Lucas S. Marchand

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.

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 .

Background: Fracture nonunion remains a major clinical challenge. Although radiographic scores such as RUST (Radiographic Union Score for Tibial fractures) and mRUST (the modified version) are widely used to assess healing, there has been limited investigation into their longitudinal use. This study evaluated whether a log-logistic statistical model of radiographic healing scores over time could quantify differences between fractures that healed and those that went on to nonunion. Methods: This retrospective cohort analysis added serial radiographs of 49 femoral shaft nonunions to radiographs from previous cohorts. Tibiae and femora were scored with RUST and mRUST, respectively. Scores were plotted over time and fitted to a log-logistic curve to generate a healing (“position”) equation. Model-derived parameters (Y _inf [ultimate score], k [a curve shape parameter], and t _half [time to half of the score change]) were compared between fractures that did and did not unite. Secondarily, first and second derivatives were used to describe the fracture healing “velocity” and “acceleration” for each group. Results: A total of 613 fractures were analyzed: 234 tibial (196 healed, 38 nonunion) and 379 femoral (330 healed, 49 nonunion). In femoral fractures, Y _inf , k, and t _half all differed significantly (p < 0.008) between healed and nonunion cases. In tibial fractures, Y _inf and k differed (both p < 0.008), whereas t _half did not (p = 0.30). The first and second derivatives at the population level suggest early differences in healing kinematics between fractures that heal and those that go on to nonunion. Conclusions: This proof-of-concept study demonstrates that log-logistic modeling of radiographic scores can quantify differences in radiographic healing between femoral and tibial shaft fractures treated with intramedullary nails that will go on to union versus nonunion. Differences in healing velocity and acceleration may emerge early, supporting the potential of the longitudinal framework for earlier identification of fractures at risk for nonunion. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Introduction: Early open fracture management aims to minimise the risk of complications. For the most severe open fracture wounds, multiple irrigation and debridement surgeries are required to overcome severe wound contamination, to reassess the evolving tissue injury or to temporise and plan further surgery. When multiple irrigation and debridement surgeries are needed, uncertainty remains about how the open fracture wound should be managed to best minimise complications. The primary aim of this trial is to compare the antibiotic cement bead pouch vs negative pressure wound therapy in the management of patients with severe open tibia fracture wounds. Methods and analysis: BvV is a multicentre, pragmatic, parallel arm randomised controlled trial that aims to enrol 312 adult patients admitted to a participating centre with a severe open tibia fracture requiring multiple irrigation and debridement surgeries. Participants will be randomly allocated on a 1:1 basis to either antibiotic cement bead pouch or negative pressure wound therapy. The primary outcome will be a composite outcome to evaluate clinical status 6 months after randomisation. Using the win ratio approach, we will hierarchically assess the composite outcome in the following order: (i) all-cause mortality, (ii) injury-related amputation of the lower extremity, (iii) unplanned reoperation to manage wound complications, an infection or promote fracture healing and (iv) clinical fracture healing assessed using the Functional IndeX for Trauma (FIX-IT) instrument. Ethics and dissemination: The BvV trial has been approved by a central institutional review board (IRB) (Advarra) for clinical sites in the USA, the ethics board at the coordinating centre at McMaster University (Hamilton Integrated Research Ethics Board), and participating sites not using the central institutional IRB (Fraser Health Research Ethics Board, The University of British Columbia Clinical Research Ethics Board, Newfoundland and Labrador Health Research Ethics Board, University of Manitoba Biomedical Research Ethics Board). Additional clinical sites who are in the start-up phase, as well as any new selected clinical sites, will obtain local approvals prior to initiating trial activities. This will include a clinical site in the UK who is in the process of obtaining the necessary approvals. Recruitment began in November 2023. Both interventions are frequently used to manage severe open fracture wounds, ensuring that the trial results can be easily transitioned into clinical practice. The results of this trial will be disseminated to national and international partners through peer-reviewed publications, academic conferences and stakeholder engagement activities. Trial registration number: NCT05615844 .

