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Objective: To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome., Design: Retrospective., Setting: Two trauma centers., Patients and Methods: Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively., Main Outcome Measurements: Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up., Results: At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910)., Conclusion: Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: External fixation is widely accepted as a provisional or sometimes definitive treatment for long-bone fractures. Indications include but are not limited to damage control surgery in poly-traumatized patients as well as provisional bridging to definite treatment with soft tissue at risk. As little is known about surgeon's habits in applying this treatment strategy, we performed a national survey., Methods: We utilized the member database of the German Trauma Society (DGU). The questionnaire encompassed 15 questions that addresses topics including participants' position, experience, workplace, and questions regarding specifics of external fixation application in different anatomical regions. Furthermore, we compared differences between trauma centre levels and surgeon-related factors., Results: The participants predominantly worked in level 1 trauma centres (42.7%) and were employed as attendings (54.7%). There was widespread consensus for planning and intra-operative radiographical control of external fixation. Surgeons appointed at a level I trauma centre preferred significantly more often supra-acetabular pin placement in external fixation of the pelvis rather than the utilization of iliac pins (75.8%, p = 0.0001). Moreover, they were more likely to favor a mini-open approach to insert humeral pins (42.4%, p = 0.003). Overall, blunt dissection and mini-open approaches seemed equally popular (38.2 and 34.1%). Department chairmen indicated more often than their colleagues to follow written pin-care protocols for minimization of infection (16.7%, p = 0.003)., Conclusion: Despite the fact that external fixation usage is widespread and well established among trauma surgeons in Germany, there are substantial differences in the method of application.

Background: The indications for sacroiliac screw (SI) removal have been under debate. Data on complication rates of SI screw removal is missing in the current literature. The objective of this study was to compare the rate of intra- and perioperative problems and complications during SI screw removal to those with SI screw fixation., Methods: A retrospective observational study with two interventions in the same cohort was performed. Consecutive patients who underwent both sacroiliac screw fixation for an isolated fracture of the pelvic ring and removal of the same implants between November 2008 and September 2015 (n = 19; age 57.3, SD 16.1 years) were included. Intraoperative technical problems, postoperative complications, duration of surgery, and radiation dose were analysed., Results: Intraoperative technical problems occurred in 1/19 patients (5%) during SI screw fixation and in 7/19 cases (37%) during SI screw removal (p = .021). Postoperative complications were seen in 3/19 patients after SI screw fixation and in 1/19 patients after SI screw removal (p = 0.128). The surgical time needed per screw was longer for screw removal than for implantation (p = .005). The amount of radiation used for the whole intervention (p = .845) and per screw (p = .845) did not differ among the two interventions., Conclusions: Intraoperative technical problems were more frequent with SI screw removal than with SI screw fixation. Most of the intraoperative technical problems in this study were implant-related. They resulted in more surgical time needed per screw removed but similar radiation time.

Background: Minimal invasive screw fixation is common for treating posterior pelvic ring pathologies, but lack of bone quality may cause anchorage problems. The aim of this study was to report in detail a new technique combining iliosacral screw fixation with in-screw cement augmentation (ISFICA)., Description of Technique: The patient was put under general anesthesia and placed in the supine position. A K-wire was inserted under inlet-outlet view to guide the fully threaded screw. The screw placement followed in adequate position. Cement was applied through a bone filler device, inserted at the screwdriver. The immediate control of cement distribution, accurate screw placement and potential leakage were obtained via intraoperative CT scan., Patients and Methods: Twenty consecutive patients treated with ISFICA were included in this study. The mean age was 74.4 years (range 48-98). Screw placement, possible cement leakage and screw positioning were evaluated via intraoperative CT scan. Postoperative neurologic deficits, pain reduction and immediate postoperative mobilization were clinically evaluated., Results: Twenty-six screws were implanted. All patients were postoperatively, instantly mobilized with reduced pain. No neurologic deficits were apparent postoperatively. No cement leakage occurred. One breach of the iliac cortical bone was noted due to severe osteoporosis. One screw migration was seen after 1 year and two patients showed iliosacral joint arthropathy, which led to screw removal., Conclusion: ISFICA is a very promising technique in terms of safety, precision and initial postoperative outcome. Long-term outcomes such as lasting mechanical stability or pain reduction and screw loosening despite cement augmentation should be investigated in further studies with larger patient numbers.

Closed reduction and percutaneous screw fixation (CRIF) of iliac crescent fractures and fractures of the anterior column of the acetabulum has become an established method in the treatment of these injuries. After reduction, safe insertion of a guide wire is a key step during this procedure. We present a technique that can facilitate introducing the guide wire under fluoroscopic guidance and allow for decreased radiation exposure., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Anterior fixation of the pelvis using subcutaneous supra-acetabular pedicle screw internal fixation (INFIX) has proven to be a useful tool by avoiding the downsides of external fixation in patients where open fixation is not suited. The purpose of this study was to find a rod-to-bone distance for the INFIX that allows for minimal hazard to the inguinal neuro-vascular structures and, at the same time, as little as possible interference with the soft tissues of the proximal thigh when the patient is sitting., Methods: An INFIX was applied to 10 soft-embalmed cadaver pelvises with three different rod-to-bone distances. With each configuration, the relations of the rod to the neuro-vascular and the muscular surroundings were measured in supine and sitting position., Results: Except for the femoral artery, vein and nerve, all investigated anatomical structures of the groin were under compression with a rod-to-bone distance of 1cm. With a rod-to-bone distance of 2cm most of the anatomical structures were safe in supine position, although less than with 3cm. With hip flexion some structures got under compression, especially the lateral femoral cutaneous nerve (LFCN, 80%) and the anterior cutaneous branches of the femoral nerve (ACBFN, 35%). With a rod-to-bone distance of 3cm almost all anatomical structures were safe in supine position, while with hip flexion most superficial structures of the proximal thigh got under compression, especially the LFCN (75%) and the ACBFN (60%)., Conclusions: Aiming for a rod-to-bone distance of 2cm is the safest way with regard to compression of the femoral neuro-vascular bundle and at the same time leads to the least compression of more superficial structures like the LFCN, the ACBFN, or the sartorius and the rectus femoris muscles in sitting position., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Clavicular nonunions with large bony defects, although rare, are difficult to treat and often result from multiple failed attempts at surgical management. Reconstruction using vascularized bone graft is the accepted standard in cases of large osseous defects., Methods: An anatomical vascular corrosion study with cadaveric dissections and finite element analyses was designed to assess the feasibility of clavicular reconstruction with a musculo-osteous graft interposition based on a pedicled serratus anterior flap., Results: Rib vascularization through the serratus anterior was demonstrated, so that the thoracic branch of the thoracodorsal artery can been considered a secondary blood supply for the seventh and eighth ribs. Single and double pedicled rib transfers allowed for reconstruction with as much as 8 cm of bone loss. The maximal stress found in the single-rib reconstruction interfaces was located at the medial contact of the plate with the clavicle. It was 2.7-fold higher than the maximal stress of the medial bow of the intact clavicle. Conversely, the double-rib reconstruction had improved mechanical resistance. A case report using a single-rib transfer supported the biomechanical study by showing that the maximal risk of material loosening was located at the medial bone interface., Conclusions: Double vascularized rib transfer as part of a serratus anterior flap should be used instead of single-rib transfer to reconstruct large clavicle defects. This technique is reproducible and does not require microvascular anastomoses. Therefore, it has potential advantages over free fibula transfer.