Determining Which Combinatorial Combat-Relevant Factors Contribute to Heterotopic Ossification Formation in an Ovine Model.

Traumatic heterotopic ossification (HO) is frequently observed in Service Members following combat-related trauma. Estimates suggest that ~65% of wounded warriors who suffer limb loss or major extremity trauma will experience some type of HO formation. The development of HO delays rehabilitation and can prevent the use of a prosthetic. To date there are limited data to suggest a standard mechanism for preventing HO. This may be due to inadequate animal models not producing a similar bone structure as human HO. We recently showed that traumatic HO growth is possible in an ovine model. Within that study, we demonstrated that 65% of sheep developed a human-relevant hybrid traumatic HO bone structure after being exposed to a combination of seven combat-relevant factors. Although HO formed, we did not determine which traumatic factor contributed most. Therefore, in this study, we performed individual and various combinations of surgical/traumatic factors to determine their individual contribution to HO growth. Outcomes showed that the presence of mature biofilm stimulated a large region of bone growth, while bone trauma resulted in a localized bone response as indicated by jagged bone at the linea aspera. However, it was not until the combinatory factors were included that an HO structure similar to that of humans formed more readily in 60% of the sheep. In conclusion, data suggested that traumatic HO growth can develop following various traumatic factors, but a combination of known instigators yields higher frequency size and consistency of ectopic bone.

Patient-Reported Outcome Measurement Information Systems Physical Function and Pain Interference Scores Are Correlated With Tibial Shaft Fracture Nonunion Following Intramedullary Nailing.

OBJECTIVES: To assess trends in Patient-Reported Outcome Measurement Information Systems (PROMIS) Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with operatively treated tibial shaft fractures (AO/OTA 42-A, B, C) using an intramedullary nail. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were compared between patients progressing to union and patients requiring nonunion repair. RESULTS: A total of 234 patients (196 union, 38 nonunion) were included consisting 144 men and 90 women. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months ( P = 0.005), 3-6 months ( P < 0.001), 6-9 months ( P = 0.003), and 6-12 months ( P = 0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, P = 0.028) and 6-9 months (OR 1.17, P = 0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months ( P = 0.001), 3-6 months ( P = 0.005), and 6-9 months ( P = 0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, P = 0.005), 3-6 months (OR 1.10, P = 0.011), and 6-9 months (OR 1.23, P = 0.011). CONCLUSIONS: Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Recovery Curves for Lisfranc ORIF Using PROMIS Physical Function and Pain Interference.

OBJECTIVES: To determine the postoperative trajectory and recovery of patients who undergo Lisfranc open reduction and internal fixation using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who underwent Lisfranc open reduction and internal fixation between January 2002 and December 2022 with documented PROMIS PF and/or PI scores after surgery. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were mapped over time up to 1 year after surgery. A subanalysis was performed to compare recovery trajectories between high-energy and low-energy injuries. RESULTS: A total of 182 patients were included with average age of 38.7 (SD 15.9) years (59 high-energy and 122 low-energy injuries). PROMIS PF scores at 0, 6, 12, 24, and 48 weeks were 30.2, 31.4, 39.2, 43.9, and 46.7, respectively. There was significant improvement in PROMIS PF between 6 and 12 weeks ( P < 0.001), 12-24 weeks ( P < 0.001), and 24-48 weeks ( P = 0.022). A significant difference in PROMIS PF between high and low-energy injuries was seen at 0 week (28.4 vs. 31.4, P = 0.010). PROMIS PI scores at 0, 6, 12, 24, and 48 weeks were 62.2, 58.5, 56.6, 55.7, and 55.6, respectively. There was significant improvement in PROMIS PI 0-6 weeks ( P = 0.016). A significant difference in PROMIS PI between high-energy and low-energy injuries was seen at 48 weeks with scores of (58.6 vs. 54.2, P = 0.044). CONCLUSIONS: After Lisfranc open reduction and internal fixation, patients can expect improvement in PF up to 1 year after surgery, with the biggest improvement in PROMIS PF scores between 6 and 12 weeks and PROMIS PI scores between 0 and 6 weeks after surgery. Regardless the energy type, Lisfranc injuries seem to regain comparable PF by 6-12 months after surgery. However, patients with higher energy Lisfranc injuries should be counseled that these injuries may lead to worse PI at 1 year after surgery as compared with lower energy injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The MCID of the PROMIS physical function instrument for operatively treated tibial plateau fractures.

