Luke A. Lopas

Objectives: To evaluate whether same-day discharge for aseptic lower extremity nonunions is associated with increased complication rates compared with patients admitted to the hospital, aiming to determine the safety and feasibility of same-day discharge in this patient population. Methods: A retrospective cohort study was conducted across 14 Level 1 trauma centers, including 981 adult patients who underwent surgical fixation of aseptic femur or tibia nonunions between 2007 and 2022. Patients were stratified by length of stay into same-day discharge and admission to the hospital (≥1 night). Primary outcomes were postoperative complications: infection, reoperation, and readmission rates. Multivariable logistic regression controlled for confounders including age, body mass index, comorbidities, ASA classification, insurance, and bone graft use. Results: Of 981 patients, 146 (14.9%) underwent same-day discharge and 835 (85.1%) were admitted to the hospital. Patients undergoing same-day discharge were younger, healthier, and had shorter operative times. Unadjusted complication rates were higher among patients admitted to the hospital; however, after adjustment, same-day discharge was not associated with increased odds of infection (odds ratio [OR] 0.75, P = 0.386), readmission (OR 0.76, P = 0.346), or reoperation (OR 0.92, P = 0.730). No significant differences in injury characteristics or procedure types were found between groups. Conclusions: Same-day discharge for aseptic lower extremity nonunion surgery was not associated with increased complication or readmission rates compared with admission to the hospital. With careful patient selection and perioperative management, same-day discharge pathways may be safely expanded for appropriately selected patients, supporting cost-effective care without compromising outcomes. Level of Evidence: III.

Summary: Tibial plateau fractures with significant articular depression can present challenges in achieving anatomic reduction, especially without an associated cortical “split” to access the depression. This case involved a 23-year-old woman with a valgus-unstable bicondylar tibial plateau fracture and substantial lateral joint depression. This review describes the use of a lateral tibial osteotomy to directly visualize and elevate a depressed articular surface during open reduction and internal fixation, allowing for restoration of alignment and stable fixation.

Summary: Displaced intra-articular calcaneal fractures disrupt hindfoot alignment and are associated with long-term morbidity. Although minimally invasive approaches reduce wound-related complications, they can limit reduction of a displaced calcaneal tuberosity. This report describes a 29-year-old man with a displaced intra-articular calcaneal fracture treated using a laterally applied femoral distractor to facilitate correction of coronal, sagittal, and axial malalignment while limiting soft-tissue disruption.

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.

Case: A 44-year-old woman with an infected pilon fracture nonunion developed Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) after prolonged intravenous vancomycin and implantation of a vancomycin/tobramycin-loaded antibiotic cement spacer (ACS). Fevers, rash, and eosinophilia persisted despite stopping systemic vancomycin and starting corticosteroids. ACS explantation led to symptom resolution; however, severe thrombocytopenia developed, requiring therapeutic plasma exchange. A daptomycin-loaded spacer was reimplanted before definitive hindfoot fusion. Conclusion: This case of DRESS in the setting of an ACS highlights management challenges, supports early recognition and spacer removal, proposes a treatment algorithm, and suggests daptomycin as an alternative for local antibiotic delivery.

Background: Researchers employ murine fracture models to study bone healing, but the temporal relationship between mouse and human fracture healing is poorly understood. The hypothesis of this study was that it was possible to quantify specific post-fracture time frames corresponding to the stages of endochondral ossification in both mice and humans. Methods: Radiographs of mice and human femoral fractures treated with intramedullary stabilization were reviewed. The study included 330 human femoral fractures (OTA/AO 32A, B, or C injuries) that ultimately healed without complications in patients aged 18 to 55 years and 309 surgically created midshaft femoral fractures in 3-month-old C57BL6/J mice. Multiple orthopaedic surgeons assessed the radiographs using the Modified Radiographic Union Score for Tibia (mRUST). A 4-parameter log-logistic curve was fit to describe fracture healing over time, with 3 parameters allowed to vary: Y_∞ (mRUST score at time = ∞), k (healing rate in [1/log(time)]), and X_0.5 (time to half-healing). Results: The values (and 95% confidence interval) for the mice were Y_∞ = 14.70 (14.54 to 14.87), k = 4.54/log(days) (4.30 to 4.77), and X_0.5 = 11.77 days (11.56 to 11.98). For the humans, the values were Y_∞ = 16.78 (16.21 to 17.36), k = 1.37/log(days) (1.28 to 1.45), and X_0.5 = 91 days (83 to 99). All parameters differed significantly between the mice and humans (p < 0.05). Conclusions: Using mRUST scoring and mathematical modeling, we were able to quantify and compare the temporal progression of fracture healing in mice and humans. Clinical Relevance: These data are relevant for designing and/or interpreting fracture healing studies of mice and humans to promote rational translation of fracture research between species.

