Abstract
Objectives:
To evaluate whether same-day discharge for aseptic lower extremity nonunions is associated with increased complication rates compared with patients admitted to the hospital, aiming to determine the safety and feasibility of same-day discharge in this patient population.
Methods:
A retrospective cohort study was conducted across 14 Level 1 trauma centers, including 981 adult patients who underwent surgical fixation of aseptic femur or tibia nonunions between 2007 and 2022. Patients were stratified by length of stay into same-day discharge and admission to the hospital (≥1 night). Primary outcomes were postoperative complications: infection, reoperation, and readmission rates. Multivariable logistic regression controlled for confounders including age, body mass index, comorbidities, ASA classification, insurance, and bone graft use.
Results:
Of 981 patients, 146 (14.9%) underwent same-day discharge and 835 (85.1%) were admitted to the hospital. Patients undergoing same-day discharge were younger, healthier, and had shorter operative times. Unadjusted complication rates were higher among patients admitted to the hospital; however, after adjustment, same-day discharge was not associated with increased odds of infection (odds ratio [OR] 0.75, P = 0.386), readmission (OR 0.76, P = 0.346), or reoperation (OR 0.92, P = 0.730). No significant differences in injury characteristics or procedure types were found between groups.
Conclusions:
Same-day discharge for aseptic lower extremity nonunion surgery was not associated with increased complication or readmission rates compared with admission to the hospital. With careful patient selection and perioperative management, same-day discharge pathways may be safely expanded for appropriately selected patients, supporting cost-effective care without compromising outcomes.
Level of Evidence:
III.
Keywords: nonunion, same-day discharge, lower extremity
Introduction
In recent years, healthcare initiatives have emphasized reducing costs by minimizing unnecessary resource utilization, such as shortening the length of stay (LOS) after surgery. As a result, outpatient surgery has gained traction across various orthopedic subspecialties, yet its role in complex orthopaedic trauma surgery procedures such as lower extremity nonunion repair remains poorly defined. Lower extremity fracture nonunion represents one of the most challenging clinical scenarios in orthopaedic surgery due to their substantial morbidity and resource demands.1 Nonunion occurs in approximately 8% to 12% of all lower extremity fractures, with rates rising as high as 16% in open fractures with extensive soft tissue damage.2,3 The impact of nonunion on patients is profound, often manifesting as severe pain, dysfunction, or emotional distress, and potential substantial financial burden due to prolonged debilitation.4 Striking a balance between achieving optimal patient outcomes and minimizing financial strain is a considerable challenge.
Outpatient surgery is emerging as a cost-effective and safe alternative in total joint arthroplasty. Many studies in the arthroplasty literature demonstrate that it can reduce expenses without compromising patient outcomes or increasing complication rates.5–9 Similar success has been observed in other areas of orthopaedics, such as spine with no compromise in surgical quality or postoperative outcomes.10–12 These studies highlight the importance of patient medical optimization as an important factor influencing outcomes and complication rates, emphasizing the need for careful selection of medically appropriate patients for outpatient procedures. Traditionally, patients undergoing operative fixation of lower extremity fracture nonunions are admitted to the hospital postoperatively. Same-day discharge in this population may be perceived as higher risk due to the complexity of nonunion procedures, the need for close postoperative monitoring, and concerns regarding pain control and early complication detection. However, recent advancements in nonunion surgery such as minimally invasive surgical techniques and multimodal pain control have mitigated some of these concerns, creating new opportunities to establish institutional protocols for same-day discharge of nonunion surgical patients.13
Despite these advances, a paucity of data exists describing the safety and efficacy of same-day discharge pathways in the management of aseptic lower extremity nonunions. This study aims to evaluate whether same-day discharge for aseptic lower extremity nonunions is associated with increased complication rates compared with patients admitted to the hospital, aiming to determine the safety and feasibility of same-day discharge in this patient population. We hypothesized that same-day discharge would not result in higher complication rates.
Methods
Institutional review board
This study was approved by each participating site's institutional review board (IRB). Owing to the retrospective nature of the study, the IRBs granted waivers of informed consent.
Study design
This retrospective cohort study pooled data from 14 Level 1 trauma centers to analyze complication rates from patients who underwent surgical fixation of aseptic tibial or femoral nonunions (i.e., free of clinical and serological signs of infection at the time of nonunion surgery). The electronic medical record systems at each center's institutional databases were queried to identify 1065 patients older than 18 years who underwent operative fixation of an aseptic femur or tibia nonunion. All patients were diagnosed with an aseptic lower extremity nonunion that was initially managed operatively between the years of 2007 and 2022. Of these 1065 patients treated for an aseptic nonunion of a tibial or femoral fracture, 84 were excluded due to the lack of 6-month follow-up data. Patients were stratified into 2 groups based on LOS: same-day discharge and admission to the hospital. Admission to the hospital was defined as remaining in the hospital for at least one night following surgery, regardless of admission status (inpatient or observation), while same-day discharge was defined as discharge on the day of surgery.
