The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries.

PURPOSE: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. METHODS: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. RESULTS: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. CONCLUSIONS: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Biologic Augmentation of Isolated Meniscal Repair.

PURPOSE OF REVIEW: The limited blood supply and intrinsic healing capacity of the meniscus contributes to suboptimal tissue regeneration following injury and surgical repair. Biologic augmentation techniques have been utilized in combination with isolated meniscal repair to improve tissue regeneration. Several innovative strategies such as Platelet-Rich Plasma (PRP), fibrin clots, mesenchymal stem cells (MSCs), bone marrow stimulation, meniscal scaffolds, and meniscal wrapping, are being explored to enhance repair outcomes. This article provides a comprehensive review of recent findings and conclusions regarding biologic augmentation techniques. RECENT FINDINGS: Studies on PRP reveal mixed outcomes, with some suggesting benefits in reducing failure rates of isolated meniscal repair, while others question its efficacy. Fibrin clots and PRF (Platelet-rich fibrin), although promising, show inconsistent results and lack sufficient evidence for definitive conclusions. MSCs demonstrate potential in preclinical studies, but clinical trials have been limited and inconclusive. Bone marrow stimulation appears effective in certain contexts, but its broader applicability remains uncertain. Meniscal scaffolds, including CMI (Collagen Meniscal Implants) and Actifit (polyurethane scaffolds), show encouraging short- and mid-term outcomes but have not consistently surpassed traditional methods in the long term. Meniscal wrapping is infrequently studied but demonstrates positive short-term results with certain applications. The review reveals a diverse range of outcomes for biologic augmentation in meniscal repair. While certain techniques show promise, particularly in specific scenarios, the overall efficacy of these methods has yet to reach a consensus. The review underscores the necessity for standardized, high-quality research to establish the definitive effectiveness of these biologic augmentation methods.

Lactic acid levels are associated with morbidity, length of stay, and total treatment costs in urban trauma patients with lower extremity long bone fractures.

INTRODUCTION: Lactic acid is well studied in the trauma population and is frequently used as a laboratory indicator that correlates with resuscitation status and has thus been associated with patient outcomes. There is limited literature that assesses the association of initial lactic acid with post-operative morbidity and hospitalization costs in the orthopedic literature. The purpose of this study was to assess the association of lactic acid levels and alcohol levels post-operative morbidity, length of stay and admission costs in a cohort of operative lower extremity long bone fractures, and to compare these effects in the ballistic and blunt trauma sub-population. METHODS: Patients presenting as trauma activations who underwent tibial and/or femoral fixation at a single institution from May 2018 to August 2020 were divided based on initial lactate level into normal, (< 2.5) intermediate (2.5-4.0), and high (> 4.0). Mechanism of trauma (blunt vs. ballistic) was also stratified for analysis. Data on other injuries, surgical timing, level of care, direct hospitalization costs, length of stay, and discharge disposition were collected from the electronic medical record. The primary outcome assessed was post-operative morbidity defined as in-hospital mortality or unanticipated escalation of care. Secondary outcomes included hospital costs, lengths of stay, and discharge disposition. Data were analyzed using ANOVA and multivariate regression. RESULTS: A total of 401 patients met inclusions criteria. Average age was 34.1 ± 13.0 years old, with patients remaining hospitalized for 8.8 ± 9.5 days, and 35.2% requiring ICU care during their hospitalization. Patients in the ballistic cohort were younger, had fewer other injuries and had higher lactate levels (4.0 ± 2.4) than in the blunt trauma cohort (3.4 ± 1.9) (p = 0.004). On multivariate regression, higher lactate was associated with post-operative morbidity (p = 0.015), as was age (p < 0.001) and BMI (p = 0.033). ISS, ballistic versus blunt injury mechanism, and other included laboratory markers were not. Lactate was also associated with longer lengths of stay, and higher associated direct hospitalization cost (p < 0.001) and lower rates of home disposition (p = 0.008). CONCLUSION: High initial lactate levels are independently associated with post-operative morbidity as well as higher direct hospitalization costs and longer lengths of stay in orthopedic trauma patients who underwent fixation for fractures of the lower extremity long bones. Ballistic trauma patients had significantly higher lactate levels compared to the blunt cohort, and lactate was not independently associated with increased rates of post-operative morbidity in the ballistic cohort alone. LEVEL OF EVIDENCE: III.

