Acetabular dysplasia and posterior wall fractures: The missing link?

BACKGROUND: Traumatologists are unable to predict hip instability based on CT scans and standard radiographs in posterior wall (PW) fractures comprising <50-60 % of the wall, necessitating an examination under anesthesia (EUA). Risk factors for instability have not been clarified, but acetabular dysplasia has been theorized as a potential etiology. Unfortunately, dysplasia is difficult to evaluate in the traumatic setting. The purpose of this study was to compare acetabular morphology between unstable and stable fractures with a novel method to detect dysplasia. METHODS: Patients ≥ 18 years old with a PW fracture that underwent an EUA from 2013 to 2023 were retrospectively identified. For our experimental measurements, the axial distances on CT between the acetabular dome, lateral acetabular opening, and femoral head vertex were recorded. Acetabular geometry was quantified at these levels. Conventional dysplasia metrics (e.g., Tonnis angle) were obtained. Variables were compared between stable and unstable fractures. RESULTS: 58 patients met inclusion criteria with 42 stable versus 16 unstable fractures. Unstable fractures had higher distances between the acetabular dome and femoral head vertex (p > 0.05). They had more cranial fracture exit points (p = 0.0015), lower femoral head coverage (p = 0.0102), and lower posterior acetabular sector angles (p = 0.0281). No other differences in acetabular geometry, demographics, injury characteristics, or other markers of dysplasia were identified. CONCLUSIONS: Unstable hips demonstrated a more recessed acetabular dome when compared to stable hips. Posterior acetabular femoral head coverage and cranial fracture exit point may be related to hip instability. A larger sample size is needed to validate these findings.

Evaluation of obesity and age as a predictive factor of lower extremity compartment syndrome: A national trauma data bank analysis.

BACKGROUND: Risk factors of acute compartment syndrome (ACS) of the leg include tibial fractures followed by soft tissue injuries. METHODS: Data collected from the National Trauma Data Bank (NTDB) between 2017 and 2019 were analyzed for adult patients with lower extremity fractures, including proximal tibia, tibial shaft, and distal tibia. The primary outcome was a diagnosis of ACS. RESULTS: There were 1052/220,868 patients with lower extremity fractures with a concomitant diagnosis of compartment syndrome. Our study has shown that patients with a BMI of ≥30 had a lower incidence of compartment syndrome when compared with patients with a BMI of 25-29 and controlled for fracture type. Increased age ≥55 in males, and females between 65 and 84, also demonstrated a decreased risk. Proximal tibial fractures (n â€‹= â€‹54,696) were significantly associated with ACS compared to midshaft (n â€‹= â€‹42,153) and distal (n â€‹= â€‹100,432), p â€‹< â€‹0.0001. CONCLUSION: We found that being overweight decreases risk for development of compartment syndrome in patients with lower extremity fractures. This big data study aids in establishing risk factors for development of ACS in adult trauma patients.

Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series.

PURPOSE: To review outcomes of spinopelvic dissociation treated with open lumbopelvic fixation. METHODS: We reviewed all cases of spinopelvic dissociation treated at three Level-I trauma centers with open lumbopelvic fixation, including those with adjunctive percutaneous fixation. We collected demographic data, associated injuries, pre- and postoperative neurologic status, pre- and postoperative kyphosis, and Roy-Camille classification. Outcomes included presence of union, reoperation rates, and complications involving hardware or wound. RESULTS: From an initial cohort of 260 patients with spinopelvic dissociation, forty patients fulfilled inclusion criteria with a median follow-up of 351 days. Ten patients (25%) had a combination of percutaneous iliosacral and open lumbopelvic repair. Average pre- and postoperative kyphosis was 30 degrees and 26 degrees, respectively. Twenty patients (50%) had neurologic deficit preoperatively, and eight (20%) were unknown or unable to be assessed. All patients presenting with bowel or bladder dysfunction (n = 12) underwent laminectomy at time of surgery, with 3 patients (25%) having continued dysfunction at final follow-up. Surgical site infection occurred in four cases (10%) and wound complications in two (5%). All cases (100%) went on to union and five patients (13%) required hardware removal. CONCLUSION: Open lumbopelvic fixation resulted in a high union rate in the treatment of spinopelvic dissociation. Approximately 1 in 6 patients had a wound complication, the majority of which were surgical site infections. Bowel and bladder dysfunction at presentation were common with the majority of cases resolving by final follow-up when spinopelvic dissociation had been treated with decompression and stable fixation.