Outcomes
Each center's institutional electronic medical record was reviewed to record patient demographics, comorbidities, injury characteristics, operative details of the nonunion surgery, and complication rates after the nonunion surgery. The primary outcome of this study was the comparison of the postoperative complications—infection, reoperation, and readmission rates—between the 2 groups based on LOS. Postoperative infections were identified by either presence of a draining sinus tract or 2 positive intraoperative cultures, in concordance with the Fracture Related infection (FRI) definition.14 Reoperation was defined as any procedure related to the nonunion that required the patient to return to the operating room after the index surgery. Readmission rates were defined as all-cause hospital readmissions within 180 days of discharge after nonunion surgery. All patients had a minimum of 6 months of follow-up, and outcomes were assessed within 180 days after the index procedure.
Statistical analysis
Descriptive statistics were used to present the demographics of patients with aseptic lower extremity nonunions. Chi–square tests, Fisher exact tests, and nonparametric tests were used to determine the significance of associations between postoperative LOS (same-day discharge or admission to the hospital) and patient demographics, treatment or injury characteristics, and complications. Multivariable logistic regression was used to identify risk factors for complications. P-value of less than 0.05 was used to determine statistical significance. Statistical analyses were conducted using SAS software (SAS Enterprise Guide 7.1, Copyright 2014 SAS Institute Inc, Cary, North Carolina).
Results
A retrospective analysis of a database comprising long bone nonunions identified 981 aseptic femur and tibia nonunions that met all inclusion criteria and were included in our analysis. Of these, 146 (14.9%) patients underwent same-day discharge and 835 (85.1%) were admitted to the hospital. The median age was 42 years (interquartile ranges [IQR] 32, 53) in the same-day discharge group and 48 years (IQR 35, 60) in the admission group (P = 0.0004). There were no significant differences between sex, race, or ethnicity between groups (Table 1). Diabetes was less common in the same-day discharge group (8.2% vs 16.4%, P = 0.011). A larger proportion of patients in the same-day discharge group were classified as ASA I or II compared with those admitted to the hospital (70.5% vs 57.6%, P = 0.0011). Patients undergoing same-day discharge were more likely to be current smokers (40.4% vs 35.6%, P = 0.031), whereas patients admitted to the hospital were more likely to be former smokers (8.2% vs 17.1%, P = 0.0307). Patients in the same-day discharge group were significantly more likely to have private insurance (45.9% vs 36.4%) and significantly less likely to have Medicaid or Medicare (P = 0.0003). Demographics and comorbidities are summarized in Table 1.
Table 1.
Cohort demographics and initial injury characteristics.
| Variable | Inpatient (n = 835) | Outpatient (n = 146) | Total (n = 981) | P |
| Age at the time of surgery, median (IQR) | 48 (35, 60) | 42 (32, 53) | 47 (35, 59) | 0.0004 |
| BMI (kg/m2), median (IQR) | 29.7 (25.4, 35.3) | 27.5 (23.7, 32.0) | 29.4 (25.1, 35.1) | 0.0004 |
| Sex (%) | ||||
| Female | 348 (41.7) | 42 (28.8) | 395 (40.3) | 0.0829 |
| Male | 487 (58.3) | 99 (67.8) | 586 (59.7) | |
| Race (%) | ||||
| White | 684 (81.9) | 118 (80.8) | 802 (81.7) | >0.99 |
| Black or African American | 108 (12.9) | 17 (11.6) | 125 (12.7) | |
| Other | 31 (3.7) | 5 (3.4) | 36 (3.7) | |
| Unknown | 12 (1.5) | 6 (4.1) | 18 (1.8) | |
| Ethnicity (%) | ||||
| Hispanic or Latino | 26 (3.1) | 4 (2.7) | 30 (3.1) | 0.7877 |
