Outcomes and safety of antibiotic-loaded calcium sulfate beads in orthopaedics: A systematic review and meta-analysis.

Introduction Controversy surrounds the optimal treatment of very proximal fractures around femoral components. No published studies exist evaluating the outcomes of ORIF of fractures with a primary fracture line proximal to the distal tip of the femoral component. These patterns typically have a short “ring” of proximal bone including the greater and lesser trochanters that is well fixed to the porous surface of the stem, but the distal portion of the stem is detached from the femur. The purpose of this multi-center study is to learn more about the results and complications of ORIF in this setting. Patients and Methods Between 2008–2022, twenty-three patients with a mean age of 83 years (Range 59 – 98) were treated at two Level One Trauma Centers with ORIF of an extremely proximal PPFX. All stems were tested intraoperatively for stability, well fixed stems were treated with ORIF, regardless of how proximal the fracture extent was. Three patients died before follow-up. The remaining 20 patients were followed until union, reoperation, or a minimum of one year with a mean follow up of 24 months. Results 20 of 20 (100%) fractures united. Three patients developed a surgical complication. There were 3 deep infections (one treated successfully with a DAIR, one with plate removal after bony union, and one treated with resection) There was one dislocation closed reduced with no further instability. There were no cases of plate breakage or trochanteric escape. Conclusions ORIF of extremely proximal fractures around well-fixed femoral components resulted in a high rate of bony union. The rate of postoperative infection was concerning, possibly related to the frail, very elderly population (mean age 83 years) sustaining these rare fracture patterns.

Background:Charcot neuroarthropathy (CN) involving both the hindfoot and midfoot represents a severe form of the disease and is often associated with significant instability, deformity, and an increased risk of ulceration. Although early-stage midfoot CN may be managed conservatively, combined hindfoot-midfoot involvement typically necessitates complex surgical reconstruction.Methods:This retrospective longitudinal case series included 21 consecutive patients with combined hindfoot and midfoot CN treated surgically at a tertiary care center in South India between 2019 and 2024. All procedures were performed by a single senior foot and ankle surgeon. Primary outcome was defined as limb salvage, operationalized as the achievement of an ulcer-free, plantigrade foot with autonomous ambulation at 12 months postoperatively.Results:The mean age of the cohort was 57.2 ± 8.2 years, with 14 of 21 patients (66.7%) being male. All patients (21/21, 100%) had Brodsky IV CN. Combined hindfoot-midfoot reconstruction was undertaken in 12 (57.1%), whereas 9 patients (42.9%) underwent isolated hindfoot reconstruction, with preservation of a stable or minimally involved midfoot to function as a pseudo joint at the level of the Chopart joint. Overall, metal hardware failure occurred in 2 (9.5%), with a mean time to implant breakage of 15.5 ± 3.5 months. Radiologic bony union was achieved in 16 of 21 hindfoot (76.2%) and 6 of 21 midfoot (28.6%). Recurrence of CN occurred in 1 (4.8%), contralateral CN in 3 (14.3%), and ulcer recurrence in 5 (23.8%). Limb salvage was achieved in all patients (21/21, 100%).Conclusion:Surgical reconstruction of combined hindfoot and midfoot CN was associated with 100% limb salvage and clinical outcomes in this single-center series; however, these findings should be interpreted cautiously given the small sample size and the high rates of surgical site infection (38.1%) and low midfoot bony union (28.6%) observed. Future research with larger cohorts and extended follow-up focusing on functional outcomes is needed to enhance understanding and optimize treatment strategies.Level of Evidence:Level IV, retrospective observational case series.

