven to be an effective initial means of stabilization in patients with these injuries. Traction may be used for both temporary and definitive treatment in a variety of orthopaedic injuries. With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications. Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons to be proficient not only in their application but also understanding of the appropriate indications for use. Here we present a case example of a patient with a right femur fracture and discuss the technique and indications for placement of proximal tibia skeletal traction.

Objectives: To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early post-operative radiographs. Design: Retrospective case series Setting: Urban academic Level 1 trauma center Patients/Participants: 303 acute tibial shaft fractures underwent intramedullary nailing between 2006-2013, met inclusion criteria, and had at least three months of radiographic follow-up. Intervention: Baseline demographic, injury, and surgical data were recorded for each patient. Each set of post-operative radiographs were scored using RUST and evaluated for implant failure. Main Outcome Measurements: Post-operative time distribution for each RUST score, RUST score distribution for four common follow-up time points, and the presence and timing of implant failure. Results: The 5^th percentile and median times, respectively for reaching: “any radiographic healing” (RUST= 5) was 4.0 weeks and 8.4 weeks, “radiographically healed” (RUST=9) was 12.1 and 20.9 weeks, and “healed and remodeled” (RUST=12) was 23.5 weeks and 47.7 weeks. At six weeks, 84% of radiographs were scored as RUST≤6 (two or fewer cortices with callus). No implant failure occurred within the first eight weeks after surgery and the indication for all seven reoperations within this period was apparent on physical examination or immediate post-operative radiographs. Conclusions: The median time to radiographic union (RUST=9) after tibial nailing was approximately twenty weeks and little radiographic healing occurred within the first eight weeks after surgery. Routine radiographs in this time period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Summary: Semiextended positioning can improve the surgeon's ability to obtain, maintain, and fluoroscopically evaluate a fracture reduction when performing fixation with an intramedullary nail, especially in fractures at the proximal and distal ends. Furthermore, this position allows for evaluation of instrument placement, including the start point, without moving the fluoroscopic unit into extremes of angulation or compromising the quality of the beam orientation. The intraarticular suprapatellar approach has been described as a soft tissue approach to maintain the leg in a position that would not complicate management of these fractures, especially those in the proximal third of the tibia. A semiextended extraarticular soft tissue approach to the start point was described by Kubiak et al, and the lateral parapatellar version has become commonly used on the Orthopaedic Trauma Service at Washington University in Saint Louis. This video demonstrates advantages of semiextended positioning while performing reduction and intramedullary nail fixation for distal tibia fractures. This lateral parapatellar approach can be performed without specialized instrumentation, results in precise establishment of the start point and completion of the fixation without injury to the knee.