INTRODUCTION: Understanding minimal clinically important differences (MCID) in patient reported outcome measurement are important in improving patient care. The purpose of this study was to determine the MCID of Patient-Reported Outcome Measurement System (PROMIS) Physical Function (PF) domain for patients who underwent operative fixation of a tibial plateau fracture. METHODS: All patients with tibial plateau fractures that underwent operative fixation at a single level 1 trauma center were identified by Current Procedural Terminology codes. Patients without PROMIS PF scores or an anchor question at two-time points postoperatively were excluded. Anchor-based and distribution-based MCIDs were calculated. RESULTS: The MCID for PROMIS PF scores was 4.85 in the distribution-based method and 3.93 (SD 14.01) in the anchor-based method. There was significantly more improvement in the score from the first postoperative score (<7 weeks) to the second postoperative time (<78 weeks) in the improvement group 10.95 (SD 9.95) compared to the no improvement group 7.02 (SD 9.87) in the anchor-based method (P < 0.001). The percentage of patients achieving MCID at 7 weeks, 3 months, 6 months, and 1 year were 37-42 %, 57-62 %, 80-84 %, and 95-87 %, respectively. DISCUSSION: This study identified MCID values for PROMIS PF scores in the tibial plateau fracture population. Both MCID scores were similar, resulting in a reliable value for future studies and clinical decision-making. An MCID of 3.93 to 4.85 can be used as a clinical and investigative standard for patients with operative tibial plateau fractures.

Meniscus Tear Requiring Intraoperative Repair Does Not Influence Midterm Patient-Reported Outcomes in Operatively Treated Tibial Plateau Fractures.

OBJECTIVES: Evaluate whether intraoperatively repaired lateral meniscus injuries impact midterm patient-reported outcomes in those undergoing operative fixation of tibial plateau fracture. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: All patients (n = 207) who underwent operative fixation of a tibial plateau fracture from 2016 to 2021 with a minimum of 10-month follow-up. OUTCOME MEASURES AND COMPARISONS: The Patient-Reported Outcomes Measurement Information System Physical Function, Knee Injury and Osteoarthritis Outcome Score, and the PROMIS-Preference health utility score. RESULTS: Overall, 207 patients were included with average follow-up of 2.9 years. Seventy-three patients (35%) underwent intraoperative lateral meniscus repair. Gender, age, body mass index, Charlson comorbidity index, days to surgery, ligamentous knee injury, open fracture, vascular injury, polytraumatic injuries, Schatzker classification, and Orthopaedic Trauma Association classification were not associated with meniscal repair ( P > 0.05). Rates of reoperation (42% vs. 31%, P = 0.11), infection (8% vs. 10%, P = 0.60), return to work (78% vs. 75%, P = 0.73), and subsequent total knee arthroplasty (8% vs. 5%, P = 0.39) were also similar between those who had a meniscal repair and those without a meniscal injury, respectively. There was no difference in Patient-Reported Outcomes Measurement Information System Physical Function (46.3 vs. 45.8, P = 0.707), PROMIS-Preference (0.51 vs. 0.50, P = 0.729), and all Knee Injury and Osteoarthritis Outcome Score domain scores at the final follow-up between those who had a meniscal repair and those without a meniscal injury, respectively. CONCLUSIONS: In patients with an operatively treated tibial plateau fracture, the presence of a concomitant intraoperatively identified and repaired lateral meniscal tear results in similar midterm PROMs and complication rates when compared with patients without meniscal injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Worse Quality of Life Associated With Hyperextension Varus Tibial Plateau Fracture Pattern.