Characterizing Trauma Patients with Delays in Orthopaedic Process Measures.

INTRODUCTION: Early operative intervention in orthopaedic injuries is associated with decreased morbidity and mortality. Relevant process measures (e.g. femoral shaft fixation <24 hours) are used in trauma quality improvement programs to evaluate performance. Currently, there is no mechanism to account for patients who are unable to undergo surgical intervention (i.e. physiologically unstable). We characterized the factors associated with patients who did not meet these orthopaedic process measures. METHODS: A retrospective cohort study of patients from 35 ACS-COT verified Level 1 and Level 2 trauma centers was performed utilizing quality collaborative data (2017-2022). Inclusion criteria were adult patients (≥18 years), ISS ≥5, and a closed femoral shaft or open tibial shaft fracture classified via the Abbreviated Injury Scale version 2005 (AIS2005). Relevant factors (e.g. physiologic) associated with a procedural delay >24 hours were identified through a multivariable logistic regression and the effect of delay on inpatient outcomes was assessed. A sub-analysis characterized the rate of delay in "healthy patients". RESULTS: We identified 5,199 patients with a femoral shaft fracture and 87.5% had a fixation procedure, of which 31.8% had a delay, and 47.1% of those delayed were "healthy." There were 1,291 patients with an open tibial shaft fracture, 92.2% had fixation, 50.5% had an irrigation and debridement and 11.2% and 18.7% were delayed, respectively. High ISS, older age and multiple medical comorbidities were associated with a delay in femur fixation, and those delayed had a higher incidence of complications. CONCLUSIONS: There is a substantial incidence of surgical delays in some orthopaedic trauma process measures that are predicted by certain patient characteristics, and this is associated with an increased rate of complications. Understanding these factors associated with a surgical delay, and effectively accounting for them, is key if these process measures are to be used appropriately in quality improvement programs. LEVEL OF EVIDENCE: Level III; Therapeutic/Care Management.

AOA Critical Issues Symposium: Gun Violence as a Public Health Crisis.

ABSTRACT: Gun violence is an epidemic throughout the United States and is increasing around the world-it is a public health crisis. The impact of gun violence is not limited to the victims (our patients); it also extends to the physicians and caregivers who are taking care of these patients every day. Even more broadly, gun violence affects those living and going to work in potentially dangerous environments. The "vicarious trauma" that is experienced in these situations can have long-term effects on physicians, nurses, and communities. Importantly, socioeconomic disparities and community deprivation strongly correlate with gun violence. Systemic factors that are deeply ingrained in our society can increase concerns for these underrepresented patient populations and cause increased stressors with substantial health consequences, including delayed fracture-healing and poorer overall health outcomes. It is incumbent on us as physicians to take an active role in speaking up for our patients. The importance of advocacy efforts to change policy (not politics) and continue to push for improvement in the increasingly challenging environments in which patients and physicians find themselves cannot be overstated. Multiple national organizations, including many orthopaedic and general surgery associations, have made statements advocating for change. The American College of Surgeons, in collaboration with many other medical organizations, has supported background checks, registration, licensure, firearm education and training, safe storage practices, red flag laws, addressing mental health issues, and more research to better inform an approach going forward and to address the root causes of violence. We encourage the orthopaedic surgery community to stand together to protect each other and our patients, both physically and mentally, with agreement on these principles.

Do Women and Minority Orthopaedic Residents Report Experiencing Worse Well-being and More Mistreatment Than Their Peers?

