Joshua L. Gary

OBJECTIVES: To assess the outcomes of patients with complete articular distal femur fractures treated with open reduction and retrograde intramedullary nailing. METHODS: Design: Retrospective cohort analysis. Setting: Single-center, Level 1 Academic Trauma Center. Patient Selection Criteria: Patients treated between January 1, 2016, and January 1, 2023, with complete articular distal femur fractures (AO/OTA 33 C1-3)W who underwent independent articular reduction and retrograde intramedullary nailing were included. Patients were included who had a minimum of 3 months of follow-up or until fracture union. Outcome Measures and Comparisons: Patient data pertaining to demographics, surgical details, and radiographic outcomes were systematically collected and analyzed. Coronal and sagittal alignments were evaluated using the anatomic lateral distal femur angle and anatomic posterior distal femoral angle, respectively. Reoperations were stratified into planned and unplanned categories and further classified as major or minor. RESULTS: The study cohort comprised 127 patients (52% males) with 130 complete articular distal femur fractures (3 patients with bilateral fractures) with a mean age of 49.9 years (range: 12–95 years). The mean clinical follow-up was 254.1 days (range: 90–1882 days). Postoperative mean anatomic lateral distal femur angle was 83.4 degrees, and anatomic posterior distal femoral angle was 1.2 degrees apex posterior. Articular reductions were anatomic (0 mm residual displacement, 93.8%) or near anatomic (between 0 and 2 mm residual displacement, 6.2%) in all cases. All reductions were maintained at final follow-up. The reoperation rate was 15.4%, with 3.8% of cases classified as major unplanned operations. Most minor unplanned reoperations (8% of cases) were for implant irritation or knee arthrofibrosis. The rate of osseous union was high, with only 1 case of nonunion observed, yielding an aseptic nonunion rate of 0% and an infected nonunion rate of 0.8%. CONCLUSIONS: Independent articular reduction and retrograde intramedullary nailing of AO/OTA 33C femur fractures resulted in an overall reoperation rate of 15.4%, major unplanned reoperation rate of 3.8%, an osseous union rate of 99%, and maintained articular and metaphyseal reductions at final follow-up. The study's findings support this technique as an effective treatment option for managing these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To compare operative time, reduction quality, and implant placement between supine and lateral decubitus positions for cephalomedullary nailing (CMN) of intertrochanteric fractures in elderly patients. Methods: A retrospective review was conducted of patients aged ≥ 60 years with intertrochanteric fractures treated with CMN at a Level I trauma center over one year. Patient demographics, injury characteristics, and operative details were recorded. Procedures were performed on either a traction table or flat-top table. The primary outcome was total operating room (OR) time. Secondary outcomes included setup time, surgical time, reduction grade, tip-apex distance, implant placement, blood loss, fluoroscopic exposure time, fluoroscopic radiation dose, and postoperative complications. Results: 54 patients positioned supine and 29 positioned lateral decubitus were included. No differences were observed between groups regarding patient and injury characteristics, including operating table type ( p > 0.05). Lateral group, compared to supine group, had significantly greater total OR time (218.2 ± 60.8 vs. 162.8 ± 45.4 min, p < 0.001), setup time (90.9 ± 21.5 vs. 64.1 ± 21.2 min, p < 0.001), surgical time (114.5 ± 43.4 vs. 85.8 ± 33.4 min, p < 0.001), and fluoroscopic radiation dose (13.5 ± 13.8 vs. 6.1 ± 3.7 Gy·cm ² , p < 0.001). There was no significant difference in reduction grade, implant placement measures, blood loss, fluoroscopy time, or postoperative complications ( p > 0.05). On multivariate regression, lateral positioning was significantly associated with increased total OR time (β = 42.17, p = 0.004), setup time (β = 21.55, p < 0.001), surgical time (β = 21.18, p = 0.040), and radiation dose (β = 6.37, p = 0.009). Conclusion: Supine positioning for CMN of intertrochanteric fractures in elderly patients was associated with shorter operative time compared to lateral positioning, with no difference in reduction quality or implant placement.