| Not Hispanic or Latino | 783 (93.8) | 136 (93.2) | 919 (93.7) | |
| Unknown | 26 (3.1) | 6 (4.1) | 32 (3.3) | |
| Insurance (%) | ||||
| Medicaid | 136 (16.3) | 17 (11.6) | 153 (15.6) | 0.0003 |
| Medicare | 248 (29.7) | 26 (17.8) | 274 (27.9) | |
| Other | 24 (2.9) | 1 (0.7) | 25 (2.5) | |
| Private | 304 (36.4) | 67 (45.9) | 371 (37.8) | |
| Self-pay | 48 (5.7) | 11 (7.5) | 59 (6.0) | |
| Unknown | 43 (5.1) | 10 (6.9) | 53 (5.4) | |
| Worker's compensation | 32 (3.8) | 14 (9.6) | 46 (4.7) | |
| ASA classification (%) | ||||
| I | 80 (9.6) | 19 (13.0) | 99 (10.1) | 0.0011 |
| II | 401 (48.0) | 84 (57.5) | 485 (49.5) | |
| III | 303 (36.3) | 35 (24.0) | 338 (34.5) | |
| IV | 29 (3.5) | 0 (0) | 29 (3.0) | |
| Unknown | 22 (2.6) | 8 (5.5) | 30 (3.1) | |
| Tobacco use (%) | ||||
| Current | 297 (35.6) | 59 (40.4) | 356 (36.3) | 0.0307 |
| Former | 143 (17.1) | 12 (8.2) | 155 (15.8) | |
| Never | 379 (45.4) | 71 (48.6) | 450 (45.9) | |
| Unknown | 16 (1.9) | 4 (2.7) | 20 (2.0) | |
| Diabetes (%) | ||||
| Yes | 137 (16.4) | 12 (8.2) | 149 (15.2) | 0.011 |
| No | 698 (83.6) | 134 (91.8) | 832 (84.8) | |
| Chronic kidney disease (%) | 43 (5.1) | 3 (2.1) | 46 (4.7) | 0.1353 |
| HIV positive (%) | 6 (0.7) | 0 (0) | 6 (0.6) | 0.5997 |
| Open vs closed fracture (%) | ||||
| Open | 356 (42.6) | 52 (35.6) | 408 (41.6) | 0.1014 |
| Closed | 467 (56.0) | 94 (64.4) | 561 (57.2) | |
| Unknown | 12 (1.4) | 0 (0) | 12 (1.2) |
ASA, American Society of Anesthesiologists; IQR, interquartile range.
Values in boldface indicate p < 0.05.
No differences in original injury characteristics reached statistical significance between groups (Table 2). In the same-day discharge group, 35.6% of the initial fractures were open, whereas 42.6% were open in patients admitted to the hospital (P = 0.101). There were no differences between groups for nonunion procedure type. In both groups, internal fixation was most common. Patients undergoing same-day discharge were more likely to receive allograft or no bone graft compared with autograft (62.3% vs 35.6%, P = 0.0001). The median operative time was significantly longer in patients admitted to the hospital (164 minutes) compared with those undergoing same-day discharge (117 minutes, P < 0.0001). No differences were found with respect to autograft donor site (Table 2).
Table 2.
Nonunion injury and treatment characteristics.
| Variable | Inpatient (n = 835) | Outpatient (n = 146) | Total (n = 981) | P |
| Operative time, median (IQR) | 164 (123.5, 220) | 117 (83, 165) | 157 (117, 212) | <0.0001 |
| Open vs closed fracture (%) | ||||
| Open | 356 (42.6) | 52 (35.6) | 408 (41.6) | 0.1014 |
| Closed | 467 (56.0) | 94 (64.4) | 561 (57.2) | |
| Unknown | 12 (1.4) | 0 (0) | 12 (1.2) | |
| Internal fixation (%) | ||||
| Yes | 720 (86.1) | 131 (89.7) | 851 (86.8) | 0.2903 |
| No | 115 (13.8) | 15 (10.3) | 130 (13.3) | |
| External fixation (%) | ||||
| Yes | 80 (9.6) | 12 (8.2) | 92 (9.4) | 0.6478 |
| No | 755 (90.4) | 134 (91.8) | 889 (90.6) | |
| Type of bone graft (%) | ||||
| Allograft | 83 (9.9) | 37 (25.3) | 120 (12.2) | <0.0001 |
| Autograft | 427 (51.1) | 44 (30.1) | 471 (48.0) | |
| Autograft and allograft | 108 (12.9) | 10 (6.8) | 118 (12.0) | |
| None | 214 (25.6) | 54 (37.0) | 268 (27.3) | |
| Unknown | 3 (0.4) | 1 (0.7) | 4 (0.4) | |
| Autograft donor site (%) | ||||
| Iliac crest | 180 (33.6) | 16 (29.6) | 196 (33.3) | 0.2174 |
| Local (distal femur, proximal tibia, etc.) | 135 (25.2) | 20 (37.0) | 155 (26.3) | |
| RIA | 183 (34.2) | 14 (25.9) | 197 (33.4) | |
| RIA and iliac crest | 10 (1.9) | 0 (0) | 10 (1.7) | |
| Other | 22 (4.1) | 4 (7.4) | 26 (4.4) | |
| Unknown | 5 (0.9) | 0 (0) | 5 (0.8) |
IQR = interquartile range; RIA = Reamer-irrigator-aspirator.
