Thomas F. Higgins

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.

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.

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.

Traumatic injuries are associated with significant acute pain and subsequent high risk of the development of chronic pain. However, addressing pain after skeletal trauma presents a complex challenge to achieve effective pain relief that minimizes risk of addiction and does not interfere with functional recovery. The Orthopaedic Trauma Association's 2023 Basic Science Focus Forum aimed to bridge the gap between basic science and clinical outcomes with an educational symposium on pain management designed to foster collaboration and provide practical strategies from the frontiers of pain research. Owing to the subjective and multifaceted nature of pain, the development of effective preclinical and clinical pain assessment measures is the first step to making impactful progress in studying pain. Preclinical models prove a valuable tool for studying the molecular mechanisms associated with pain following orthopaedic trauma. These models also allow study of the efficacy of novel pain management techniques, such as testing novel analgesics. Translating novel analgesics and pain management strategies to the clinic requires that we have accurate methods to describe pain to determine whether new approaches are meaningful. It is also necessary to recognize the patient's role and the importance of patient education in the prevention of pain medication misuse, particularly in light of the current national opioid crisis. Overall, collaboration with orthopaedic surgeons in the application of these strategies in a clinical setting is vital for addressing the downfalls of current pain management efforts and providing patients with safe and effective improvements in pain relief after skeletal trauma.

Background: Schatzker type-4 to 6 tibial plateau fractures most commonly occur when the distal femur is driven through the proximal tibial articular surface. This mechanism of injury can be equivalent to a knee dislocation and carries an increased risk of vascular injury. Our institution screens all Schatzker type-4 to 6 tibial plateau fractures with symmetric pulses for a vascular injury by measuring the ankle-brachial index (ABI). The purpose of this study was to describe our screening protocol and to determine its effectiveness at identifying vascular injuries. Methods: Our screening protocol consisted of measuring the ABI of the injured limb for all Schatzker type-4 to 6 tibial plateau fractures that presented with symmetric pulses. An ABI of ≤0.9 prompted a computed tomographic angiogram (CTA) of the injured extremity. We retrospectively reviewed all Schatzker type-4 to 6 tibial plateau fractures from 2006 to 2023 that presented to a single level-I academic trauma center. We collected demographic, fracture, ABI, and vascular injury data and examined the effectiveness of our screening protocol. Results: We identified 437 Schatzker type-4 to 6 tibial plateau fractures (mean age, 47 years; 59% male). There were 102 (23%) Schatzker type-4 fractures, 4 (1%) type-5 fractures, and 331 (76%) type-6 fractures. Eight fractures (2%) had a concomitant vascular injury; none of the vascular injuries were missed. An ABI of ≤0.9 had a positive predictive value of 0.250, and an ABI of >0.9 had a negative predictive value of 1.000. The sensitivity of the ABI was 1.000, whereas the specificity was 0.056. Thirty-seven fractures were in patients with an ABI of >0.9 at presentation who underwent a CTA of the injured limb for nonorthopaedic indications, with no vascular injuries identified. Conclusions: The ABI has frequently been cited as a valuable screening tool for vascular injury after a knee dislocation, but its application to Schatzker type-4 to 6 tibial plateau fractures had not yet been described. Our results indicate that this screening protocol is both safe and effective, with no missed vascular injuries over a 17-year period. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose The operative treatment of mid-shaft clavicle fractures shows benefit in union rates, return to work, and lower pain scores relative to non-operative treatment. We sought to determine if the surgical treatment of isolated mid-shaft clavicle fractures would result in fewer opioids prescribed as compared to those managed non-operatively. Methods All mid-shaft clavicle fractures treated at a Level 1 trauma center were identified from 2012 to 2016. Demographics, fracture characteristics, surgical complications/outcomes, non-operative outcomes, and all narcotics prescribed for 6 months post-injury were collected. Narcotic prescriptions, in morphine equivalents (ME), were obtained through the state prescription drug monitoring program (PDMP). Results One hundred and ten operative and 48 non-operative patients were included. Age, gender, previous alcohol, tobacco or drug use, and final range of motion were similar between groups. Pre-treatment fracture shortening (1.8 cm vs. 0.7 cm, p < 0.001) and displacement (150% vs. 70%, p < 0.001) were greater in the operative group. Total ME’s (604 vs. 187, p < 0.001) and post-operative ME’s (420 vs. 187, p < 0.001) were greater for the operative group. In either group, no other variable influenced ME’s prescribed. Conclusion Clavicles treated operatively receive substantially more opiates than those treated non-operatively, despite data suggesting that operative treatment makes clavicle fractures less painful. The total amount of narcotic analgesics obtained by operatively treated patients was over three times that obtained by non-operatively managed patients, which equates to 55 5 mg oxycodone pills or 85 5 mg hydrocodone pills per patient. While there may certainly be advantages to the operative treatment of clavicle fractures, they must be weighed against the risks of a significant increase in opiate prescribing and potential consumption.