Objectives: The orthopaedic community has largely avoided the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the management of pain after fractures based on a combination of animal and clinical data, which suggest their association with impeded fracture healing. Given the significant deleterious effects of opiate analgesics, the use of NSAIDs for pain management in fracture care would be advantageous if potential concerns related to bone healing could be resolved. This study is designed to determine whether planned use of scheduled NSAIDs after fracture leads to a difference in fracture union rates, which in turn provides evidence regarding whether prohibition of NSAID use is justified. Design: This was a prospective, two-arm, pragmatic, randomized-controlled multicenter Phase III noninferiority trial. Setting: The study was conducted at 14 Level I trauma centers across the United States and Canada. Patients: Patients aged 18 to 80 years with open (Gustilo Type I, II, or IIIA) or closed tibia fractures treated with intramedullary nailing were included. Intervention: Patients received 600 milligrams of ibuprofen, 3 times daily, for up to 6 weeks. Main Outcome Measurements: Secondary surgery to achieve union within 12 months of definitive fixation was recorded.

Background: Infection and nonunion are common sequelae of open fractures. Studies have shown infection and nonunion rates ranging from 2% to 52% and 12% to 17%, respectively. The present article describes the rates of surgical site infection (SSI) and delayed union/nonunion following open fractures in a large contemporary series of patients from prospective clinical trials with adjudicated outcomes. Methods: A descriptive analysis was performed with use of patient data from the FLOW, Aqueous-PREP, and PREPARE-Open studies. These studies, published within the past 10 years, included multiple international trauma centers and shared definitions for SSI and delayed union/nonunion. SSI and delayed union/nonunion rates were stratified by the OTA/AO fracture and Gustilo-Anderson open fracture classification systems. Kaplan-Meier estimators were utilized to obtain point estimates, and the log-log transformation approach was utilized to calculate 95% confidence intervals (CIs) for outcome rates. Results: A total of 6,042 open fractures were included. The cumulative SSI rates at 12 months for Gustilo-Anderson Types 1, 2, 3A, 3B, and 3C were 5.1%, 9.7%, 13.8%, 28.9%, and 26.2%, respectively. The cumulative rates of delayed union/nonunion at 12 months for Gustilo-Anderson Types 1, 2, 3A, 3B, and 3C were 3.0%, 5.2%, 8.0%, 14.0%, and 17.0%, respectively. Utilizing the OTA/AO fracture classification to increase the point estimate granularity, the estimated 12-month SSI and delayed union/nonunion rates in 156 Gustilo-Anderson type 3B open tibial shaft fractures (OTA/AO 42) were 34.7% (95% CI, 26.7% to 41.9%) and 18.4% (95% CI, 12.0% to 24.4%), respectively. A companion website with SSI and delayed union/nonunion rates was developed to supplement this article. Conclusions: Open fractures are a substantial problem with complications that include infection and nonunion. The present data are useful for prognosis, research study design, and informing public awareness and policy. These results show that, despite current treatment approaches, the rates of SSI and delayed union/nonunion following treatment of open fractures remain high at 1 year and are not substantially improved from historical rates spanning several decades. Although open fracture sequelae remain a burden for patients, orthopaedic surgeons, and health-care systems, there may be opportunities for improvement in outcomes. Level of Evidence: Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

Fracture-related infections (FRIs) play a significant role in poor clinical outcomes and patient morbidity for patients with orthopaedic trauma. FRI diagnosis has become more standardized, which will strengthen research efforts to identify prognostic factors and improve clinical management. Biofilm research continues to advance our understanding of how FRIs develop and improve FRI prevention. Antibiotic bead pouches are a useful technique to locally administer high antibiotic concentrations for open fractures that are at high risk for FRI. There are a variety of techniques for managing critical sized bone defects in the setting of infection including serial bone grafting, induced membrane, distraction osteogenesis, and vascularized bone transfer. Management of acute and chronic FRI relies on successful debridement of necrotic tissue with infection eradication and bony reconstruction.