Search

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 cohort SETTING: 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% CI: 1.3-2.8)]. Total scores < 7 were 81% accurate in predicting nonoperative treatment. Total scores > 9 were 89% accurate in predicting an operative recommendation. In the LC-1 cohort, scoring accuracy was 100% (95% CI: 85%-100%). CONCLUSIONS: Based on survey results and patient cohort data, scores < 7 predict nonoperative treatment recommendation, scores >9 indicate surgical recommendations, and scores 7-9 indicate indeterminate stability that should be further evaluated LEVEL OF EVIDENCE: V, expert opinion

OBJECTIVES To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery. DESIGN Prospective, multicenter, observational study. SETTING Sixteen trauma centers. PATIENTS/PARTICIPANTS Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. MAIN OUTCOME MEASUREMENTS Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement. RESULTS Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively. CONCLUSIONS Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous osseointegrated (OI) prostheses (POPs) are used to skeletally attach artificial limbs in amputees. While any permanent percutaneous interface is at risk of becoming infected by the resident microbiota colonizing the stoma, most of these patients remain infection-free. Avoidance of infection likely depends upon a mechanically and/or biologically stable skin-to-implant interface. The ultimate question remains, "why do some stomata become infected while others do not?" The answer might be found in the dynamic bacterial communities of the patient and within the stomal site itself. This study is an appendix to the first Food and Drug Administration approved prospective early feasibility study of OI prosthetic docking, in which, 10 transfemoral amputees were implanted with a unique POP device. In this analytical, longitudinal cohort study, each patient's skin and stomal microbiota were analyzed from the initial surgery to 1 year following the second-stage surgery. During each follow-up visit, three swab samples-stomal, device thigh skin and contralateral thigh skin-were obtained. DNA was extracted, and bacterial 16S ribosomal RNA (rRNA) genes were amplified and sequenced to profile microbial communities. The stomal microbiota were distinct from the microbiota on the adjacent thigh skin and the skin of the contralateral thigh, with a significantly increased abundance of Staphylococcus aureus within the stoma. Early on stomal microbiota were characterized by high diversity and high relative abundance of obligate anaerobes. Over time, the stomal microbiota shifted and stabilized in communities of lower diversity dominated by Streptococcus, Corynebacterium, and/or Staphylococcus spp. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2645-2654, 2019.

Objective To determine if an open, semi-extended, parapatellar tibial nailing technique (SEK) imparts any undue knee symptoms/pain compared with the traditional infrapatellar tibial nailing technique (FK). Design Randomized controlled trial. Setting Level 1 trauma center. Patients Forty-seven patients with OTA/AO 42A-C tibial shaft fractures were included in the study. Intervention Patients were randomized to treatment with either a SEK or an FK technique. Main outcome The main outcome was a symptoms subset of the International Knee Documentation Committee (SS-IKDC) pertaining to knee symptoms/pain. Results Final follow-up was collected at 1 year for 24 SEK and 23 FK patients. No significant differences were found between the groups in regards to demographics, injury, or surgery-related variables. The 2 techniques did have equivalent symptoms scores [mean for the difference (SEK - FK): 0.29, 90% confidence interval: -4.16 to 4.75] but did not have equivalent pain scores [mean for the difference (SEK - FK): 0.2, 90% confidence interval: -3.18 to 3.59]. When comparing demographic and injury-related variables to the SS-IKDC, only Kellgren-Lawrence classification was statistically significant (P = 0.026), where increasing presence of osteoarthritis was associated with lower scores. Conclusions The results of this single-center randomized controlled trial show that SEK and FK techniques for tibial nailing are equivalent in regards to knee symptoms (defined as ±5 points on the SS-IKDC) but not specifically pain that showed trends toward decreasing knee pain with the open SEK technique. This randomized controlled trial demonstrates that the use of the open semi-extended, parapatellar technique for tibial nailing should not be associated with any higher likelihood of knee pain/symptoms than the traditional flexed knee, infrapatellar technique. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12–125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P =.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P =.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P =.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [ Orthopedics . 2021;44(2):e248–e252.]

Over time, what was considered urgent or emergent in orthopaedic trauma has been revisited, and as awareness of factors associated with outcomes has increased, priorities have changed. There are multiple procedures performed urgently in the belief that early intervention allowed for better outcomes for the injury and the patient. Classic examples of conditions for which urgent intervention has been implemented include open fractures, femoral neck fractures in the young adult, talus fractures, and compartment syndrome. All of these conditions are considered nonurgent except for compartment syndrome, which requires urgent and timely intervention. Studies have demonstrated that these injuries need to be managed in a timely fashion but not necessarily in the middle of the night. Outcomes can be improved by measures such as early antibiotic administration for open fractures, closed reduction of talus fracture-dislocations, and anatomic reduction of femoral neck fractures. These measures are more important and useful than an emergent trip to the operating room by inexperienced surgeons with staff who may be unprepared. Orthopaedic surgeons should be familiar with open fractures and the timing of irrigation and débridement, the relative urgency of managing talus fractures, and the need for immediate reduction and fixation of femoral neck fractures. For each of these injuries, factors other than timing that affect outcomes will be described. Finally, the emergent nature of diagnosis and management of compartment syndrome must also be understood.