Background: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. Methods: We performed a secondary analysis of data from the FIXIT study. Adults with severe open tibial fractures were randomized to undergo definitive modern external ring fixation (n = 122) or internal fixation (n = 132). Primary outcomes were pain intensity and interference at 6 and 12 months, measured by the Brief Pain Inventory. Secondary outcomes were Numeric Pain Rating Scale (NPRS) scores and the incidence of moderate to severe pain. Post hoc subanalysis compared pain in patients with and without pin-site infections and with and without external fixation removal. Results: At 6 months, median pain intensity did not differ significantly between the external fixation group (4.1 [interquartile range (IQR), 2.2 to 5.5]) and the internal fixation group (3.0 [IQR, 1.8 to 5.8]) (p = 0.11); however, patients who underwent external fixation had greater median pain interference (6.0 [IQR, 3.3 to 8.0]) than patients who underwent internal fixation (4.0 [IQR, 1.9 to 7.4]) (p = 0.01). At 12 months, pain intensity, pain interference, and NPRS scores did not differ by treatment type. The overall incidence of moderate to severe pain was 33% at 6 months and 35% at 12 months. At 6 months, pin-site infections were associated with greater pain intensity (p = 0.01) but not greater interference (p = 0.10). At 12 months, the presence of external fixation was associated with greater pain intensity (p = 0.01) and interference (p < 0.01). Conclusions: At 6 months after a severe open tibial fracture, patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation, partly because of pin-site infections. No differences in pain interference or intensity were seen at 12 months. At 12 months, patients with external fixation in place had greater pain intensity and interference than those whose external fixation had been removed, but this was not the case at 6 months. Approximately one-third of all patients had moderate to severe pain at both time points, highlighting that persistent pain is common, regardless of treatment type. These findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background: Venous thromboembolism (VTE) poses significant risk of morbidity and mortality in orthopaedic trauma patients. Thromboelastography (TEG) analysis has been demonstrated to provide value in demonstrating hypercoagulability and predicting the risk of post-injury VTE. The primary aim was to investigate if TEG analysis at the time of admission following severe extremity trauma predicts thromboembolic events. We hypothesized that previously described elevations in maximal amplitude (MA) on initial TEG would correlate with an increased risk of VTE. Methods: This was a secondary study of PREVENT CLOT, a multicenter, randomized trial that enrolled adult patients with an extremity fracture (from hip to midfoot or shoulder to wrist) treated operatively or any pelvic or acetabular fracture. TEG at admission was performed according to local protocols. The primary outcome of this analysis was postoperative VTE. We assessed the association between admission TEG values and VTE using bivariate and multivariable regression analyses. Statistical significance was set at p < 0.05. Results: Thousand one hundred eighty-three patients enrolled participants in the PREVENTion of CLots in Orthopedic Trauma (PREVENT CLOT) trial had TEG analysis performed on initial presentation. Of these patients, 47 (3.97%) had a symptomatic postoperative VTE at a median of 9 days (interquartile range, 4-18 days). There were no differences in VTE rates when examining MA of ≥65, ≥69, or ≥72 (p = 0.12, 0.21, and 0.19, respectively). However, on admission TEG, reaction time (R-time) was significantly higher among those who experienced a postoperative deep venous thrombosis (2.45 vs. 1.79, p < 0.01). After controlling for confounders, R-time of ≥2.0 was associated with a 2.1-fold increased odds of VTE (OR 2.13, 95% confidence interval 1.06-4.28, p < 0.001). Conclusion: In contrast to previous smaller retrospective studies, elevated admission-TEG MA values were not predictive of VTE following operative orthopaedic extremity trauma in this secondary analysis of a large multicenter prospective study. Our findings suggest that an increased R-time on the admission TEG, which is thought to be indicative of a longer time to form a clot, may be paradoxically associated with an increased VTE risk in orthopedic trauma patients. Level of Evidence: Level II . See Instructions for Authors for a complete description of levels of evidence.

Introduction: Complex articular fractures of the proximal (plateau) and distal (pilon) tibia carry a substantial risk of deep surgical site infections (SSIs), often resulting in serious complications and hospital readmissions. The TOBRA study is a multicenter, randomized controlled trial designed to determine if the combination of vancomycin plus tobramycin powder is more effective than vancomycin alone in decreasing the risk of deep SSIs after definitive fixation of these high-risk fractures. Methods and Analysis: Adults aged 18–80 years with at least one risk factor for infection (eg, open fracture, fasciotomy) are randomized 1:1 to receive either 1 gram of vancomycin alone or 1 gram of vancomycin plus 1.2 grams of tobramycin applied directly into the wound at the time of closure. The primary outcome is a deep SSI requiring surgery within 182 days of fixation, adjudicated by an expert panel blinded to treatment allocation. Secondary outcomes include infection subtypes (gram-negative, culture-negative), wound complications, and adverse drug reactions. The study uses Bayesian Cox regression to evaluate the primary end point, with superiority defined as a posterior probability greater than 0.95. The trial will enroll 1550 participants across sites in the Major Extremity Trauma Research Consortium (METRC). Findings will help guide antibiotic prophylaxis strategies in orthopaedic trauma patients at high risk of infection. Ethics and Dissemination: Ethical approval has been granted by the Pearl Institutional Review Board, the Department of Defense Human Research Protections Office, and the local Institutional Review Board at each participating site. Alongside journal publications, dissemination activities include sharing results with participating trial sites and patients and data sharing (upon reasonable request) with researchers.

