Mitchel R. Obey

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.

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 compare ambulatory status, union, mortality, and operative complications in patients with distal femur fracture treated with the nail plate combination (NPC) and alternative fixation constructs. METHODS: . Design: Retrospective Cohort Study. Setting: Single Level 1, tertiary referral Academic center Patient Selection Criteria: This study included adults with a low-energy distal femur fracture (OTA/AO33A/C and Su 1–3) that received ORIF within 2018–2024. Exclusions were pathologic fractures, antegrade intramedullary devices, and baseline nonambulators (from ambulatory status evaluation only). Outcome Measures and Comparisons: The primary outcome was ambulatory status at postoperative intervals using Koval-Walking-Score. Secondary outcomes included radiographic union, mortality, and reoperation. RESULTS: A total of 404 patients with a low-energy distal femur fracture were included, with 342 included for mobility analysis. Fixation constructs included 189 NPC (mean age 75.0 ± 10.2, 83.1% female), 118 lateral locking plate (LLP) (mean age 73.4 ± 10.2; 76.3% female), 79 retrograde intramedullary nail (rIMN) (mean age 73.7 ± 11.1, 74.7% female), and 18 dual plate combination (mean age 74.6 ± 10.9, 83.3% female) (age P = 0.567, sex P = 0.701). NPC was more frequently selected for Su 2 (56.2%) and Su 3 (65.9%) ( P = 0.001). NPC demonstrated lower average ambulatory impairment score over LLP: 3 weeks (−0.8; P = 0.002), 6 weeks (−1.1; P < 0.001), and both LLP and rIMN at 3 months (−0.9/−0.8; P = 0.049/0.013) and 6 months (−0.9/−0.8; P = 0.043/0.021). After Bonferroni correction to account for multiple testing, post hoc pairwise comparisons showed that NPC ambulation scores remained lower at 3 and 6 weeks (−0.8, P = 0.024; −1.1, P < 0.001). Six-month mortality was lower in NPC than rIMN (9% vs. 19%; P = 0.04). Dual plate combination showed higher infection (22.2%; P = 0.012), wound dehiscence (11.1%; P = 0.013), and drainage (5.6%; P < 0.001); although sample size limited analysis. Radiographic union was comparable (36.3% vs. 52.9% vs. 39.6% vs. 54.5%, P = 0.104). CONCLUSIONS: In this study, NPC was associated with superior ambulatory recovery rates to preinjury status over single-implant constructs and improved mortality rates over rIMN. Thus, NPC represented a reliable construct for early ambulation and recovery in these injuries. 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.

Expert consensus recommendations from 21 academic centers were established for appropriate radiography utilization at 12 potentially low-yield anatomic sites through a multidisciplinary process endorsed by six major American medical societies.

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.

Case: This case report describes a rare low-energy extrathoracic scapular dislocation, from axial loading of the upper extremity, in the setting of previous glenohumeral arthrodesis. By 4 months after closed reduction, the patient’s scapulothoracic joint felt stable and his neurologic symptoms had returned to baseline. Over a seventeen-month follow-up period, he did not sustain a recurrent dislocation. Conclusion: Glenohumeral arthrodesis may increase the risk of extrathoracic scapular dislocation. Orthopedic surgeons should recognize that extrathoracic scapular dislocations can be reduced by direct manipulation of the scapula under sedation and that outcomes after successful closed reduction are likely good.