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Introduction There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. Methods A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. Results Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. Discussion This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Pelvic ring injuries presenting in hemorrhagic shock have historically had a mortality rate greater than 30%. To address this high mortality rate our institution has had a multi-disciplinary protocol for hemodynamically unstable pelvic ring injuries since 1993. In 2004, this protocol was revised to prioritize pre-peritoneal pelvic packing over angiography to rapidly control hemorrhage, reduce high-volume blood transfusions, and decrease the number of deaths from acute blood loss. This protocol has been successful in reducing deaths from hemorrhage by 30%. Despite the benefits of such a protocol, many trauma centers are not routinely stabilizing pelvic ring injuries or controlling pelvic hemorrhage. Subsequently, mortality rates remain high with a significant proportion of patients dying from acute blood loss. Trauma centers adhering to multi-disciplinary protocols that allow for rapid stabilization of the pelvis and simultaneous control of multiple sites of hemorrhage in hybrid operative suites are promising future directions for the management of patients with these lethal injuries.

Objective: Evaluate cost of care of all-terrain vehicle (ATV) related injuries sustained by riders 16 years and younger in Pennsylvania. Methods: Population-based retrospective cohort design reviewing costs of care of 78 patients (

Background Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values. Methods Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis. Results The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p Table 2 ). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p = 0.001, Table 2 ). Conclusion Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.

Background Periprosthetic distal femur fractures associated with total knee replacement are increasing in incidence. We hypothesized that a standardized management protocol would result in few implant failures and a low rate of postoperative complications. Methods Retrospective observational cohort study at an urban level 1 trauma center and academic level 2 trauma center. Consecutive patients with periprosthetic distal femur fractures and stable total knee arthroplasty were included between January 1, 2011 and December 31, 2014. Patients were managed by a standardized protocol of co-management by a hospitalist service, fracture fixation within 24 h of admission by less-invasive locked bridge plating, and immediate unrestricted postoperative weight bearing. The primary outcome measure was the rate of postoperative complications. Secondary outcome measures included time to surgery, intraoperative blood loss, duration of surgery, length of hospital stay, time to full weight bearing, and time to radiographic fracture healing. Results Fifty four fractures were treated in 52 patients. There were three implant failures, one deep infection, one nonunion and two patients with symptomatic malunion. One patient had knee pain due to patellar component instability associated with valgus alignment. There were ten thromboembolic complications despite consistent anticoagulation. Two patients died within 12 months of injury. Thirty-eight patients had returned to their pre-injury ambulation status at 1 year follow-up. Conclusion A standardized approach of less-invasive locked plating fixation and immediate unrestricted weight bearing appears safe and feasible in the management of this vulnerable patient cohort. Trial registration number This is a retrospective observational study without a Trial registration number.

Study design Retrospective review of arterial injury with prospective intra-observer and inter-observer analyses. Aim To introduce a new classification system for arterial injuries in the extremities and trunk. Methods Retrospective review of all patients with arterial injuries treated at a level I trauma centre during a 3.5-year period. Major arteries were located and coded, and the arteries’ lesion was categorised in reference to the alphanumeric format of the AO fracture coding system and injury classification. Each major artery was coded in a numeric format and further divided into three segments: proximal, middle and distal. The severity of artery injury was classified into different types and subtypes in an alphanumeric format. Inter-observer and intra-observer reliabilities were tested. Results Systemic arteries were coded and arterial injuries were classified in the alphanumeric notation. The intra- and inter-observers’ reliabilities were found to be acceptable in the application of the new system. Conclusion The preliminary data demonstrate that the new coding and injury classification system for arteries in the trunk and extremities are reliable and efficient for data storage and retrieval, and provide a favourable environment for discussion among different physicians or centres.

