Low reoperation rate after fixation of displaced femoral neck fractures with the femoral neck system (FNS).

PURPOSE: Operative fixation of femoral neck fractures (FNFs) remains challenging. Complications are not infrequent, especially in displaced patterns. Numerous fixation techniques have been previously described in the literature; however, there remains a paucity of data regarding outcomes of these injuries treated with the femoral neck system (FNS). METHODS: Patients with a displaced FNF (OTA/AO 31B) treated with the FNS at a single level 1 academic trauma center between 1/1/2019 and 1/1/2023 were identified. Radiographs were reviewed to assess fracture displacement, location, and characteristics. Patient records were further reviewed to assess for complications, reoperations, and osseous union. RESULTS: Forty-three patients (65% male) with 44 FNFs were identified with a mean age of 35.0 years (range, 13-61 years). Two patients developed a deep infection requiring surgical debridement, four patients underwent a total hip arthroplasty, and one patient underwent a valgus intertrochanteric osteotomy for nonunion. There were three cases of femoral head AVN. Mean follow-up was 482.5 days among all patients, and 36 fractures had at least 6 months of follow-up or reached bony union. CONCLUSIONS: Here, we present a series of patients treated with the FNS for internal fixation and report a 18% reoperation rate. This is lower than the average rate that has been previously reported in similar patient populations in the literature treated with alternative methods of internal fixation. Thus, the FNS appears to be a safe and effective option for treatment of these injuries.

Sinus Tarsi Versus Extended Lateral Approach for Displaced Intra-Articular Calcaneal Fractures: A Single Surgeon's Experience.

BACKGROUND: The aim of the study is to investigate the differences between the extensile lateral (EL) and sinus tarsi (ST) approaches for the treatment of displaced intra-articular calcaneus fractures as treated by a single surgeon. METHODS: A retrospective cohort study performed at a Level 1 trauma center. One hundred twenty-nine consecutive intra-articular calcaneus fractures from 2011 to 2018 that were surgically treated by a single surgeon. Primary outcomes were time to surgery, operative time, postoperative restoration of the critical angle of Gissane, postoperative wound complications, and need for unplanned re-operation. RESULTS: Patient characteristics, including demographics, mechanism of injury, and fracture patterns were similar between the EL and ST approach groups. There was a significant decrease in unplanned secondary procedures (P = .008), shorter time to definitive fixation (P = .00001), and shorter average operative time in the ST group (P = .00001). Postoperative measurement of the critical angle of Gissane between the two groups was significantly different, but minute with an average difference of approximately 3 degrees (P = .025). Measurements in both groups were within the expected range of normal. CONCLUSIONS: For displaced intra-articular calcaneus fractures, a limited open ST approach is associated with a significant reduction in the time to definitive fixation and decreased operative time. The EL approach was associated with a small, but significant improvement in the restoration of the critical angle of Gissane compared with the ST approach. Therefore, an ST approach may allow for earlier surgical intervention and result in equivalent quality of reduction compared with an EL approach. LEVEL OF EVIDENCE: Level III.

The injury characteristics of open pilon fractures predictive of complications.

OBJECTIVE: Determine predictive injury factors for wound complications in open pilon fractures (OTA/AO 43B and 43C). DESIGN: Retrospective Case Series. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 61 open pilon fractures in 60 patients were evaluated after meeting inclusion and exclusion criteria. INTERVENTION: The majority of injuries underwent a staged protocol with immediate antibiotics, debridement, irrigation and external fixation. Following soft tissue stabilization, internal fixation was performed and wound closure achieved in a coordinated fashion depending on the type of closure required. MAIN OUTCOME MEASUREMENTS: Early amputation rate, 90-day major (wound dehiscence or deep infection requiring operative intervention) and minor (superficial infection) wound complications. RESULTS: Four patients incurred early amputations, 11 had major wound complications and 5 had minor wound complications. An early amputation was more likely if they presented with an OTA Open Fracture Classification (OTA-OFC) Bone Loss Grade 3. A major wound complication was more likely if they presented with a fall from > 3 m, a multifragmentary articular surface, a segmental fibula fracture, or an OTA-OFC Contamination Grade 3. A multifragmentary articular surface was also predictive of developing any wound complication. CONCLUSIONS: Open pilon fractures are severe, limb-threatening injuries and are at risk for wound complications. Patients presenting with these injuries and a predictive factor should be counseled regarding the possibility of early limb loss or experiencing a wound complication that will require additional treatment. LEVEL OF EVIDENCE: Level III.