Intraoperative tibial periprosthetic fractures during total knee arthroplasty (TKA) are uncommon, but clinically relevant complications with distinct mechanisms compared with postoperative fractures. This review summarizes the incidence, intraoperative risk factors and mechanisms, recognition, and early outcomes to provide a practical, procedure-based framework. In primary TKA, intraoperative tibial fractures occur in approximately 0.1 to 0.5% of cases, with higher rates reported in keeled tibial components and revision procedures, where incidence may approach 1.5%. These fractures occur at predictable high-force steps, most commonly during keel preparation and final component impaction, with 90 to 100% occurring at these stages across multiple series. The medial tibial plateau is particularly susceptible, and excessive insertion forces, implant size and geometry, and depth of tibial resection contribute to fracture risk. Recognition relies on intraoperative awareness of timing, tactile feedback, and subtle visual and mechanical cues. Audible cracking, sudden loss of resistance, abnormal component seating, and unexpected instability should prompt suspicion. Some fractures remain occult and are identified only on postoperative imaging, emphasizing the importance of vigilance during high-risk steps. Early outcomes are generally favorable when fractures are recognized and addressed at the time of surgery, with high rates of union and implant survivorship. Large series report survivorship free from tibial component revision exceeding 95% at up to a mean 6-year follow-up, although outcomes vary by fracture pattern. Intraoperative tibial periprosthetic fractures are predictable, mechanically driven complications that occur during specific steps of TKA. Understanding their timing, mechanisms, and presentation is essential to improve recognition and optimize outcomes.

ABSTRACTBackgroundThe role of bone grafting in subtalar joint arthrodesis (SJA) remains controversial. This study aimed to compare clinical and radiographic outcomes of SJA performed with and without bone graft and to evaluate the influence of different graft types on fusion and functional results.MethodsA multicenter retrospective observational study was conducted including 66 patients who underwent isolated SJA between 2023 and 2025. Patients were divided into graft (n = 51) and no graft (n = 15) groups. A subgroup analysis compared autologous, fresh frozen allogeneic, and commercial allogeneic grafts. Outcomes included osseous union, time to union, complications, and functional scores (AOFAS, FAAM‐ADL, and FAAM‐Sports). Multivariable regression and ROC analyses were performed to identify independent predictors of nonunion and delayed union.ResultsOverall, the union rate was 90.9%. Union was achieved in 92.2% of grafted patients and 86.7% of nongrafted patients (p = 0.612). Bone graft use was not independently associated with union, complications, or time to union in the adjusted exploratory analyses. Increasing age and BMI were independently associated with a prolonged time to union. ROC analysis identified age ≥ 60 years as a predictor of nonunion (AUC 0.782) and age ≥ 59 years and BMI ≥ 25.9 kg/m2 as predictors of delayed union. Both groups showed significant postoperative improvements in all functional scores (all p < 0.001). Autologous graft was associated with higher postoperative functional scores, although this finding should be interpreted cautiously given potential baseline differences and selection bias.ConclusionsIn isolated SJA performed in a well‐aligned hindfoot, high union rates and significant functional improvement were achieved regardless of bone graft use. However, due to the retrospective, nonrandomized design and limited number of nonunion events, no definitive conclusions can be drawn regarding the routine necessity or superiority of bone grafting. Though, bone graft use appeared to be associated with improved functional outcomes in selected higher risk patients, although these findings should be interpreted cautiously given the exploratory nature of the analysis. All subgroup and threshold analyses should be interpreted as exploratory.

The aim of this research was to evaluate clinical and radiographic outcomes in patients with Ogden type IV and V tibial tubercle fractures treated at two tertiary hospitals. We conducted a retrospective review of patients with Ogden type IV and V tibial tubercle fractures treated between 2010 and 2024. Demographic data, fracture characteristics, mechanism of injury, treatment modality, and fixation method were recorded. Radiographic parameters were measured before and after treatment, and at final follow-up. Clinical outcomes included range of motion, return to sports and complications. Forty-one patients met the inclusion criteria; 95.1% were male, with a median age of 14 years and a mean follow-up of 3 years and 8 months. Sports-related trauma accounted for 80.4% of injuries. Forty fractures were Ogden type IV and one type V. Conservative treatment was used in four (9.7%) patients, whereas 37 (90.3%) patients underwent surgical fixation, mostly with 7.0-mm cannulated screws. Fracture union was achieved in all cases. Complications occurred in eight (19.5%) patients, including screw prominence, infection, varus deformity, limb-length discrepancy, and transient peroneal neuropraxia. No cases of compartment syndrome were observed. At final follow-up, 95.2% of patients returned to their preinjury level of sports participation, and 92.6% regained full knee range of motion. Radiographic evaluation demonstrated restoration and maintenance of tibial alignment. We conclude that Ogden type IV tibial tubercle fractures and the only one Ogden type V demonstrated favorable clinical, functional, and radiographic outcomes, with high union rates and a low incidence of severe complications.