The purpose of our study is to introduce a new Three-Column Classification for tibial plateau fractures and evaluate its reproducibility and reliability.From December 2004 to December 2006, 278 consecutive patients with tibial plateau fractures were treated operatively at the Department of Orthopedics and Trauma III in Shanghai Sixth People's Hospital. Computed tomography (CT) and three-dimensional reconstruction were preformed for each patient before open reduction and internal fixation. The approaches were instructed by the Three-Column Classification. To test the reproducibility of the Three-Column Classification, the interobserver and intraobserver reliability of this classification system compared with that of the Schatzker Classification was investigated by four observers.Fourteen cases could not be classified by Schatzker Classification. Meanwhile, all cases could be classified by the Three-Column Classification. Using plain radiographs, the mean κ values for interobserver reliability using Schatzker Classification systems were 0.567 (range, 0.513-0.589), representing "moderate agreement," whereas the mean κ values were 0.766 (range, 0.706-0.890), representing "substantial agreement" by the use of the Three-Column Classification based on the CT scan. The mean κ values for intraobserver reliability using Schatzker Classification and the Three-Column Classification based on the CT scan were 0.758 (range, 0.691-0.854) and 0.810 (range, 0.745-0.918), respectively, representing "substantial agreement."The Three-Column Classification demonstrates a higher interobserver reliability and can be used as a supplement to the conventional Schatzker Classification, especially in the complex and posterior comminuted tibial plateau fractures. Furthermore, the Three-Column Classification is clinically relevant and, to some degree, can instruct the surgeon in preoperative planning.Diagnostic study, level III.

BACKGROUND The treatment of interprosthetic femoral fractures is challenging because of several factors. Poor bone stock, advanced age, potential prosthetic instability, and limited fracture fixation options both proximally and distally can complicate standard femur fracture treatment procedures. The purpose of this report was to describe our experience treating interprosthetic femoral fractures, providing an emphasis on treatment principles and specific intraoperative management. METHODS All patients with fractures occurring between ipsilateral hip and knee prostheses between 2004 and 2010 were identified from a comprehensive database and included in this study. Patients had been treated using principles adapted from two isolated periprosthetic fracture classification systems, the Vancouver and Su classifications. The electronic medical record (including inpatient medical records, operative notes, outpatient medical records, and all radiographs) was reviewed for each patient and demographic and treatment-related variables as well as complications and outcomes were recorded. RESULTS Thirteen consecutive patients with interprosthetic fractures were included. Four fractures occurred around a clearly loose prosthesis, which were subsequently treated with long-stemmed revisions. The remaining 12 fractures were treated with a locked-plate construct. Two of nine patients (22.2%) died before fracture union. Follow-up averaged 28 months ± 4 months, with fracture union achieved at an average of 4.7 months ± 0.3 months. All patients returned to their self-reported preoperative ambulatory status except one who developed a loose hip prosthesis at 3-year follow-up after fracture union. CONCLUSIONS The principles for treatment of isolated periprosthetic fractures are useful to guide the fixation of interprosthetic fractures. Locked plating is an effective method for the treatment of interprosthetic femoral fractures. Bypassing the adjacent prosthesis by a minimum of two femoral diameters is a necessary technique to prevent a stress riser.

Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE).In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center.Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p0.05). The fresh frozen plasma-red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage.PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.

The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury.During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images.The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of2.5 cm during the stress examination, which changed their treatment from nonoperative to operative.Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.

Beyond a doubt, the menace of underreporting infor-mation related to adverse events in surgery, including “near misses” (ie, an error that was realized in time to be aborted) and “no harm” events (ie, an error that occurred but did not lead to patient harm), bears the inherent risk of a recurrence of the said adverse event in a different patient.

Objectives: To describe the clinical characteristics of combined injuries of the pelvis and acetabulum, which have not been previously described. We hypothesize that this combination of injuries affects not only the postinjury hemodynamics of the patient, but the outcome of subsequent acetabular fracture treatment. Design: Retrospective study. Setting: Level I trauma center. Methods: The data collected included patient demographics, fracture classification, Injury Severity Score, systolic blood pressure on arrival, amount of packed red blood cells transfused, time to operation, perioperative complications, and radiographic outcomes. Age- and sex-matched control groups of patients with pure pelvic fractures and pure acetabular fractures were compared with the combined injury group to assess injury severity characteristics. To determine the independent factors influencing the postoperative residual displacement of the acetabulum, multiple linear regression analysis was used. Results: Between January 1, 1998, and December 31, 2007, there were 1612 patients with either pelvic or acetabular fractures requiring admission to our institution, of which 82 (5.1%) had the combination of an unstable pelvic injury (Orthopaedic Trauma Association [OTA] 61 Types B/C) and a displaced acetabular fracture (OTA 62). Eighty-two patients with an isolated unstable pelvic injury and 82 patients with an isolated displaced acetabular fracture were chosen from the same study period to act as control groups. Patients in the combined group were significantly more injured as compared with the displaced acetabular fracture control group with regard to Injury Severity Score (P < 0.001), systolic blood pressure (P < 0.001), and packed red blood cells (P < 0.001). In the combined group, the most common pelvic fracture patterns were OTA 61.B1 and B2. Transverse-type acetabular fractures patterns (OTA 62.B1 and B2) accounted for 61.2% of all acetabular fractures in the combined group. The most frequent injury combination was a transverse-type acetabular fracture with an associated ipsilateral anterior disruption of the sacroiliac joint. Sixty-eight patients underwent surgical intervention at a mean time of 5.7 days. The mean postoperative displacement of acetabular fracture reduction was 2.2 mm as evaluated by radiographs. Multiple regression analysis revealed that the amount of postoperative posterior pelvic displacement, Type B2 acetabular fractures, and patient age were significant predictors of the amount of residual acetabular displacement found postoperatively. Conclusion: Patients with combined pelvic and acetabular fractures represent a serious injury that includes the resuscitative challenges of pelvic injuries coupled with the difficulties of precise reduction of acetabular fractures. To obtain optimal reduction of the acetabulum, initial accurate reduction of the posterior pelvic lesion appears to be necessary.