Is retrograde nailing superior to lateral locked plating for complete articular distal femur fractures?

INTRODUCTION: Nonunion rates for distal femur fractures treated with lateral locked plating (LLP) remains as high as 18-22% despite significant advances with implant design and construct modulation. However, whether treatment of distal femur fractures with rIMN has improved outcomes compared to LLP has not been well characterized. The purpose of this study was to compare outcomes of complete articular distal femur fractures (AO/OTA 33-C) treated with either LLP or rIMN. METHODS: 106 distal femur fractures in 106 patients between January 2014 and January 2018 were identified. Medical records were reviewed to collect patient age, gender, body mass index, sagittal and coronal plane alignment on immediate postoperative radiographs, time to union, incidence of nonunion, and incidence of secondary operative procedures for repair of a nonunion. RESULTS: Of 106 patients, 50 underwent rIMN and 56 underwent LLP. The mean age at the time of injury was 51 years (21 to 86 years) and there were 55 males. Average coronal alignment of 83.7° of anatomic lateral distal femoral angle (aLDFA) and sagittal alignment of <1° of apex anterior angulation in the rIMN group. In the LLP group there was an average of 87.9° of aLDFA and 1.9° of apex anterior angulation (p = .005 and p = .36). Average time to union in the rIMN group was 6 months and 6.6 months in the LLP group (p = .52). Incidence of nonunion in the rIMN group was 11.8% and 27.5% in the LLP group (p = .008). There were 8 secondary procedures for nonunion in the rIMN group and 18 in the LLP group (p = .43). CONCLUSIONS: Our results demonstrated a higher nonunion rate and coronal plane malalignment with LLP compared to rIMN. While prospective data is required, rIMN does appear to be an appropriate treatment for complete articular distal femur fractures with a potentially decreased rate of nonunion .

Implementation of a novel MRI protocol for diagnosing femoral neck fractures in high energy femoral shaft fractures: One year results.

INTRODUCTION: Preliminary results using a novel rapid-sequence MRI to diagnose ipsilateral femoral neck fractures in patients sustaining high-energy femoral shaft fractures have been favorable compared to radiographic and CT imaging alone. To evaluate and optimize this new institutional imaging protocol further, we reviewed our results one year after implementation. METHODS: Rapid-sequence MRI was added to the imaging evaluation of patients with high-energy femoral shaft fractures without femoral neck fractures identified on radiographs or CT imaging. Data was retrospectively reviewed from a consecutive series of patients who met inclusion criteria. RESULTS: From September 2018 through September 2019, 114 patients sustained 121 high-energy femoral shaft fractures. The average patient age was 29.9 years, 73.7% (84/114) of patients were male, and 16.5% (20/121) were open fractures. Of patients indicated for a rapid-sequence MRI, 86% (92/107) underwent MR imaging. 5% (6/121) of patients had an ipsilateral femoral neck fracture identified on radiographs alone. Three additional femoral neck fractures were identified with CT imaging for an initial incidence of 7.4% (9/121). MRI identified 10 additional non-displaced femoral neck fractures, three complete and seven incomplete fractures, for an incidence of 15.7% (19/121). All identified femoral neck fractures were stabilized. DISCUSSION/CONCLUSION: The addition of rapid-sequence MRI of the pelvis in patients with high-energy femoral shaft fractures reliably increases the diagnosis of ipsilateral femoral neck fractures not identified with standard imaging. There were no cases of missed/delayed femoral neck fractures in patients with a negative MRI. This new imaging protocol effectively and safely improves the diagnosis of this injury pattern.

Improving the Diagnosis of Ipsilateral Femoral Neck and Shaft Fractures: A New Imaging Protocol.