The purpose of the study was to compare the inflammatory cytokine and matrix metalloproteinase (MMP) concentrations in synovial fluid after acute plafond fracture with acute tibial plateau fracture. Between December 2011 and August 2014, we prospectively enrolled patients with acute tibial plateau and plafond fractures. Synovial fluid aspirations were obtained from injured and uninjured joints. The concentrations of IL-1β, IL-1RA, IL-6, IL-8, IL-10, MCP-1, TNF-α, MMP-1, -3, -9, -10, -12, and -13 were quantified using multiplex assays. A Bonferroni correction was used so that the adjusted alpha level for significance was p

The purpose of this study was to evaluate the role and the necessity of radiographs and office visits obtained during follow-up of intertrochanteric hip injuries.Retrospective study.Two level I trauma centers.Four hundred sixty-five elderly patients who were surgically treated for an intertrochanteric fracture of the femur at 2 level I trauma centers between January 2009 and August 2014 were retrospectively identified from orthopaedic trauma databases.Analysis of all healed intertrochanteric hip fractures, including demographic characteristics, quality of reduction, time of healing, number of office visits, number of radiographs obtained, and each radiograph for fracture alignment, implant position or any pathological changes.The surgical fixation of 465 fractures included 155 short nails (33%), 232 long nails (50%), 69 sliding hip screw devices (15%), 7 trochanteric stabilizing plates (1.5%), and 2 proximal femur locking plates (0.5%). The average fracture healing time was 12.8 weeks and the average follow-up was 81.2 weeks. Radiographs of any patient obtained after the fracture had healed did not reveal any changes, including fracture alignment or implant position and hardware failure. In 9 patients, pathological changes, including arthritis (3), avascular necrosis (3), and ectopic ossification (3) were noted. The average number of elective office visits and radiographs obtained after the fracture had healed were 2.8 (range: 1-8) and 2.6 (range: 1-8), respectively. According to Medicare payments to the institution, these radiographs and office visits account for a direct cost of $360.81 and $192, respectively, per patient.The current study strongly suggests that there is a negligible role for radiographs and office visits during the follow-up of a well-healed hip fracture when there is documented evidence of radiographic and clinical healing with acceptable fracture alignment and implant position. Implementation of this simple measure will help in reducing the cost of care and inconvenience to elderly patients.Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND In the United States intertrochanteric and pertrochanteric fractures occur at a rate of more than 150,000 cases annually. Current standard of care for these fractures includes fixation with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). The purpose of this study was to compare failure and medical complications of intertrochanteric femoral fractures repaired by CMN or SHS. METHODS This study is a retrospective cohort study that included 249 patients with AO/OTA 31 A1.1-3, 31 A2.1-3 nonpathological fractures of the femur, of which 137 received CMN and 112 received SHS. Analysis was stratified by fracture type as stable (AO 31A1.1-2.1) or unstable (AO 31A2.2-3). RESULTS The tip-apex distance in stable fractures fixed with CMN was 17.3 ± 5.9 compared to 26.2 ± 7.9 in the stable SHS group (p 0.05). Among patients with unstable fractures CMN had significantly less collapse (P < 0.001) and failure (P = 0.046) but no difference in complications (P = 0.126) or mortality (P = 0.586). CONCLUSIONS There were no significant differences in failure or complication rates when comparing the CMN to the SHS in stable intertrochanteric fractures. CMN demonstrated significantly reduced failure and collapse rates in unstable intertrochanteric fractures when compared to SHS; however, this study had a relatively small sample size of unstable fractures and all results must be interpreted within this context.

The number of periprosthetic fractures is expected to increase given the growing number of elderly individuals who are living longer and advances in technology that allow for total hip and knee arthroplasty in younger patients. Evolving technologies in combination with a better understanding of required total hip and knee reconstruction has allowed for continued improvements in applied fixation strategies and patient outcomes. Current fixation and revision options have led to reliable, reproducible management of periprosthetic fractures about the hip and knee, including proximal femur and supracondylar femur fractures, which are common, and fractures about an acetabular component and between proximal and distal hip and knee prostheses, which are rare. Orthopaedic surgeons should understand the most contemporary techniques, strategies, and formulas for the successful management of periprosthetic fractures about the hip and knee.

Ankle fractures are increasingly common in elderly patients given the number of aging individuals who remain active. The already difficult aspects of ankle fixation are amplified by the compromised soft-tissue envelope and bone quality present in elderly patients with an ankle fracture. In addition, elderly patients with an ankle fracture often have compromised neuroprotective mechanisms and are physically unable to follow postoperative protected weight-bearing protocols during ambulation. Surgeons should be aware of strategies to improve fixation and maintain the tibiotalar relationship during ambulation in elderly patients with an ankle fracture.

Objectives To compare pain after operative versus nonoperative pelvic ring injuries with unilateral sacral fractures. Design Prospective, multicenter, observational. Setting Sixteen trauma centers. Patients/participants Skeletally mature patients with pelvic ring injury and minimally displaced unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. Main outcome measurements Pelvic displacement was documented on injury plain radiographs and computed tomography scans; a 10 point Visual Analog Scale (VAS) was used to evaluate pain was obtained in the anterior and posterior pelvic ring during the time of union (12 weeks). Results One hundred ninety-four patients with unilateral sacral fractures displaced less than 5 mm, mean age of 38.7, and mean Injury Severity Score of 14.5 were included. Ninety-nine percent had lateral compression injuries, and 62% were in zone 1. Seventy-four percent were treated nonoperatively. Nonoperative patients had more zone 1 fractures (71%, P = 0.004). Nonoperative patients reported mean VAS 2.7 points higher in the posterior pelvis (P = 0.01) and 1.9 points higher anteriorly (P = 0.11) 24 hours after injury compared with patients treated operatively. After 3 months, nonoperative patients reported higher VAS scores than operative patients: 4.0 versus 2.9 posteriorly (P = 0.019) and 3.2 versus 2.3 anteriorly (P = 0.035). Conclusions For sacrum fractures with minimal or no displacement, slight differences in the VAS were noted within 24 hours after injury or surgery, but limited differences were seen at 3 months for either operatively treated minimally or undisplaced sacrum fractures. It is unknown whether this represents clinical relevance. These differences were below the minimally important clinical difference for VAS scores for other orthopaedic conditions. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to compare failure and complication rates associated with short cephalomedullary nail vs long cephalomedullary nail fixation for stable vs unstable intertrochanteric femur fractures. This study included 201 adult patients with nonpathologic intertrochanteric femur fractures without subtrochanteric extension (OTA 31-A1.1-3, 31-A2.1-3, 31-A3.1-3) who were treated with a short cephalomedullary nail (n=70) or a long cephalomedullary nail (n=131) and had at least 6 months of follow-up. Treatment groups were similar in terms of age, sex, and comorbidities. In the stable fracture group (N=81), there was no difference in total complications (adjusted P =.73), failure (adjusted P =.78), or mortality (adjusted P =.62) between short cephalomedullary nails and long cephalomedullary nails. Unstable fracture patterns were more likely to be treated with a long cephalomedullary nail than a short cephalomedullary nail ( P =.01). In the unstable fracture group (N=120), there was no difference in total complications (adjusted P =.32) or failure (adjusted P =.31) between short cephalomedullary nails and long cephalomedullary nails. A cumulative mortality curve showed a trend toward increasing mortality in unstable fractures treated with short cephalomedullary nails. Traumatologists did not display a statistically significant preference between short cephalomedullary nails and long cephalomedullary nails when compared with nontraumatologists. [ Orthopedics . 2019; 42(2):e202–e209.]