An extended trochanteric osteotomy (ETO) is used in complex cases to enhance access to the femoral canal and aid implant and cement removal during revision total hip arthroplasty (RTHA). However, there is no consensus regarding postoperative rehabilitation protocols. The aim of this study was to assess the efficacy and safety of immediate weight-bearing (WB) protocols in patients undergoing ETO during RTHA. A multicenter retrospective review was conducted at two academic medical centers between 2014 and 2021 to identify patients undergoing an ETO during RTHA with a minimum 1-year follow-up. Thirty-nine patients underwent an immediate WB protocol postoperatively. Union rates, ambulatory status, 90-day orthopaedic-related complications, revision surgeries, revisions, and Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) scores were collected. Fifty-three patients were included in the final analysis. The average follow-up time was 15.8 ± 20.4 months, with a mean age of 63.7 ± 11.5 years. Bony union was achieved in 46 patients (86.8%). The mean earliest time to union was 4.2 ± 5.4 months. Average HOOS JR scores significantly improved from preoperative to 1-year follow-up (mean 16.4 ± 4.1 vs 3.5 ± 4.2), P ≤ 0.000001). At the final follow-up, ambulatory status improved, with fewer patients kept as non-weight bearing (11 (21.6%) versus 7 (15.2%)). Two complications (3.8%) due to deep infection, 5 revision surgeries (9.4%), and 6 revisions (11.0%) were observed within 90 days. Most patients who underwent ETO during RTHA and were placed on an immediate WB protocol achieved union at 4.2 months on average. HOOS JR scores improved as early as 2 weeks. More importantly, a greater proportion of patients experienced an improved ambulatory status at the final follow-up. These findings suggest that an immediate WB protocol-particularly WBAT-may be effective and safely implemented in patients undergoing an ETO during RTHA. Level III retrospective cohort comparison study.

The objective of this study was to evaluate the rate of nonunion repair success in tibia nonunions treated with exchange nailing. This retrospective cohort study was conducted across five academic Level 1 trauma centers and included 63 patients with tibia nonunions. Patients who sustained a tibia fracture (AO/OTA 42) treated with intramedullary fixation that developed a nonunion and were subsequently treated with exchange nailing were retrospectively reviewed. The primary outcome measure was nonunion repair success based on osseous union. Additional analyses included union rate by AO/OTA classification, nonunion type, implant(s) used, graft used, time from initial procedure, and infection status. All patients sustained an AO/OTA type 42 fracture. Out of 63 patients, 47 tibias (75%) achieved osseous union after the index exchange nail procedure. The rates of nonunion revision success were similar across nonunion types and time from initial procedure until exchange nailing. There was no significant difference in union rate when infection was present. Complications included re-operation, readmission, infection, and implant failure. This large, multicenter study with contemporary implants, instruments, and techniques for exchange nailing tibia nonunions demonstrates a nonunion repair success rate of 75%, consistent with the lower end of reported data in previous literature. No identifiable risk factors for failure of exchange nailing in tibia nonunions were found. Level III Evidence.

Free fibular flaps (FFF) and pedicled fibular grafts (PFG) are established techniques for reconstructing pediatric long bone defects. While the FFF provides versatility through microvascular transfer, PFGs avoid anastomosis but are limited by anatomic constraints. Clinical questions remain regarding optimal fixation strategies, donor-site morbidity, and graft outcomes in children. This retrospective cohort study analyzed 22 pediatric patients undergoing FFF or PFG between 1994 and 2025. Outcomes included time to radiographic union, time to weight bearing, fibular regeneration, and donor-site complications. Subgroup analyses compared external fixation use, periosteal sleeve preservation, and graft type/location. The average time to radiographic union was 41 weeks. External fixation was associated with shorter radiographic union time (30.1 vs. 86.4 wk) and earlier full weight bearing on the graft-receiving limb (52.0 vs. 127.2 d), though these findings should be interpreted as exploratory given the limited sample size and inconsistent significance across statistical tests. Younger patient age correlated with faster union (r = 0.60, P = 0.004). Preservation of a periosteal sleeve at the donor site significantly promoted fibular regeneration ( P = 0.0004) and may hasten donor limb recovery. Ankle valgus deformity was associated with shorter residual distal fibula length (mean 5.6cm, P = 0.0498). All grafts showed remodeling over time. Tibial graft location and use of PFG were significantly associated with need for refixation ( P = 0.0001 and P = 0.0002, respectively). Pediatric FFF reconstruction demonstrates high union and remodeling rates with favorable functional outcomes. External fixation was found to be weakly associated with acceleration of union and weight bearing, while periosteal sleeve preservation supports fibular regeneration and potentially expedites return to weight bearing on the donor limb. PFGs may be effective in select tibial cases but showed higher reoperation rates. Preserving an adequate distal fibula segment may mitigate ankle valgus. These findings support tailored fixation strategies and highlight the importance of surgical planning to optimize outcomes and minimize donor-site morbidity in pediatric patients. Level III-therapeutic study.

