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Abstract. Objectives:. To identify risk factors for developing a fracture-related infection in operatively treated ballistic tibia fractures and to report the microbiologic results of intraoperative cultures. Design:. Retrospective review. Setting:. Level 1 trauma center. Patients/Participants:. One hundred thirty-three adults with operatively treated low-velocity ballistic tibia fractures, from 2011 to 2021. Intervention:. One dose of prophylactic cefazolin or equivalent as well as perioperative prophylaxis. Main Outcome Measurements:. Deep infection rate. Results:. The deep infection rate was 12% (16/134) with no significant difference in injury characteristics, index surgical characteristics, or time to antibiotics between the groups (P > 0.05). Patients who were slightly older (35.5 vs. 27 median years, P = 0.005) and with higher median body mass indexes (BMIs) (30.09 vs. 24.51, P = 0.021) developed a deep infection. 56.3% of patients presented with signs of infection within the first 100 days after injury. Nine patients had polymicrobial infections. There were 29 isolated organisms, 69% were uncovered by first-generation cephalosporin prophylaxis (anaerobes, gram-negative rods, Enterococcus, methicillin resistant Staphylococcus Aureus [MRSA]), and 50% of patients developed recalcitrant infection and required a second reoperation where 6 organisms were isolated, half of which were not covered by first-generation prophylaxis (Enterococcus, Staphylococcus Aureus MRSA). Conclusions:. We found a deep infection rate of 12% among ballistic tibia fractures receiving standard-of-care antibiotic prophylaxis. Increased age and body mass index were associated with deep infections. Half became recalcitrant requiring a second reoperation. 66.7% of isolated organisms were not covered by first-generation cephalosporin prophylaxis. Consideration should be given to treatment options such as broader prophylaxis or local antibiotic treatment. Level of Evidence:. IV.

Abstract. Objectives:. To describe operative results after humerus nonunion surgery in patients whose initial humerus shaft fracture (OTA/AO code 12) was treated nonoperatively and to identify risk factors of nonunion surgery failure in the same population. Design:. Case series. Setting:. Nine academic level 1 trauma centers. Patients/Participants:. One hundred twenty patients with humerus nonunion whose initial fracture was treated nonoperatively. Intervention:. Operative treatment of humerus nonunions. Main Outcome Measurements:. Rate of recalcitrant nonunion after humerus nonunion surgery. Results:. Of 108 humerus nonunions, 26 (24.07%) failed to unite after nonunion surgery. Moreover, 34 patients (31.48%) experienced 1 or more postoperative complications. Multivariate analysis found that the use of bone graft or bone graft substitute was not associated with successful nonunion surgery (95% odds ratio confidence interval [CI] [0.67–5.3], P = 0.23). Tobacco use was associated with an increased risk of persistent nonunion (P = 0.0041). Postoperative complications (P = 0.0001) were also associated with an increased risk of persistent nonunion. Diabetes and open fracture were not associated with differences in the nonunion repair success rate. Conclusions:. As the largest and most generalizable to date, this multicenter study found that nearly 1 in 4 patients with a humeral nonunion after initial nonoperative management failed their nonunion surgical treatment. While postoperative complications were associated with recalcitrant nonunion, surgical adjuncts such as bone grafting and type did not seem to influence the success rate of nonunion surgery. Smoking is a modifiable risk factor suggesting that smoking cessation should be part of the intervention. These findings can be used to give patients and surgeons a realistic expectation of results and complications after humerus nonunion surgery. Level of Evidence:. Therapeutic level III.

Abstract. Objectives:. To report outcomes and risk factors of complications following low-velocity ballistic fractures of the femur. Design:. Retrospective case series. Setting:. Academic Level I trauma center. Patients/Participants:. Retrospective series of 104 patients aged 18+ years presenting with low-velocity civilian ballistic femur fractures from 2011 to 2020 (OTA/AO types 31–33). Intervention:. Treatment following ballistic femur fracture. Main Outcome Measurements:. All cause complications. Results:. Our cohort experienced a 39% complication rate and 19% reoperation rate, including 3 deep surgical site infections, 15 hardware failures, and 12 nonunions. All-cause complications did not differ significantly between OTA/AO or Gustilo classifications (P = 0.56, P = 0.94). Skin and muscle management, arterial injury, amount of contamination, or muscle loss did not differ significantly between those with and without complication. Factors not associated with increased complications included time to initial antibiotics, time from injury, operative time, duration of prophylactic antibiotics, and hospital length of stay. However, all of these factors were based on our typical clinical care routine within the standard of care and were not purposefully varied. Conclusions:. We did not find any modifiable or nonmodifiable factors that increased risk of complication in our sample. We found that time to prophylactic antibiotics or time to operative debridement was within quality standards and was not associated with increased risk of complications. Our complication rate was similar to previous reports. While we found lower rates of vascular complications than previous reports and 0 cases of compartment syndrome, complication rates in our sample were driven by nonunion and implant failure. These continue to be challenging injuries with high rates of complications. Level of Evidence:. IV.