BACKGROUND: Despite increased awareness of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures and advanced imaging with thin-cut high-resolution computed tomography (CT), failure of diagnosis remains problematic. The purpose of the present study was to determine if the preoperative diagnosis of ipsilateral femoral neck fractures in patients with high-energy femoral shaft fractures can be improved with magnetic resonance imaging (MRI) compared with radiographic and CT imaging. METHODS: In response to delayed diagnoses of femoral neck fractures despite thin-cut high-resolution CT, our institutional imaging protocol for acute, high-energy femoral shaft fractures was altered to include rapid limited-sequence MRI to evaluate for occult femoral neck fractures. All patients received standard radiographic imaging as well as thin-cut high-resolution pelvic CT imaging upon presentation. Rapid limited-sequence MRI of the pelvis was obtained to evaluate for an occult femoral neck fracture. RESULTS: Thirty-seven consecutive patients with 39 acute, high-energy femoral shaft fractures resulting from blunt trauma were included. The average age of the patients was 29.1 years (range, 14 to 82 years). Ten (25.6%) of the 39 femoral shaft fractures were open. Two femoral shaft fractures (5.1%) were associated with ipsilateral femoral neck fractures that were detected on radiographs, and no MRI was performed. None of the remaining 37 femoral shaft fractures were associated with a femoral neck fracture that was identified on CT imaging. Thirty-three (89.2%) of 37 patients underwent pelvic MRI to evaluate the ipsilateral femoral neck. Four (12.1%) of those 33 patients were diagnosed with a femoral neck fracture (2 complete, 2 incomplete) that was not identified on thin-cut high-resolution CT or radiographic imaging. CONCLUSIONS: Rapid limited-sequence MRI of the pelvis for patients with femoral shaft fractures identified femoral neck fractures that were not diagnosed on thin-cut high-resolution CT in 12% of our patients. Our results suggest that the frequency of femoral neck fractures may be underrepresented on CT imaging; rapid limited-sequence MRI was feasible without delaying definitive treatment even in polytraumatized patients. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma.

Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Fractures of the Calcaneus.

Calcaneal fractures are potentially devastating injuries. To effectively manage calcaneal fractures, surgeons must understand the anatomy of the calcaneus as well as the surgical techniques necessary to restore normal biomechanics of the foot. Surgeons also must understand calcaneal fracture patterns and classifications; initial management techniques, surgical indications and rationale, temporizing management techniques, surgical approaches, definitive management techniques, and postoperative management for calcaneal fractures; as well as outcomes and common complications of calcaneal fractures.

Symptomatic Implant Removal Following Dual Mini-Fragment Plating for Clavicular Shaft Fractures.

OBJECTIVES: To determine the proportion of patients requiring secondary surgery for symptomatic implant removal after open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures. DESIGN: Retrospective observational study. SETTING: Single university Level 1 trauma center. PATIENTS: Eighty-one patients treated with open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures (OTA/AO 15-B1, B2, and B3) with minimum 12-month follow-up (median 477 days; range 371-1549 days). INTERVENTION: Open reduction, internal fixation using dual mini-fragment plating technique for clavicular shaft fractures. MAIN OUTCOME MEASUREMENTS: Incidence of secondary surgery, QuickDASH (Disabilities of the Arm, Shoulder, and Hand) scores. RESULTS: Six of 81 patients (7.4%) underwent secondary surgery for implant removal for any reason. Of these, 3 (3.7%) underwent symptomatic implant (soft-tissue irritation) removal, 2 (2.5%) required implant removal in the setting of infection, and 1 patient (1.2%) required revision open reduction internal fixation for early implant failure. The mean QuickDASH score in this series was 8.44 (±6.94, range 0-77.27). The associated implant cost of the typical construct utilized in this series was $1511.38. The mean surgical time was 97 minutes (range 71-143 minutes). CONCLUSIONS: The utilization of a dual mini-fragment plating technique in the treatment of clavicular shaft fractures results in a low rates of secondary surgery for symptomatic implant removal (3.7%) and similar QuickDASH scores when compared with historical controls treated with 3.5-mm plates placed on the superior clavicle. Potential disadvantages in using this technique include a higher surgical implant cost and length of surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Mechanical Failures of the Synthes Variable Angle Locking Distal Femur Plate.

