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To evaluate outcomes using an interlocking antibiotic cement-coated nail and culture-specific systematic antibiotics in the treatment of infected nonunion after intramedullary nailing.Retrospective observational cohort study.Urban level I trauma center.Forty-one nonconsecutive patients who presented to a level I trauma center who underwent interlocked antibiotic nailing for treatment of infected nonunion status after primary intramedullary nailing.Eradication of infection, radiographic union by 2-year follow-up.Antibiotic nailing successfully eradicated infection and led to fracture healing in 35 patients (85.4%), while 6 patients (14.6%) had persistent infection and required further surgical treatment. Of the 6 patients who required further treatment, 5 eventually went on to heal with fracture union and eradication of their infection, while 1 required a salvage procedure. Of the 5 patients who eventually went on to heal, 4 of them healed with repeat antibiotic or intramedullary nails, while 1 required segmental resection and bone grafting before healing.This study suggests that the proposed interlocked antibiotic nailing technique is a viable therapeutic option to eradicate infected nonunion and support fracture healing.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Triangular osteosynthesis is a technique used to stabilize posterior pelvic ring injuries. Conventional triangular fixation can be problematic for several reasons, including the need for advanced skill sets to place instrumentation, difficulty with pelvic reduction and placing the connecting construct, and prominent instrumentation. The purpose of this study is 2-fold: (1) to describe in detail a technique for lumbopelvic fixation using implants that are easy to connect, allow distraction for complex lumbosacral displacements, and are placed in a location minimizing soft tissue prominence and (2) to present our initial case series using this technique. We present a retrospective review of 18 consecutively treated patients with this technique. Inclusion criteria were patients with complete disruption through the sacrum or sacroiliac joint from blunt trauma (OTA/AO type C injuries). Outcomes included pelvic reduction/malreduction, wound healing, and complications. Fourteen patients underwent unilateral fixation (81%), and 4 patients underwent bilateral fixation (19%). All patients (18 of the 18) had a well-reduced pelvis after fixation. No patient (0%) required a return trip to the operating room for loss of reduction/malreduction, wound breakdown, or implant failure. This study presents an updated technique for a low-profile triangular osteosynthesis construct with straightforward application for unstable posterior pelvic ring injuries. This technique does not require rod bending, results in a consistently more recessed iliac screw and connecting rod, and can be used in a wide variety of unstable posterior pelvic ring injuries, including comminuted sacral fractures, L5/S1 facet fractures, and vertical shear injuries.

Objectives To compare immediate internal fixation with primary wound closure to temporary fixation/stabilization with delayed fixation and wound closure protocols for management of open ankle fractures. Design Retrospective case-control study. Setting Level 1 trauma center. Patients Eighty-eight consecutive patients who presented with a Gustilo-Anderson type I, II, or IIIa open ankle fracture to a single center. Intervention Patients were divided into 2 cohorts: either immediate internal fixation with primary wound closure (EARLY) or temporary fixation/stabilization with delayed fixation and wound closure (STAGED) due to practice differences of the attending surgeons. Main outcome measures Infection, length of stay, number and type of operations, and clinical measures. We also assessed the 2 groups with regard to demographics and radiographic classification. Results Overall, incidence of infection was 6 (6.8%) with no significant difference between patients treated with EARLY versus STAGED protocols. The EARLY cohort had a significantly shorter length of hospital stay, fewer number of reoperations but similar clinical outcomes for pain, ambulation, and radiographic evidence of osteoarthritis for patients followed for >12 months. Conclusion Our study showed that early definitive treatment compared with a staged protocol for Gustilo-Anderson type I, II, and IIIa open ankle fractures has similar rates of infection, shorter hospital stay, fewer surgical interventions, and similar clinical outcomes. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective The purposes of this article were to (1) compare our combined pelvic ring and acetabular fracture patients' rate of mortality and Injury Severity Score (ISS) to those of patients with isolated injuries at our center and to those with combined injuries as reported in the literature, (2) describe our treatment algorithm using the INFIX for these combination injuries, and (3) report our patients' radiographic and functional outcomes. Design Retrospective IRB-approved case series and literature review. Setting US Level 1 Trauma Center. Patients/participants Thousand six hundred ninety-seven with acetabular or pelvic ring injury, 174 patients with combination pelvic ring acetabular injuries, and 39 patients with 41 acetabular injuries treated with a surgical protocol. Intervention Pelvic ring reduction using INFIX and posterior fixation followed by acetabular reduction fixation. Anterior injury fixed with INFIX. Main outcome Mortality, ISS, pelvic reduction by Keshishyan index, acetabular reduction by the Matta criteria, and functional outcome by the Majeed score. Results Mortality was 5.7% and ISS was 12.5 for 174 combined injury patients. In the 39 patients with 41 injuries, excellent pelvic reduction was found in 39, and acetabular reduction was anatomic in 25 (61%), imperfect in 12 (29%), and poor in 4 (10%). Clinically 78% of the patients had good or excellent outcome and 22% had a fair or poor outcome. Nonanatomic acetabular reduction, persistent sciatic nerve palsy, and heterotopic ossification associated with poor clinical outcome. Conclusions Our treatment protocol resulted in excellent pelvic reduction, anatomic acetabular reduction in 61% of patients, and 78% good to excellent clinical outcome. Level of evidence Case series Level IV.