Periprosthetic femur fractures about a total hip arthroplasty (THA) are increasing. A subset of these fractures involve fractures of the femur around a stable femoral prosthesis. These fractures include fractures of the greater trochanter (Vancouver AG), fractures at the level of the stem with a stable femoral prosthesis (Vancouver B1), and fractures below the level of the femoral stem (Vancouver C). Most Vancouver Ag fractures can be treated nonoperatively unless the displaced fracture is greater than 2.5 cm or patient has painful nonunion or limp. Vancouver B1 and Vancouver C fractures are treated with open reduction internal fixation techniques. With these fractures, accurate assessment of radiographs must be performed preoperatively to assess for stem stability. Revision implants should be available if component loosening or failure is observed intraoperatively. This chapter summarizes different surgical techniques and tips for management of these fractures.

Objectives The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Design Retrospective cohort study. Patients 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Intervention Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Outcomes measured Intraoperative displacement, quality of reduction. Results Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Conclusion Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in associated fracture pattern. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation.Retrospective comparative study.Three academic level 1 trauma centers.From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated.Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon.Majeed Pelvic Score.There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84).Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE Concern about radiation exposure during surgery has focused on surgeon exposure. However, the patient receives exposure that is more direct and, in surgery about the pelvis and hip, internal pelvic nonskeletal organs often cannot be shielded without obscuring the region of surgical interest. The purpose of this study was to prospectively evaluate patients' radiation exposure during fracture surgery of the acetabulum, pelvic ring, and femur to calculate future cancer incidence (CI). DESIGN Prospective descriptive cohort. SETTING Level-1 trauma center. PATIENTS/PARTICIPANTS One hundred eight patients with acetabulum, pelvic, or femur fractures requiring operative repair were prospectively enrolled. INTERVENTION Dosimeters were placed in locations determined for each surgery type by a medical physicist. MAIN OUTCOME MEASUREMENTS Demographics, operative records, and average x-ray emission energy were recorded. Effective dose, specific organ doses, and lifetime CI for a 30-year-old patient were calculated. RESULTS Diagnoses included 27 acetabular fractures, 30 intertrochanteric femur fractures, 26 femoral shafts, and 25 pelvic ring injuries. Patients with pelvic ring injuries received the highest effective dose at 0.91 ± 0.74 mSv. The average lifetime increase in CI, for any cancer type, after pelvic ring fixation is 0.0097% for females and 0.0062% for males. The greatest mean single-organ dose to the ovaries (3.82 ± 3.34 mGy) occurred during pelvic ring surgery, correlating to an increased ovarian cancer risk of 0.0013%. The greatest mean single-organ dose to the prostate (6.81 ± 5.91 mSv) also occurred during pelvic surgery, correlating to increased prostate cancer risk of 0.0024%. CONCLUSIONS Fracture surgery to the pelvis and femur is exceptionally fluoroscopy-dependent; however, the radiation exposure incurred represents a relatively small increased risk of future cancer development in patients. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined.Is delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning.We performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds) in the delayed external fixation cohort. Deep infection rate was 13% in plateau fractures and 18% in plafond fractures. Rates of infection, compartment syndrome, secondary surgeries, time to definitive fixation, and length of hospitalization were recorded.Controlling for differences in open fracture severity between groups, there was no difference in infection for plafond (early fixation: 12 of 38 [32%]; delayed fixation: seven of 34 [21%]; adjusted relative risk = 1.39 [95% confidence interval {CI}, 0.45-4.31], p = 0.573) and plateau (early fixation: eight of 42 [19%]; delayed fixation: nine of 45 [20%]; adjusted relative risk: 0.93 [95% CI, 0.31-2.78], p = 0.861) groups. For compartment syndrome risk, there was no difference between early and delayed groups for plateau fractures (early fixation: six of 42 [14%]; delayed fixation: three of 45 [7%]; relative risk = 0.47 [0.12-1.75], p = 0.304) and plafond fractures (early fixation: two of 38 [5%]; delayed fixation: three of 34 [9%]; relative risk = 1.67 [0.30-9.44], p = 0.662). There was no difference for length of hospitalization for early (9 ± 7 days) versus delayed fixation (9 ± 6 days) (mean difference = 0.24 [95% CI, -2.9 to 3.4], p = 0.878) for patients with plafond fracture. Similarly, there was no difference in length of hospitalization for early (10 ± 6 days) versus delayed fixation (8 ± 4 days) (mean difference = 1.6 [95% CI, -3.9 to 0.7], p = 0.170) for patients with plateau fracture. Time to definitive fixation for plateau fractures in the early external fixation group was 8 ± 6 days compared with 11 ± 7 days for the delayed external fixation group (mean difference = 2.9 [95% CI, 0.13-5.7], p = 0.040); there was no difference in time to definitive fixation for early (12 ± 7 days) versus delayed (12 ± 6 days) for patients with plafond fractures (mean difference = 0.39 [95% CI, -2.7 to 3.4], p = 0.801). There was no difference in risk of secondary surgeries between early external fixation (21 of 38 [55%]) and delayed external fixation (13 if 34 [38%]) for plafond fractures (adjusted relative risk = 0.69 [95% CI, 0.41-1.16], p = 0.165) and no difference between early fixation (24 of 42 [57%]) and delayed fixation (26 of 45 [58%]) for plateau fractures (adjusted relative risk = 1.0 [95% CI, 0.70-1.45], p = 1.00).We were unable to detect a difference in infection, compartment syndrome, secondary procedures, or length of hospitalization for patients who undergo early versus delayed external fixation for high-energy tibial plateau or plafond fractures. This may affect decisions for resource use at trauma centers such as whether high-energy periarticular lower extremity fractures need to be spanned on the evening of presentation or whether this procedure may wait until the morning trauma room. Given the high complication rate of these injuries and clinical relevance of this question, this may also need to be examined in a prospective manner.Level IV, therapeutic study.