Values in boldface indicate p < 0.05.
Evaluation of early postoperative outcomes is particularly important when comparing inpatient and same-day discharge pathways, as inpatients remain under direct medical monitoring while outpatients transition immediately to home recovery. At 1 week, readmission rates were similar between groups (0.8% inpatient vs 2.1% outpatient, P = 0.18); however, outpatient procedures were associated with a significantly higher rate of emergency department visits (0.2% vs 2.1%, P = 0.026). At 180 days, all unadjusted complication rates were higher among patients admitted to the hospital (Table 3). Patients admitted to the hospital were more likely to be readmitted at 18.6% compared with 11.0% of those with same-day discharge (P = 0.03). Among patients admitted to the hospital, 11.5% developed an infection compared with 8.9% in the same-day discharge group (P = 0.36), and 24.5% versus 20.5% required reoperation (P = 0.34). However, after controlling for confounders such as age, body mass index (BMI), tobacco, ASA classification, insurance, and use of bone graft, same-day discharge was not associated with increased odds of infection (odds ratio [OR] 0.75, 95% CI 0.38–1.45, P = 0.386), readmission (OR 0.76, 95% CI 0.42–1.35, P = 0.346), or reoperation (OR 0.92, 95% CI 0.56–1.50, P = 0.730) compared with admission to the hospital (Table 4).
Table 3.
Complications after nonunion surgery by discharge type.
| Complication | Inpatient (n = 835) | Outpatient (n = 146) | Total (n = 981) | P |
| Readmission within 1 wk | 7 (0.8) | 3 (2.1) | 10 (1.0) | 0.18 |
| Emergency department visits within 1 wk | 2 (0.2) | 3 (2.1) | 5 (5.0) | 0.026 |
| Infection (%) | ||||
| Yes | 96 (11.5) | 13 (8.9) | 109 (11.1) | 0.3577 |
| No | 739 (88.5) | 133 (91.1) | 872 (88.9) | |
| Readmission within 180 d (%) | ||||
| Yes | 155 (18.6) | 16 (11.0) | 171 (17.4) | 0.0255 |
| No | 680 (81.4) | 130 (89.0) | 810 (82.6) | |
| Reoperation (%) | ||||
| Yes | 205 (24.5) | 30 (20.5) | 235 (23.9) | 0.3443 |
| No | 630 (75.5) | 116 (79.5) | 746 (76.1) | |
| DVT | 4 (0.48%) | 0 | 4 (0.41%) | n/a |
DVT, deep vein thrombosis.
Values in boldface indicate p < 0.05.
Table 4.
Results of multivariate model* assessing risk factors for complications of outpatient nonunion surgery.
| Relative risk estimates | ||||
| Effects | Odds ratio | 95% confidence limits | P | |
| Infection | 0.745 | 0.382 | 1.451 | 0.3863 |
| Readmission | 0.755 | 0.421 | 1.354 | 0.3462 |
| Reoperation | 0.917 | 0.56 | 1.501 | 0.7297 |
Adjusted for age, BMI, tobacco use, ASA class, insurance type and use of bone graft.
ASA, American Society of Anesthesiologists.
Discussion
For same-day discharge to be feasible, it must be both safe for the patient and cost effective. To the best of our knowledge, this is the first study to compare the risks and outcomes of aseptic lower extremity nonunion surgery based on LOS, while also highlighting the potential for cost-effective care without compromising patient outcomes. After controlling for confounders, rates of infection, readmission, and reoperation were not significantly different between patients undergoing same-day discharge after lower extremity nonunion surgery and those admitted to the hospital. Therefore, our findings suggest that same-day discharge may be a reasonable alternative in appropriately selected patients. The relatively low number of patients undergoing same-day discharge in this cohort likely reflects the historically limited adoption of this approach in nonunion surgery, although its utilization has likely increased over time with advancements in surgical techniques, anesthesia, and perioperative care.
Most of the previously published research on lower extremity nonunions does not assess outcomes in a way that considers the relationship between LOS and postoperative complications. To best of the authors' knowledge, only one study in the literature examines nonunion outcomes exclusively in the outpatient setting and included LOS as a primary outcome. In a cohort of 50 lower extremity nonunions, Rice et al13 found patient outcomes were similar to those reported in literature for inpatient cohorts. The LOS for their cohort was 0.36 days, and 78% of the nonunions were presumably aseptic. Infections occurred in 6 (12%) patients, aligning with the rate found in our study. In addition, 4 (8%) patients were readmitted, and 7 (14%) patients underwent reoperation, which is slightly lower than what was seen in the same-day discharge group in our study. All patients in their cohort went on to complete union.
