To identify reasons for nonmedical delays in femur, pelvis, and acetabular fracture fixation at an institution with a dedicated orthopaedic trauma room (DOTR) and an early appropriate care practice model. Retrospective review of a prospective registry. Urban Level 1 trauma center. Two hundred ninety-four patients undergoing 313 procedures for 226 femur, 63 pelvis, and 42 acetabular fractures. Definitive fixation. Reasons for delays in fixation after hospital day 2. Delays occurred in 12.5% of procedures (39/313), with 7.7% (24/313) having medical delays and 4.8% (15/313) having nonmedical delays. Nonmedical delays were most commonly due to the operating room being at-capacity (n = 6) and nonpelvic trauma specialists taking weekend call (n = 5). Procedures with nonmedical delays were associated with younger age (median difference -16.0 years, 95% confidence interval [CI], -28 to -5.0; P = 0.006), high-energy mechanisms (proportional difference [PD] 58.5%, 95% CI, 37.0-69.7; P < 0.0001), Thursday through Saturday hospital admission (PD 30.3%, 95% CI, 5.0-50.0; P < 0.0001), pelvis/acetabular fractures (PD 51.8%, 95% CI, 26.7-71.0%; P < 0.0001), and external fixation (PD 33.0%, 95% CI, 11.8-57.3; P < 0.0001). Only 4.8% of procedures experienced nonmedical delays using an early appropriate care model and a DOTR. Nonmedical delays were most commonly due to 2 modifiable factors-the DOTR being at-capacity and nonpelvis trauma specialists taking weekend call. Patients with nonmedical delays were more likely to be younger, with pelvis/acetabular fractures, high-energy mechanisms, external fixation, and to be admitted between Thursday and Saturday. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. Multicenter retrospective cohort study. Ten Level 1 trauma centers. Patients with OTA/AO 33A or 33C fractures. Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To compare perioperative, 90-day, and 1-year postoperative complications and outcomes between the direct anterior approach (DAA) and the posterior approach for total hip arthroplasty in geriatric patients with displaced femoral neck fractures (FNFs). Retrospective cohort study. Multicenter Health care Consortium. Seven-hundred and nine patients 60 years or older with acute displaced FNFs between 2009 and 2021. Total hip arthroplasty using either DAA or posterior approach. Rates of postoperative complications including dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. Secondary outcome measures included ambulation capacity at discharge, ambulation distance with inpatient physical therapy, discharge disposition, and narcotic prescription quantities (morphine milligram equivalents). Through a multivariable regression analysis, DAA was associated with significantly shorter operative time ( B = -6.89 minutes; 95% confidence interval [CI] -12.84 to -0.93; P = 0.024), lower likelihood of blood transfusion during the index hospital stay (adjusted odds ratios = 0.54; 95% CI 0.27 to 0.96; P = 0.045), and decreased average narcotic prescription amounts at 90 days (B = -230.45 morphine milligram equivalents; 95% CI -440.24 to -78.66; P = 0.035) postoperatively. There were no significant differences in medical complications, dislocations, reoperations, and mortality at 90 days and 1 year postoperatively. When comparing the DAA versus posterior approach for total hip arthroplasty performed for displaced FNF, DAA was associated with shorter operative time, lower likelihood of blood transfusion, and lower 90-day postoperative narcotic prescription amounts. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided. Retrospective cohort study. Academic Level I trauma center. A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures. Surgical fixation of extremity fractures. Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure). 34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 ( P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42-0.61), equivalent to random chance. Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The objective of this study was to assess the impact of using simulation software for preoperative planning: a patient-specific biomechanical model (PSBM) in acetabular surgery. The secondary objectives were to assess operating time, intraoperative bleeding, and peroperative complications. This is a prospective control study. Level 1 trauma center. Between January 2019 and December 2022, patients with operative acetabular fracture treated by the first author were prospectively enrolled. Patients were divided into 2 groups according to the use or not of PSBM for preoperative planning. When PSBM was used, data were extracted from the preoperative high-resolution computed tomography scans to build a biomechanical model implemented in a custom software [simulation (SIM group)]. When computed tomography scans were not performed in our hospital, PSBM was not feasible (non-SIM group). Radiological results, surgery duration, blood loss, and peroperative complications were recorded. Sixty-six patients were included; 26 in the PSBM group and 40 in the standard group. The 2 groups were comparable regarding fracture patterns and epidemiological data. After simulation, in the SIM group, a poor reduction (>3 mm) was found in 2 of 26 patients (7.7%) versus 11 of 40 patients (27.5%) in the non-SIM group, P = 0.048. The mean operative time was shorter after simulation (110 minutes vs. 155 minutes, P = 0.01), and the mean blood loss was reduced (420 vs. 670 mL, P = 0.01). By reducing the peroperative trials for reduction, PSBM allows better reduction in a shorter operative time and with less blood loss. Level II: prospective study.