Trephine-based in situ arthrodesis of the central tarsometatarsal joints: Clinical outcomes.

Intramedullary nailing is the preferred treatment for lower limb long bone fractures, but stability is reduced in extra-isthmic fractures due to nail-metaphysis mismatch. Poller screws may help, but their use is controversial. This study evaluates whether Poller screws are associated with improved prognosis in intramedullary nailing for lower limb extra-isthmic fractures and explores their mechanical mechanisms. PubMed, EMBASE, Cochrane Library, and Web of Science were searched up to December 2025 using keywords like 'Fracture,' 'Intramedullary nail,' 'Poller screw,' and 'Blocking screw.' Studies were screened, and data were collected for meta-analysis. A 3D tibial model was created, and finite element analysis assessed Poller screws' effect on distal tibial fractures under axial load. Out of 1134 studies, 5 trials with 413 participants were included. The Poller screw group showed increased union rates (OR = 2.48; 95% CI, 1.13-5.46; p = 0.020). Surgery duration increased, but secondary surgical procedures decreased. No differences were found in malalignment, time to union, or infection. Poller screws reduced fracture site displacement by 54.88%. The use of Poller screws in intramedullary nailing for lower limb extra-isthmic fractures is associated with higher union rates without affecting alignment or healing time. While surgery duration increases, infection remains unchanged, and secondary surgery decreases. The improved healing outcomes may contribute to Poller screws enhancing construct stiffness and reducing micro-motion.

Do Preoperative Intra-Articular Steroid Injections Affect the Choice of Surgical Procedures for Thumb Carpometacarpal Osteoarthritis?

Displaced scaphoid fractures warrant surgical fixation to mitigate the risk of nonunion or malunion. We hypothesized that two-screw fixation would result in higher rates of union at shorter times. We retrospectively reviewed data of patients who presented with scaphoid fractures and underwent surgical fixation between 1 January 2013 and 30 November 2024. Patients were propensity score matched using demographics and Herbert classification as covariates. After propensity score matching, 92 patients were identified, 47 receiving one screw and 45 receiving two screws. At 6 months after surgery, wrist extension was significantly greater in the one-screw cohort than in the two-screw cohort (71.0°, standard deviation (SD) 10.7° vs. 56.2°, SD 20.5°, p = 0.03); all other range of motion variables were similar between the cohorts at this timepoint. Visual analogue scale scores postoperatively significantly improved compared with preoperatively for both cohorts (p < 0.001 for both). Patients in the one-screw cohort showed significant improvements in Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) and Physical Function scores after surgery as compared with before surgery. The PROMIS PI scores in the two-screw cohort also showed significant differences after and before surgery. Rates of nonunion, time to union and hardware complications did not show statistically significant differences between the one- and two-screw cohorts. In this study, we reject our hypothesis as two screws were similar to one-screw fixation for rates of healing and outcomes. III, case-control study.

Ankle fractures are the third most common fractures in old age with an incidence of up to 150/100,000 inhabitants per year. While anatomical joint reconstruction of the ankle using open reduction and internal fixation (ORIF) achieves good results in younger patients, geriatric patients are particularly prone to complications after surgery due to osteoporosis, multimorbidity and limited ability to maintain partial weight-bearing. Primary arthrodesis, usually performed as retrograde tibiotalocalcaneal (TTC) nailing, does not follow the anatomical reconstruction of the joint but pursues a different goal of aload-stable fixation that enables immediate full weight-bearing and thus avoids complications associated with immobilization. Studies have shown union rates of 85-100%, moderate functional results and atendency towards fewer soft tissue complications compared to anatomical joint reconstruction. The indications are strictly selective and include nonreconstructable fractures, critical soft tissue situations, inability to bear partial weight and frail low-demand patients; however, the level of evidence is not high enough to derive recommendations. The currently available studies only have a retrospective study design, so that prospective randomized studies are required.