Despite excluding septic nonunions from our study, 109 (11%) patients developed postoperative infections. While some of these were likely true postoperative infections, it is suspected that some of these infections may have been due to latent subclinical infections that were undetectable through clinical or serologic evaluation (C-reactive protein, erythrocyte sedimentation rate, and white blood cell count) which initially led to the incorrect classification of these nonunions as aseptic.15 Nevertheless, the infection rate found in our study aligns with those reported in other nonunion literature.16–18 There was no statistically significant difference in infection rates between patients undergoing same-day discharge and those admitted to the hospital. Previous research in total joint arthroplasty (TJA) has reported similar risks of infection for inpatient and outpatient cohorts. For instance, a matched cohort analysis by Darrith et al19 of 243 patients undergoing either inpatient or outpatient arthroplasty, 0.8% of the outpatient group experience infection as opposed to 1.2% of the inpatients. In a study of 243 matched pairs undergoing arthroplasty, infections occurred in 0.5% of the outpatient group compared with 0.8% of the inpatients.20 In addition, a recent systematic review of complications in total shoulder arthroplasty supports these findings, with only 6 of 955 patients experiencing infections after same-day discharge.21
After adjusting for baseline patient characteristics in a multivariate analysis, there were no statistically significant differences in the odds of readmission or reoperation between patients undergoing same-day discharge and those admitted to the hospital. While no nonunion studies to date specifically compare readmission or reoperation rates by LOS, our results align with prior nonunion literature in both the upper and lower extremities.16,17,22 Complications requiring readmission after operative treatment of lower extremity nonunions are predominantly surgical rather than medical.13 While inpatient admission may allow for closer monitoring and management of early medical complications, many surgical complications present after discharge and require outpatient evaluation or return to the operating room, which may limit the impact of postoperative admission on overall complication rates. Numerous studies have reported no differences in readmission and reoperation rates based on LOS in TJA and minimally invasive spine surgery.5,19,23,24 Even so, a recent review found outpatient total hip arthroplasty to have lower odds of 30- and 90-day readmission but no differences were found in the total knee arthroplasty cohort.25 Lands et al20 reported the risk of 90-day readmission was significantly higher for inpatients among a TJA cohort, with no increased risk of reoperation. Similarly, low rates of readmissions and reoperations have been noted for outpatient total shoulder arthroplasty.21,26
Proper patient selection is a key factor in the reduced complication rates observed among patients undergoing same-day discharge in our study. Patients who were deemed medically appropriate for same-day discharge tended to be younger and with fewer comorbidities than those admitted to the hospital. Based on our findings, patients undergoing same-day discharge tended to be younger, have fewer comorbidities, and undergo less complex procedures with shorter operative times. While these characteristics may help guide clinical decision-making, this study was not designed to establish definitive selection criteria, and prospective studies are needed to develop validated risk stratification tools for same-day discharge in this population. In addition, the median operative time was significantly longer in patients who were admitted, which may reflect more technically complex nonunion cases such as deformity correction or larger open procedures. These more extensive surgeries may have necessitated longer monitoring and contributed to the decision for inpatient admission. Only after accounting for age, BMI, and comorbidities did we see no difference in the risk of readmission between groups. Pain management in the early postoperative period is another important factor to consider, as patients admitted to the hospital benefit from being closely monitored by hospital staff and the availability of intravenous analgesics if needed. However, the recent advances in multimodal pain control including regional anesthesia likely mitigate the need for this. In addition, the availability of an at home caregiver is essential for safe same-day discharge as patients continue to require pain medication and may have ambulatory precautions necessitating mobility assistance in the immediate postoperative period. Other intangible factors, such as pain tolerance and patient resiliency, also play a role in the success of same-day discharge, which are exceedingly difficult for surgeons to gauge.27 Risk stratification tools have been developed in TJA28–30 and spine surgery31,32 to predict discharge disposition and assist with the selection of medically appropriate patients. Currently, nonunion surgery relies on existing scoring systems such as the ASA classification and the Charlson Comorbidity Index, as algorithms specific to nonunion discharge disposition have yet to be developed. Ultimately, selecting medically appropriate patients is a complex decision that relies on surgeon expertise with the consideration of many patient-specific factors.