BACKGROUND: Despite the increased risk of attrition for women and minority residents during orthopaedic residency, there is currently a paucity of research examining the training environment of these residents. To address this, we examined how well-being constructs may differ for women or minority residents compared with their peers, and whether these residents report experiencing more mistreatment during residency. QUESTIONS/PURPOSES: (1) How does the psychologic wellbeing of women and minority residents compare with that of their peers regarding the constructs of burnout, lifestyle satisfaction, social belonging, and stereotype threat? (2) Do reported mistreatment experiences during residency differ among women and minority residents compared with their peers? (3) Is there a difference in the proportion of women and minority orthopaedic residents with thoughts of leaving residency compared with their peers? METHODS: Seventeen orthopaedic residency programs in the 91 programs comprising the Collaborative Orthopaedic Educational Research Group agreed to participate in the study. Program directors sent an anonymous one-time survey with two reminders to all orthopaedic residents at their respective institutions. The survey instrument comprised validated and previously used instruments with face validity designed to measure burnout, satisfaction, duty-hour violations, belonging, stereotype threat, mistreatment, and thoughts of leaving residency, in addition to demographic information. Forty-three percent (211 of 491) of residents responded to the survey. Race or ethnicity data were combined into "White" and "underrepresented in orthopaedics" (URiO), which included residents who self-identified as Asian, African American, Hispanic or Latino, Native American, or other, given that these groups are all underrepresented racial and ethnic groups in orthopaedics. The demographic makeup of our study, 81% men and 75% White, is roughly comparable to the current demographic makeup of orthopaedic residency programs, which is 82% men and 74% White. Data were analyzed using chi-square tests, Fisher exact tests, and t-tests as appropriate. For comparisons of Likert scale measures, we used an anchor-based approach to determining the minimum detectable change (MDC) and set the MDC as a 1-point difference on a 5-point scale and a 1.5-point difference on a 7-point scale. Stereotype threat is reported as the mean ▵ from the neutral response, and ▵ of 1.5 or greater was considered significant. RESULTS: Women residents were more likely than men to report experiencing emotional exhaustion (odds ratio 2.18 [95% confidence interval 1.1 to 4.5]; p = 0.03). Women reported experiencing stereotype threat regarding their identity as women surgeons (mean ▵ 1.5 ± 1.0). We did not identify a difference in men's and women's overall burnout (OR 1.4 [95% CI 0.7 to 3.0]; p = 0.3), lifestyle satisfaction across multiple domains, or sense of social belonging (men: 4.3, women 3.6; mean difference 0.7 [95% CI 0.4 to 0.9]; p < 0.001). We did not identify differences in overall burnout (OR 1.5 [95% CI 0.8 to 3.0]; p = 0.2), lifestyle satisfaction across multiple domains, sense of social belonging (White: 4.2, URiO: 3.9; mean difference 0.3 [95% CI 0.17 to 0.61]; p < 0.001), or stereotype threat (mean ▵ 0.8 ± 0.9) between White and URiO surgeons. Women were more likely than men to report experiencing mistreatment, with 84% (32 of 38) of women and 43% (70 of 164) of men reporting mistreatment at least a few times per year (OR 7.2 [95% CI 2.8 to 18.1]; p < 0.001). URiO residents were more likely than White residents to report experiencing mistreatment overall, with 65% (32 of 49) of URiO residents and 45% (66 of 148) of White residents reporting occurrences at least a few times per year (OR 2.3 [95% CI 1.2 to 4.6]; p = 0.01). Women were more likely than men to report experiencing gender discrimination (OR 52.6 [95% CI 18.9 to 146.1]; p < 0.001), discrimination based on pregnancy or childcare status (OR 4.3 [95% CI 1.4 to 12.8]; p = 0.005), and sexual harassment (OR 11.8 [95% CI 4.1 to 34.3]; p < 0.001). URiO residents were more likely than White residents to report experiencing racial discrimination (OR 7.8 [95% CI 3.4 to 18.2]; p < 0.001). More women than men had thoughts of leaving residency (OR 4.5 [95% CI 1.5 to 13.5]; p = 0.003), whereas URiO residents were not more likely to have thoughts of leaving than White residents (OR 2.2 [95% CI 0.7 to 6.6]; p = 0.1). CONCLUSION: Although we did not detect meaningful differences in some measures of well-being, we identified that women report experiencing more emotional exhaustion and report stereotype threat regarding their identity as women surgeons. Women and URiO residents report more mistreatment than their peers, and women have more thoughts of leaving residency than men. These findings raise concern about some aspects of the training environment for women and URiO residents that could contribute to attrition during training. CLINICAL RELEVANCE: Understanding how well-being and mistreatment affect underrepresented residents helps in developing strategies to better support women and URiO residents during training. We recommend that orthopaedic governing bodies consider gathering national data on resident well-being and mistreatment to identify specific issues and track data over time. Additionally, departments should examine their internal practices and organizational culture to address specific gaps in inclusivity, well-being, and mechanisms for resident support.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient.

ABSTRACT: Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

OBJECTIVES: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. DESIGN: Retrospective case series. SETTING: Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS: Success rate of nonunion surgery. RESULTS: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Computed tomography assessment of pelvic bone density: Associations with age and pelvic fracture in motor vehicle crashes.