The ideal timing and modality of femur shaft fracture fixation in head-injured patients remains a topic of debate. Several groups advocate the immediate definitive fixation of femur fractures ("early total care"), whereas others support the concept of "damage control orthopaedics" with temporary fracture fixation by means of external fixation and staged, planned conversion to internal fixation. The present review was designed to address this unresolved controversy by outlining the underlying immunopathophysiology of traumatic brain injury and providing clinical recommendations on the timing of femur shaft fracture fixation in patients with severe head injuries.

Background: The understanding of the mortality risk posed by pelvic fracture is incomplete. The purposes of this study were (1) to compare the mortality risk associated with a pelvic fracture with the risk conferred by other injuries and (2) to determine if the association of a pelvic fracture with mortality varies when combined with other known risk factors. Methods: Trauma registry records from two level-I trauma centers were examined. Regression analysis was done on 63,033 patients to assess the odds ratio for mortality associated with pelvic fracture compared with other variables such as age, shock, head injury, abdominal or chest injury, and extremity injury. A second analysis was carried out to determine if the impact of a pelvic fracture on mortality varied when combined with other known risk factors for mortality. Results: Logistic regression analysis demonstrated that pelvic fracture was significantly associated with mortality (p < 0.001). The odds ratio for mortality associated with a pelvic fracture (approximately 2) was similar to that posed by an abdominal injury. Hemodynamic shock, severe head injury, and an age of sixty years or more all had an odds ratio for mortality greater than that associated with pelvic fracture. Conclusions: For the majority of trauma patients, pelvic fracture is significantly associated with a greater risk of mortality. However, pelvic fracture is one variable among many that contribute to mortality risk, and it must be considered in relation to these other variables. Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Traumatic brain injury represents the leading cause of death in young individuals. Various animal models have been developed to mimic human closed head injury (CHI). Widely used models induce head injury by lateral fluid percussion, a controlled cortical impact or impact acceleration. The presented model induces a CHI by a standardized weight-drop device inducing a focal blunt injury over an intact skull without pre-injury manipulations. The resulting impact triggers a profound neuroinflammatory response within the intrathecal compartment with high consistency and reproducibility, leading to neurological impairment and breakdown of the blood-brain barrier. In this protocol, we define standardized procedures for inducing CHI in mice and determine various severity grades of CHI through modulation of the weight falling height. In experienced hands, this CHI model can be carried out in as little as 30 s per animal, with additional time required for subsequent posttraumatic analysis and data collection.

Intramedullary fixation has advanced to the standard of care for fractures of the femoral shaft. Current controversies center on whether to prepare the intramedullary canal by reaming, particularly in certain subsets of patients. As understanding of the local and systemic effects of reaming deepens, there is a role for maximizing the benefits of intramedullary preparation before nail fixation, while attempting to minimize the major disadvantages of this technique. Several treatment strategies have emerged to address the downsides of intramedullary reaming. The purpose of this review is to discuss the history and current knowledge of intramedullary reaming with respect to problems associated with its use and the evolution of treatment modalities and their clinical applicability for orthopaedic trauma care.

