Mullis, Brian

Abstract OBJECTIVES: · To determine if patients with knee flexion contracture after distal femur fracture have poorer outcomes than patients who regain full knee extension. · To determine if factors such as patient age, gender, open fracture or implant used favors knee flexion contracture. METHODS: Design: Prospective, multicenter trial Setting: Twenty academic level I trauma centers Patient Selection Criteria: Patients with a distal femur fracture. Patients were evaluated for knee flexion contracture at 3, 6 and 12 months post-operatively. Outcome Measures and Comparisons: SMFA, Bother Index and EQ Health Index scores were recorded. Walking and stair climbing ability were assessed. RESULTS: · 126 patients had radiographic follow up for 12 months. There was clinical follow-up for 99 patients at 3 months, 90 patients at 6 months and 74 pts at 12 months. · Patients with full knee extension had better SMFA scores at 12 months than patients with knee flexion contracture (p = 0.308). · Bother Index (p = 0.29) and EQ Health State (p = 0.12) scores did not demonstrate a difference between patients with or without knee flexion contracture at any time point. · Patients with full knee extension had improved walking ability compared to patients with flexion contracture (p = 0.008). Patients with full knee extension had better stair climbing ability than patients with flexion contracture (p = 0.02). · Only older patient age showed a difference in likelihood of flexion contracture (p = 0.01) The rates of flexion contracture in women versus men (p = 0.51), RIMN versus LLP (p = 0.74) and open versus closed fracture (p = 0.24) were not statistically different. CONCLUSIONS: · Patients with knee flexion contractures after distal femur fracture do worse than patients who regain full extension. · Older patients with distal femur fractures are at greater risk for knee flexion contracture. LEVEL OF EVIDENCE: Level I

Objectives: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. Design: Multicenter randomized controlled trial. Setting: Twenty academic trauma centers. Patients/Participants: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. Intervention: Lateral locked plating or retrograde intramedullary nailing. Main Outcome Measurements: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. Results: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. Conclusions: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. Setting: Fourteen level-1 trauma centers across the United States. Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. Intervention: Delay definitive fixation and flap coverage in tibial type III fractures. Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives:To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample.Design:Consecutive retrospective cohort review.Setting:Eighteen academic orthopedic trauma centers.Patients/Participants:Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery.Intervention:Humeral shaft nonunion repair and assessment of postoperative radial nerve function.Main Outcome:Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery.Results:Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18–93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P= 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved.Conclusion:In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.