Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

Surgeon Learning Curve for the Sinus Tarsi Approach to Intra-articular Calcaneus Fractures - Improvement with Experience.

OBJECTIVE: To analyze the relationship between surgeon experience with the sinus tarsi approach (STA) and outcomes in the treatment of displaced intra-articular calcaneus fractures (DIACF). SETTING: Single level 1 trauma center. DESIGN: Retrospective.Patients/Participants: 103 consecutive DIACF (OTA/AO 82C; Sanders II-IV) treated operatively using STA from 2015 to 2021. INTERVENTION: Open management using the STA performed by two fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENT: Quality of anatomic reduction based on postoperative CT scans and standard radiographs. RESULTS: Sixty-six patients met inclusion criteria. Patients were primarily men (75.8%) with mean age 41 years (range 20-71 years), including 14 smokers (21.2%), 9 diabetics (13.6%), and 10 open fractures (15.2%). Sanders III fractures were most common (68.2% vs 28.5% and 6.1% Sanders II/IV respectively). Reduction quality was predominantly Good (59.1%, n=39) or Excellent (25.8%, n=17). Complications included wound necrosis (1), superficial infection (1), deep infection (1), and symptomatic posttraumatic arthritis requiring arthrodesis (3). There was a 29.3% reduction in likelihood of surgical complication with each year in surgeon experience with the STA and an 8.9% reduction per case (p<0.001). The likelihood of achieving a Good or Excellent reduction was 1.8 and 2.3 times greater than achieving a Fair reduction, respectively, for each year increase in surgeon experience with the STA (p=0.012 and 0.007, respectively). For each successive case, there was a 1.2 times greater likelihood of achieving a Good reduction (p=0.03). CONCLUSION: Surgeon experience plays a critical role in outcomes. We found that outcomes (reduction, complications) improve with each cumulative case and year of experience with the STA to treat DIACF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High- Versus Low-Energy Intertrochanteric Hip Fractures in Young Patients: Injury Characteristics and Factors Associated With Complications.

OBJECTIVE: To compare fracture patterns and associated injuries for young patients with high- versus low-energy intertrochanteric hip fractures and to report on factors associated with complications after surgical fixation of high-energy fractures. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 Trauma Center. PATIENTS: A total of 103 patients 50 years of age or younger were included: 80 high-energy fractures and 23 low-energy fractures. INTERVENTION: Cephalomedullary nailing (N = 92) or a sliding hip screw (N = 11). MAIN OUTCOME MEASURES: Radiographic characteristics of fracture morphology, implant position, and reduction quality and postoperative complications were the main outcome measures. RESULTS: Compared with young patients with low-energy fractures, those with high-energy fractures had more fracture comminution ( P = 0.013) and higher ISS scores ( P < 0.003) and were more likely to require open reduction ( P < 0.001). Patients with low-energy fractures from a ground-level fall had higher rates of alcohol abuse (0.032), cirrhosis (0.010), and chronic steroid use (0.048). Overall reoperation rate for high-energy fractures was 7%, including 2 IT fracture nonunions (5%) and 1 deep infection (2%). For high-energy fractures, ASA class ( P = 0.026), anterior lag screw position ( P = 0.001), and varus malreduction ( P < 0.001) were associated with malunion. Four-part fracture (OTA/AO 31A2.3/Jensen 5) ( P = 0.028) and residual calcar gap >3 mm ( P = 0.03) were associated with reoperation. CONCLUSIONS: Surgical treatment of high-energy IT fractures in young patients is technically demanding with potential untoward outcomes. Injury characteristics and severity are significantly different for young patients with high-energy IT fractures compared with low-energy fractures. For young patients with a high-energy IT fracture, surgeons can anticipate a high rate of associated injuries and complex fracture patterns requiring open reduction. For young patients with a low-energy IT fracture, comanagement with a hospitalist or a geriatrician should be considered because they may be physiologically older. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Acute Versus Staged Fixation of Complete Articular Tibial Plafond Fractures.

OBJECTIVE: To determine the outcomes after acute versus staged fixation of complete articular tibial plafond fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 Trauma center. PARTICIPANTS: 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had a minimum 6 months of follow-up. INTERVENTION: Acute open reduction internal fixation (aORIF) versus staged (sORIF) definitive fixation. MAIN OUTCOME MEASUREMENT: Rates of wound dehiscence/necrosis and deep infection. RESULTS: Acute (N = 40) versus staged (N = 58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs. 0%, P < 0.001), which correlated with higher American Society of Anaesthesiologist scores (>American Society of Anaesthesiologist 3: 37.5% vs. 13.8%, P = 0.02). Both groups achieved anatomic/good reductions, as determined by postoperative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs. sORIF: 121 vs. 146 minutes, P = 0.02). Postoperatively, both groups had similar rates of wound dehiscence (2.5% vs. 6.9%, P = 0.65), superficial infections (10% vs. 17.2%, P = 0.39), and deep infections (10% vs. 8.6%, P = 0.99). While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs. sORIF:12.5% vs. 25.9%, P = 0.13). CONCLUSIONS: In select patients managed by fellowship-trained orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Immediate Weight Bearing as Tolerated Is Safe Following Intramedullary Fixation of Extra-articular Metaphyseal Proximal Tibia Fractures (OTA/AO 41-A).