Motor vehicle crash (MVC) occupants routinely get a computed tomography (CT) scan to screen for internal injury, and this CT can be leveraged to opportunistically derive bone mineral density (BMD). This study aimed to develop and validate a method to measure pelvic BMD in CT scans without a phantom, and examine associations of pelvic BMD with age and pelvic fracture incidence in seriously injured MVC occupants from the Crash Injury Research and Engineering Network (CIREN) study. A phantom-less muscle-fat calibration technique to measure pelvic BMD was validated using 45 quantitative CT scans with a bone calibration phantom. The technique was then used to measure pelvic BMD from CT scans of 252 CIREN occupants (ages 16+) in frontal MVCs who had sustained either abdominal or pelvic injury. Pelvic BMD was analyzed in relation to age and pelvic fracture incidence. In the validation set, phantom-based calibration vs. phantom-less muscle-fat calibration yielded similar BMD values at the anterior superior iliac spine (ASIS; R2 = 0.95, p < 0.001) and iliac crest (R2 = 0.90, p < 0.001). Pelvic BMD was measured in 150 female and 102 male CIREN occupants aged 16-89, and 25% of these occupants sustained pelvic fracture. BMD at the ASIS and iliac crest declined with age (p < 0.001). For instance, iliac crest BMD decreased an average of 25 mg/cm3 per decade of age. The rate of iliac crest BMD decline was 7.6 mg/cm3 more per decade of age in occupants with pelvic fracture compared to those not sustaining pelvic fracture. Findings suggest pelvic BMD may be a contributing risk factor for pelvic fracture in MVCs.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Effect of Lawsuits on Professional Well-Being and Medical Error Rates Among Orthopaedic Surgeons.

INTRODUCTION: Orthopaedic surgery is one of the most cited specialties among legal claims. Malpractice lawsuits are financially burdensome, increase defensive practices, and incur a notable emotional toll on defendants. We sought to determine the effect of malpractice lawsuits on professional well-being and self-reported medical errors among orthopaedic surgeons. METHODS: We surveyed 305 members of the American Orthopaedic Association to collect information on experiences with medical malpractice lawsuits, demographic and practice characteristics, professional well-being on the Professional Fulfillment Index, and self-reported medical errors. Multivariable logistic regression identified predictors of malpractice lawsuits, professional well-being, and self-reported medical errors. RESULTS: Seventy-three percent (224 of 305) respondents had been involved in a medical malpractice lawsuit. The odds of experiencing a malpractice lawsuit increased by seven percent with each year in practice (OR = 1.07, 95% CI: 1.04 to 1.10, P < 0.001) and with specialization in spine surgery. Respondents with a lawsuit in 2 years before the survey reported comparable professional well-being and medical error rates with those without a lawsuit. However, compared with respondents without a lawsuit, respondents with a lawsuit more than 2 years in the past were less likely to report burnout (OR = 0.43, 95% CI: 0.20 to 0.90, P = 0.03) and more likely to report a medical error in the past year, which resulted in patient harm (OR = 3.51, 95% CI: 1.39 to 8.91, P = 0.008). DISCUSSION: While malpractice lawsuits negatively affect professional well-being, this effect resolves with time. The effect on medical errors may be more permanent; orthopaedic surgeons who have experienced a lawsuit reported greater rates of medical errors even after these legal issues have been settled. Among orthopaedic surgeons dealing with lawsuits, supportive interventions to protect professional well-being and mitigate the factors which lead to greater medical errors are needed. LEVEL OF EVIDENCE: Prognostic Level III.

Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health.

PURPOSE: A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals. METHODS: One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis. RESULTS: Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office. CONCLUSION: Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.

Percutaneous Posterior Pelvic Fixation of Spinopelvic Dissociation: A Multicenter Series of Displaced Patterns.