Background: Whereas partial quadriceps tendon ruptures may be treated nonoperatively if the extensor mechanism remains functional, complete ruptures require primary operative repair to achieve optimal functional results ^1,2 . The 2 most common techniques are the use of transosseous tunnels and the use of suture anchors. The goal of these procedures is to reconstruct and restore mobility of the extensor mechanism of the leg. Description: The patient is positioned supine with the injured leg exposed. A midline incision to the knee is made over the quadriceps tendon defect, exposing the distal quadriceps and proximal patella. Irrigation is utilized to evacuate the residual hematoma, and the distal quadriceps and proximal patella are debrided of degenerative tissue. When utilizing transosseous tunnels, a nonabsorbable suture is passed full-thickness through the medial or lateral half of the quadriceps tendon in a locked, running pattern (i.e., Krackow). A second nonabsorbable suture is passed full-thickness through the other half of the tendon. There should then be 4 loose strands at the distal quadriceps. The anatomic insertion of the quadriceps tendon is roughened with a sharp curet to expose fresh cancellous bone. Three parallel bone tunnels are created along the longitudinal axis of the patella. The knee is placed in full extension, with a bump under the heel in order to provide slight recurvatum at the knee and to allow for a properly tensioned repair. In pairs, the free ends of the sutures are passed through the tunnels. The sutures are tensioned and tied together in pairs at the distal aspect of the patella. Alternatively, when utilizing suture anchors, Arthrex FiberTape is passed full-thickness through the medial or lateral half of the quadriceps tendon in a Krackow pattern. A second FiberTape is passed full-thickness through the other half of the tendon. There should then be 4 loose tails at the distal quadriceps. The 2 tails of the medial FiberTape are placed into a knotless Arthrex SwiveLock anchor; this step is repeated for the 2 lateral tails. The anatomic insertion of the quadriceps tendon is roughened to expose fresh cancellous bone. With use of a 3.5-mm drill, create 2 parallel drill holes along the longitudinal axis of the patella, with sufficient depth to bury the SwiveLock anchor. Unlike in the transosseous tunnel technique, these drill holes do not run the length of the patella. The holes are then tapped. Following irrigation, the anchors are tensioned into the bone tunnels, and extra tape is cut flush to the bone. For both techniques, additional tears in the medial and lateral retinacula are repaired if present. Alternatives: Alternatives include nonoperative treatment with use of a hinged knee brace; operative treatment with use of simple sutures; and augmentation with use of wire reinforcement, cancellous screws, the Scuderi technique, the Codivilla technique, tensor fasciae latae reinforcement, and/or MERSILENE tape (Ethicon). Rationale: Primary operative repair of quadriceps tendon ruptures is a well-documented, successful procedure with biomechanical, clinical, and patient-reported data to support its use ^3–7 . However, literature comparing the 2 most common surgical techniques remains controversial. Transosseous tunnel repair is the most common technique utilized to repair quadriceps tendon ruptures, but suture anchors have become increasingly popular in the past several years ^1,4 . Most studies have reported no significant difference in biomechanical, clinical, and patient-reported outcome measures between these 2 techniques ^3,4,8–10 . Decreased operative time and a smaller incision have been suggested as advantages of suture anchors ^4,9 . However, this method incurs a higher average cost of surgery and risks a more complex revision in the event of deep infection ^9,10 . Simple suture repair is a less commonly utilized technique and is now reserved for midsubstance tendon repairs. Nonoperative treatment of complete quadriceps tendon rupture is exceedingly rare and not recommended because of the profound functional consequences. Relative indications for nonoperative treatment include a patient who is unfit for surgery, is not ambulatory at baseline, or retains full extensor mechanism function. Nonoperative treatment is typically reserved for partial quadriceps ruptures and typically involves early immobilization with a hinged knee brace. Expected Outcomes: Primary repair of quadriceps tendon ruptures, utilizing either the transosseous tunnel or suture anchor technique, yields excellent outcomes. Following surgical treatment, patients have near-full recovery in range of motion, with studies reporting a 90%) return to pre-injury levels of function and work ^3,4,7,11 . The majority of patients also report satisfactory results, as assessed with use of patient-reported outcome measures ^3,4,10 . The most commonly reported complications are knee stiffness and quadriceps muscle atrophy, which can both be treated with proper rehabilitation. Even in the event of these complications, however, patients can maintain adequate knee function ^2,3 . More severe complications are rare ( 2–4,10–12 . Delayed operative treatment is associated with worse outcomes and increased complication rates ^1,3,4,10,11 . Important Tips: When performing the Krackow stitch, be sure to tension and remove all slack before performing another tissue pass. Surgical repair should be performed as soon as possible from the time of injury in order to minimize risks and to achieve optimal surgical outcomes. If there is concern that the primary construct would be unstable, it can be augmented with wire reinforcement, cancellous screws, the Scuderi technique, the Codivilla technique, tensor fasciae latae reinforcement, and/or MERSILENE tape. Identify and repair patellar retinaculum tears, which are common concomitant injuries in the setting of complete quadriceps rupture. Acronyms and Abbreviations: MRI = magnetic resonance imaging