OBJECTIVE In orthopaedic trauma, patients' functional status scores cannot be collected before injury. Due to the lack of these data, it is difficult to reliably determine if patients have returned to their preinjury level of physical function. The goal of this article is to determine if patients' assessment of preinjury function agrees with that of familiar proxies, to determine whether patient assessment of preinjury function may be regarded as reliable. METHODS At first postinjury outpatient follow up, orthopaedic trauma patients and their proxies were asked to independently complete the PROMIS physical function computer adaptive test (PF CAT) based on how they perceived the function of the patient before injury. Intraclass correlation, paired sample t tests, and 95% confidence intervals were used to analyze patient-proxy agreement. RESULTS Fifty patient-proxy pairs completed the questionnaire at an average of 14.3 (SD = 1.1) days postoperative (average 19.3, SD = 12.1 days postinjury). Patient mean PF CAT score was 57.92 (SD = 10.38) for patients and 56.59 (SD = 11.50) for proxies. Paired samples t test showed that patient's PF CAT scores were not significantly different from proxy scores [mean score difference = 1.33; 95% CI = (-1.28, 3.94); P = 0.311]. Intraclass correlation between patient and proxy scores was 0.79. There was no notable bias. DISCUSSION Good agreement in PF CAT preinjury assessment between patients and proxies support patients' ability to report reliable preinjury physical functioning in the early postinjury setting using the PF CAT.

On evaluation of the clinical indications of computed tomography (CT) scan of head in the patients with low-energy geriatric hip fractures, Maniar et al. identified physical evidence of head injury, new onset confusion, and Glasgow Coma Scale (GCS)15 as predictive risk factors for acute findings on CT scan. The goal of the present study was to validate these three criteria as predictive risk factors for a larger population in a wider geographical distribution.Patients ≥65 years of age with low-energy hip fractures from 6 trauma centers in a wide geographical distribution in the United States were included in this study. In addition to the relevant patient demographic findings, the above mentioned three criteria and acute findings on head CT scan were gathered as categorical variables.In total 799 patients from 6 centers were included in the study. There were 67 patients (8.3%) with positive acute findings on head CT scan. All of these patients (100%) had at least one criteria positive. There were 732 patients who had negative acute findings on head CT scan with 376 patients (51%) having at least one criteria positive and 356 patients (49%) having no criteria positive. Sensitivity of 100% and negative predictive value of 100% was observed to predict negative acute findings on head CT scan when all the three criteria were negative.With the observed 100% sensitivity and 100% negative predictive value, physical evidence of acute head injury, acute retrograde amnesia, and GCS15 can be recommended as a clinical decision guide for the selective use of head CT scans in geriatric patients with low energy hip fractures. All the patients with positive acute head CT findings can be predicted in the presence of at least one positive criterion. In addition, if these criteria are used as a pre-requisite to order the head CT, around 50% of the unnecessary head CT scans can be avoided.

Background Studies have shown that the ambulatory behavior and amount of weight bearing performed by lower leg fracture patients, increases over time. It is likely that gait features, such as center of pressure (CoP), also change over time. Research Question The purpose of this study was to characterize changes in CoP exhibited by lower leg fracture patients wearing a walking boot during the recovery period. Methods Approximately 2 weeks post-surgery, seven lower leg fracture patients were fitted with a MaxTrax walking boot which was integrated with the Ambulatory Tibia Load Analysis System, an underfoot load monitoring system. Patients wore the walking boot for 2–12 weeks resulting in continuous load data during the recovery period. Ambulation was filtered from the raw data and daily average CoP values were calculated by averaging the CoP vectors from all steps in a given day. Result In general, the CoP vector varied in both the x and y directions during the initial stages of recovery but was more uniform during the later stages of healing. In 6/7 patients, the CoP in the y direction was closer to the forefoot during the initial stages of healing but shifted posteriorly as time post-surgery increased. The single patient that did not exhibit a posterior shift in CoP was also the only patient to develop a non-union. CoP in the x direction show a less clear trend. CoP in the x direction exhibited a medial shift in 5 patients and a lateral shift in 2 patients. Significance During lower leg fracture recovery in a walking boot, the CoP in the y direction shifts posteriorly as time post-surgery increases and CoP monitoring may become a useful tool to monitor individual patient healing progression.