Ethical Considerations of Artificial Intelligence in Health Care: Examining the Role of Generative Pretrained Transformer-4.

The integration of artificial intelligence technologies, such as large language models (LLMs), in health care holds potential for improved efficiency and decision support. However, ethical concerns must be addressed before widespread adoption. This article focuses on the ethical principles surrounding the use of Generative Pretrained Transformer-4 and its conversational model, ChatGPT, in healthcare settings. One concern is potential inaccuracies in generated content. LLMs can produce believable yet incorrect information, risking errors in medical records. Opacity of training data exacerbates this, hindering accuracy assessment. To mitigate, LLMs should train on precise, validated medical data sets. Model bias is another critical concern because LLMs may perpetuate biases from their training, leading to medically inaccurate and discriminatory responses. Sampling, programming, and compliance biases contribute necessitating careful consideration to avoid perpetuating harmful stereotypes. Privacy is paramount in health care, using public LLMs raises risks. Strict data-sharing agreements and Health Insurance Portability and Accountability Act (HIPAA)-compliant training protocols are necessary to protect patient privacy. Although artificial intelligence technologies offer promising opportunities in health care, careful consideration of ethical principles is crucial. Addressing concerns of inaccuracy, bias, and privacy will ensure responsible and patient-centered implementation, benefiting both healthcare professionals and patients.

All-suture fixation of syndesmotic injuries: a case series.

BACKGROUND: To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS: This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS: In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS: In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

ChatGPT's Ability to Assist with Clinical Documentation: A Randomized Controlled Trial.

INTRODUCTION: Clinical documentation is a critical aspect of health care that enables healthcare providers to communicate effectively with each other and maintain accurate patient care records. Artificial intelligence tools, such as chatbots and virtual assistants, have the potential to assist healthcare providers in clinical documentation. ChatGPT is an artificial intelligence conversational model that generates human-like responses to text-based prompts. In this study, we sought to investigate ChatGPT's ability to assist with writing a history of present illness based on standardized patient histories. METHODS: A blinded, randomized controlled study was conducted to compare the use of typing, dictation, and ChatGPT as tools to document history of present illness (HPI) of standardized patient histories. Eleven study participants, consisting of medical students, orthopaedic surgery residents, and attending surgeons, completed three HPIs using a different documentation technique for each one. Participants were randomized into cohorts based on the type of documentation technique. Participants were asked to interview standardized patients and document the patient's history of present illness using their assigned method. RESULTS: ChatGPT was found to be intermediate for speed; dictation was fastest, but produced markedly longer and higher quality patient histories based on Physician Documentation Quality Instrument score compared with dictation and typing. However, ChatGPT included erroneous information in 36% of the documents. Poor agreement existed on the quality of patient histories between reviewers. DISCUSSION: Our study suggests that ChatGPT has the potential to improve clinical documentation by producing more comprehensive and organized HPIs. ChatGPT can generate longer and more detailed documentation compared with typing or dictation documentation methods. However, additional studies are needed to investigate and address concerns regarding privacy, bias, and accuracy of information.

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy.

OBJECTIVE: Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair. METHODS: Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables. RESULTS: Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk. CONCLUSION: The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

Optimal Treatment of Proximal Humeral Fractures in the Elderly: Risks and Management Challenges.