OBJECTIVES: To document the high failure rate of a specific implant: the Synthes Variable Angle (VA) Locking Distal Femur Plate. DESIGN: Retrospective. SETTING: Urban University Level I Trauma Center. PATIENT/PARTICIPANTS: All distal femur fractures (OTA/AO 33-A, B, C) treated from March 2011 through August 2013 were reviewed from our institutional orthopaedic trauma registry. Inclusion criteria were fractures treated with a precontoured distal femoral locking plate and age between 18 and 84. Exclusion criteria were fractures treated with intramedullary nails, arthroplasty, non-precontoured plates, dual plating, or screw fixation alone. The population was divided into 3 groups: less invasive stabilization system (LISS) group (n = 21), treated with LISS plates (Synthes, Paoli, PA); locking condylar plates (LCPs) group (n = 10), treated with LCPs (Synthes, Paoli, PA); and VA group (n = 36), treated with VA distal femoral LCPs (Synthes, Paoli, PA). Average age was 54.6 ± 17.5 years. INTERVENTION: Open reduction internal fixation with one of the above implants was performed. MAIN OUTCOME MEASURES: The patients were followed radiographically for early mechanical implant failure defined as loosening of locking screws, loss of fixation, plate bending, or implant failure. RESULTS: There were no statistically significant differences between groups for age, gender, open fracture, mechanism of injury, or medial comminution. There were 3 failures (14.3%) in group LISS, no failures (0%) in group LCP, and 8 failures (22.2%) in group VA. All 3 failures in group LISS were in A-type fractures (2 periprosthetic) and all failures in group VA were in C-type fractures. When all fractures for all 3 groups were compared for failure rate, there was no statistically significant difference (P = 0.23). However, when only 33-C fractures were compared, there was significantly greater failure rate in the VA group (P = 0.03). The mean time to failure in group VA was 147 days (range 24-401 days) and was significantly earlier (P = 0.034) when compared with group LISS (mean 356 days; range 251-433 days). CONCLUSIONS: Early mechanical failure with the VA distal femoral locking plate is higher than traditional locking plates (LCP and LISS) for OTA/AO 33-C fractures. We caution practicing surgeons against the use of this plate for metaphyseal fragmented distal femur fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Can Thrombelastography Predict Venous Thromboembolic Events in Patients With Severe Extremity Trauma?

OBJECTIVES: An elevated maximal amplitude (mA) value with rapid thrombelastography on admission can identify general trauma patients with an increased risk of venous thromboembolic events (VTEs). We hypothesized that (1) the risk of VTE traditionally assigned to injury lies specifically in those who sustain major orthopaedic trauma and (2) an elevated admission mA value could be used to identify patients with major orthopaedic injuries at risk for VTE during initial hospital admission. DESIGN: Retrospective. SETTING: University level 1 trauma center. PATIENTS/PARTICIPANTS: Consecutive trauma patients admitted to an urban level 1 trauma center between September 2009 and February 2011 who met the criteria for level 1 trauma activation and who were between 18 and 85 years of age were included in our study group. Two groups were created, one whose extremity abbreviated injury severity score was 2 or greater (ORTHO) and the other whose extremity abbreviated injury severity score was <2 (non-ORTHO). MAIN OUTCOME MEASUREMENTS: Pulmonary emboli were confirmed by computed tomography angiography, and deep vein thromboses were confirmed by venous duplex. Univariate analyses were conducted and followed by purposeful regression analysis. RESULTS: Of note, 1818 patients met the inclusion criteria (310 ORTHO and 1508 non-ORTHO). Despite more hypocoagulable r-TEG values on arrival (alpha angle 71 vs. 73 and mA 62 vs. 64, both P < 0.05), ORTHO patients had higher rates of VTE (6.5% vs. 2.7%, P < 0.001). Stepwise regression generated 4 values to predict development of VTE (age, male gender, white race, and ORTHO). After controlling for these variables, admission mA values ≥65 (odds ratio 3.66) and ≥72 (odds ratio 6.70) were independent predictors of VTEs during hospitalization. CONCLUSIONS: Admission rapid thrombelastography mA values can identify patients with major orthopaedic trauma injuries who present with an increased risk of in-hospital deep vein thromboses and pulmonary embolism with a 3.6-fold and 6.7-fold increased risk for mA values ≥65 and ≥72, respectively. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions.