Introduction: Ambulation can be used to monitor the healing of lower extremity fractures. However, the ambulatory behavior of tibia fracture patients remains unknown due to an inability to continuously quantify ambulation outside of the clinic. The goal of this study was to design and validate an algorithm to assess ambulation in tibia fracture patients using the ambulatory tibial load analysis system during recovery, outside of the clinic. Methods Data were collected from a cyclic tester, 14 healthy volunteers performing a 2-min walk test on the treadmill, and 10 tibia fracture patients who wore the ambulatory tibial load analysis system during recovery. Results The algorithm accurately detected 2000/2000 steps from simulated ambulatory data. During the 2-min walk test, step counts derived from the algorithm and treadmill showed a strong correlation (r2>0.98) to the visual (“actual”) step count. Applying the algorithm to continuous data from tibia fracture patients revealed qualitative differences in gait between the initial and later stages of recovery. Additionally, a relatively large standard deviation (≤3000 steps) in the daily average step count indicated a variety of patient ambulatory behaviors. Conclusion The algorithm reported in this study can assess the ambulatory activity of tibia fracture patients during the recovery period.

To evaluate the healing rate, complications, role of reduction and screw placement, and the 1-year mortality in the treatment of reverse oblique and transverse intertrochanteric femoral fractures treated with the long cephalomedullary nail.Retrospective review.Two different Level-1 trauma centers: Geisinger Medical Center and the University of Utah.One hundred forty-eight patients with intertrochanteric fractures (AO/OTA class 31-A3) eligible for review. All patients had a minimum of 12 months of follow-up and were available for radiologic checks and assessment of outcomes and complications.Long cephalomedullary nail.Medical records were reviewed for reoperation, demographic parameters, length of hospital stay, estimated blood loss, and need for transfusion. Mortality rates at 1 month, 6 months, and 1 year were also recorded. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, 12 months, and yearly as needed.The average age of patients was 69.9 (range, 19-95) years. Average length of follow-up was 53 (range, 12-148) months. The average surgical time was 71.8 (range, 26-229) minutes. Twenty-four patients (16%) required blood transfusions, and the average transfusion required was 205.1 mL (range, 20-800). Five different long nail designs were used to treat the patients. One patient (0.6%) experienced an intraoperative complication. Eighteen patients (12%) sustained postoperative complications. Twelve (8%) patients required reoperations. One-year mortality rates were 10.1%.Long cephalomedullary nails remain the preferred treatment option for the treatment of 31-A3-type fractures, demonstrating acceptable complication rates, low reoperation rates, and high rates of healing.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The aim of this study was to report the incidence of arthrofibrosis of the knee and identify risk factors for its development following a fracture of the tibial plateau. We carried out a retrospective review of 186 patients (114 male, 72 female) with a fracture of the tibial plateau who underwent open reduction and internal fixation. Their mean age was 46.4 years (19 to 83) and the mean follow-up was16.0 months (6 to 80).A total of 27 patients (14.5%) developed arthrofibrosis requiring a further intervention. Using multivariate regression analysis, the use of a provisional external fixator (odds ratio (OR) 4.63, 95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly associated with the development of arthrofibrosis. Similarly, the use of a continuous passive movement (CPM) machine was associated with significantly less development of arthrofibrosis (OR = 0.32, 95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external fixator was found to be significant, with each extra day of external fixation increasing the odds of requiring manipulation under anaesthesia (MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy fracture, surgical approach, infection and use of tobacco were not associated with the development of arthrofibrosis. Patients with a successful MUA had significantly less time to MUA (mean 2.9 months; sd 1.25) than those with an unsuccessful MUA (mean 4.86 months; sd 2.61, p = 0.014). For those with limited movement, therefore, performing an MUA within three months of the injury may result in a better range of movement.Based our results, CPM following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation.Cite this article: Bone Joint J 2015;97-B:109–14.

OBJECTIVES To better characterize operative agreement and disagreement among orthopaedic surgeons treating lateral compression type 1 (LC-1) pelvic fractures in an effort to improve communication between care providers and improve patient care. DESIGN Decision analysis. SETTING Level 1 trauma center. METHODS Twenty-seven LC-1 cases were selected to represent a wide array of LC-1 injuries. Each case was presented with 3 plain pelvic radiographs (anteroposterior, inlet, and outlet) and a scrollable computed tomography at the OTA national meeting. Attendees were queried whether they would perform operative stabilization "yes/no." Years of surgical practice (0-5, 6-10, and >10), annual pelvic fracture case volume (0-20, 21-50, and >50), and completion of a trauma fellowship (yes/no) were also collected. Fleiss' kappa (K) was used to measure operative agreement among survey respondents, where K = 0.21-0.40 was fair and K = 0.41-0.60 was moderate agreement. RESULTS One hundred eleven surgeons completed the survey where the average tendency to operate across surveys was 40%. Of the 27 cases presented, only 9 cases (33%) showed substantial agreement. There were 4 cases where nearly everyone chose operative stabilization (93.1%-94.4%) and 5 cases where nearly no one chose operative stabilization (0%-8.7%). The overall agreement was fair with K = 0.39 [95% confidence interval (CI), 0.34-0.44]. Although there was a trend for surgeons with more years of surgical practice to have a lower tendency to operate, it did not achieve statistical significance (odds ratio for >10 years vs. 0-5 years = 0.73; 95% CI, 0.48-1.11). Annual case volume and completion of a trauma fellowship were not statistically significant predictors of operative tendency. CONCLUSIONS Our results show only fair operative agreement (K = 0.39; 95% CI, 0.34-0.44) in a radiographic survey representing a broad range of LC-1 fracture morphologies among OTA surgeons. Only 9 of the 27 cases (33%) had substantial agreement. There was no difference in the decision to operate based on surgical volume, completion of a trauma fellowship, or time in practice. These results highlight the differing practice decisions among surgeons currently treating LC-1 injuries, and there is need for further studies to more fully understand stability after this injury pattern.