Proximal humeral fractures (PHFs) are a common type of fracture, particularly in older adults, accounting for approximately 5-6% of all fractures. This article provides a comprehensive review of PHFs, focusing on epidemiology, injury mechanism, clinical and radiographic assessment, classification systems, and treatment options. The incidence of PHFs varies across regions, with rates ranging from 45.7 to 60.1 per 100,000 person-years. Females are more susceptible to PHFs than males, and the incidence is highest in women over the age of 85. The injury mechanism of PHFs is typically bimodal, with high-energy injuries predominant in younger individuals and low-energy injuries in the elderly. Clinical assessment of PHFs involves obtaining a thorough history, physical examination, and evaluation of associated injuries, particularly neurovascular injuries. Radiographic imaging helps assess fracture displacement and plan for treatment. The Neer classification system is the most commonly used classification for PHFs, although other systems, such as AO/OTA, Codman-Hertel, and Resch classifications, also exist. The choice of treatment depends on factors such as patient age, activity level, fracture pattern, and surgeon expertise. Nonoperative management is typically preferred for elderly patients with minimal displacement, while operative fixation is considered for more complex fractures. Nonoperative treatment involves sling immobilization followed by physiotherapy, with good outcomes reported for certain fracture patterns. Operative management options include closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), or arthroplasty. CRPP is suitable for specific fracture patterns, but the quality of reduction is crucial for favorable outcomes. ORIF is used when CRPP is not feasible, and various surgical approaches are available, each with its advantages and potential complications. PHFs are a significant clinical challenge due to their prevalence and complexity. Treatment decisions should be patient centered based on patient factors and fracture severity.

Team Approach: The Unstable Trauma Patient.

¼ A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.¼ The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries¼ Effective and open dialog with consulting specialists is paramount for effective team-based care.¼ Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough?

➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.

Comparison between micro-anchor skin dressing and liquid bonding agent for elective knee arthroscopy portal closure.

OBJECTIVE: The objective of the current study was to evaluate outcomes of elective knee arthroscopy portal closure comparing two skin closure techniques. METHOD: This was a randomised controlled trial including healthy volunteers aged ≥18 years undergoing elective knee arthroscopy that used two portals. At the time of surgery, each patient's two arthroscopy portal closures were randomised to one of two closure techniques; the first technique used approximation of the skin with a micro-anchor skin dressing (BandGrip Inc., US), while the second closure technique used an absorbable suture (Biosyn Monofilament, Medtronic) and a liquid bonding agent skin closure (Dermabond, Ethicon Inc., US). Postoperative complications and patient-reported outcomes were evaluated at the first visit after knee arthroscopy and at six weeks postoperatively. RESULTS: A total of 38 patients (76 portals) were enrolled in this study. No patients reported wound complications of either portal; thus, there was no significant difference (p>0.05) in wound complication rates between the skin closure techniques. Survey questions regarding any difference in appearance and cosmesis between the closure techniques' portal sites were responded to by 15 patients, all of whom indicated no difference in appearance between the portal sites. There was also no statistically significant difference between the two closure techniques with regards to appearance. CONCLUSION: There was no significant difference in presence of wound complications or appearance between skin closure with the micro-anchor skin dressing and the absorbable suture/liquid bonding agent skin closure.

Firearm-Related Injuries-Wound Management, Stabilization, and Associated Injuries: A Critical Analysis Review.

¼: Gun violence-related and firearm-related injuries are a public health crisis with increasing rates, particularly among younger demographics, in the United States despite a decline in incidence worldwide. ¼: There exists limited high-quality evidence to guide the management of firearm-related orthopaedic injuries. ¼: Associated injuries (i.e., neurological and vascular) are common in ballistic injuries to the extremity. ¼: Where indicated, low-energy orthopaedic injuries can be managed successfully with standard fixation and management strategies with similar complications to closed fractures.

Isolated ballistic femoral condyle fractures: a case series of eighteen patients.

