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Delays in bone healing or even the development of a nonunion could be related to the concentrations and/or functions of the bone morphogenetic proteins (BMPs). The RNA expression profile of the BMPs within fracture nonunion tissue is unknown. This preliminary descriptive study was performed to define the RNA profiles of the BMPs, their receptors, and their inhibitors within human fracture nonunion tissue and correlate them to matched healing bone. All patients had hypertrophic nonunions. Tissue samples taken from the nonunion site of 15 patients undergoing surgical treatment for an established nonunion were analyzed. The RNA expression patterns of BMP-2, BMP-4, BMP-5, BMP-6, BMP-7, BMP-8; BMP receptor Types IA, IB, and II; and the BMP inhibitors chordin, Noggin, Drm (Gremlin), and follistatin were determined in the nonunion (fibrous tissue) and healing bone (callus tissue) using quantitative real-time PCR. Comparison between the nonunion and healing bone samples revealed substantially elevated concentrations of BMP-4, Drm/Gremlin, follistatin, and Noggin in nonunion tissue when compared to healing bone. In contrast, BMP-7 concentration was higher in the healing bone. Our data suggest inhibition of BMP-7, by Drm (Gremlin), follistatin, and Noggin and upregulation of BMP-4 may play an integral role in the development of nonunions. [ABSTRACT FROM AUTHOR]

Low-energy shotgun fractures involving the arm are complex injuries. Previously published reports have emphasized various problems associated with these injuries. This case report describes a low-energy shotgun wound managed by a staged treatment protocol involving: (1) a spanning external fixator and immediate soft tissue management, followed by (2) osteosynthesis and autogenous bone grafting and (3) epineural suturing of injured radial nerve, with a successful outcome. Although adequate debridement of the fracture and soft tissue wound is the key to open fracture management, some difference of opinion exists with regard to the timing of bone reconstruction and grafting. In severe type III open fractures, or in wounds that are marginal, it may be best to delay cancellous bone grafting until soft tissue has stabilized following acute trauma when the risk of infection has been minimized. If early coverage of vital structures is not possible, local or remote flap coverage may be necessary. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this trial was to determine whether coronal plane angulation affects functional and clinical outcomes after the fixation of distal femur fractures., Design: Multicenter, randomized controlled trial SETTING: 20 academic trauma centers PATIENTS/PARTICIPANTS: 156 patients with distal femur fractures were enrolled. 123 patients were followed 12 months. There was clinical outcome data available for 105 patients at 3 months, 95 patients at 6 months and 81 patients at one year., Intervention: Lateral locked plating or retrograde intramedullary nailing MAIN OUTCOME MEASUREMENTS: Radiographic alignment, functional scoring including SMFA, Bother Index, and EQ-5D. Clinical scoring of walking ability, need for ambulatory support and ability to manage stairs., Results: At 3 months, there was no difference between groups (varus, neutral or valgus) with respect to any of the clinical functional outcome scores measured. At 6 months, compared to those with neutral alignment, patients with varus angulation had a worse Stair Climbing score (4.33 vs. 2.91, p = 0.05). At 12 months, the average patient with neutral or valgus alignment needed less ambulatory support than the average patient in varus. Walking distance ability was no different between the groups at any time point. With respect to the validated patient-based outcome scores, we found no statistical difference in in the SMFA, Bother, or EQ-5D between patients with valgus or varus mal-alignment and those with neutral alignment at any time point (p > 0.05). Regardless of coronal angulation, the SMFA trended towards lower (improved) scores over time, while EQ-5D scores for patients with varus angulation did not improve over time., Conclusions: Valgus angulation and neutral angulation may be better tolerated in terms of clinical outcomes like stair climbing and need for ambulatory support than varus angulation, though patient reported outcome measures like the SMFA, Bother Index and EQ-5D show no statistical significance. Most patients with distal femur fractures tend to improve during the first year after injury but many remain significantly affected at 12 months post injury., Competing Interests: Declaration of competing interest Dr. Tornetta receives royalty IP payments from and has pending and issued intellectual property with Smith & Nephew, owns stock or stock options in 4 Web, and publishing royalties with WK. For the remaining authors none were declared., (Copyright © 2024. Published by Elsevier Ltd.)