OBJECTIVES: To determine whether immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) results in change of alignment before union. DESIGN: Retrospective Review. SETTING: Level I and Level II Trauma Center. PATIENTS/PARTICIPANTS: Thirty-seven patients with 37 proximal tibial fractures, all whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 41-A2, and 19 were OTA/AO 41-A3. INTERVENTION: Intramedullary nailing of extra-articular proximal tibia fractures. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of reduction. RESULTS: The average change in coronal alignment at the final follow-up was 1.22 ± 1.28 degrees of valgus and 1.03 ± 1.05 degrees of extension in the sagittal plane. Twenty-five patients demonstrated excellent initial alignment, 10 patients demonstrated acceptable initial alignment, and 2 patients demonstrated poor initial alignment. Five patients demonstrated a change in alignment from excellent to acceptable at the final follow-up. No patient went from excellent or acceptable initial alignment to poor final alignment. Five patients required unplanned secondary surgical procedures. Two patients required return to the operating room for soft-tissue coverage procedures, 2 patients required surgical debridement of a postoperative infection, and 1 patient underwent debridement and exchange nailing of an infected nonunion. No patient underwent revision for implant failure or loss of reduction. CONCLUSION: Immediate weight bearing after intramedullary fixation of extra-articular proximal tibia fractures (OTA/AO 41A) led to minimal change in alignment at final postoperative radiographs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posteromedial Accessory Incision for Posterior Capsular Release and Retractor Placement in a Total Ankle Replacement.

The standard approach for performing a total ankle replacement (TAR) is the anterior approach as this offers good direct visualization of the tibiotalar joint. Irrespective of implant system used, most commonly, bone cuts are made in the anterior to posterior direction and may potentially injure the posterior neurovascular structures and tendons running close to the ankle joint. Careful consideration must be taken to ensure these structures are protected. We introduce a new intraoperative technique of protection for the posteromedial soft tissues and neurovascular structures and include the early results of 60 consecutive patients where the described technique was employed. There were no technique-related complications, or evidence of injury to the PTT, FHL, flexor digitorum longus (FDL), or neurovascular bundles.

Outcomes of Various Antibiotic Cement-Coated Intramedullary Implants on the Treatment of Long Bone Septic Nonunion.

OBJECTIVE: To determine the effectiveness of various types of antibiotic-coated intramedullary implants in the treatment of septic long bone nonunion. DESIGN: Retrospective chart review. SETTING: Level 1 trauma center. PARTICIPANTS: Forty-one patients with septic long bone nonunion treated with an antibiotic cement-coated intramedullary implant. INTERVENTION: Surgical debridement and placement of a type of antibiotic-coated intramedullary implant. MAIN OUTCOME MEASUREMENTS: Union and need for reoperation. RESULTS: At an average 27-month follow-up (6-104), 27 patients (66%) had a modified radiographic union score of the tibia of 11.5 or greater, 12 patients (29%) a score lower than 11.5, and 2 patients (5%) underwent subsequent amputation. Six patients underwent no further surgical procedures after the index operation. Patients treated with a rigid, locked antibiotic nail achieved earlier weight-bearing (P = 0.001), less frequently required autograft (P = 0.005), and underwent fewer subsequent procedures (average 0.38 vs. 3.60, P = 0.004) than those treated with flexible core antibiotic rods. CONCLUSIONS: Antibiotic-coated intramedullary implants are successful in the treatment of septic nonunions in long bones. In our cohort, rigid, statically locked nails allowed faster rehabilitation, decreased the need for autograft, and decreased the number of additional surgical procedures. Further study is needed to confirm these findings. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Biomechanical Effects of Femoral Neck Buttress Plate used for Vertical Femoral Neck Fractures.