PURPOSE: Ballistic fractures of the femoral condyles are rare injuries with limited literature to help guide treatment. The purpose of this study is to report on the presentation, management, and outcomes for patients with isolated ballistic condylar fractures. METHODS: Eighteen patients between ages 16 and 65 with low-energy ballistic injuries isolated to the femoral condyles (OTA 33B) were included, 15 with CT imaging. Clinical records and imaging were reviewed, as well as treatment strategy. Fractures were classified by AO/OTA classification. Outcome and follow-up data were gathered at outpatient appointments and telephone calls. RESULTS: Of the 18 patients, 78% were treated operatively (61% with open reduction and internal fixation, 17% with removal of foreign body alone). There were two instances of traumatic vascular injury and no neurologic injuries. Furthermore, there were no identified infections. Only 58% of the patients had follow-up for more than 6 weeks with average KOOS Jr. Score of 50, and average VAS pain score of 5.2. CONCLUSIONS: Ballistic femoral condyle fractures are rare Orthopaedic injuries seen in relatively high frequency at our institution. Most (78%) were treated operatively and with few complications. These fractures are not easily classified according to common classification schemes and may benefit from more rigorous study to guide treatment and anticipate outcomes.

Dual mini-fragment plate fixation of midshaft clavicle fractures is biomechanically equivalent to anatomic pre-contoured plating.

OBJECTIVES: To biomechanically compare the stiffness of midshaft synthetic clavicle osteotomies fixed with either superior anatomic pre-contoured locking plates, anterior anatomic pre-contoured locking plates, or short-segment dual orthogonal mini-plate fixation. DESIGN AND SETTING: Controlled laboratory study. Specimens Twenty-one synthetic pre-osteotomized clavicles were separated into three groups: superior plating, anterior plating, or dual-plating. Each clavicle was sequentially tested in non-destructive cycles of axial compression, three-point bending, and torsion. Load and displacement were recorded. Stiffness was calculated. RESULTS: No statistically significant differences were found between construct stiffness during axial compression, three-point bending, or torsional testing. One superior plated clavicle suffered catastrophic failure during axial compression. One dual mini-fragment plated clavicle suffered catastrophic failure during torsion. CONCLUSIONS: Orthogonal dual mini-fragment fixation of transverse clavicle fractures is biomechanically similar to superior and anterior pre-contoured anatomic locking plate fixation. No statistically significant differences in construct stiffness were found in axial compression, three-point bending, or torsion testing. Further clinical research is required to determine the long-term stability of dual mini-fragment plate fixation. LEVEL OF EVIDENCE: IV.

Bilateral femur fractures are associated with concomitant femoral neck fracture.

OBJECTIVE: The purpose of this study is to determine the rate of femoral neck fractures in patients who have sustained bilateral femur fractures compared to unilateral femur fractures. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: All patients treated for a femur fracture between May 1, 2018 and December 31, 2020 were included. RESULTS: Twenty-one patients sustained bilateral femur fractures (11%) and 166 sustained unilateral femur fractures. Fifteen associated ipsilateral femoral neck fractures were identified. Eight of the 15 (53%) associated femoral neck fractures were observed in patients who sustained bilateral femur fractures. Eight of the 21 patients with bilateral femur fractures, 42 fractures in total, had an associated ipsilateral femoral neck fracture (38% of patients; 19% of fractures, respectively), while only seven of the 166 patients (4%) with a unilateral femur fracture had an associated femoral neck fracture (p < 0.001). Of the 208 femur fractures, 19 (9%) were open fractures. Ten of the 21 patients with bilateral femur fractures, 42 fractures in total, were identified to have an open femur fracture (48% of patients, 24% of fractures), while only nine of the 166 (5%) unilateral femur fractures were open (p < 0.001). CONCLUSIONS: Our results demonstrate an association between bilateral femur fractures, open femur fractures, and associated femoral neck fractures. Surgeons treating these injuries should maintain a high index of suspicion for associated ipsilateral proximal.

Protective Sport Bracing for Athletes With Mid-Season Shoulder Instability.