Objectives: To compare postoperative pain and opioid requirements between lateral compression types 1 (LC1) and lateral compression type 2 (LC2) injuries treated with anterior and posterior fixation (PF) [anterior fixation (AF) + PF] versus PF only. Methods: . Design: Retrospective review of propensity matched cohorts for sex, age, LC1 versus LC2, sacral fracture type, and preoperative Visual Analogue Scale (VAS) pain scores were created in a 1:1 ratio. Setting: Level 1 trauma center and academic tertiary care hospital. Patient Selection Criteria: Adult patients with LC1 or LC2 (OTA/AO 61B2.1, 61B2.2) injuries treated surgically with PF or AF + PF between March 2019 through January 2024. Outcome Measures and Comparisons: VAS and morphine milligram equivalents (MMEs) were measured at 24 and 48 hours postoperatively, and 24 hours before discharge between the groups. Secondary outcomes included postoperative days to mobilization (DTM) and length of stay. Results:Intotal,: 56 patients (28 AF + PF, mean age 49.4 ± 16.9, 57.1% female, 28 PF, mean age 49.8 ± 16.9, 53.6% female) were included. There were no differences between the groups for demographic data (all P > 0.78). Patients with AF + PF had lower VAS scores than patients with PF 24 hours postoperatively [difference in mean (DIM): 2.18 cm (95% confidence interval (95% CI): 0.9068–3.4532], P = 0.001), 48 hours postoperatively [DIM: 3.43 cm (95% CI: 2.11 to 4.75), P < 0.001] and 24 hours before discharge [DIM: 2.68 (95% CI: 1.31 to 4.04), P < 0.001]. Patients with AF + PF required lower MMEs 24 hours before discharge [DIM: 6.989 (95% CI: 0.873 to 13.105), P = 0.026]. Patients with AF + PF also had shorter DTM [DIM: 3.21 (95% CI: 0.03 to 6.40), P = 0.048]. There were no differences in MMEs 24 hours postoperatively [DIM: 3.64 (95% CI: −4.15 to 11.44), P = 0.35], 48 hours postoperatively [DIM: 4.78 (95% CI: −3.12 to 12.67), P = 0.23], or length of stay [DIM: 1.96 (95% CI: −2.03 to 5.95), P = 0.33]. Conclusions: Anterior and posterior fixation was associated with significantly decreased inpatient postoperative pain, predischarge narcotics use, and DTM compared with PF alone. The combination of percutaneous AF and PF for LC1 and LC2 pelvic ring injuries should be considered when the goals are maximizing pain control. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose: To compare the proximity of rafting screws to the articular surface in lateral split-depression (LSD) tibial plateau fractures using mini-fragment (MF) and pre-contoured anterolateral (AL) proximal tibia plates. Secondary aims included comparing patient-reported outcome scores and rates of hardware failure and reoperation. Methods: Design Retrospective review. Setting : Multi-center Level I Tertiary Academic Center. Patient Selection Criteria : Adult patients with AO/OTA 41B3.1 LSD tibial plateau fractures treated over 30 months by a single surgeon were identified. Patients were included when their fractures were treated with either a MF T-plate (2.7 mm in thickness) or a pre-contoured anatomic AL plate. Main Outcome Measures : The primary outcome was the distance from the lateral joint line to the most proximal screw (screw-to-joint distance [SJD]) as measured on intraoperative fluoroscopy. Results: Twenty-four patients were included with patients having received either a 2.7-mm MF T-plate (n = 14) or a standard AL proximal tibia plate (n = 10) and were followed for a median time of 29 weeks. Average SJD was 3.79 mm in the MF group and 8.67 mm in the AL group (p < 0.001). There was no difference in PROMIS scores between the groups. No patients experienced loss of reduction, implant loosening/failure, reoperation, or removal of tibial plateau hardware. Conclusions: Mini-fragment plates allow for a significantly shorter SJD compared to AL plates, allowing surgeons to provide more proximal rafting of LSD fractures while maintaining low rates of postoperative complications. No increase in fracture subsidence was observed when using mini-fragment fixation alone compared to AL plates.