Supplemental Digital Content is Available in the Text., Objective: To describe our experience using the anterior internal pelvic fixator (INFIX) for treating pelvic ring injuries. Design: Case Series. Setting: Level 1 Trauma Center. Patients: Eighty-three patients with pelvic ring injuries were treated with INFIX. Follow-up average was 35 months (range 12–80.33). Intervention: Surgical treatment of pelvic ring injuries included reduction, appropriate posterior fixation, and INFIX placement. Outcome Measurements: Reduction using the pelvic deformity index and pubic symphysis widening, Majeed functional scores, complications; infection, implant failure, heterotopic ossification (HO), nerve injury, and pain. Results: All patients healed in an appropriate time frame (full weight bearing 12 weeks postoperation). The average pelvic deformity index reduction (injury = 0.0420 ± 0.0412, latest FU = 0.0254 ± 0.0243) was 39.58%. The average reduction of pubic symphysis injuries was 56.92%. The average Majeed score of patients at latest follow-up was 78.77 (range 47–100). Complications were 3 infections, 1 case of implant failure, 2 cases implantation too deep, 7 cases of lateral femoral cutaneous nerve irritation, and 3 cases of pain associated with the device. HO was seen in >50% of the patients, correlated with increased age (P < 0.007), injury severity score (P < 0.05) but only 1 case was symptomatic. Conclusions: The pelvic injuries had good functional and radiological outcomes with INFIX and the appropriate posterior fixation. The downside is removal requiring a second anesthetic, there is a learning curve, HO often occurs, the lateral femoral cutaneous nerve may get irritated which often resolves once the implants are removed. Surgery-specific implants need to be developed. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives To assess the diagnostic sensitivity of computed tomography (CT) in patients with an unstable pelvic ring injury after application of a pelvic binder. Design An institutional review board approved retrospective study from 2003 to 2010. Setting Level 1 trauma center. Patients Inclusion criteria were patients in our trauma database with AO/OTA B or C type pelvic ring injury, which first had an anterior-posterior pelvic x-ray followed by application of a pelvic circumferential compression device (PCCD), then a CT, and a fluoroscopic stress examination under anesthesia (FEUA) (used as gold standard). Of 867 patients, 43 met the inclusion criteria. Intervention A senior Orthopaedic Resident and Trauma Attendings assessed x-rays, CTs, and FEUAs. Binomial test was used to compare imaging against final diagnosis. Results In Anterior Posterior Compression/Vertical Shear (OTA 61-B1, 61-B3.1, 61-C) injury patterns, prebinder x-rays were diagnostic in 69.4% (CI, 51.9%-83.7%) of cases, compared with 50% (CI, 32.9%-67.1%) with CT + PCCD. The x-ray was superior to CT + PCCD for identification of the anterior pelvic injury (McNemar exact P = 0.0352). If x-ray and CT + PCCD were viewed in tandem, 83.3% (CI, 67.2%-93.6%) of classifications were in agreement with the FEUA. For lateral compression mechanisms, the binder did not effect of the sensitivity of the CT except in the open book component of an lateral compression 3 (61-B3.2) mechanism. Conclusions The placement of a pelvic binder has the potential to mask the severity of unstable pelvic ring injuries when relying only on CT for diagnosis. Fluoroscopic manual pelvic stress examination under anesthesia is an essential adjunct when a binder is placed before imaging. Level of evidence Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To (1) evaluate using the inherent anteversion of a second or third generation femoral nail to set the version of the femur during locked intramedullary nailing of comminuted femoral shaft fractures (Espinosa Technique [ET]) and compare it with our traditional method (traditional group [TG]) and (2) assess the variation of anteversion because of the inherent play in the nail itself. Design A prospective IRB-approved study. Setting Academic US Level 1 Trauma Center. Patients Fifty-two consecutive patients with comminuted femur fractures all completed the study. Intervention The first 27 patients had the anteversion determined using the patellar shadow and lesser trochanter (TG), and the next 25 patients were treated by ET. Main outcome measure Computed tomography scanogram for femoral anteversion and length in the normal versus operated femur. Results A >15 degree difference from native to operated legs was found in 8/27 TG (29%, 95% CI 15.3%-54.2%), with a mean difference of 11.6 ± 10.2 degrees (95% CI 8.8-16.17) verses 1/25 in the ET group (2.5%, 95% CI 0%-15.3%), with a mean difference of 4.8 ± 6.2 degrees (95% CI 1.38-8.9) (P = 0.0068). There was a 5 degree variability in our ability to center the proximal locking screw in the femoral head and 5 degrees variation in distal locking. Conclusions The inherent anteversion of a second generation nail can be used to minimize malrotation of the femur after comminuted fractures during locked intramedullary nailing in patients with normal anteversion and is superior to our present fluoroscopic technique. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction The purpose of this article is to review the available literature on anterior subcutaneous internal pelvic fixation (ASIPF) to identify indications, clinical and radiographic outcomes, and compare these with alternative fixation methods. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search on PubMed and Google Scholar was performed. Articles included were in the English language or English translations and published between 2007 and 2018. Studies included were appraised with narrative data synthesis. Results Twenty-five articles with 496 patients were included. These included 17 case series, with 3 case reports reporting adverse events. Conclusions ASIPF and the appropriate posterior fixation resulted in healing of pelvic ring injuries in 99.5% of cases. Indications include unstable pelvic ring injuries with the appropriate posterior fixation. Radiographic parameters and outcome measures were infrequently reported. ASIPF is a valuable tool for reduction and fixation in unstable pelvic ring injuries. Complications include lateral femoral cutaneous nerve irritation (26.3%); heterotopic ossification (36%); infection (3%); and femoral nerve palsy (1%), which is likely related to placing the bar and screws too deep.