Tibial shaft fractures distal to total knee arthroplasty are rare, but they are likely to become more common with the increasing number of arthroplasty procedures being performed. These fracture patterns have been treated in the past either with closed reduction and casting/bracing or with open reduction internal fixation using plates. Weight-bearing precautions in the elderly patient population can affect patient disposition, and weight bearing on extramedullary fixation can lead to early hardware failure. We present a series of nailing techniques that can be used for tibial fractures distal to a well-fixed total knee arthroplasty that avoids the tibial baseplate, provides stable fracture fixation, and allows for early weight bearing.

OBJECTIVE To determine whether radiographic measurements are predictive of involvement of the distal tibia articular surface in tibial shaft fractures. DESIGN Retrospective review. SETTING Academic Level-I trauma hospital. PATIENTS Two-hundred seventeen patients with tibial shaft fractures distal to the isthmus (OTA/AO: 42-A1-3; 42-B1-3; 42-C1-3; and 43-A1-3). INTERVENTION Analysis of anteroposterior (AP) and lateral radiographs. The following parameters were measured: (1) angle between the predominant fracture line and the plane of the tibial plafond (α-angle), (2) length of the shaft fracture, (3) distance from the most inferior extent of the shaft fracture to the tibial plafond (DTP), (4) width of the tibial plafond, (5) width of the tibial isthmus, (6) ratio of fracture length to DTP (FTP), and (7) fibular fracture distance. MAIN OUTCOME MEASURE Distal intra-articular involvement (DIA). RESULTS A total of 217 patients were identified, 56 (26%) with DIA. The FTP ratio as measured on both the AP (odds ratio: 8.20, confidence interval, 4.26-17.22, P < 0.0001) and lateral radiographs (10.00, 4.78-23.23

Objective To assess radiographic markers of ankle stability in stable OTA/AO 44-B1 ankle fractures. Design Retrospective review. Setting Academic Level-I trauma hospital. Patients One hundred thirty-four patients with stable OTA/AO 44-B1 (Danis-Weber B, Supination-External Rotation-II) ankle fractures. Intervention Analysis of mortise view radiographs at the time of initial evaluation and final follow-up. Variables measured (1) medial clear space; (2) Mueller-Nose Distance. Main outcome measure Change in radiographic measurements resulting in conversion to operative intervention. Results Patients followed up an average of 2.6 visits in our clinics (SD 1.06). Patients received an average of 11.2 individual radiographic images to evaluate their injury (SD 3.9, maximum 29). No patients progressed to surgery in this cohort. Mean medial clear space at the time of injury was 3.4 mm (SD 0.8) and was 3.3 mm (SD 0.7) at the time of final follow-up (P = 0.1). Mean Mueller-Nose measurement at the time of injury was 3.5 mm (SD 1.0) and was 3.5 mm (SD 0.8) at the time of final follow-up (P = 0.47). Conclusions No patients with stable OTA/AO 44-B1 fractures proceeded to surgery for loss of tibiotalar reduction or any other cause. Radiographic relationships were conserved during the follow-up, and serial radiographs may not be needed when managing these patients. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

To document the complications among obese patients who underwent surgical fixation for intertrochanteric femur (IT) fractures and to compare with nonobese patients.Retrospective cohort study.Four level I trauma centers.1078 IT fracture patients.None.Patient and fracture characteristics, surgical duration, surgical delay intraoperative and postoperative complications, inpatient mortality, and length of stay.A retrospective review at 4 academic level I trauma centers was conducted to identify skeletally mature patients who underwent surgical fixation of intertrochanteric fractures between June 2008 and December 2014. Descriptive data, injury characteristics, OTA fracture classification, and associated medical comorbidities were documented. The outcomes measured included in-hospital complications, length of stay, rate of blood transfusion, change in hemoglobin levels, operative time, and wound infection.Of 1078 unique patients who were treated for an IT fracture, 257 patients had a Body mass index (BMI) of 30 or greater. Patients with a high BMI (≥30) had a significantly lower mean age (73 vs. 77 years, P0.0001), higher percentage of high-energy injuries (18% vs. 9%, P = 0.0004), greater mean duration of surgery (96 vs. 86 minutes, P = 0.02), and higher mean length of stay (6.5 vs. 5.9 days, P = 0.004). The high-BMI group (n = 257) had significantly higher percentages of patients with complications overall (43% vs. 28%, P0.0001), respiratory complications (11% vs. 3%, P0.0001), electrolyte abnormalities (4% vs. 2%, P = 0.01), and sepsis (4% vs. 1%, P = 0.002). Patients with BMI ≥ 40 had a much higher rate of respiratory complications (18%) and wound complications (5%) than obese (BMI: 30-39.9) and nonobese patients (BMI30).Intertrochanteric hip fracture patients with a BMI of30 kg/m are much more likely to sustain systemic complications including respiratory complications, electrolyte abnormalities, and sepsis. In addition, morbidly obese patients are more likely to sustain respiratory complications and wound infections than obese (BMI: 30-39.9 kg/m) and nonobese patients (BMI:30 kg/m). The findings from this study can help direct surgeons in the counseling to obese patients and their family, and perhaps increase hospital reimbursement for this group of patients.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To investigate the blood loss and transfusion rate associated with the use of reamer irrigator aspirator (RIA).Retrospective review.Academic Level-I trauma hospital.One hundred eight patients requiring bone graft harvest for surgical reconstruction of nonunion or failed arthrodesis.Bone graft harvest preformed via RIA or iliac crest bone graft (ICBG).Blood loss as measured by a change in preoperative and postoperative hematocrit (Hct). In addition, postoperative transfusion reported intraoperative blood loss, volume of graft harvested, and major complications.The average Hct drop was found to be 13.7 (4.1-27.4) in the RIA cohort of 61 patients and 7.36 (1.2-14.5) in the ICBG cohort of 47 patients (P = 0.013). Operative reports documented an average estimated blood loss of 674 mL (100-2000 mL) in the RIA cohort compared with 255 mL (50-1000 mL) in the ICBG cohort (P0.001). Twenty-seven patients (44%) required blood transfusion after RIA, whereas 10 patients (21%) required blood transfusion after ICBG (odds ratio 5.32, 95% confidence interval 2.2-6.3, P0.001). RIA procedures collected an average 53 mL (20-100 mL) of bone graft compared with 27 mL (15-50 mL) with ICBG. There was no significant difference between groups regarding age, sex, medical comorbidities, or postoperative major complications.This series demonstrated that 44% of patients undergoing RIA bone graft harvest required transfusion, with a mean Hct drop of 13.7 across all subjects, which is significantly greater than that associated with ICBG.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