The shift toward same-day discharge in TJA and minimally invasive spine surgery is largely driven by the cost-effectiveness of reducing LOS. The healthcare system in the United States has become economically burdened by rising costs and pressure from payors, reflecting a genuine concern for our current economic healthcare model. In recent years, hospital reimbursement models are evolving to value-based healthcare, emphasizing the reduction of unnecessary costs through minimizing inpatient admissions and postoperative complications. Shortening postoperative LOS has been associated with significant cost savings for various surgical procedures without increases in complications.12 Fracture nonunions, in particular, pose a sizeable economic burden on the healthcare system due to the high costs associated with multiple implants, surgeries, and hospitalizations.13 Although a comprehensive cost analysis specific to nonunion LOS has not yet been performed, the findings of our study further underscore the importance of understanding the economic role of same-day discharge for nonunion surgery within our healthcare system.
Limitations
Owing to the multicenter, retrospective nature of our study, this analysis was limited by the availability of information in our institutional EMRs and the collaborative database. In addition, there was likely some degree of variability in nonunion treatment protocols used among the included academic centers. Although we had a large cohort of nonunions, the number of patients who had same-day discharge was substantially smaller number compared with those admitted to the hospital. As such, selection bias likely influenced discharge disposition, as patients undergoing same-day discharge were younger, healthier, and underwent less complex procedures. While multivariable regression was used to control for measured confounders, residual confounding remains possible, and these findings demonstrate association rather than causation. Notably, an alternative interpretation of these data is that hospital admission may have mitigated risk in a more medically complex population, resulting in comparable complication rates between groups. Importantly, our findings must be interpreted in the context of increasing institutional and payer-driven pressures to reduce the length of stay and promote same-day discharge pathways. Understanding complication rates alone is insufficient—future prospective studies should also incorporate patient-reported outcomes, satisfaction scores, and measures of functional recovery. The decision to pursue same-day discharge versus admission to the hospital should reflect not only clinical appropriateness but also shared decision-making that includes patient preference, comfort, and home support systems. Given these limitations, prospective, randomized trials are warranted to validate these findings and further delineate the role of same-day discharge in aseptic lower extremity nonunion surgery.
Conclusion
With careful patient selection and perioperative management, same-day discharge for aseptic lower extremity nonunions may be a safe alternative to admission to the hospital. These findings support the expansion of same-day discharge pathways in appropriately selected patients, particularly in the context of increasing financial burden from rising healthcare cost.
Acknowledgment
The authors acknowledge the role of the Southeastern Fracture Consortium in establishing connections among the participating centers and supporting the development of this multisite retrospective database of nonunions.
Appendix 1. Evidence-Based Musculoskeletal Injury and Trauma Collective (EMIT)
EMIT Collective: Donald Adams, DO,6 Eddie Komi Afetse, BS, BA,2 Harvey Allen, MD,12 Laura E. Bess, MD,3 Mikhail Bethell, MD, MS,12 Ainsley Bloomer, MD,1 Lucy C. Bowers, MSPAS,11 Matthew J. Braswell, MD,2 Landon Bulloch, MD,2 Joseph Burger, MD,2 Eben Carroll, MD,4 Christine Churchill, MA,2 Samuel Cohen-Tanugi, MD,2 Andrew Z. Coskey, MD,11 Mario Cuadra, MD,2 Kerry A. Danelson, PhD,4 Malcolm DeBaun, MD,12 Andrew Du, BS,10 Cara Girardi, MD,2 Joseph T. Gutbrod, BS,14 Jason Halvorson, MD,4 Noah Harrison, MD, MMSc,6,14 William B. Haynes III, MD,2 Anna Hemminger, BS,7 Kate Hickson, BS,1 Martha Holden, AAS, AA,4 Zachary Hong, BA,14 Joseph R. Hsu, MD,2 Alexander Hysong, MD,2 Katelin J. Isakoff, BS,10 Josef Jolissaint, MD,2 Jenna Jones, MD,3 Madhav A. Karunakar, MD,2 Laurence B. Kempton, MD,2 Nathaniel Koutlas, MD, BA,1 Shreyas Kudrimoti, BA,7 Cara Lai, MD,10 Alexis Amani LeMone, BA,4 Thea Lance, MD,4 Kathryn Leighty, BA,2 David Macknet, MD,2 Julia Mastracci, MD,2 Amber S. McKinney, BSPH,2 Kyle McNamara, MD, PhD,1 Casey Merz, BS,8 Joseph Michalski, MD, MPH, MS,7 John B. Michaud, BA,10 Anna N. Miller, MD,14,15 Deron Morrison, BS,4 Roman M. Natoli, MD, PhD,3 William Obremskey, MD, MPH,6 Alexander Padovano, MD,1 Patrick Pallitto, MD,1 Daniel E. Pereira, MD,6,14 Kevin Phelps, MD,2 Sarah Pierrie, MD,2 Holly Pilson, MD,4 Samuel L. Posey, MD,2 Brandon Ponce, MD,6 Zachary D. Randall, MD, MPHS,14 Kristoff Reid, MD,13 Rosalynn Rice, BS,9 Gabriella Rivas, MD,13 Jessica Rivera, MD, PhD,5 Elsa Rodriguez, MD, MPH,6 Michael Ruth Jr, MD,2 Mir Ibrahim Sajid, MD,7 Ryan Seltzer, MD,10 Ryan P. Serbin, MD,2 Rachel B. Seymour, PhD,2 Marc Schatz, MD,5 Sharrieff Shah, BS,12 Ishani Sharma, MD, MBA,3 Jigyasa Sharma, BA,10 Stephen H. Sims, MD,2 Abigail Smith, MD,1 Juliette Sweeney, BS,2 Stephanie L. Tanner, MS,9 Lauren M. Tatman, MD,6 Noelle Van Rysselberghe, MD,10 William H. Waddell, MD,6 Harsh Wadhwa, MD,10 Meghan K. Wally, PhD,2 Andrew Wohler, MD,2 Sean Wrenn, MD6
1Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC
2Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC
3Department of Orthopaedic Surgery, Indiana University School of Medicine, IU Health Methodist Hospital, Indianapolis, IN
4Wake Forest University School of Medicine, Winston-Salem, NC
5Department of Orthopaedics, Louisiana State University, New Orleans, LA
6Vanderbilt University Medical Center, Nashville, TN
7Florida Orthopedic Institute, Tampa, FL
8Novant Health, University of North Carolina Charlotte SOM, Charlotte, NC
9 Prisma Health, Greenville, SC
10Stanford University, Stanford, CA
11University of Kentucky, Lexington, KY
12Duke Department of Orthopaedic Surgery, Durham, NC
13Medical University of South Carolina, Charleston, SC
14Washington University School of Medicine, St. Louis, MO
15Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH
Footnotes
Lauck B, Paterno A, Odum S, Hsu J, Seymour R, Natoli R, Matuszewski P, Obremskey W, Babcock S, Zura R, Mir H, DeBaun M, Cannada L, Adams JD, Miller A, Gardner M, Reid K, Chen A, and EMIT. Comparison of Outpatient versus Inpatient Lower Extremity Nonunion Surgery. Podium Presentation at: Limb Lengthening and Reconstruction Society Annual Meeting; July 2024; Hollywood Beach, FL. Lauck B, Paterno A, Odum S, Hsu J, Seymour R, Natoli R, Matuszewski P, Obremskey W, Babcock S, Zura R, Mir H, DeBaun M, Cannada L, Adams JD, Miller A, Gardner M, Reid K, Chen A, and EMIT. Comparison of Outpatient versus Inpatient Lower Extremity Nonunion Surgery. Poster presentation at: Military Health System Research Symposium Annual Meeting; August 2024; Kissimmee, FL. Chen A, Paterno A, Lauck BJ, and EMIT Collaborative. Comparison of Outpatient versus Inpatient Lower Extremity Nonunion Surgery. Poster presentation at: American Academy of Orthopaedic Surgeons; March 2025; San Diego, CA.
J. R. Hsu reports consultancy for Globus Medical and personal fees from Smith and Nephew speakers' bureau. M. K. Wally has received financial or material support from Johnson and Johnson. H. Mir reports being a board or committee member for AAOS BOS Representative from OTA. He also notes that he has received stock from Abryx and OrthoGrid, and has been a paid consultant for Smith and Nephew, Acumed LLC, Stryker, and Synthes. H. Mir also notes that he is a board or committee member for ACS Committee on Trauma, the American Orthopaedic Association, OTA BOD, and OTA CFO. He reports receiving research support from AO Trauma North America. H. Mir also reports that he is on the editorial or governing board for JAAOS Consultant Reviewer, JBJS Consultant Reviewer, Journal of Orthopaedic Trauma Associate Editor, and OTA International Digital Editor. K. Reid states he has received research support from SI-Bone. Eben Carroll reports receiving financial support and being a paid speaker for the AO Foundation, DePuy, A Johnson and Johnson Company, Smith and Nephew, and Synthes. Dr. Carroll also states being a board member for AO North America and has received research support from them in addition to financial or material support and being a paid speaker. Eben Carroll reports IP royalties from Globus Medical and was a paid consultant and speaker for them. Dr. Carroll notes being a board or committee member for OTA. Madhav Karunakar reports being on the editorial or governing board for the Journal of Orthopaedic Trauma and is a board or committee member for OTA. He notes he received stock or stock options and was an unpaid consultant for Osteocentric. Dr. Karunakar reports being a paid speaker for Synthes. R. D. Zura reports royalties or licenses from Stryker, consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Bioventus, and leadership or fiduciary roles in other board, society, committee or advocacy group, paid or unpaid, from Kuntscher. R. D. Zura also reports other financial or nonfinancial interests in Osteocentric. Malcolm DeBaun reports Azra Care: Stock or stock Options DePuy, A Johnson and Johnson Company: Research support Next Science: Paid consultant; Research support NSite: Stock or stock Options Orthopaedic Trauma Association: Board or committee member Osteocentric: IP royalties; Paid consultant Reselute: IP royalties; Paid consultant; Stock or stock Options Shukla: IP royalties; Paid consultant SI Bone: Paid consultant; Paid presenter or speaker Synthes: Paid consultant; Paid presenter or speaker Wolters Kluwer Health—Lippincott Williams and Wilkins: Publishing royalties, financial or material support.