Objectives To prevent leg length discrepancy (LLD) after locked femoral nailing in patients with comminuted femoral shaft fractures. Design Prospective consecutive case series aimed at quality improvement. Setting Level 1 Trauma Center PATIENTS:: Ninety-eight consecutive patients with a comminuted femoral shaft fracture underwent statically locked intramedullary nailing, with a focused attempt at minimizing LLD during surgery. Intervention A computed tomography scanogram of both legs was performed on postoperative day 1 to assess for residual LLD. Patients were offered the option to have LLD >1.5 cm corrected before discharge. Main outcome measure LLD >1.5 cm. Results Twenty-one patients (21.4%) were found to have an LLD >1.5 cm. An LLD >1.5 cm occurred in 10/55 (18%) antegrade nail patients and 11/43 (26%) retrograde nail patients (P = 0.27). No difference was noted based on the mechanism of injury, surgeon training and OTA/AO type B versus C injury. Ninety of 98 patients left with Conclusions No patient left the hospital with an LLD >1.5 cm after locked intramedullary nailing for a comminuted femoral shaft fracture without being informed and the option of early correction. We recommend using a full-length computed tomography scanogram after IM nailing of comminuted femur fractures to prevent iatrogenic LLD. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To present a novel internal fixation device for stabilizing unstable pelvic fractures using supra-acetabular spinal pedicle screws and a subcutaneous connecting rod (INFIX).Level I trauma center.Case series.Twenty-four patients with rotational or vertically unstable pelvic fractures that reported to a level I trauma center. METHODS/INTERVENTION: Surgical treatment of unstable pelvic fractures included reduction, appropriate posterior fixation where indicated, and an anterior subcutaneous internal fixator.Healing time, quality and loss of reduction, ease of nursing, incidence of complications, including nonunion, infection, and patient mobility and comfort.In the present clinical series, all fractures healed without significant loss of reduction. There were no infections, delayed unions or nonunions. Nursing care was observed to be easier especially in the intensive care unit setting. Complications included unilateral anterior thigh paresthesias in 2 patients, and 1 patient each required repositioning of the pedicle screw and readjustment of screw rod junction. Patients tolerated the procedure well and were fairly mobile after the procedure.The reported technique allows for a definitive and stable anterior fixation of vertically and rotationally unstable pelvic fractures when combined with the appropriate posterior fixation if indicated. The potential complications are acceptable with this technique and good outcomes were achieved. A second operative procedure is required for removal of the device. It is our view that its best indication is in obese individuals, in whom other options have shortcomings.

Objectives The purpose of this video is to describe the equipment, anatomy, and surgical technique of anterior subcutaneous pelvic fixation (INFIX) using pedicle screws and a rod in an Anterior Posterior Compression 3 pelvic fracture, as well as how to distract in lateral compression fractures. Methods The equipment required includes standard spine pedicle screw sets with long screws, 70-110 mm in length, and 7 or 8 mm in diameter. The approach is a mini open and one needs to be familiar with the iliac oblique, obturator outlet, and obturator inlet views. The length of the screw is measured from the sciatic notch to the skin, and they are placed so that the head sits just below the skin. The rod is passed just under the skin along the bikini line and the construct compressed or distracted against a c-clamp while monitored with fluoroscopy. In Orthopaedic Trauma Association C type injuries, we leave c-clamps on the outside the screws to reinforce them or use monoaxial screws. The implants are removed at 3-6 months postop. Results The patients tolerate the implants and are able to sit and stand with out difficulty. Complications include lateral femoral cutaneous nerve irritation, heterotopic bone, loss of fixation if the implants are applied incorrectly. Conclusions The INFIX procedure for anterior pelvic fixation is based on standard techniques that are familiar to the Orthopaedic Pelvic Surgeon including supraacetabular screws. Rod bending, rod passing, determining the ideal height of the screws, and distraction/compression maneuvers are demonstrated in this video.