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions. Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis. Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

Zusammenfassung Die schockierende Publikation von 1999 durch das “Institute of Medicine” zur Pravalenz medizinischer Fehler und iatrogener Todesfalle hat in den letzten Jahren zu einer signifikanten Verbesserung der Qualitatsstandards und der Patientensicherheit in den USA beigetragen. Viele der innovativen US-amerikanischen Modelle sind jedoch in deutschen Kliniken bisher nicht etabliert. Im vorliegenden Artikel werden exemplarische Kernpunkte der aktuellen US-amerikanischen Qualitatsstandards erlautert und diskutiert, mit einem Fokus auf Patientensicherheit in der Chirurgie. Diese ausgewahlten Themenbereiche sollen die Grundlage bieten zur Entwicklung neuer und modifizierter Qualitatssicherungsprotokolle zur Forderung der Patientensicherheit in Deutschland.

Pelvic angiography is an established technique that has evolved into a highly effective means of controlling arterial pelvic haemorrhage. The current dominant paradigm for haemodynamically unstable patients with pelvic fractures is angiographic management combined with mechanical stabilisation of the pelvis. However, an effective rapid screening tool for arterial bleeding in pelvic fracture patients has yet to be identified. There is also no precise way to determine the major source of bleeding responsible for haemodynamic instability. In many pelvic fracture patients, bleeding is from venous lacerations which are not effectively treated with angiography to fractured bony surfaces. Modern pelvic packing consists of time-saving and minimally invasive techniques which appear to result in effective control of the haemorrhage via tamponade. This review article focuses on the recent body of knowledge on angiography and pelvic packing. We propose the optimal role for each modality in trauma centres.

To estimate the prevalence of posttraumatic stress disorder (PTSD) and depression among hand-injured patients and assess the impact of these disorders on general health status.A total of 106 adult hand-injured patients (40 women, 66 men) with a mean age of 42 years (range, 18-79 years) participated. Patients with a chronic mental illness or cognitive impairment were excluded. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD and the Beck Depression Inventory. General health status was evaluated with the Short Form-36 health survey (SF-36). We obtained demographics and injury characteristics from the patient medical records.Prominent mechanisms of injury included a fall (n = 38), traffic-related injuries (n = 14), machine versus operator (n = 8), gunshot wounds (n = 6), and assault (n = 6). Using the screening questionnaires, 32 persons qualified for PTSD and 19 for depression. Sixteen patients met the criteria for both PTSD and depression. The association between PTSD and depression was significant (p.01). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role-emotional (p.01), body pain (p = .013), social function (p = .028), and mental health (p.01). We found no significant differences between groups for the subscales of role-physical (p = .289), general health (p = .147), vitality (p = .496), and physical functioning (p = .476). Patients who had concurrent PTSD and depression had significantly lower scores than patients who had neither PTSD nor depression on all subscales (p.05 for all) except role-physical (p = .135). We found significant negative correlations between Beck Depression Inventory scores and all of the SF-36 subscales (p.05 for all).In this study, nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, according to the thresholds of the instruments used to measure these psychological aspects of illness. PTSD and depression had a negative effect on general health status after hand injury. It may be important to consider psychological status when caring for patients with hand injuries.

Objective To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation. Methods A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n = 20) or early pelvic angiography (ANGIO group, n = 20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded. Results The PACK group underwent operative packing at a median of 45 min from admission; the median time to angiography in the ANGIO group was 130 min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24 h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage. Conclusions Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.

Nasal colonization with Staphylococcus aureus (SA) increases the risk of surgical site infection (SSI). We first (1) determined the prevalence of asymptomatic nasal colonization with SA, (2) assessed trends in methicillin resistance with time, (3) ascertained risk factors for nasal colonization; and (4) correlated SSI to nasal colonization status and procedure. We performed a cross-sectional analysis of SA nasal colonization among healthy preoperative orthopaedic outpatients between 2003–2005 who were within 2 weeks of surgery. Of 284 patients, 86 (30%) carried SA; of these, 81 (94%) were colonized with methicillin-sensitive and five (6%) with methicillin-resistant SA (MRSA). Total SA colonization increased from 25/78 (32%) in 2003 to 37/97 (38%) in 2005, and colonization with MRSA increased from 0/78 (0%) to four of 97 (4%), respectively. We found no associations between nasal carriage and demographics or procedures. Surgical site infection occurred in nine of 282 (3%), four of which were attributable to SA; these included 0/43 (0%) carriers who received decolonization with 2% mupirocin, two of 43 (4.7%) who declined decolonization, and two of 196 (1.0%) who were noncarriers. Nasal colonization with SA, including MRSA, among preoperative orthopaedic outpatients is increasing and their rates reflect community rates. Knowledge of colonization status may be important in decolonization, choosing perioperative or any subsequent empiric antibiotics.