To determine the effect of insertion angle, from 45° to 135° in 15° increments, on the number of cycles withstood, the ultimate pullout strength, and the stiffness of threaded suture anchors subjected to load.Threaded anchors were inserted into polyurethane foam at angles from 45° to 135°, in 15° increments, relative to the direction of pull. Five anchors were tested at each angle. The anchors were first cycled for 30 cycles (10 each at 100 N, 150 N, and 200 N). The surviving specimens were then tensioned to failure. The McNemar test was used to compare cyclic failure rates. Paired-samples t tests were used to compare load-to-failure (LTF) and stiffness data. All P values are multiplicity adjusted by the Hommel procedure.Four of 5 anchors inserted at 45° failed during cyclic testing at a mean of 27 cycles (P = .13). One of 5 anchors placed at 60° failed after 29 cycles (P = .99). All other anchors survived cyclic testing. Mean LTF was 234 N, 243 N, 297 N, 373 N, 409 N, 439 N, and 417 N at insertion angles of 45°, 60°, 75°, 90°, 105°, 120°, and 135°, respectively. LTF was significantly less for the 60° group when compared with the 90°, 105°, 120°, and 135° groups (P.05). LTF was significantly less for the 75° group when compared with the 105°, 120°, and 135° groups (P.05). For the 90° group, LTF was only significantly less when compared with the 135° group (P = .022). The differences in LTF between the 105°, 120°, and 135° groups were not significant. Stiffness increased from 28.13 N/mm at 90° to 43.4 N/mm at 105° (P = .03), 61.48 N/mm at 120° (P = .003), and 86.83 N/mm at 135° (P = .008).Anchors placed at more acute angles, that is, anchors placed closer to the so-called deadman's angle, failed at lower loads and provided less construct stiffness than anchors placed at angles greater than 90°. Stiffness also increased sequentially from an angle of insertion of 90° up to our maximum angle tested of 135°. For threaded metallic suture anchors, an obtuse insertion angle of 90° to 135° in relation to the line of pull of the suture and rotator cuff withstands a greater LTF and provides a stiffer construct than the more acute insertion angle advocated by the "deadman theory."This study offers a biomechanical validation for optimal placement of threaded suture anchors at an angle of 90° or more, as anatomic restraints allow, from the vector of pull of the attached suture and rotator cuff, rather than the 45° angle recommended by the deadman theory.

Surgical management of extra-articular distal tibia fractures has evolved because of the high rate of complications with conventional techniques and the technically challenging aspects of the surgery. Open reduction and internal fixation with plating or nailing remain the gold standards of treatment, and minimally invasive techniques have reduced wound complications and increased healing. Adequate reduction and stabilization as well as appropriate soft tissue management are imperative to achieving good outcomes in these fractures.

Objectives Document fixation and healing of distal femur fractures stabilized by plate osteosynthesis using far cortical locking (FCL) screws. Design Prospective and observational. Setting Two level 1 and 1 level 2 trauma centers. Patients Thirty-two consecutive patients with 33 distal femur fractures (AO/OTA types 33A, 33C). Intervention Fractures were stabilized by plate osteosynthesis with MotionLoc FCL screws without supplemental bone graft or bone morphogenic proteins. Patients were followed up for a minimum of 1 year with functional and radiographic assessments obtained at postoperative weeks 6, 12, and 24 and computed tomography scans at week 12. If union was not confirmed within 1 year, follow-up was continued until union or revision surgery. Main outcome measures The primary end point was fracture union in the absence of complications and secondary interventions. Fracture healing was defined by resolution of pain at the fracture site and cortical bridging on biplanar radiographs. Complications were defined by fixation failure, loss of reduction, implant breakage, infection, nonunion, and need for revision. Results Thirty-one fractures were available for follow-up. None of the 125 FCL screws used for diaphyseal fixation broke or lost fixation. One of the 31 fractures displaced into varus (ΔVarus = 5.8 degrees). Thirty of the 31 fractures healed within 15.6 ± 6.2 weeks. At an average follow-up of 17 ± 4 months, there were 2 revisions: one to correct a malrotation at day 5 and one to treat a nonunion at 6 months. Conclusions Absence of implant and fixation failure suggests that dynamic plating of distal femur fractures with FCL screws provides safe and effective fixation.

Orthopedic surgeons frequently provide weight-bearing recommendations to guide patient recovery following lower extremity fractures. This article discusses the available literature regarding the effects of early weight bearing on fracture healing, patient compliance with weight bearing restrictions, and the effect of different weight bearing protocols following acetabular, tibial plateau, tibial plafond, ankle, and calcaneus fractures.