OBJECTIVES: Compare patient-reported outcome measures between hyperextension varus tibial plateau (HEVTP) fracture patterns to non-HEVTP fracture patterns. DESIGN: Retrospective study. SETTING: Single academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA: All patients who underwent fixation of a tibial plateau fracture from 2016 to 2021 were collected. Exclusion criteria included inaccurate Current Procedural Terminology code, ipsilateral compartment syndrome, bilateral fractures, incomplete medical records, or follow-up <10 months. OUTCOME MEASURES AND COMPARISONS: In patients who underwent fixation of a tibial plateau fracture, compare Patient-Reported Outcomes Measurement Information System-Physical Function, PROMIS Preference, and Knee Injury and Osteoarthritis Outcome Score (KOOS) between patients with a HEVTP pattern with those without. RESULTS: Two-hundred and seven patients were included, of which 17 (8%) had HEVTP fractures. Compared with non-HEVTP fracture patterns, patients with HEVTP injuries were younger (42.6 vs. 51.0, P = 0.025), more commonly male (71% vs. 44%, P = 0.033), and had higher body mass index (32.8 vs. 28.0, P = 0.05). HEVTP fractures had significantly more ligamentous knee (29% vs. 6%, P = 0.007) and vascular (12% vs. 1%, P = 0.035) injuries. Patient-Reported Outcomes Measurement Information System-Physical Function scores were similar between groups; however, PROMIS-Preference (0.37 vs. 0.51, P = 0.017) was significantly lower in HEVTP fractures. KOOS pain, activities of daily living, and quality-of-life scores were statistically lower in HEVTP fractures, but only KOOS quality-of-life was clinically relevant (41.7 vs. 59.3, P = 0.004). CONCLUSIONS: The HEVTP fracture pattern, whether unicondylar or bicondylar, was associated with a higher rate of ligamentous and vascular injuries compared with non-HEVTP fracture patterns. They were also associated with worse health-related quality of life at midterm follow-up. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Return to Skiing After Tibial Plateau Fracture.

Background: Tibial plateau fractures in skiers are devastating injuries with increasing incidence. Few studies have evaluated patient-reported outcomes and return to skiing after operative fixation of a tibial plateau fracture. Purpose: To (1) identify demographic factors, fracture characteristics, and patient-reported outcome measures that are associated with return to skiing and (2) characterize changes in skiing performance after operative fixation of a tibial plateau fracture. Study Design: Case series; Level of evidence, 4. Methods: We reviewed all operative tibial plateau fractures performed between 2016 and 2021 at a single level-1 trauma center. Patients with a minimum of 10-month follow-up data were included. Patients who self-identified as skiers or were injured skiing were divided into those who returned to skiing and those who did not postoperatively. Patients were contacted to complete the Patient-Reported Outcomes Measurement Information System-Physical Function domain (PROMIS-PF), the Knee injury and Osteoarthritis Outcome Score-Activities of Living (KOOS-ADL), and a custom return-to-skiing questionnaire. Multivariate logistic regression was performed with sex, injury while skiing, PROMIS-PF, and KOOS-ADL as covariates to evaluate factors predictive of return to skiing. Results: A total of 90 skiers with a mean follow-up of 3.4 ± 1.5 years were included in the analysis. The rate of return to skiing was 45.6% (n = 41). The return cohort was significantly more likely to be men (66% vs 41%; P = .018) and injured while skiing (63% vs 39%; P = .020). In the return cohort, 51.2% returned to skiing 12 months postoperatively. The percentage of patients who self-reported skiing on expert terrain dropped by half from pre- to postinjury (61% vs 29.3%, respectively). Only 78% of return skiers had regained comfort with skiing at the final follow-up. Most patients (65%) felt the hardest aspect of returning to skiing was psychological. In the multivariate regression, the male sex and KOOS-ADL independently predicted return to skiing (P = .006 and P = .028, respectively). Conclusion: Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up. The knee-specific KOOS-ADL outperformed the global PROMIS-PF in predicting a return to skiing.

Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications.

OBJECTIVE: Compare mortality and complications of distal femur fracture repair among elderly patients who receive operative fixation versus distal femur replacement (DFR). DESIGN: Retrospective comparison. SETTING: Medicare beneficiaries. PATIENTS/PARTICIPANTS: Patients 65 years of age and older with distal femur fracture identified using Center for Medicare & Medicaid Services data from 2016 to 2019. INTERVENTION: Operative fixation (open reduction with plating or intramedullary nail) or DFR. MAIN OUTCOME MEASUREMENTS: Mortality, readmissions, perioperative complications, and 90-day cost were compared between groups using Mahalanobis nearest-neighbor matching to account for differences in age, sex, race, and the Charlson Comorbidity Index. RESULTS: Most patients (90%, 28,251/31,380) received operative fixation. Patients in the fixation group were significantly older (81.1 vs. 80.4 years, P < 0.001), and there were more an open fractures (1.6% vs. 0.5%, P < 0.001). There were no differences in 90-day (difference: 1.2% [-0.5% to 3%], P = 0.16), 6-month (difference: 0.6% [-1.5% to 2.7%], P = 0.59), and 1-year mortality (difference: -3.3% [-2.9 to 2.3], P = 0.80). DFR had greater 90-day (difference: 5.4% [2.8%-8.1%], P < 0.001), 6-month (difference: 6.5% [3.1%-9.9%], P < 0.001), and 1-year readmission (difference: 5.5% [2.2-8.7], P = 0.001). DFR had significantly greater rates of infection, pulmonary embolism, deep vein thrombosis, and device-related complication within 1 year from surgery. DFR ($57,894) was significantly more expensive than operative fixation ($46,016; P < 0.001) during the total 90-day episode. CONCLUSIONS: Elderly patients with distal femur fracture have a 22.5% 1-year mortality rate. DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, 6 months, and 1 year of surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics.

