Intervention: Surgical fixation of distal femur fracture.Main Outcome Measurement: The outcome of interest was deep surgical site infection.Results: There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P , 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillinsensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%).Conclusions: Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective.

Introduction:Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature.Methods:Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score.Results:The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5–72), suggesting that included studies were of moderate-to-poor quality.Conclusions:Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Intervention: Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. Main Outcome Measurements:The outcome of interest was unplanned reoperation to promote union.Results: There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P , 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P , 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive.Conclusions: Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intraarticular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups.

Previously published animal studies have shown positive skeletal effects with local or systemic administration of beta blockers (BBs). However, population studies have shown mixed effects on bone mineral density (BMD) and fracture risk with BB use. The goal of this study was to evaluate whether exposure to BB is associated with fracture nonunion. Fee-for-service Medicare beneficiaries with an extremity fracture were identified by International Classification of Diseases (ICD)-10 and current procedural terminology (CPT) codes from 2016-2019. Charlson Comorbidity Index (CCI) was assigned using diagnoses prior to index fracture and nonunion identified by ICD-10 or CPT codes within one year from index fracture diagnosis. Patients were classified by BB exposure based on Part D (Pharmacy) claims between 90 days prior to and one year following index fracture. Chi square and Student T-tests were performed on categorical and continuous variables, respectively. Logistic regression was performed to evaluate the association between BB use and nonunion, controlling for age, sex, race, and comorbidity. Total number of fractures meeting inclusion criteria was 253,266 with 45% of patients having used a BB during the study period. The incidence of nonunion was 3.9% overall. BBs were associated with a 13% increase in non-union for all fracture types, after controlling for age, sex, fracture location, and CCI (OR 1.13 [CI 1.06-1.20], p<.001). Results of this study suggest a negative influence of BB on bone healing, contrary to results of previously published animal models and epidemiologic observations, and demonstrate that BB use during fracture care is associated with significant increase in incidence of nonunion.

Intervention: Operative treatment with placement of cement spacer within 3 weeks of initial injury followed by staged removal and bone grafting to the defect.Main Outcome Measurements: Fracture union, infection, revision grafting, time to union, and amputation.Results: One hundred twenty fractures met inclusion criteria, including 43 diaphyseal fractures (DIM) and 77 metaphyseal fractures (MIM). Demographic characteristics were not significantly different, except for age (DIM 34 years vs. MIM 43 years, P , 0.001). Union after treatment with IMT was 89.2% overall. After controlling for age, this was not significantly different between DIM (41/43, 95.3%) and MIM (66/77, 85.7%) (P = 0.13) nor was the rate of infection between groups. There was no difference in any secondary outcomes. Conclusions:The overall union rate in the current series of acute lower extremity fractures treated with the induced membrane technique was 89%. There was no difference in successful union between patients with diaphyseal bone loss or metaphyseal bone loss treated with IMT. Similarly, there was no difference in patients with tibial or femoral bone loss treated with induced membrane. Defect size after debridement may be more prognostic for secondary operations rather than the limb segment involved or the degree of soft-tissue injury.