Summary Objective To evaluate the outcome of recalcitrant deep pelvic infection that required a hemipelvic amputation. Study design Retrospective cohort. Setting Tertiary referral centre; Level I trauma. Patients There were 20 patients with an infection of the pelvic girdle who developed life-threatening sepsis or had an intolerable existence due to putrefied tissues that prevented end of life care. All patients failed other more conservative treatments such as limited debridement and local wound care. The indication for amputation was life-threatening sepsis (eight patients), intolerable state with putrid tissue (four patients), and both sepsis/putrefaction (eight patients). Intervention A hemipelvic amputation, multidrug antibiotic treatment, and long-term suppression. Ten internal hemipelvectomies, eight external hemipelvectomies, and two hemicorporectomies were performed. Main outcome measure Survival and recurrence of infection. Results Six patients died within 6 months (mean time 17 weeks, range 2–24). The 14 surviving patients had a mean follow-up time of 28 weeks (9–48). Of these, 10 patients survived with no evidence of ongoing infection, and four patients had ongoing infection requiring suppressive antibiotics. All of the six deaths were in C-hosts with an average of six comorbidities each; mean age was 62 years old. Aetiologies of the infection were vasculopathy (5), spinal cord injury (4), post fracture (3), post abdominal surgery (2), gunshot wound (2), seeding from bacteraemia (4). Cierny–Mader host class was C (11) and B systemic/local (9) with an average of four (4) comorbidities each. Mean estimated blood loss = 3100 cc and operative time = 157 min. There were 11 cases of minor wound problems and no flap loss. Pathogens were polymicrobial (16 total pathogens) with mean of three per patient (most common was MRSA). Multi-agent antibiotic and suppression were used in all patients. In cases with putrefied tissues, appropriate nursing care was possible. Conclusion Patients requiring hemipelvectomies usually present with sepsis or an intolerable state. Despite expected complications, we found that hemipelvectomy is an effective palliative tool in selected cases. Age and vascular disease seemed to be associated with worse outcomes.

Autologous Reamer-Irrigator-Aspirator bone grafting represents a safe and efficient procedure to treat fracture nonunions of long bones.

Background: Open acetabular fractures in children are rare, but potentially devastating injuries. Secondary to the low incidence, there is an apparent lack of reports on appropriate management strategies for open pediatric acetabular fractures in the literature. Methods: Description of a case study. Results: A 3 years and ten months-old girl was ejected as a passenger from an all terrain vehicle. She sustained a dis- placed, grade IIIA open left anterior column acetabular fracture. The injury was treated by extending the open wound to a formal first window of the ilioinguinal approach. After surgical debridement, the anterior column was reduced anatomi- cally and fixed by two lag screws which avoided the tri-radiate cartilage. A vaginal laceration was debrided and repaired. The patient was treated in a spica cast without weight bearing on the left lower extremity for 8 weeks. No perioperative complications occurred. The acetabular fracture healed in an anatomic position within 8 weeks. To avoid premature clo- sure of the tri-radiate cartilage, the patient underwent a physeal bar resection at one year after injury. At two-year follow up, she was walking and running without pain and had a free range of motion of her left hip. Conclusions: Operative management should represent the therapy of choice for open, displaced pediatric acetabular frac- tures. After fracture healing, a scheduled physeal bar resection may be required for injuries which involve the tri-radiate cartilage.