OBJECTIVE: To characterize the success and complications of percutaneous posterior pelvic fixation in the treatment of displaced spinopelvic dissociation patterns. DESIGN: Retrospective cohort study. SETTING: Three Level I trauma centers. PATIENTS: 53 patients with displaced spinopelvic patterns were enrolled. INTERVENTION: Percutaneous iliosacral screw fixation was used. MAIN OUTCOME MEASURES: Main outcome measures include incidence of union, fixation failure, and soft tissue complications. RESULTS: All patients had displaced, unstable patterns with a mean preoperative kyphosis of 29.7 ± 15.4 degrees (range, 0-70). Most of the patients treated were neurologically intact (72%) or had an unknown examination at the time of fixation (15%). The median follow-up was 254 days (interquartile range, 141-531). The union rate was 98%. Radiographic and clinical follow-up demonstrated 1 case (2%) of nonunion. Two patients (4%) had radiographic evidence of screw loosening at the final follow-up, both of whom had fixation with a single sacroiliac-style screw placed bilaterally and went on to uneventful union. Neurologic recovery occurred at an average of 195 ± 114 days (range, 82-363 days). When present, long-term neurologic sequelae most commonly consisted of radicular pain and paresthesias at the final follow-up (n = 3, 6%). CONCLUSIONS: Percutaneous posterior pelvic fixation of select displaced spinopelvic dissociation seems to be safe with a low complication rate and reliable union. In a cohort of displaced fractures that were fixed in situ, we found a 2% rate of fixation failure/nonunion. Although rare, radicular pain and paresthesias were the most common long-term neurologic sequela. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

State of the Union: Timeliness to Antibiotics in Open Fractures.

OBJECTIVE: In open fractures, early administration of systemic antibiotics has recently been recognized as a universal recommendation, with the current American College of Surgeons Trauma Center Verification recommendation for administration within 1 hour of facility arrival. We sought to quantify the baseline rate of timely antibiotic administration and the various factors associated with delay. METHODS: Data from the National Trauma Data Bank were obtained for all patients treated for open fractures in 2019. 65,552 patients were included. Univariate and multivariate analyses were performed, first for patient, prehospital, and hospital factors compared with rate of antibiotic administration within 1 hour of hospital arrival, then with a multivariate analysis of factors affecting these times. RESULTS: The overall rate of antibiotic administration within 1 hour of arrival was 47.6%. Patient factors associated with lower rates of timely antibiotics include increased age, Medicare status, and a higher number of comorbidities. Associated prehospital factors included non-work-related injuries, fixed-wing air or police transport, and walk-in arrival method. Patients with lower extremity open fractures were more likely to receive antibiotics within 1 hour of arrival than those with upper extremity open fractures. Traumatic amputations had a higher rate of timely administration (67.3%). ACS trauma Level II (52.5%) centers performed better than Level III (48.3%), Level I (45.5%), and Level IV (34.5%) centers. Multivariate analysis confirmed the findings of the univariate analysis. CONCLUSIONS: Despite current clinical standards, rates of adherence to rapid antibiotic administration are low. Certain patient, facility, and environmental factors are associated with delays in antibiotic administration and can be a focus for quality improvement processes. We plan to use these data to evaluate how focus on antibiotic administration as this quality standard changes practice over time. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gender Diversity, Leadership, Promotion, and Opportunity Among the Members of the Orthopaedic Trauma Association (OTA).

OBJECTIVES: To demonstrate the gender distribution in leadership positions and academic promotion of Orthopaedic Trauma Association (OTA) members. METHODS: We conducted a cross-sectional examination of the 2020-2021 OTA membership cohort dataset provided by the OTA. Professional and academic information of OTA members at their site of appointment was also abstracted from publicly available online resources. Data included: gender, OTA membership category, OTA leadership position, trauma fellowship completion, trauma practice setting, level of trauma center, percentage of trauma work, year of first practice, academic rank, and university/hospital/institutional leadership role. Statistical analysis included chi-squared, Wilcoxon two-sample, and Fisher exact tests. RESULTS: 2608 OTA members were identified; 14.1% were women. Female representation was highest in the Trauma Practice Professional category (67.1%) and significantly lower in the Active category (9.1%) ( P < 0.0001). No statistically significant gender differences were observed regarding level of trauma center, percentage of trauma work, or trauma practice setting. In the Active, Clinical and Emeritus categories, men achieved a higher level of academic rank than women at their site of employment ( P = 0.003), while more men completed trauma fellowships ( P = 0.004) and had been in practice for significantly longer ( P < 0.0001). Men held more of the highest leadership positions (eg, Board of Directors) ( P = 0.0047) and the greatest number of leadership positions ( P = 0.017) within the OTA compared with women. CONCLUSION: Gender disparity exists within the upper echelon of leadership and academic representation in orthopaedic trauma. Our findings will help inform strategic policies to address gender diversity within the OTA and the broader orthopaedic trauma subspecialty.

Risk of Infection Following Gunshot Wound Fractures to the Foot and Ankle: A Multicenter Retrospective Study.