Background: Dual plating of the distal femur is indicated for the treatment of complex intra-articular fractures, supracondylar femoral fractures, low periprosthetic fractures, and nonunions. The aim of this procedure is anatomical alignment of the articular surface, restoration of the articular block, and prevention of varus collapse. Description: Following preoperative planning, the patient is positioned supine with the knee flexed at 30°. The lateral incision is made first, with a mid-lateral incision that is in line with the femoral shaft. If intra-articular work is needed this incision can be extended by curving anteriorly over the lateral femoral condyle. Next, the iliotibial band is transected in line with its fibers. The vastus lateralis fascia is incised and elevated off the septum, working distal to proximal. Care should be taken to maintain hemostasis when encountering femoral artery perforating vessels. Once there is adequate exposure, several reduction aids can be utilized, including a bump under the knee, Schanz pins, Kirschner wires, and reduction clamps. A lateral precontoured plate is placed submuscularly, and the most proximal holes are filled percutaneously. The medial incision begins distally at the adductor tubercle and is a straight incision made proximally in line with the femoral shaft. The underlying fascia is transected in line with the skin incision, and the vastus medialis is elevated. Care should be taken to avoid the descending geniculate artery, as well as its articular branch and the muscular branch to the vastus medialis. A lateral tibial plateau plate is contoured and placed. Alternatives: Nonoperative treatment of distal femoral fractures is rare, but relative indications for nonoperative treatment include frailty of the patient, lack of ambulatory status, a non-reconstructible fracture, or a stable fracture. These patients are placed in a long-leg cast followed by a hinged knee brace ¹ . There are several other surgical fixation options, including lateral plating, retrograde intramedullary nailing, distal femoral replacement, and augmentation of a retrograde nail with a plate. Rationale: Dual plating has several benefits, depending on the clinical scenario. Biomechanical studies have found that dual plating results in increased stiffness and construct strength ^2,3 . Additional construct stability can be offered through the use of locking plates, particularly in osteoporotic bone. Taken together, this increased stability and construct strength can allow for earlier weight-bearing, which is particularly important for fractures in the geriatric population. Furthermore, the increased stiffness and construct strength make this procedure a favorable treatment option for nonunion, and it has been shown to result in lower rates of postoperative nonunion compared with lateral plating alone ^4–7 . Adjunctive use of a medial plate also has been suggested to prevent varus collapse, particularly with metaphyseal comminution and poor bone quality ^2,3,8 . Finally, in the periprosthetic fracture population, dual plating also removes the concern of incompatibility with a retrograde nail. Expected Outcomes: The outcomes of dual plating are promising, given the severity of the injury. When comparing operative to nonoperative treatment outcomes, nonoperatively managed patients had worse functional outcomes and higher rates of complications related to immobility ¹ . Dual plating of supracondylar fractures and intra-articular distal femoral fractures yields nonunion rates ranging from 0% to 12.5%, lower than the 18% to 20% reported with lateral locking plates ^4–7,9–12 . This reduction in nonunions has been shown to lead to fewer revisions when compared with single-plating techniques ⁷ . In prior studies, 95% of nonunions treated with the dual-plating technique achieved union postoperatively ¹¹ . One concern when utilizing the medial approach is critical damage to medial vascularity; however, this result has not been reported in the literature, and there is a safe operating window ¹³ . Despite the benefits of dual plating, there are relatively high rates of infection following dual plating (0% to 16.7%) compared with lateral plating alone (3.6% to 8.5%) ^5,14–17 . However, many of these studies are small case series, highlighting that a surgeon’s comfort and skill with these procedures is paramount to patient outcomes. Important Tips: Meticulous placement and contouring of lateral and medial plates are required to prevent malreduction of the articular block that creates a “golf-club deformity.” ^18,19 During the medial approach, be aware of descending geniculate artery—particularly its muscular branch, which is ∼5 cm from the adductor tubercle/medial epicondyle, and its root, which enters the compartment at the adductor hiatus at ∼16 cm ¹³ .