PURPOSE: To investigate both the biomechanical and clinical effect of an inferomedial femoral neck buttress plate (FNBP) used to augment a sliding hip screw (SHS) and anti-rotational screw (ARS) in the treatment of traumatic vertical femoral neck fractures. METHODS: Part 1: Clinical - Retrospective review of patients under age 65 treated with open reduction of a vertical femoral neck fracture. Patients were divided into two groups: Group 1 patients (18 patients) had SHS/ARS fixation augmented with a FNBP, while Group 2 patients (18 patients) had SHS/ARS fixation alone and were matched for age and sex. Demographic data, OTA fracture classification, immediate post-operative and follow-up radiographs were analyzed for quality of reduction, femoral neck shortening (FNS), neck-shaft angle (NSA), avascular necrosis (AVN) and union. Part 2: Biomechanical - Pauwels III femoral neck osteotomy was created in five pairs of cadaveric specimens, then each fracture was reduced and stabilized with a SHS/ARS construct. Specimens were matched and split into Groups 1 and 2, similar to Part 1. Cadaveric specimens were axially loaded in cyclical fashion to analyze for construct stiffness, fracture displacement femoral neck shortening and changes in the neck shaft angle. RESULTS: Part 1: There were 18 matched patients (14 males and 4 females) in both Group 1 and Group 2. There were no statistically significant differences between the two groups with respect to Pauwels angle, femoral neck shortening, changes in neck-shaft angle, AVN or nonunion. One reoperation in Group 1 and four in Group 2. Part 2: All five cadaveric specimens in both groups survived the 10,000-cycle loading regimen. We were unable to detect any significant differences between the two groups with respect to construct stiffness, change in neck-shaft angle or amount of femoral neck shortening. CONCLUSION: Based on the results of both clinical case series and biomechanical testing, an inferomedial neck buttress plate does not appear to offer long-term benefits with respect to maintenance of alignment or achieving union but may potentially help in obtaining the reduction.

Single-Stage Versus 2-Stage Bilateral Intramedullary Nail Fixation in Patients With Bilateral Femur Fractures: A Multicenter Retrospective Review.

OBJECTIVE: To evaluate rates of complications in patients with bilateral femur fractures treated with intramedullary nailing (IMN) during either 1 single procedure or 2 separate procedures. DESIGN: A multicenter retrospective review of patients sustaining bilateral femur fractures, treated with IMN in single or 2-stage procedure, from 1998 to 2018 was performed at 10 Level-1 trauma centers. SETTING: Ten Level-1 trauma centers. PATIENTS/PARTICIPANTS: Two hundred forty-six patients with bilateral femur fractures. INTERVENTIONS: Intramedullary nailing. MAIN OUTCOME MEASURES: Incidence of complications. RESULTS: A total of 246 patients were included, with 188 single-stage and 58 two-stage patients. Gender, age, injury severity score, abbreviated injury score, secondary injuries, Glasgow coma scale, and proportion of open fractures were similar between both groups. Acute respiratory distress syndrome (ARDS) occurred at higher rates in the 2-stage group (13.8% vs. 5.9%; P value = 0.05). When further adjusted for age, gender, injury severity score, abbreviated injury score, Glasgow coma scale, and admission lactate, the single-stage group had a 78% reduced risk for ARDS. In-hospital mortality was higher in the single-stage cohort (2.7% compared with 0%), although this did not meet statistical significance (P = 0.22). CONCLUSIONS: This is the largest multicenter study to date evaluating the outcomes between single- and 2-stage IMN fixation for bilateral femoral shaft fractures. Single-stage bilateral femur IMN may decrease rates of ARDS in polytrauma patients who are able to undergo simultaneous definitive fixation. However, a future prospective study with standardized protocols in place will be required to discern whether single- versus 2-stage fixation has an effect on mortality and to identify those individuals at risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Regulation of orthopaedic devices: Future implications for research and innovation.

The conception-to-market development of orthopaedic devices occurs across the total product life cycle including device design and preclinical testing, clinical investigations to support marketing applications, and monitoring of device performance after market introduction. This process involves industry, regulatory agencies, health care providers, engineers, scientists, and patients. The Food and Drug Administration (FDA) is responsible for regulating medical devices in the United States, and uses a 3-tier classification system based on the level of control necessary to provide reasonable assurance of safety and effectiveness. Classification directs the required regulatory pathway and premarket submission type. Variations in global regulations, particularly between the United States, European Economic Area (EEA), and the United Kingdom (UK), may impact industry response to orthopaedic device development. Changing device innovation and reimbursement models have led to the consolidation of market share among larger companies. Although larger companies are better able to cope with more rigorous regulatory requirements, this leads to decreased competition and increased upward price pressure. To assist with the complex regulatory processes, the FDA offers pre-submission assistance as an opportunity for early collaboration and discussion about the medical device or device-led combination product submissions. Orthopaedic organizations, such as the Orthopaedic Trauma Association (OTA), may assist in postmarket device surveillance through the coordinated development and maintenance of clinical data registries. Such registries can longitudinally follow patients with a specific orthopaedic pathology or device usage, and monitor outcomes towards improvements in next-generation device development. As technology evolves, the nexus of regulation, industry, and patient outcome monitoring will continue to support safe and effective device innovation.

"Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications.