Evidence-Based Musculoskeletal Injury and Trauma Collective (EMIT) members are listed in Appendix 1.
Source of funding: None.
Contributor Information
Bradley J. Lauck, Email: bradley_lauck@med.unc.edu.
Anthony V. Paterno, Email: anthony.paterno@unchealth.unc.edu.
Yu Min Suh, Email: YuMin.Suh@unchealth.unc.edu.
Susan Odum, Email: sodum65@gmail.com.
Olivia Rice, Email: oliviarice16@gmail.com.
Benjamin J. Averkamp, Email: Benjamin.Averkamp@advocatehealth.org.
Luke A. Lopas, Email: llopas@iuhealth.org.
Luke Haag, Email: lhaag@iu.edu.
Hassan Farooq, Email: hassanfar009@gmail.com.
Sharon Babcock, Email: shbabcoc@wakehealth.edu.
Robert D. Zura, Email: rzura@lsuhsc.edu.
Andres Fidel Moreno Diaz, Email: andres.f.moreno.diaz@vumc.org.
Hassan Mir, Email: hmir@floridaortho.com.
Lisa K. Cannada, Email: cannada.lisa@gmail.com.
John D. Adams, Jr, Email: Jd.Adams@prismahealth.org.
Michael J. Gardner, Email: michaelgardner@stanford.edu.
Paul E. Matuszewski, Email: pmatuszewski@uky.edu.
Andrew T. Chen, Email: andrew_chen@med.unc.edu.
The Evidence-Based Musculoskeletal Injury and Trauma Collective (EMIT):
Donald Adams, Eddie Komi Afetse, Harvey Allen, Laura E. Bess, Mikhail Bethell, Ainsley Bloomer, Lucy C. Bowers, Matthew J. Braswell, Landon Bulloch, Joseph Burger, Eben Carroll, Christine Churchill, Samuel Cohen-Tanugi, Andrew Z. Coskey, Mario Cuadra, Kerry A. Danelson, Malcolm DeBaun, Andrew Du, Cara Girardi, Joseph T. Gutbrod, Jason Halvorson, Noah Harrison, William B. Haynes, III, Anna Hemminger, Kate Hickson, Martha Holden, Zachary Hong, Joseph R. Hsu, Alexander Hysong, Katelin J. Isakoff, Josef Jolissaint, Jenna Jones, Madhav A. Karunakar, Laurence B. Kempton, Nathaniel Koutlas, Shreyas Kudrimoti, Cara Lai, Alexis Amani LeMone, Thea Lance, Kathryn Leighty, David Macknet, Julia Mastracci, Amber S. McKinney, Kyle McNamara, Casey Merz, Joseph Michalski, John B. Michaud, Anna N. Miller, Deron Morrison, Roman M. Natoli, William Obremskey, Alexander Padovano, Patrick Pallitto, Daniel E. Pereira, Kevin Phelps, Sarah Pierrie, Holly Pilson, Samuel L. Posey, Brandon Ponce, Zachary D. Randall, Kristoff Reid, Rosalynn Rice, Gabriella Rivas, Jessica Rivera, Elsa Rodriguez, Michael Ruth, Jr, Mir Ibrahim Sajid, Ryan Seltzer, Ryan P. Serbin, Rachel B. Seymour, Marc Schatz, Sharrieff Shah, Ishani Sharma, Jigyasa Sharma, Stephen H. Sims, Abigail Smith, Juliette Sweeney, Stephanie L. Tanner, Lauren M. Tatman, Noelle Van Rysselberghe, William H. Waddell, Harsh Wadhwa, Meghan K. Wally, Andrew Wohler, and Sean Wrenn
Data availability statement
The data sets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data sets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.