Distal femoral fractures (DFF) present significant challenges in orthopedic surgery because of their complex biomechanical environment and limited bone stock for fixation. Dual plating (DP), involving the application of both lateral and medial plates, has emerged as a promising alternative to enhance construct stability. We hypothesize that distal femoral DP improves union rates and functional outcomes in patients with complex or non-united DFFs. This prospective observational study was conducted on 30 cases with DFF who had either complex primary fixation or developed nonunion. Patients were monitored and followed up at regular intervals postoperatively (2 weeks, 6 weeks, 3 months, 6 months, and 12 months). Functional recovery was assessed using the Neer scoring system. The range of motion (ROM) ranged from 70 to 100° with a mean ± SD of 90.17 ± 10.3°. The majority of patients (66.67%) achieved an excellent outcome, and 20% had a good result. Only a small proportion had fair (6.67%) or poor (6.67%) outcomes. There were no cases of malunion or nonunion. However, delayed union and infection were each reported in 3 patients (10%). Patients with excellent outcomes were significantly younger (mean age 24.9 years) and had a lower BMI (24.31kg/m²) compared to those with poorer outcomes, who were older (≥ 55 years) and had higher BMIs (≥ 28.7kg/m²). Distal femur dual plating is a viable salvage option for complex primary fixation of complex distal femur fractures. Good to excellent outcomes can be achieved with a low complication rate especially in patients with normal BMI and younger than 55 years of age.

To compare lateral locked plating (LLP) to a combined treatment approach utilizing a retrograde intramedullary nail (rIMN) alongside a minimally invasive lateral locked periprosthetic plating system (PPS) (Smith & Nephew; Memphis, TN) in the management of Vancouver C periprosthetic femoral fractures. Retrospective chart review. Single, academic, Level-1 Trauma center. All adult patients who underwent fixation of a Vancouver C periprosthetic femur fracture (AO/OTA Type 32C [IVC/D]) with a rIMN and PPS (NP Group) or LLP (LLP group) between 2019 and 2025 with follow-up to union, reoperation, or a minimum of one year were included. Patients in the NP group were recommended to fully bear weight immediately while patients in the LLP group were recommended to remain non-weight bearing for 8 weeks. The primary outcome was fracture union. Secondary outcomes included implant failure, infection, and alignment immediately postoperatively and at final follow-up. Primary and secondary outcome measures were compared between the NP and LLP groups. A total of 52 patients were included. 31 in the NP group (68% female, mean age 79 years (range, 67 - 99)) and 21 in the LLP group (67% female, 69 years (range, 53 - 85)), (p = 0.54 for sex, p = 0.26 for age). In both groups, the lateral plate extended proximal to the hip prosthesis by at least 3 screw holes. There were no differences when comparing body mass index, diabetes, smoking status, mechanism of injury, or fracture classification between groups (p > 0.05). In the NP group the mean immediate aLDFA was 82 degrees range (79-87 degrees) compared to 80 degrees (range 79 - 87 degrees) at final follow-up (p = 0.37; 95% CI -5.08 to 12.9). In the LLP group the mean immediate aLDFA was 80 degrees (range, 63 - 87 degrees), compared to 82 degrees (range 69 - 87 degrees) at final follow-up (p = 0.43; 95% CI, -5.35 to 2.37). There was no difference in alignment both immediately postoperatively and at final follow-up between groups (p = 0.20 and 0.45, respectively). There were 2 reoperations (6%) in the NP group, both a removal of a loose interlocking screw. There were 3 reoperations (14%) in the LLP group, all nonunions without implant failure that were revised to nail-plate constructs and subsequently achieved union. There was no difference in reoperation between groups (p = 0.68). There were 0 nonunions in the NP group compared to 3 (14%) in the LLP group (p = 0.03). There were no cases of implant failure or infection. Retrograde nail/plate combination demonstrated a high union rate when treating Vancouver C periprosthetic femur fractures. When compared to lateral locked plating alone which does not facilitate immediate weight-bearing, this implant combination demonstrated lower rates of nonunion with the benefit of allowing immediate post-operative weight bearing. Level III.