INTRODUCTION: Weight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes. METHODS: Prospective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics. RESULTS: Twenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day). CONCLUSION: Step count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.

Transfusion after harvesting bone graft with RIA: Practice changes reduced transfusion rate by more than half.

INTRODUCTION: The Reamer Irrigator Aspirator (RIA) is frequently used as a tool for bone graft harvesting procedures. The initial use of this instrument for bone grafting was met with significant blood loss and high transfusion rates. However, the RIA remains an excellent tool to obtain large volumes of viable autologous graft. The aim of this study was to investigate how changes in the technical use of the RIA may affect blood loss. MATERIALS AND METHODS: We conducted a retrospective chart review of all patients who underwent RIA bone graft harvest over a 12-year study period. The patients were divided into two cohorts based upon changes in the technique used to obtain autograft harvest with the RIA. The traditional cohort (2008-2012) connected the RIA to dilation and curettage suction and selected reamer size based on radiographic parameters. The modified cohort (2012-2020) connected the RIA to wall suction, used improved techniques for reamer head sizing, and more diligence was paid toward the time the RIA was suctioning in the canal. Demographic information, surgical details, pre- and post-operative hematocrit (HCT), transfusion rate, intra-operative blood loss, reported volume of graft harvested, and iatrogenic fracture were recorded. RESULTS: 201 patients were included in the study with 61 patients in the traditional and 140 patients in the modified cohorts respectively. The average age was 51 years (range: 18-97) with 107 (53%) males. There was no difference in the demographic data between the two cohorts. No difference was noted between the traditional and modified cohorts in terms of the amount of average graft harvested (54cc vs 51cc; p = 0.34) or major complications (1 vs 2; p = 0.91). However, when comparing the traditional versus modified cohorts the traditional group demonstrated a larger average blood loss (675cc vs 500cc; p=<0.01) and HCT drop (13.7 vs 9.5; p=<0.01) with a higher transfusion rate (44% vs 19%; p = 0.001). CONCLUSION: This series demonstrated a significant improvement in blood loss and transfusion with modified techniques used to obtain autologous bone graft with the RIA. Importantly, these techniques do not appear to limit bone graft harvest yield and can therefore be efficiently implemented without limiting the utility of the RIA.

Recovery Curve for Patients With Pilon Fractures Using Patient-Reported Outcome Measurement Information System.

BACKGROUND: The time frame in which patients can expect functional improvement after open reduction internal fixation (ORIF) of pilon fractures is unclear. The purpose of this study was to determine the trajectory and rate at which patients' physical function improves up to 2 years postinjury. METHODS: The patients studied sustained a unilateral, isolated pilon fractures (AO/OTA 43B/C) and followed at a level 1 trauma center over a 5-year period (2015-2020). Patient-Reported Outcomes Measurement Information Systems (PROMIS) Physical Function (PF) scores from these patients at defined follow-up times of immediately, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery defined the cohorts and were retrospectively studied. RESULTS: There were 160 patients with PROMIS scores immediately postoperatively, 143 patients at 6 weeks, 146 patients at 12 weeks, 97 at 24 weeks, 84 at 1 year, and 45 at 2 years postoperatively. The average PROMIS PF score was 28 immediately postoperatively, 30 at 6 weeks, 36 at 3 months, 40 at 6 months, 41 at 1 year, and 39 at 2 years. There was a significant difference between PROMIS PF scores between 6 weeks and 3 months (P < .001), and between 3 and 6 months (P < .001). Otherwise, no significant differences were detected between consecutive time points. CONCLUSION: Patients with isolated pilon fractures demonstrate the majority of their improvement in terms of physical function between 6 weeks and 6 months postoperatively. No significant difference was detected in PF scores after 6 months postoperatively up to 2 years. Furthermore, the mean PROMIS PF score of patients 2 years after recovery was approximately 1 SD below the population average. This information is helpful in counseling patients and setting expectations for recovery after pilon fractures. LEVEL OF EVIDENCE: Level III, prognostic.

Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System.

INTRODUCTION: Lateral compression type 1 (LC1) pelvic ring injuries represent a heterogeneous group of fractures with controversial surgical indications. Recently, multiple institutions have suggested the safety and reliability of an emergency department (ED) stress to evaluate for occult instability. The purpose of this study was to correlate ED stress examination of LC1 pelvis fractures against a validated fracture instability scoring system. METHODS: This was a retrospective review of a consecutive series of 70 patients presenting with minimally displaced LC1 fractures at a level 1 academic trauma center. All patients were stressed in the ED radiology suite, and displacement was measured by comparing calibrated stress radiographs with static radiographs (>10 mm displacement defined positivity). ED stress results were compared with radiographic scores assigned according to the validated Beckmann scoring system (score <7: stable-nonsurgical recommendation; score 7 to 9: indeterminant recommendation; and score >9: unstable-surgical recommendation). RESULTS: Thirteen patients had a positive ED stress examination, and 57 patients stressed negative. The mean displacement was significantly different between the three groups (Beckmann 5 to 6: 3.31 mm, SD = 2.4; Beckmann 7 to 9: 4.23 mm, SD = 3.2; Beckmann 10+: 12.1 mm, SD = 8.6; P < 0.001). Zero of 18 patients in the stable group stressed positive, and only 3 of 38 patients in the indeterminant group stressed positive (7.9%). Finally, 10 of 14 patients in the unstable group stressed positive (71.4%; P < 0.001) . Sacral displacement ( P = 0.001), superior ramus location ( P < 0.02), and sacral columns ( P < 0.001) significantly predicted ED stress positivity in multivariate analysis. CONCLUSIONS: Comparison of a validated instability scoring system with ED stress examination of minimally displaced LC1 fractures in awake and hemodynamically stable patients showed excellent correlation. This suggests that the ED stress examination is a useful diagnostic adjunct. LC1 fracture characteristics should be analyzed to determine which pelvic fracture characteristics determine occult instability before stress examination. LEVEL OF EVIDENCE: Level III diagnostic.

Patient-reported Anxiety Scores Are Associated With Lower Physical Function in Patients Experiencing Orthopaedic Trauma.

BACKGROUND: The outcomes of orthopaedic trauma are not solely determined by injury severity or surgical treatment. Studies of numerous orthopaedic outcomes have found that psychosocial factors are also important. Symptoms of anxiety have been linked to long-term pain and disability. Although the existence of a relationship between psychosocial factors and functional outcomes is accepted across multiple disciplines, quantification of this association in patients who have experienced orthopaedic trauma has remained limited. Measuring the anxiety experienced by these individuals and the association with long-term functional outcomes remain poorly understood. QUESTIONS/PURPOSES: (1) Is there an association between early postoperative anxiety symptoms and late recovery of self-reported physical function in patients with orthopaedic trauma? (2) What was the impact of other factors such as demographic variables and comorbidities on late recovery physical function scores, and how did the magnitude of these factors compare with the association with anxiety score? (3) Did patients who presented as trauma activations differ regarding their anxiety symptoms and late-recovery self-reported physical function? METHODS: A total of 1550 patients with lower extremity fractures and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and physical function scores treated between January 1, 2014, and January 1, 2021, at an academic Level I trauma center in North America were assessed. We performed a bivariate regression between the initial PROMIS anxiety and physical function, as well as a multivariate regression including age, gender, BMI, and American Society of Anesthesiologists class to control for potential confounding variables. In a subgroup of 787 patients presenting as trauma activations, we performed a separate regression including Injury Severity Score. RESULTS: PROMIS anxiety was associated with decreased late-recovery physical function (ß = -2.64 [95% CI -3.006 to -2.205]; p < 0.001). The relationship between PROMIS anxiety and physical function remained after controlling for confounding variables in our overall cohort (ß = -2.54 [95% CI -2.93 to -2.15]; p < 0.001) and in the trauma activation cohort (ß = -2.71 [95% CI -3.19 to -2.23]; p < 0.001). Age and American Society of Anesthesiologists score were associated with worse PROMIS physical function scores, while being a man was associated with better PROMIS physical function scores (age: ß= -1.26 [95% CI -1.50 to -1.02]; American Society of Anesthesiologists class: ß=-2.99 [95% CI -3.52 to -2.46]; men: ß = 0.95 [95% CI 0.16 to 1.75]). There were no differences in initial anxiety symptoms or late-recovery physical function between patients who presented as trauma activations and those who did not. Injury Severity Scores were independently associated with worse function (ß = -1.45 [95% CI -2.11 to -0.79]. CONCLUSION: Initial patient self-reported anxiety is negatively associated with patient-reported physical function at the final follow-up interval in a broad cohort of patients with orthopaedic lower extremity injuries undergoing surgery. Identifying patients with high initial PROMIS anxiety scores may allow us to determine which patients will report lower functional scores at the final follow-up. Future investigations could focus on the effect of psychosocial interventions such as cognitive behavioral therapy and mindfulness on functional scores. LEVEL OF EVIDENCE: Level III, therapeutic study.