CONTEXT: In-season glenohumeral instability is a common clinical dilemma faced by physicians who care for athletes. Both nonoperative and operative management of athletes with in-season glenohumeral instability have been well described. Functional bracing remains less understood as a treatment modality. This review aims to provide an update on the most recent literature regarding the use of functional bracing for shoulder instability. EVIDENCE ACQUISITION: MEDLINE (PubMed and Ovid platforms), Web of Science, Embase, and Cochrane Database of Systemic Reviews were searched for articles available in English through June 1, 2021. The search terms shoulder brace, shoulder instability, athlete, in-season, glenohumeral instability, anterior shoulder instability, posterior shoulder instability, and bracing were used. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: Research on the clinical outcomes of functional bracing remains mixed for patients with shoulder instability. Two studies have demonstrated improved return to play with functional bracing, while 1 study demonstrated no difference in return to play between braced athletes and nonbraced athletes with anterior instability. One previous study demonstrated that prophylactic use of bilateral shoulder stabilizing braces significantly decreased time lost due to injury in athletes with posterior instability. Previous biomechanical studies have demonstrated improved proprioception with brace wear as well as successful limitation of active shoulder range of motion. CONCLUSION: Bracing in athletes with shoulder instability remains an important nonoperative treatment modality. While clinical benefits are yet to be validated through high-quality studies, preliminary results suggest a potential benefit to recovery, with minimal downsides. Nevertheless, the use of bracing remains an individual choice but is especially recommended in settings of high-risk sports for shoulder instability, such as football.

Effect of nailing technique on length of stay in isolated ballistic femoral shaft fractures.

PURPOSE: The purpose of this study was to investigate length of stay, postoperative mobilization and discharge disposition following intramedullary nailing of ballistic femoral shaft fractures stratified by nailing technique. METHODS: All adult patients with isolated ballistic femoral shaft fractures between May 1, 2018, and September 1, 2021, were reviewed. The final cohort included 69 ballistic femur fractures in 69 patients. Of the 69 patients included, 29 were treated with retrograde nailing while 40 were treated with antegrade nailing. RESULTS: The average length of stay of patients treated with antegrade nailing was 2.55 days (SD 1.3 days) compared with 3.45 days (SD 2.3 days) for patients treated with retrograde nailing; this was statistically significant (P = 0.04). Median steps on POD1 for antegrade nailing were 20 and 8 for retrograde. There was no significant difference in VAS pain scores between the two cohorts. All patients were discharged home. CONCLUSION: The average length of stay for patients who underwent antegrade nailing was significantly shorter when compared with the retrograde nailing. Patients in the antegrade cohort mobilized further than the retrograde cohort in the immediate postoperative setting. We found no significant difference in VAS pain scores between the two cohorts.

A comparison of the incidence of concomitant ipsilateral femoral neck fractures in ballistic versus blunt femur fractures.

OBJECTIVE: The purpose of this study is to evaluate the rate of ipsilateral femoral neck fractures in ballistic femur fractures and compare this to similar non-ballistic blunt fractures. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single Level 1 trauma academic medical center. PATIENTS: All patients treated for a ballistic or blunt femur fracture presenting to our institution between May 1, 2018, and February 29, 2020, were included. In all, 270 femur fractures were identified. We excluded 73, including 29 pediatric fractures and 44 geriatric peritrochanteric fractures. The final cohort included 197 femur fractures in 187 patients. Of the 197 femur fractures included, 68 were ballistic and 129 were blunt mechanism. RESULTS: Four ipsilateral femoral neck fractures were identified in the ballistic fracture cohort. There was no significant difference between ipsilateral femoral neck fractures associated with blunt femur fractures when compared with ballistic fractures, 7.7 versus 5.8%, respectively. We identified one occult femoral neck fracture that was associated with a ballistic 32-B3 femoral shaft fracture. The ipsilateral femoral neck fracture associated with the 32-B3 ballistic femoral shaft fracture was not identified on plain films (Fig. 3A, B) and review of CTA during initial trauma workup. Identification of this fracture intra-operatively changed the treatment plan from standard proximal locking to recon proximal locking for this case. Patients included in the blunt fracture cohort were more likely to be poly-trauma patients with a higher rate of associated fractures. CONCLUSIONS: We detected no difference in rate of associated femoral neck fracture between blunt and ballistic femur fractures. These fractures can be missed on initial evaluation, which may lead to a delayed diagnosis and alter treatment plans. The authors conclude that treating surgeons must remain vigilant with a high index of suspicion for occult femoral neck fractures in patients who suffer ballistic femoral shaft fractures. Low-energy ballistic injuries should not rule out the possibility of an occult femoral neck fracture.