Comparison of weight-bearing restriction periods using a patellar tendon-bearing brace after arthroscopic and open ankle arthrodesis.

Subtrochanteric femur fractures are challenging to treat due to complex anatomy and high mechanical stresses. Cephalomedullary nailing is the standard treatment, often performed with the patient supine on a traction table, but this can prolong setup and cause complications (pressure or nerve injuries). Lateral decubitus positioning without a traction table may facilitate reduction and reduce traction-related risks, yet comparative data in subtrochanteric fractures are limited. This study compared outcomes of lateral decubitus versus traction table positioning for subtrochanteric fracture nailing. A retrospective cohort study included 68 patients with subtrochanteric femur fractures treated with cephalomedullary nails. Patients underwent surgery supine on a traction table (n = 37) or in lateral decubitus without a traction table (n = 31). Operative metrics (entry point determination time, operative time, fluoroscopy duration, and blood loss) and postoperative outcomes (transfusion requirements, time to mobilization, complications, and final Harris Hip Score) were compared between groups. Lateral decubitus positioning was associated with shorter entry-point determination time (median 2 vs. 7min; p = 0.05), shorter operating-room time (80.3 ± 23.6 vs. 108.2 ± 23.2min; p = 0.03), reduced fluoroscopy time (151.2 ± 19.2 vs. 178.2 ± 16.1s; p = 0.03), and lower estimated blood loss (752 ± 346 vs. 1459 ± 611 mL; p = 0.01) compared with traction-table positioning. No statistically significant differences were observed in transfusion requirements, time to mobilization, final Harris Hip Score, or complication rates (all p > 0.05). Compared with traction-table positioning, lateral decubitus cephalomedullary nailing was associated with better functional outcome, shorter operative and fluoroscopy times, and lower estimated blood loss, while union and complication rates were similar between groups. These findings suggest that lateral decubitus positioning is a viable alternative for subtrochanteric fracture fixation, particularly when traction-table setup may compromise operating-room efficiency. Given the observational design and potential confounding related to reduction techniques and surgeon factors, these findings should be interpreted as associations; prospective studies are warranted.

To assess the outcomes and complication rates of early weightbearing (either immediate weightbearing as tolerated or partial weightbearing) and delayed weightbearing (an initial period of non-weightbearing or toe-touch weightbearing) following distal femoral osteotomy (DFO). A systematic literature search using PubMed, Embase and Cochrane Reviews was performed. Inclusion criteria were studies reporting on outcomes and complications after DFO with a minimum 1-year follow-up. Methodologic quality of studies was assessed using the methodological index for non-randomised studies (MINORS) criteria. Data collection included incidence of nonunion, delayed union, loss of fixation or deformity correction, knee stiffness, venous thromboembolism (VTE) and patient-reported outcome measures (PROMs). Meta-analysis was performed utilising random effects models, with statistically significant results denoted by a p-value < 0.05. Twenty-six studies (23 level IV and 3 level III) with 814 patients were included (mean age 42 years, mean follow-up 5.2 years). All but one study (25/26 [96.2%]) had moderate quality methodology. Statistical comparison was limited by low event frequency, and thus no statistically significant associations were identified, and p-values were omitted. The overall complication rates were nonunion 2.5% (95% confidence interval [CI] 1.6%-3.8%), delayed union 0.6% (95% CI 0.1%-3.3%), loss of fixation or deformity correction 1.4% (95% CI 0.5%-3.5%), knee stiffness 2.9% (95% CI 1.4%-6.1%), VTE 0.9% (95% CI 0.3%-2.3%). Validated PROMs were reported in 11 of 26 studies (42%) using heterogeneous instruments, precluding quantitative pooling and meta-analysis. There were relatively low overall mean rates of delayed union, nonunion, loss of fixation or deformity correction, and VTE after DFO, regardless of an early or delayed post-operative weightbearing protocol. Due to limited comparative data and the risk of selection bias, definitive conclusions cannot be drawn regarding the safety of early weightbearing after DFO, underscoring the need for prospective controlled studies. Level IV.

Functional and patient-reported outcomes after halo-vest immobilisation for C2 fractures: A retrospective analysis of prospectively collected data.