Background: There are numerous autograft alternatives promoted. Although most have laboratory or animal data, few have evaluations of clinical performance. We performed an evaluation of a new calcium sulfate-demineralized bone matrix/ Allomatrix in the treatment of nonunions. Methods: A consecutive series of patients requiring bone grafting for atrophic/ avascular nonunions were retrospectively studied. Patients were monitored for healing and adverse effects, which included local or systemic reactions, wound problems, infection, and any secondary surgery caused by graft complications. Results: Over half of the patients (51%) developed postoperative drainage. Of the 41 patients, 13 (32%) had drainage that required surgical intervention and 14 (34%) developed a deep infection. Eleven patients with deep infections also required surgical treatment of drainage. Also, 19 (46%) patients did not heal and required secondary surgical intervention. Using)? it was found that there were correlations between infection and a history of previously treated infection (p < 0.007), as well as wound drainage (p < 0.001). Failure of treatment correlated to the presence of a postoperative infection (p < 0.001). Other analyses were not performed because of the small sample size, which was because of early termination of the study. Conclusions: The use of Allomatrix/ demineralized bone matrix as an alternative for autogenous bone graft in the treatment of nonunions resulted in an unacceptably high rate of complications. Although we recommend further study, we do not recommend the use of Allomatrix for the treatment of nonunions, especially if there is a large volumetric defect or a history of any prior contamination of the tissue bed.

The PF-LCP represents a feasible alternative for the treatment of unstable inter- and subtrochanteric fractures.

Summary: Moore type I tibial plateau fracture-dislocations pose a significant challenge to the treating surgeon. The displaced posteromedial fragment is difficult to reduce and adequately stabilize through traditional approaches. The Lobenhoffer approach provides the necessary access to the posterior surface of the proximal tibia but has only been described in the German-language literature. It involves a less extensive soft tissue dissection than that required by other posterior approaches. We provide the first English-language description of the technique, with 2 cases presented as illustrations of the approach.

The current management of pelvic fracture patients who are hemodynamically unstable in the United States consists of aggressive resuscitation, mechanical stabilization, and angioembolization. Despite this multidisciplinary approach, our recent analysis confirms an alarming 40% mortality in these high-risk patients. Therefore, we pursued alternate therapies to improve patient outcomes. European trauma groups have suggested the technique of pelvic packing via laparotomy to directly address the venous bleeding that comprises 85% of pelvic fracture hemorrhage. We hypothesized that a modified technique of direct preperitoneal pelvic packing (PPP) would reduce the need for angiography, decrease blood transfusion requirements, and lower mortality.Since September 2004, all patients at our ACS-verified level I trauma center with hemodynamic instability and pelvic fractures underwent PPP/external fixation, according to our protocol. Statistics are reported as mean +/- SEM and analyzed using Student's t test.During the study period, 28 consecutive patients underwent PPP. There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury. The majority were men (68%) with a mean age of 40 +/- 3.9 years and a mean injury severity score of 55 +/- 3.0. The mean emergency department (ED) systolic blood pressure was 77 +/- 3.0 mm Hg, heart rate was 120 +/- 4.3 bpm, and base deficit 13 +/- 0.8 mmol/L. Pelvic fracture classifications included lateral compression (LC) II (9), anteroposterior compression (APC) III (8), LC I (3), vertical shear (3), LC III (3), and APC II (2). Patients required 4 +/- 1.2 units of packed red blood cells (PRBCs) during 82 +/- 13 minutes in the ED. Blood transfusion requirements before postoperative surgical intensive care unit (SICU) admission compared with the subsequent 24 postoperative hours were significantly different (12 +/- 2.0 versus 6 +/- 1.1; p = 0.006). The first 4 patients underwent routine angiography postPPP, with 1 undergoing therapeutic embolization; 4 of the subsequent 24 patients underwent angioembolization with clinical concern of ongoing pelvic hemorrhage. Seven (25%) patients died from multiple organ failure (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), withdrawal of care (1), and closed head injury (1); there were no deaths as a result of acute blood loss.PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.

Segmental bone defects cause significant disability in patients. Modern orthopaedic surgical techniques have proved to be reliable for reconstruction of these defects. Autogenous bone graft remains the standard of care for reconstruction of small defects (