Objectives: The aim of this study was to determine the applicability of the Revised Risk Analysis Index (RAI-Rev) in orthopaedic trauma and compare the predictive discrimination for the RAI-Rev and the 5-Item Modified Frailty Index (mFI-5) for 30-day postoperative outcomes. Methods: Design: This is a retrospective cohort study. Setting: The American College of Surgeons National Surgical Quality Improvement database was used. Patient Selection: All patients aged 18 or older who underwent surgical treatment for forearm, humerus, pelvis, acetabulum, femur, tibia, and hindfoot fractures from 2015 to 2020 were included. Outcome: 30-day postoperative mortality, major complications, and wound complications consisting of surgical site infection, and wound dehiscence were measured. Results: A total of 206,352 patients met inclusion criteria. The mean age was 69 years, with 64.2% (n = 132,514) being female. Multivariate regression analysis showed that increasing frailty tiers in both RAI-Rev and mFI-5 were independent predictors of mortality, major complications, readmission, and wound complications. The cohort with the highest degree of frailty in both RAI-Rev and mFI-5 had the greatest risk of poor outcomes. RAI-Rev had significantly superior predictive discriminatory thresholds compared with mFI-5 for predicting 30-day mortality (C-statistic: RAI-Rev [0.84] and mFI-5 [0.67], P < 0.001), major complications (C-statistic: RAI-Rev [0.73] and mFI-5 [0.65], P < 0.001), and readmission (C-statistic: RAI-Rev [0.68] and mFI-5 [0.63], P < 0.001). However, mFI-5 outperformed RAI-Rev when predicting wound complications (C-statistic: RAI-Rev [0.52] and mFI-5 [0.55], P < 0.001). Conclusion: The RAI-Rev tool demonstrated superior predictability of postoperative morbidity, mortality, and readmission rates compared with mFI-5 but was less effective in predicting surgical site complications. These findings demonstrate the utility of RAI-Rev in anticipating postoperative complications in the setting of orthopaedic trauma, where optimizing surgical candidate selection is not always possible. Assessing the predicted morbidity and mortality through RAI-Rev enables surgeons to accurately identify patients at high risk of complications, which can further research investigation to mitigate this risk.

OBJECTIVES: To evaluate mechanical failure rates of retrograde femoral nails in the treatment of distal femur fractures. METHODS: Design: Retrospective chart review. Setting: Urban Academic Level 1 Trauma Center. Patient Selection Criteria: Included were adult patients who sustained a distal femur fracture (Arbeitsgemeinschaft fur Osteosynthesefragen Foundation/Orthopaedic Trauma Association 33) who were treated with a retrograde intramedullary nail from August 2021 through September 2022. Outcome Measures and Comparisons: The primary outcome was the rate of mechanical failure of the intramedullary nail defined as deformation and/or breakage of the intramedullary nail. The rate of mechanical failure was compared among retrograde femoral nails used at the same institution during the same time period. RESULTS: One hundred and twenty distal femur fractures were identified (77 native distal femur, 43 periprosthetic) that were treated with a retrograde intramedullary nail. Average patient age was 67 years (SD 15.1, range 18–96 years). Eighty-three (69.2%) patients were women. Four mechanical nail failures (deformation and/or breakage of the intramedullary nail) were observed within 6 months of surgery, 2 in patients with native distal femur fractures and 2 in patients with periprosthetic distal femur fractures. All failures occurred among 49 fractures treated with a newly released retrograde femoral nail, the T2 Alpha Retrograde Femoral Nail (Stryker, Mahwah, NJ). This represents an 8.2% mechanical failure rate of distal femur fractures treated with this new nail compared with no failures observed with any other nail (P = 0.03). CONCLUSIONS: Mechanical nail failures, within 6 months of surgery for distal femur fracture, of a new retrograde femoral nail were observed to be higher than seen with other nails. Further evaluation is needed to determine whether this experience represents factors related to patient, injury, or surgical characteristics, an anomaly, or a safety signal. LEVEL OF EVIDENCE: Prognostic Level III. See instructions for authors for a complete description of levels of evidence.

Objectives: To evaluate rates of nonunion repair, osseous healing, and outcomes in femoral nonunions with contemporary healing. Design: Retrospective review. Setting: Five academic level 1 trauma centers. Patients/Participants: This study includes adult patients (age older than 18) seen at one of the participating institutions between 2012 and 2019 who sustained a femur fracture (OTA/AO 31, 32, 33) initially treated with intramedullary fixation that developed nonunion and were treated with exchange nailing for the index nonunion surgery. Seventy-nine patients with femoral nonunion met inclusion criteria. Intervention: Exchange nailing for treatment of femoral nonunion. Main Outcome Measurements: The primary outcome measure was radiographic osseous union. We further analyzed union rates by OTA/AO classification, nonunion type, implants used, graft used, time from the initial procedure, and infection status. Results: Seventy-nine patients met inclusion criteria. Rates of osseous union were similar by OTA/AO classification (P = 0.48), nonunion type (hypertrophic, oligotrophic, atrophic) (P = 0.52), implant/biologic used (P = 0.45), and time from the initial procedure until exchange nail procedure (P = 0.09). Forty-two patients had inflammatory laboratory markers (C-reactive protein, erythrocyte sedimentary rate) and cultures obtained during the first nonunion surgery with no significant differences in union (P = 0.29) based on laboratory and culture results. However, a considerable number of complications were encountered (n = 32; 41%). Common complications included reoperation (n = 30; 38%) secondary to recalcitrant nonunion, readmission, implant failure, and infection. Conclusions: This large, multicenter study with modern implants, instruments, and techniques for exchange nailing of femoral nonunions demonstrates high rates of reoperation (n = 30; 38%), but higher rates of osseous healing (n = 68; 86% healed) than previously reported data in the literature. Level of Evidence: III.