Purpose: To determine when patients return to work following operative repair of tibial shaft fractures (TSF) and what risk factors are associated with a delayed return to work (RTW), defined as greater than 180 days after operative repair., Methods: Retrospective chart review was performed on a consecutive series of TSF patients who underwent operative repair. Time to RTW was based on documented work-clearance communications from the operating surgeon. Patients were divided into 3 groups based on when they returned to work: early (≤ 90 days), average (91-80 days), and late (≥ 180 days). Univariate analysis was performed, and significant variables were included in multinomial logistic regression., Results: There were 168 patients identified. Eighteen were excluded (retired, unemployed, or never returned to work) leaving 150 patients. The average time to RTW for the overall study population was 4.17 ± 2.06 months. There were 39 (26.0%) patients in the early RTW group, 85 (56.7%) in the average RTW group, and 26 (17.3%) in the late RTW group. Patient with high-energy injuries (p = 0.024), open fractures (p = 0.001), initial external-fixation (p = 0.036), labor-intensive job (p = 0.018) and post-operative non-weight bearing status (p = 0.023) all had significantly longer RTW. Multinomial logistic regression including these parameters found a closed fracture was associated with a 1.9 decreased risk of delayed RTW (p = 0.004, 95% CI 0.039-0.533)., Conclusions: Open fractures, initial external-fixation, restricted post-operative weight-bearing and labor-intensive jobs are associated with a delayed RTW following operative repair of TSFs., Level of Evidence: Therapeutic Level III., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Introduction: There has been much debate on use of bipolar or unipolar femoral heads in hemiarthroplasty for the treatment of femoral neck fractures. The outcome of these implants should be studied in the America Joint Replacement Registry (AJRR)., Methods: All primary femoral neck fractures treated with hemiarthroplasty between January 2012 and June 2020 were searched in the AJRR. All cause-revision of unipolar and bipolar hemiarthroplasty and reasons for revision were assessed for these patients until June of 2023., Results: There were no differences in number and reason for all cause revisions between unipolar and bipolar hemiarthroplasty ( p   =  0.41). Bipolar hemiarthroplasty had more revisons at 6 months postoperatively ( p   =  0.0281), but unipolar hemiarthroplasty had more revisions between 2 and 3 years ( p   =  0.0003), and after 3-years ( p   =  0.0085), as analysed with a Cox model. Patients with older age (HR = 0.999; 95% CI, 0.998-0.999; p   =  0.0006) and higher Charlson Comorbidity Index (HR = 0.996; 95% CI, 0.992- 0.999; p   =  0.0192) had a significant increase in revision risk., Conclusions: We suggest that surgeons should consider using bipolar prosthesis when performing hemiarthroplasty for femoral neck fracture in patients expected to live >2 years post injury., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs., Methods: Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX., Results: From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX., Conclusion: The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Purpose: To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach., Methods: A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing., Results: All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015)., Conclusion: The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

We sought to determine what effect the size of a displaced coronoid fracture fragment in Monteggia injuries has on clinical outcome. Sixty-seven patients presented to an academic medical center for operative fixation of a Monteggia fracture. Radiographs were assessed for length and height of the displaced coronoid fragment using measuring tools in our center's imaging archive system. Data were analyzed using binary logistic or linear regression, as appropriate, controlling for sex, age, and Charlson Comorbidity Index. Outcome measurements included radiographic healing, range of motion, postoperative complications, and reoperation. The cohort had a mean follow-up of 16.7 months. Mean coronoid fragment area was 362.4±155.9 mm 2 . Elbow range of motion decreased by 3.8° of elbow flexion ( P <.001), 3.3° of elbow extension ( P <.001), and 3.8° of forearm supination ( P =.007) for every 1-cm 2 increase in coronoid fragment area. Complications ( P =.012) and reoperation ( P =.036) were associated with increasing coronoid fragment area. Nonunion rate, nerve injury, and pronation range of motion were not correlated to increasing coronoid fracture fragment area ( P =.777, P =.123, and P =.351, respectively). As displaced coronoid fragment size increases in Monteggia fracture patterns, elbow range of motion decreases linearly. Coronoid displacement was also associated with increased rates of postoperative complication and need for reoperation. [ Orthopedics . 2024;47(1):15-21.].

Objective: To report on demographics, injury patterns, management strategies and outcomes of patients who sustained fractures of the tibial plateau seen at a single center over a 16-year period., Design: Prospective collection of data.Patients/ Participants: 716 patients with 725 tibia plateau fractures, were treated by one of 5 surgeons., Intervention: Treatment of tibial plateau fractures., Main Outcome Measurements: Outcomes were obtained at standard timepoints. Complications were recorded. Patients were stratified into 3 groups: those treated in the first 5 years, those treated in the second 5 years and those treated in the most recent 6 years., Results: 608 fractures were followed for a mean 13.4 months (6-120) and 82% had a minimum 1-year follow up. Patients returned to self-reported baseline function at a consistent proportion during the 3 time periods. The average knee arc was 125 degrees (75 - 135 degrees) at latest follow up and did not differ over time. The overall complication rate following surgery was 12% and did not differ between time periods. Radiographs demonstrated excellent rates of healing and low rates of PTOA and improved articular reductions at healing (0.58 mm in group 3 compared to 0.94 mm in Group 1 and 1.12 mm in Group 2) (P<0.05)., Conclusion: The majority of patients regained their baseline functional status following surgical intervention and healing. Over time the ability of surgeons to achieve a more anatomic joint reduction was seen, however this did not correlate with improved functional outcomes., Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Conflicts of Interest: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Case: A 75-year-old woman presented with left thigh pain 14 years after initial diagnosis of bilateral atypical femoral fractures secondary to chronic bisphosphonate use. New radiographic imaging and magnetic resonance imaging demonstrated bilateral incomplete femur fractures with surrounding marrow edema, cortical remodeling, and periosteal edema in a manner similar to that found 14 years earlier upon original diagnosis., Conclusion: Recurrence of pain 14 years after initial diagnosis supports consideration of initial surgical management of atypical femur fractures (AFFs), even in patients with nonoperative symptom improvement. Patients who decline surgical intervention should be informed that incomplete AFFs may become a chronic medical condition moving forward., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C196)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population., Methods: Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points., Results: Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications., Conclusions: Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population., Methods: Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments., Results: Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group., Conclusions: Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI)., Methods: Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed., Results: Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029)., Conclusions: Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)