Venous thromboembolism is a preventable cause of death in the severely injured patient. Low-molecular-weight heparins (LMWHs) have been recommended as effective, safe prophylactic agents. However, LMWH use remains controversial in patients at risk for bleeding, those with traumatic brain injury, and those undergoing multiple invasive or operative procedures. We hypothesized that a protocol utilizing once-daily LMWH prophylaxis in high-risk trauma patients, regardless of the need for invasive procedures, is feasible, safe, and effective. From August 1998 to August 2000, all patients admitted to our American College of Surgeons-verified Level I trauma facility following injury were evaluated for deep venous thrombosis (DVT) risk and prospectively followed. Patients at high risk for DVT, including those with stable intracranial injuries, were placed on our institutional protocol and prospectively followed. Patients on the protocol received daily injections of the LMWH, dalteparin; DVT screening was performed with duplex ultrasonography within 48 hours of admission and after 7 to 10 days after injury. Regimen compliance, bleeding complications, DVT rates, and pulmonary embolus (PE) rates were analyzed. During the 2-year study period, 6247 trauma patients were admitted; 743 were considered at high risk for DVT. Most of the patients were men (72%), with a mean age of 38.7 years (range 15–89 years) and a mean injury severity score (ISS) of 19.5. Compliance with the daily regimen was maintained in 74% of patients. DVT was detected in 3.9% and PE in 0.8%. The wound complications rate was 2.7%, and the need for unexplained transfusions was 3%. There were no exacerbations of head injury following dalteparin initiation due to bleeding. There were 16 patient deaths; none was caused by PE or late hemorrhage. Once-daily dosing of prophylactic LMWH dalteparin is feasible, safe, and effective in high-risk trauma patients. Our protocol allows one to “operate through” systemic prophylaxis and ensures timely prophylaxis for brain-injured and multisystem trauma patients.

Bone loss in the forearm results from high-energy trauma or follows non-union with infection. Ilizarov methodology provides stable fixation without implantation of permanent foreign bodies while permitting wrist and elbow movement. We are reporting our experience using distraction osteogenesis in the treatment of traumatic bone loss in the forearm. From 1991 to 2000, 11 consecutive patients with traumatic forearm bone loss were treated with Ilizarov ring fixation. Records were reviewed retrospectively. All patients were contacted 2-10 years after surgery at the Ilizarov Clinic in Lecco, Italy. Eleven atrophic non-unions with bone loss were treated. The time from injury to Ilizarov treatment averaged 2.1 years. Follow-up averaged 6.2 years. The union rate with Ilizarov treatment alone was 64%. Thirty-six percent of the patients were converted to a hypertrophic non-union and underwent compression plating. The overall rate of union was 100%. There were four unplanned reoperations and no refractures, neurovascular injuries or deep infections. Three patients had significant limitations of wrist function. Nine patients described their function as excellent. Ilizarov fixation with bone transport is a viable treatment option for atrophic forearm non-unions with bone loss. Treatment resulted in ablation of infection, healing of atrophic non-unions with minimal complications and early extremity use.

Currently, the most common treatment of peritrochanteric fractures is surgical stabilization with use of either a compression hip screw or an intramedullary hip screw and early mobilization of the patient1-3. The compression hip screw provides secure fixation and controlled impaction of the fracture, but use of this device in the treatment of fractures with posteromedial comminution and subtrochanteric extension can be problematic4,5. Cephalomedullary nails combine the advantages of intramedullary fixation with those of a sliding screw. Such devices are load-sharing and offer a decreased bending strain, because the moment arm is reduced. These devices may also offer a biological advantage by combining a closed surgical technique with limited periosteal disruption6. Some of the problems encountered with intramedullary devices have been fracture propagation, difficulties with interlocking, stress mismatch, and jamming of the compression screw within the nail. If there is no sliding, the implant essentially functions as a fixed-angle device. This may result in screw migration, cutout, or failure2,7. Fig. 1 A photograph of the damage to the nail after the errant passing of the reamer. It could not be noted intraoperatively that the guide pin was anterior to the nail, and the nature of the instrumentation made it hard to tell that reaming was not progressing properly. Recently, a new device that allows a metal rod to expand inside the bone has been developed. This device is purported to provide rotational stability with use of rails that act as flutes. Because it is a thin-walled implant and is inserted at a diameter that is smaller than the medullary canal, it is also purported to be less likely to cause fracture propagation. Furthermore, it eliminates the need for screws and interlocking8. The use of this technology in …

The management of post-traumatic long bone osteomyelitis remains challenging [1]. While significant progress has been made over the past 10–20 years, many simple questions such as optimal duration or route of antibiotics administration remain unanswered [2]. General principles of early aggressive management, optimization of host factors and wide debridement of affected tissues with later reconstruction are commonly accepted. These principles share similarities with those applied in tumor surgery [3]. Unfortunately, specific diagnostic and treatment strategies are ill-defined and lack prospective evidence. In this paper, we highlight some of the limitations that remain regarding the prevention, diagnosis and treatment of post-traumatic long bone osteomyelitis. Numerous variables in the disease and host type