Introduction Certain patients with pilon fractures present with significant soft-tissue swelling or with a poor soft-tissue envelope typically not amenable to definitive fixation in the early time period. The objective of this study was to review the treatment of simple intra-articular fractures of the tibial plafond (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 43C1–C2) via intramedullary nailing (IMN) with the assessment of clinical and radiographic results and any associated complications. Materials and methods Retrospective clinical and radiological reviews of 31 patients sustaining AO/OTA type 43C distal tibial fractures treated with IMN were evaluated. Our main outcome measurement included achievable alignment in the immediate postoperative period and at the time of union along with complications or need for secondary procedures within the first year of follow-up. Results Seven patients were lost to follow-up. All the remaining patients achieved bony union at a mean union time of 14.1 ± 4.9 weeks with no evidence of malunion or malrotation. All patients were at full-weight-bearing status at 1-year follow-up. Complications were notable for one delayed union, one non-union, one patient with superficial wound drainage, two with deep infection, one with symptomatic hardware and one with deep vein thrombosis. Conclusion Simple articular fractures of the tibial plafond (AO/OTA type 43C) treated via IMN can achieve excellent alignment and union rates with proper patient selection and surgical indication. One should not hesitate to use additional bone screws or plating options to help achieve better anatomic reduction. However, larger, prospective randomised trials comparing plating versus nailing, in experienced hands, are needed to completely delineate the utility of this treatment modality.

High energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries.137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism].121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p=0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p0.001) and fracture of the first metatarsal (p=0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N=51) demonstrated no difference in physical function for patients with and without amputations.High-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.

We hypothesized that use of a novel fluoroscopic grid would decrease operative time and component positioning variability during anterior supine total hip arthroplasty (THA). We reviewed 99 anterior supine THAs: 39 using a fluoroscopic grid, and 60 using fluoroscopy alone. Goals were cup abduction of 40° ± 10° and limb length and hip offset within 10 mm of the contralateral side. Surgical time was decreased in the study group (79 vs 94 minutes, P = .002). In the study group, more components met the goal for cup abduction (97% vs 83%, P = .046), limb length (100% vs 88%, P = .04), hip offset (85% vs 67%, P = .047), and all 3 combined (82% vs 52%, P = .002). We demonstrated decreased component positioning variability during anterior supine THA with assistance of a fluoroscopic grid.

Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF).We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate.We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6-40 months).All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients.The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Physicians routinely prescribe partial weight bearing in a walking boot following fractures of the lower limbs in order to produce the needed mechanical environment to facilitate healing. Plantar pressure measurements can provide key information regarding the mechanical environment experienced by lower limb bones. The effect of walking boots on plantar pressure distribution has been well reported, however, the combined effects of partial weight bearing and walking boots on plantar pressure distribution and center of pressure is unknown. Thirteen healthy volunteers with no known gait pathologies were fitted with a multi-pressure sensor insole that recorded their plantar pressure distribution during four walking trials: (i) normal walking, (ii) full weight bearing in a walking boot, (iii) 27 kg partial weight bearing in a walking boot and (iv) 9 kg partial weight bearing in a walking boot. Results demonstrated that changing from trial (i) to (iv) resulted in a posterior shift in weight distribution; the percentage of total weight experienced at the heel increased while the percentage of total weight experienced at the forefoot (both medial and lateral) and the hallux decreased. Center of pressure trajectories also shifted more posteriorly. Additionally, while in a walking boot the gait during full and partial weight bearing resulted in more even foot loading.

Talar body fractures are severe injuries with a historically poor prognosis. Outcomes of the injuries are optimized by stable accurate internal fixation. We describe a posteromedial approach for the treatment of posterior talar body fractures, which forgoes the need for a periarticular osteo

The lag screw technique has historically been a successful and accepted way to treat oblique metacarpal fractures. However, it does take additional time and involve multiple steps that can increase the risk of fracture propagation or comminution in the small hand bones of the hand. An alternate fixation technique uses bicortical interfragmentary screws. Other studies support the clinical effectiveness and ease of this technique. The purpose of this study is to biomechanically assess the strength of the bicortical interfragmentary screw versus that of the traditional lag screw. Using 48 cadaver metacarpals, oblique osteotomies were created and stabilized using one of four methods: 1.5 mm bicortical interfragmentary (IF) screw, 1.5 mm lag technique screw, 2.0 mm bicortical IF screw, or 2.0 mm lag technique screw. Biomechanical testing was performed to measure post cyclic displacement and load to failure. Data was analyzed using one-way analysis of variance (ANOVA). There was no significant difference among the fixation techniques with regard to both displacement and ultimate failure strength. There was a slight trend for a higher load to failure with the 2.0 mm IF screw and 2.0 mm lag screw compared to the 1.5 mm IF and 1.5 mm lag screws, but this was not significant. Our results support previously established clinical data that bicortical interfragmentary screw fixation is an effective treatment option for oblique metacarpal fractures. This technique has clinical importance because it is an option to appropriately stabilize the often small and difficult to control fracture fragments encountered in metacarpal fractures.

Fractures of the tibial pilon may present an array of problems and potential complications. Staged treatment with initial spanning external fixation of the ankle has proven to be a successful strategy for the treatment of these difficult fractures in many cases. A subset of the tibial pilon fractures, with an oblique extension to the diaphysis may constitute a treatment problem, as these long fractures may be difficult to reduce at the time of definitive fixation, often 1-3 weeks post-injury due to interposed soft tissues, hematoma and/or early callus. Anatomic reduction of this fracture may thus require more extensive dissection than might be desirable in this injury. We offer a technique to assist in the treatment of the subset of these difficult fractures. In appropriate cases, a small fragment plate may be applied to the diaphyseal component of the fracture in an anti-glide type plate application, through a small incision proximal to the area of greatest injury. This re-establishes the length, rotation and alignment of this fragment which is commonly attached to either the Chaput anterolateral or the Volkmann posterolateral fragment. It additionally provides the intimate contact that may favor early union or minimize the need for secondary procedures. The fracture is thereby converted from a complete articular AO/OTA 43-C type pattern to a partial articular, or AO/OTA 43-B type pattern.