Gunshot-related lower extremity nerve injuries.

OBJECTIVE: The purpose of this study was to describe the frequency of nerve injury associated with lower extremity ballistic trauma, the associated skeletal and soft tissue injuries, and the rate of neurologic recovery. DESIGN AND SETTING: A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS: This was an institutional review board approved retrospective cohort study of patients over 16 years of age presenting with ballistic-related traumatic injury to the lower extremities between May 2018 and May 2019. All patients identified with lower extremity ballistic trauma were included in this study. The rate of nerve palsy, associated skeletal injury, and operative fixation were recorded for each anatomic zone. Rates of associated concomitant vascular injury, fracture, and compartment syndrome were collected through a review of the electronic medical records. Chart review was performed to evaluate outcomes and nerve recovery. RESULTS: Twenty-one patients (21 extremities, 21/148, 14%) were diagnosed by attending physicians, fellowship-trained in orthopedic trauma, as having ballistic-related nerve injuries. Seventy-three percent of patients with a documented neurologic injury (11/15) demonstrated complete nerve recovery as measured by the MRC and sensory scale assessment at most recent follow-up, while the rest demonstrated no improvement in their neurologic deficits from presentation. The rate of associated vascular injury in patients with lower extremity nerve palsies was 38% (8/21). While the rate of vascular injury in the absence of neurologic injury was 3% (4/127). CONCLUSIONS: This series of lower extremity nerve injuries in a large sample of urban lower extremity ballistic trauma noted a high rate of concomitant nerve injuries. An associated diagnosis of a vascular injury appears to portend a higher risk of neurologic injury. Treating surgeons should have a high index of suspicion for associated vascular injury in patients presenting with a ballistic lower extremity nerve palsy.

Comparison of a Novel Modified All-Suture Construct versus Suspensory Suture-button Fixation in a Syndesmotic Injury Model.

OBJECTIVES: To biomechanically investigate a novel modified all-suture construct compared with commercially available suspensory button fixation for stabilization of the syndesmosis. METHODS: Eight matched pairs of cadaver lower limbs were obtained. We used a material testing machine and Optotrak optoelectronic 3D motion measurement system for testing. Syndesmotic injuries were simulated, and specimens were fixed with either a suspensory suture button or modified all-suture construct. Repaired specimens were then cyclically loaded for 500 cycles. Spatial relationship of the tibia and fibula were continuously monitored for the intact, destabilized, and repaired states. The results were analyzed using independent samples t test. RESULTS: There was no significant difference in sagittal or coronal plane translation between intact and either repair. Compared with the intact state, both repair techniques demonstrated significantly more external rotation of the fibula relative to the tibia and decreased construct stiffness. Cycling of the specimens did not significantly increase coronal or sagittal plane translation; however, external rotation of the fibula relative to the tibia increased and stiffness decreased with cycling for both repair techniques. CONCLUSIONS: Our data suggest that sagittal and coronal plane translation is no different from the intact state for both fixation techniques. However, rotation of the fibula relative to the tibia was increased, and construct stiffness was decreased compared with the intact state for both fixation techniques. These findings suggest that an all-suture construct could offer syndesmotic fixation comparable with proprietary suspensory button fixation in a cadaver model.