Butterfly fragments in diaphyseal tibial fractures heal unpredictably: Should we be adopting other strategies for these high risk fractures?

INTRODUCTION: The natural history of diaphyseal tibial butterfly fragments is poorly documented. Numerous studies have analyzed risk factors for nonunions in the tibial shaft with known factors including Gustilo classification, ASA class, and cortical contact. However, the healing potential and ideal management of nonsegmental butterfly fragments in this setting remains unknown. The aim of this study was to determine the nonunion rate of diaphyseal tibial fractures with a butterfly fragment. METHODS: A performed a retrospective review of patients at a single academic Level 1 Trauma Center from 2000-2020 who underwent intramedullary nailing of tibial shaft fractures. Those with non-segmental butterfly fragments (OTA/AO: 42-B) and minimum 12 month follow up were included. Morphologic measurements of butterfly fragments were performed to measure location, size, and displacement, and mRust scores at final follow up were calculated. Outcome measures were surgery to promote union, and mRust scores. RESULTS: A total of 99 patients were included with 21 patients requiring revision surgery to promote union. Thirty six patients had open fractures and 77% of patients were male with a mean age of 34 (range: 12-80). Average follow up was 19 months (3 months - 12 years). The most common location of the butterfly fragment was the anterior cortex (42%), with a mean length of 7.8cm (SD: 3.3) and width of 1.8cm (SD: 0.5cm). At final follow-up 37% of fractures had persistent lucency without callus at the site of the butterfly while only 31% of fractures had remodeled cortex. Average time to complete healing was 13.3 months. Open fractures with butterfly fragments were more likely to go on to nonunion than closed (44% vs 9.2%, p=<0.001). The length of the butterfly fragment was not different between the union and nonunion groups (7.7 vs 7.5, P=0.42). CONCLUSIONS: Open tibial shaft fractures with a butterfly fragment have a high risk of nonunion. Further research may seek to determine if adjunct treatment of butterfly fragments (ie inter-fragmentary compression) in the acute setting could improve healing rates.

Conversion of External Fixator to Intramedullary Nail in Tibial fractures.

INTRODUCTION: Conversion of provisional external fixation to intramedullary nail (IMN) in femur fractures has been reported to be safe within 14 days of initial surgery. However, there is no current literature guiding this practice in tibial fractures. The purpose of this study was to identify the time period when conversion of external fixation to nail in tibial fractures is safe. METHODS: After obtaining IRB approval, tibial fractures (OTA 41A, 42, 43A) that received provisional ex-fix and were converted to IMN from 2009 to 2019 were retrospectively reviewed. Skeletally mature patients with minimum 6 months of follow-up were included. The primary outcome was deep infection. External fixation days were categorized as less than 7, 8 to 14, and 15+ days. Risk ratios of infection were estimated using generalized linear regression with a Poisson distribution. A separate regression model evaluated risk factors for infection using both the external fixation and non-external fixation tibial cohorts. RESULTS: Twenty-eight patients (32%) were treated for deep infection. The infection rate for closed fractures was 28% (11 of 39 patients) and for open fractures was 35% (17 of 49 patients) ( P = 0.56). Examining both tibial cohorts, external fixation (odds ratio [OR] = 2.39, P = 0.017), open fracture (OR = 3.13, P = 0.002), and compartment syndrome (OR = 2.58, P = 0.01) were all associated with infection in regression modeling. Median external fixation days for patients with deep infection was 8 days (Inter-quartile range, 3 to 18 days) as compared with 4 days (IQR, 2 to 9 days) in patients without infection ( P = 0.06). While controlling for open fractures, the 8- to 14-day group had RR = 1.81 ( P = 0.2), and the 15+-day group had RR = 2.67 ( P = 0.003) as compared with the <7-day group. DISCUSSION: Infection rates of tibial fracture patients treated with external fixation and converted to IMN were high. Surgeons should strongly consider the necessity of external fixation for these fractures. Earlier conversion of external fixation to definitive fixation reduced infection rates. LEVEL OF EVIDENCE: Level IV-case series.