The purpose of this multicenter retrospective chart review was to describe demographics, fracture and wound characteristics, and treatments for foot and/or ankle fractures caused by gunshot wounds (GSWs) and identify factors that increase risk of infection in adults treated at 5 urban level 1 trauma centers in South and Midwest regions of the United States. A total of 244 patients sustained GSW-related fractures of the foot/ankle during 2007-2017, of whom 179 had ≥30 days of follow-up data after the initial injury. Most patients were male (95.1%; 232/244) with an average age of 31.2 years. On average, patients sustained 1.3 GSWs (range 1-5) to the foot/ankle. Most GSWs were categorized as low energy (85.1%; 171/201) and the majority (58.2%; 142/244) had retained bullet fragments. Antibiotics were administered at initial presentation to 78.7% (192/244) of patients and 41.8% (102/244) were managed operatively at the time of initial injury. Nerve injury, vascular injury, and infection were documented in, respectively, 8.6% (21/243), 6.6% (16/243), and 17.2% (42/244) of all cases. Multivariable analysis revealed that high-energy injuries and retained bullet fragments increased the risk of infection by 3-fold (odds ratio 3.09, 95% confidence interval 1.16-8.27, p = .025) and 3.5-fold (OR 3.48, 95% CI1.40-8.67; p = .008), respectively. Side of injury, primary injury region, and vascular injury were not significant predictors of infection risk. Further research should examine whether retained bullet fragments are directly associated with infection risk and support the development of guidelines regarding the management of patients with GSW-related fractures to the ankle/foot.

Analysis of 101 Mechanical Failures in Distal Femur Fractures Treated with 3 Generations of Precontoured Locking Plates.

OBJECTIVES: To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP). DESIGN: This retrospective case-control series evaluated mechanical treatment failures of DFLPs. SETTING: The study was conducted at 8 Level I trauma centers from 2010 to 2017. PATIENTS AND PARTICIPANTS: One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure. INTERVENTION: The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage). MAIN OUTCOME MEASURE: The main outcome measures included injury and DFLP details; modes and timing of failure were studied. RESULTS: One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P < 0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P < 0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P < 0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks). CONCLUSION: Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Small residual fracture gaps delay time to union in length stable femur fractures treated with intrameduallary fixation.

OBJECTIVES: The purpose of this study was to investigate whether residual fracture gapping and translation at time of intramedullary nail (IMN) fixation for diaphyseal femur fractures were associated with delayed healing or nonunion. DESIGN: Retrospective cohort study SETTING: Level 1 trauma hospital, quaternary referral center PATIENTS/PARTICIPANTS/INTERVENTION: Length stable Winquist type 1 and 2 diaphyseal femur fractures treated with IMN at a single Level I trauma center were retrospectively reviewed. MAIN OUTCOME MEASURE: The largest fracture gap and translation were evaluated on immediate anteroposterior (AP) and lateral postoperative radiographs. Radiographic healing was assessed using Radiographic Union Score in Femur (RUSF) scores at each follow-up. Radiographic union was defined as a RUSF score ≥8 and consolidation of at least 3 cortices. ANOVA and student's t-tests were used to evaluate the influence of fracture gap parameters on time to union (TTU) and nonunion rate. Patients were stratified to measured average gap and translation distances <1mm, 1-3mm and >3mm for portions of the analysis. RESULTS: Sixty-six patients who underwent IMN with adequate follow-up were identified. A total of 93.9% of patients achieved union at an average of 2.8 months. Fractures with average AP/lateral gaps of <1mm, 1-2.9 mm, and >3mm had an average TTU of 70.1, 91.7, and 111.9 days respectively; fractures with larger residual gap sizes had a significantly longer TTU (p=0.009). Fractures with an average gap of 1-2.9mm and >3 mm had a significantly higher nonunion rate (1.5% and 4.5% respectively) compared to 0% nonunion in the <1 mm group (p=0.003). CONCLUSION: Residual gapping following intramedullary fixation of length stable diaphyseal femur fractures is associated with a significant increase in likelihood of nonunion. SUMMARY: Residual displacement of length stable femoral shaft fractures following intramedullary nailing can have a significantly negative impact on fracture healing. An average 3 mm AP/lateral residual fracture gap or a total of 6 mm of the AP + lateral fracture gap appeared to be a critical gap size with increased rates of nonunion and time to union. Therefore, we suggest minimizing the sum of the residual AP and lateral fracture gap to less than a total of 6 mm.