Weight-bearing protocols should optimize fracture healing while avoiding fracture displacement or implant failure. Biomechanical and animal studies indicate that early loading is beneficial, but high-quality clinical studies comparing weight-bearing protocols after lower extremity fractures are not universally available. For certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit. Several randomized, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (≥6 weeks) weight bearing. Retrospective series have reported low complication rates with immediate weight bearing following intramedullary nailing of femoral shaft fractures and following surgical management of femoral neck and intertrochanteric femur fractures in elderly patients. For other fracture patterns, particularly periarticular fractures, the evidence in favor of early weight bearing is less compelling. Most surgeons recommend a period of protected weight bearing for patients with calcaneal, tibial plafond, tibial plateau, and acetabular fractures. Further studies are warranted to better define optimal postoperative weight-bearing protocols.

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.

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Objectives: To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. Design: Retrospective cohort study. Setting: Four Level 1 Academic Trauma Centers. Patients/Participants: All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. Intervention: Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6–8 weeks. Main Outcome Measurements: Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. Results: One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12–148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN.” Conclusions: This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Objectives: Develop a radiographic fracture scoring system for LC-1 pelvic fractures based on OTA survey data and preliminarily evaluate this system within a LC-1 pelvis fracture cohort. Design: Survey study with validation patient cohortSetting: 2 Level-1 academic trauma centers Patients/Participants: 2013 OTA national meeting attendees (n = 111) reviewed imaging from 27 LC-1 fractures and indicated surgical recommendations ("yes/no"). A separate LC-1 fracture cohort (33 patients) was used to evaluate the scoring system.Intervention: LC-1 scoring system (range: 5-14) based on radiographic morphology of sacral, superior ramus (SR), and inferior ramus (IR) fracture components Main Outcome Measurement: Numeric scores were compared against 1) OTA attendees' operative recommendations and 2) LC-1 cohort treatment and outcomes.Results: Operative tendency of OTA survey respondents -defined as the percent of "yes" responses to recommend surgical stabilization -was highly correlated with radiographic findings: sacral displacement [OR=18.9 (95% confidence interval CI: 11.7-30.6)]; sacral column 2-3 vs. 1 [OR=5.7 (95% CI: 3.9-8.3)]; Denis classification [OR=10 (95% CI: 6.7-14.9); IR displacement OR=3.4 (95% CI: 2.3-4.8)]; SR fracture [OR=1.9 (95%

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.