The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. This is a retrospective case series with prospectively collected data. Level I Trauma Centre in the United Kingdom. Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Trauma Service Promedical Toledo Hospital, Toledo, Ohio. Corresponding Author: Gregory Minas Georgiadis, MD ProMedica Toledo Hospital Toledo, Ohio UNITED STATES The authors report no conflicts of interest related to this work.

The management of bone defects and nonunions creates unique clinical challenges. Current treatment alternatives are often insufficient and frequently require multiple surgeries. One promising option is bone morphogenetic protein-2 (BMP-2), which is the most potent inducer of osteogenesis. However, its use is associated with many side effects, related to the delivery and high doses necessary. To address this need, we developed an ex vivo biomimetic hematoma (BH), replicating naturally healing fracture hematoma, using whole blood and the natural coagulants calcium and thrombin. It is an autologous carrier able to deliver reduced doses of rhBMP-2 to enhance bone healing for complex fractures. More than 50 challenging cases involving recalcitrant nonunions and bone defects have already been treated using the BH delivering reduced doses of rhBMP-2, to evaluate both the safety and efficacy. Preliminary data suggest the BH is currently the only clinically used carrier able to effectively deliver reduced doses (∼70% less) of rhBMP-2 with high efficiency, rapidly and robustly initiating the bone repair cascade to successfully reconstruct complex bone injuries without side effects. The presented case provides a clear demonstration of this technology's ability to significantly alter the clinical outcome in extremely challenging scenarios where other treatment options have failed or are considered unsuitable. A favorable safety profile would portend considerable promise for BH as an alternative to bone grafts and substitutes. Although further studies regarding its clinical efficacy are still warranted, this novel approach nevertheless has tremendous potential as a favorable treatment option for bone defects, open fractures, and recalcitrant nonunions.

Electronic patient-reported outcome measure (E-PROM) collection is a technological advancement that has the potential to facilitate PROM collection in orthopaedic trauma. The purpose of this study was to compare E-PROM versus in-person PROM collection. This is a retrospective comparative study. Urban Level I trauma center. One hundred and fifty consecutive operative orthopaedic trauma patients. The Percent of Normal single assessment numerical evaluation and patient-reported outcomes measurement information system physical function were collected through automated e-mails from an online patient-engagement platform (PatientIQ, Chicago, IL) 2-week, 6-week, 3-month, and 6-month postoperatively. The Percent of Normal was also administered to patients in clinic at the same time intervals. Completion of PROMs; Loss to follow-up. The median clinical follow-up time was 4 months (interquartile range: 1.3-6 months), and 42.7% (64/150) were lost to follow-up. Loss to follow-up was associated with a more disadvantaged area deprivation index [observed difference, 7.0, 95% confidence interval, 1.0 to 13.0; P = 0.01] and noncommercial/no insurance (observed difference 34.8%, confidence interval, 20.9%-45.5%; P < 0.0001). In-person PROM collection was more successful than E-PROM collection at all intervals [2-week (51.3% vs 20.7), 6-week (46.7% vs 20.0%), 3-month (50.0% vs 18.7%), and 6-month (38.0% vs 18.7%), P < 0.0001]. Patients who completed 3-month E-PROMs had longer clinical follow-up (5.2 vs. 3.0 months, P = 0.004) and a trend of being less likely to be lost to follow-up (28.6% vs 45.9%, P = 0.13). E-PROMs were less successful than in-person PROM collection in trauma patients at an urban safety net trauma center. Diagnostic Level III.

Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.