OBJECTIVES: To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. DESIGN: Retrospective cohort study. SETTING: One Level 1 and One Level 2 academic trauma centers. PATIENTS/PARTICIPANTS: One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. MAIN OUTCOME MEASUREMENT: Major and minor complications. RESULTS: One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). CONCLUSION: Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable." LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Quality of Reduction of Displaced Intra-articular Calcaneal Fractures Using a Sinus Tarsi Versus Extensile Lateral Approach.

OBJECTIVE: To evaluate the difference in the quality of fracture reduction between the sinus tarsi approach (STA) and extensile lateral approach (ELA) using postoperative Computed Tomography (CT) scans in displaced intra-articular calcaneal fractures (DIACFs). DESIGN: Retrospective. SETTING: Level 1 and level 2 academic centers. PATIENTS: Consecutive patients undergoing operative fixation of DIACFs with postoperative CT scans and standard radiographs. METHODS: Patients were identified based on Current Procedural Terminology code and chart review. All operative calcaneal fractures treated between 2012 and 2018 by fellowship-trained orthopaedic trauma surgeons were evaluated. Those with both postoperative CT scans and radiographs were included. Exclusion criteria included extra-articular fractures, malunions, percutaneous fixation, ORIF and primary fusion, and those patients without a postoperative CT scan. The Sanders classification was used. Cases were divided into 2 groups based on ELA versus STA. Bohler angle and Gissane angle were evaluated on plain radiographs. CT reduction quality grading included articular step off/gap within the posterior facet, and varus angulation of the tuberosity: CT reduction grading included: excellent (E): no gap, no step, and no angulation; good (G): <1 mm step, <5 mm gap, and/or <5° of angulation, fair (F): 1-3 mm step, 5-10 mm gap, and/or 5-15° angulation; and poor (P): >3 mm step, >10 mm gap, and/or >15° angulation. RESULTS: Seventy-seven patients with 83 fractures were included. Average age was 42 years (range, 18-74 years), with 57 men. Four fractures were open. There were 37 Sanders II and 46 Sanders III fractures; 36 fractures were fixed using the STA, whereas 47 used the ELA. Average days to surgery were 5 for STA and 14 for ELA (P < 0.001). A normal Bohler angle was achieved more often with the ELA (91.5%) than with STA (77.8%) (P < 0.001). There was no difference by approach for Gissane angle (P = 0.5). ELA had better overall reduction quality (P = 0.02). For Sanders II, there was no difference in reduction quality with STA versus ELA (P = 0.51). For Sanders III, ELA trended toward better reduction quality (P = 0.06). CONCLUSIONS: The ELA had a better overall reduction of Bohler angle on plain radiographs and of the posterior facet and tuberosity on postoperative CT scans. For Sanders type II DIACFs, there was no difference between STA and ELA. Importantly, for Sanders III DIACFs, ELA trended toward better reduction quality. In addition to fracture reduction, surgeon learning curve, early wound complications, and long-term outcomes must be considered in future studies comparing the ELA and STA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Navicular Body Fractures-Surgical Treatment and Radiographic Results.

OBJECTIVE: To assess injury patterns and outcomes after navicular fractures. DESIGN: Retrospective radiographic review using the Schmid classification. SETTING: Academic Level 1 Trauma Center; PATIENTS/PARTICIPANTS:: Thirty-nine navicular fractures associated with additional foot injuries. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Radiographic evaluation of nonunion, malunion, and post-traumatic arthritis; secondary operations. RESULTS: A total of 12/18 (67%) Schmid type II fractures healed without complications. Ten fractures were treated with tension band plates (56%) and 8 with screws (44%). Three complications were in cases treated with screws (3/8 = 37.5%). No case went on to develop avascular necrosis. In the 21 Schmid type III fractures, radiographic results were uniformly poor. Only 3 healed after the index procedure without evidence of radiographic post-traumatic arthritis. Four required a primary talonavicular (TN) fusion for an unreconstructable articulation found at the time of the index surgical treatment. The remaining 14 (67%) all had radiographic evidence of severe collapse, end-stage post-traumatic arthritis, and/or a significant midfoot deformity at the time of follow-up examination. Three of these required a late triple arthrodesis. CONCLUSION: Type II navicular body fractures are substantial injuries in which the amount of comminution belies the amount of damage to the talonavicular articulation. Tension band plate augmentation seemed to keep the navicular fracture secure and prevent lag screw loosening. Schmid type III navicular body fractures are devastating injuries. They are associated with additional severe trauma to the foot and require extensive surgical reconstruction of the medial column, lateral column, or both. Residual problems should be expected and may not be due to the navicular injury, but rather to the associated fractures and dislocations. Patients should be aware that their foot will be stiff and may require further reconstructive treatment. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN: Multicenter, retrospective analysis. SETTING: Nine Level 1 trauma centers across the United States. PATIENTS: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION: Functional brace. MAIN OUTCOME MEASUREMENTS: Conversion to surgery. RESULTS: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.