From July 1997 to March 2001, 209 consecutive patients with 215 femoral shaft fractures amenable to antegrade femoral nailing were enrolled. A true percutaneous insertion technique was performed using a stab wound incision. One hundred ninety-seven (92%) fractures achieved primary union with anatomic or near anatomic alignment. Eighteen (8%) healing problems and two deep infections (1%) responded to repeat interventions. There was one iatrogenic complication related to an anterior starting point. External blood loss was minimal (generally

“Listen, here's the thing. If you can't spot the sucker in your first halfhour at the table, then you are the sucker.” This line from Mike McDermott, a high-stakes poker genius in the popular movie...

Background: The intimate relationship between the pelvis and related vasculature can lead to life-threatening arterial hemorrhage after blunt trauma. Unfortunately, hemorrhage related to pelvic fracture is often associated with other serious injuries, complicating clinical decision making. Previous clinical reviews have associated fracture geometry with arterial hemorrhage, specifically implicating those injuries with evidence of major ligamentous disruption (MLD). Methods: We analyzed pelvic fractures for evidence of a relationship between MLD and the need for angiographic embolization. Our trauma registry was reviewed from 1996 to 2002; 283 patients with pelvic fractures arrived in the emergency department with a systolic blood pressure £ 90 mm Hg. MLD was defined as anteroposterior compression types II and III, lateral compression type III, combined mechanism, and vertical shear according to the Young-Burgess classification. Results: Thirty-seven (13%) of the patients studied required angiographic embolization for control of pelvic hemorrhage. The pelvic fracture pattern (MLD vs. non-MLD) did not differ significantly between the embolized and nonembolized groups. The predictive value of other variables varied by gender. Age had a significant correlation with the need for embolization in women, whereas Injury Severity Score did not. Conversely, age had no predictive value for men, whereas Injury Severity Score had a significant correlation. Conclusion: The findings in this study suggest that pelvic fracture pattern does not consistently correlate with the patient's need for urgent embolization and should not be used as the sole determinant for angiography. Furthermore, variables such as age and gender should be further investigated, as they may potentially have a predictive value in this clinical setting.

The treatment of distal humerus fractures has traditionally been performed via a posterior approach and an olecranon osteotomy. The article reports the authors' clinical experience using a triceps-splitting approach for a consecutive series of patients with distal humerus fractures.A consecutive series of 37 patients with 39 distal humerus fractures were treated with a triceps-splitting approach. All the fractures were managed with two-column fixation.A total of 33 patients (34 fractures) were available for follow-up evaluation over an average of 26 months (range, 13-48 months). There were five type A and 29 type C fractures. Five of the fractures were grade 1 open. There were three elbows with clinically asymptomatic valgus instability (5 degrees at 30 degrees flexion) and one elbow with symptomatic varus instability. There was one case of heterotopic ossification, limiting motion; one transient ulnar nerve palsy; one severe infection requiring resection arthroplasty; and five nonunions. Four of the five nonunions involved patients older than 65 years.The use of a triceps-splitting approach to gain access to the distal humerus provided adequate exposure and had an acceptable complication rate. In addition to allowing for distal humerus reconstruction, it avoided the reported complications of olecranon osteotomy and is easily extensile if required.

The term “damage control” was originally coined by the United States Navy to describe tactical approaches to permit a damaged sea vessel in naval battle to continue functioning. Subsequent use in the medical field appears to have begun with the experience of military surgeons in Korea. General trauma surgeons extended the damage control concept to the multiply injured patient in extremis who required life-saving interventional procedures, such as laparotomy and thoracotomy, but in whom any further procedures were believed to jeopardize the potential for survival. This surgical strategy was named “damage control surgery” by Rotondo et al1 in 1993. Practices evolved to rapidly control bleeding and shock, and to relieve brain injury with procedures that were nondefinitive and less stressful to the patients’ physiology, trying to avoid the lethal triad of acidosis, hypothermia, and coagulopathy. During the 1980s and 1990s, research in multiply injured patients showed that early stabilization of long bone fractures decreased the incidence of systemic complications such as adult respiratory distress syndrome and multisystem organ failure, and decreased mortality. Early and aggressive stabilization of open fractures was found to decrease sepsis. The concept of “early total care” evolved from these findings and has become a hallmark of trauma and orthopedic care around the world.