Posterior Approach for Open Reduction and Internal Fixation for Scapular Fractures.

Background: This technique utilizes a full-thickness flap to provide a posterior approach to the scapula for open reduction and internal fracture fixation. The present video article outlines the Judet approach along with an incision modification tip for the surgeon's consideration. Description: Prior to making the incision, perform preoperative planning, patient and C-arm positioning, and identification of the primary fragments of the fracture that necessitate fixation on imaging. The Judet incision is made, and the full-thickness flap is retracted laterally (also described as a "boomerang-shaped" incision, allowing for the flap to be reflected medially). Next, detach and reflect the deltoid off the scapular spine superolaterally to reveal the internervous plane between the infraspinatus and teres minor. Utilize this interval to access the fracture sites while making sure to reflect the infraspinatus cranially, carefully minding the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. A longitudinal arthrotomy may then be created parallel to the posterior border of the glenoid, with careful attention paid toward protecting the labrum from iatrogenic injury. The arthrotomy will allow for intra-articular evaluation of the reduction if needed. Primary fractures are then reduced. Reduction is confirmed with use of fluoroscopy, and fixation is applied to maintain the reduction. Alternatives: Most scapular fractures do well with nonoperative treatment, and this has been well documented in the literature. Open reduction and internal fixation has been shown to offer good-to-excellent clinical outcomes with minimal risk of complications in patients with traumatic scapular fractures that necessitate operative treatment1. In certain fractures of the glenoid fossa, operative treatment is necessary to restore normal anatomy, provide stability to the glenohumeral joint, and facilitate functional rehabilitation. Operative treatment is typically reserved for injuries with intra-articular involvement that results in joint incongruity or joint instability2,3. When operative treatment is indicated, an open posterior approach is utilized for some fractures. The posterior Judet approach is the best-known operative technique for such fractures, while other modifications of the Judet technique have also been described in the literature3-5. Rationale: Reports state that scapular body or neck and glenoid fossa fractures account for up to 80% of scapular fractures6. Open reduction and internal fixation of the scapula is an invasive procedure, requiring large incisions and manipulation of soft tissues to expose the various possible fracture sites on the scapula. Thus, numerus surgical techniques have been described that allow surgeons to best tailor treatment to their patients on a case-by-case basis. However, the Judet approach is the workhorse approach for the operative treatment of scapular fractures and is a technique that should be mastered7. The Judet approach allows access to the posterior scapula and provides excellent exposure for fractures that require posterior fixation. The alternative boomerang-shaped incision represents a mirrored version of the Judet incision, with the skin flap reflected medially. The benefit of this modified approach is that it increases the degree of lateral surgical exposure of the scapula and provides easier access to the glenohumeral joint. Expected Outcomes: With this technique for open reduction and internal fixation of scapular fractures, patients can expect comparable outcomes to those described in the literature for the standard Judet technique. These outcomes have been reported as clinical scores and defined as good-to-excellent in a few retrospective case series1,2. Given the variability in scapular fracture morphology, a trauma surgeon should have a strong repertoire of approaches to address these fractures on a case-by-case basis. The Judet approach is one of these necessary approaches and has been shown in the literature to have acceptable outcomes1-3,7. Important Tips: Placing the vertical limb of the boomerang incision too medial can limit lateral exposure of the scapula and make glenohumeral joint access difficult. To avoid this, be sure that the vertical limb of the incision remains in line with the posterior axillary fold.Wound-healing complications can occur following such an extensive surgical approach. A thorough and secure wound closure with repair of the deltoid back to the scapular spine may avoid these problems.Difficulty with intra-articular visualization may occur. Placing a threaded pin into the humeral head or a small distractor across the glenohumeral joint (with a pin in the extra-articular proximal humerus) may improve visualization. Manipulation of the arm can also be beneficial in this regard.Lateral positioning offers easier imaging and allows for exposure to the coracoid or clavicle if these structures are also injured and require operative fixation.Drawing a boomerang-shaped incision with the horizontal limb paralleling the scapular spine and vertical limb along the posterior axillary fold of the arm allows the skin flap to be reflected medially, increasing the degree of lateral surgical exposure of the scapula.After identifying the internervous plane between the infraspinatus and teres minor, take care to reflect the infraspinatus cranially, protecting the suprascapular neurovascular bundle, and the teres minor inferiorly, protecting the axillary nerve. Acronyms and Abbreviations: ORIF = open reduction and internal fixationK-wire = Kirschner wire.

Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study.

INTRODUCTION: The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores. METHODS: Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union. RESULTS: The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance. DISCUSSION: The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings. LEVEL OF EVIDENCE: Therapeutic Level 1.

Greater Acute Articular Inflammatory Response in Tibial Plafond Fractures as Compared to Ankle Fractures.

BACKGROUND: Several factors are thought to contribute to posttraumatic osteoarthritis (PTOA) development, including the posttraumatic inflammatory response. The purpose of this study was to compare 2 injuries at the same joint with a different severity and prognosis. This study compared the intra-articular inflammatory response after rotational ankle fracture (lower energy and less PTOA) with tibial plafond fracture (higher energy and more PTOA). METHODS: This prospective comparative study was conducted at a level 1 trauma center between 2014-2019. Patients between 18 and 60 years of age with acute ankle or tibial plafond fractures were enrolled. Patients with preexisting ankle OA, autoimmune disease, additional injury, or open fractures were excluded. Synovial fluid aspirations were obtained within 24 hours of injury. The concentrations of interleukin (IL)-1ß, IL-1 receptor antagonist (IL-1RA), IL-6, IL-8, and IL-10 and matrix metalloproteinase (MMP)-1, MMP-3, and MMP-13 were quantified. RESULTS: Aspiration were obtained from 29 plafond fractures and 36 ankle fractures. Mean age was 43 years, and patients were predominately female (64%). Age, gender, and comorbidities did not vary between cohorts. Of the plafond fractures, 13 were 43-B and 16 were 43-C injuries. Ankle fractures were predominately 44-B injuries, and 15 ankle fracture had articular impaction. IL-10, IL-1ß, IL-6, IL-8, MMP-1, MMP-3, and MMP-13 were all significantly higher in acute plafond fractures as compared to acute ankle fractures. CONCLUSION: This study compared articular inflammatory marker profiles after fractures of different severities. Several cytokines were elevated in plafond fractures as compared to ankle fractures, suggesting a greater inflammatory response with plafond fractures. Given the difference in prognosis for and higher rate of PTOA after plafond fractures, these data strengthen the case that postinjury inflammatory response plays a role in PTOA development. Given that the postinjury inflammatory response is one of the few modifiable variables of these injuries, future research in this area remains important. LEVEL OF EVIDENCE: Level II, prospective.

Reformatting of Computed Tomography Scans Parallel to the S1 End Plate Increases Visualization of Trans Sacral Pathway in the First Sacral Segment, Especially With Dysmorphism.

OBJECTIVE: To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment. SETTING: Level 1 trauma center. DESIGN: A retrospective cohort study. PATIENTS/PARTICIPANTS: There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents. MAIN OUTCOME MEASUREMENTS: The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans. RESULTS: Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P < 0.001). CONCLUSIONS: CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways.

The Prevalence of Metabolic and Endocrine Disturbances on Fracture Nonunion.

OBJECTIVE: This study aims to determine the prevalence of metabolic disturbance in all fracture nonunion cases and identify the most common endocrine abnormalities seen using a simple screening algorithm. METHODS: A retrospective review study was performed evaluating patients who underwent operative intervention for nonunion from January 2010 to December 2018 at 2 level-1 trauma centers. Preoperative laboratory values were recorded for a 9-test "nonunion panel." A metabolic or endocrine abnormality, specifically an abnormality in the thyroid or parathyroid axis, was evaluated. RESULTS: 42% of patients had an undiagnosed metabolic laboratory abnormality. When multiple tests were used, the rate of metabolic dysfunction was between 60% and 75%, depending on the definition of vitamin D insufficiency vs deficiency used. CONCLUSION: Results indicate a relatively high prevalence of metabolic disturbance in patients with nonunion and suggest metabolic screening for all nonunion patients not only those without a mechanical or infectious cause. LEVEL OF EVIDENCE: IV, retrospective case series.