BACKGROUND: Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases. QUESTIONS/PURPOSES: We wished to determine (1) the proportion of patients who achieve radiographic signs of osseous union for distal femoral nonunions with an in situ lateral plate after treatment with addition of a medial locking plate and autogenous bone grafting, and (2) the frequency and types of complications associated with this treatment. METHODS: Between 2007 and 2013, we treated 22 patients for 23 distal femoral nonunions, defined as an unhealed fracture with no radiographic signs of osseous union at a mean of 16 months (SD, 13 months) after injury. During that time, we used a treatment algorithm consisting of treatment in one or two stages. The single-stage procedure performed in 16 aseptic nonunions with a stable lateral plate involved addition of a medial locking plate and autogenous bone graft. A two-stage treatment performed in seven nonunions with lateral plate failure involved placement of a new lateral locking plate followed by addition of a medial locking plate with autogenous bone graft at least 2 months after the first procedure. Of the 22 patients treated, 20 had a median followup of 18 months (SD, 6-94 months). We defined osseous union by bridging bone on three of four cortices with absence of a radiolucent line or more than 25% cross-sectional area of bridging bone via CT. RESULTS: Twenty of the 21 nonunions attained radiographic signs of osseous union by 12 months. Six of the 20 patients experienced complications: one patient had a persistent nonunion; four patients underwent removal of symptomatic hardware; and one patient experienced skin breakdown at the bone graft harvest site. CONCLUSIONS: A very high proportion of patients achieve union when using medial locking plates to treat distal femoral nonunions after lateral plating of the original injury. Addition of bone graft, staged reconstruction, and revision of the initial lateral plate is indicated when the nonunion is associated with fatigue failure of the initial lateral plate. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Do Safe Radiographic Sacral Screw Pathways Exist in a Pediatric Patient Population and Do They Change With Age?

OBJECTIVES: Iliosacral screw pathways in the first (S1) and second (S2) sacral segments are commonly used for adult pelvic ring stabilization. We hypothesize that radiographically "safe" pathways exist in pediatric patients. SETTING: Academic level I Trauma Center. PATIENTS: All patients between ages 2 and 16 years with a computed tomography scan including the pelvis obtained over a 6-week period (174 children, mean age 10.8 ± 3.9 years; 90 boys, 84 girls). INTERVENTION: The width and height at the "constriction point" in 3 safe screw pathways were measured bilaterally by 3 orthopaedists (resident, trauma fellow, trauma attending). Pathways corresponding to: (1) an "iliosacral" screw at S1, a "trans-sacral trans-iliac" (TSTI) screw at S1, and a TSTI screw at S2. MAIN OUTCOME MEASUREMENTS: (1) Mean width and height of pathways, (2) interrater reliability coefficient, (3) availability of pathways greater than 7 mm, (4) growth of pathways with age, (5) sacral morphology. RESULTS: The interrater reliability coefficient was above 0.917 for all measurements. Radiographically safe pathways were available for 99%, 51%, and 89% of children for iliosacral screws at S1 (width 16.4 ± 2.8 mm, height 15.1 ± 3.3 mm), TSTI screws at S1 (width 7.2 ± 4.9 mm, height 8.3 ± 5.6 mm), and TSTI at S2 (width 9.3 ± 2.2 mm, height 11.5 ± 2.7 mm), respectively. CONCLUSIONS: Contrary to our hypothesis, almost all children aged 2-16 had a radiographically safe screw pathway for an iliosacral screw at S1, and most of the children had an available pathway for a TSTI screw at S2. However, only 51% had a pathway for a TSTI screw at S1.

Do Transsacral-transiliac Screws Across Uninjured Sacroiliac Joints Affect Pain and Functional Outcomes in Trauma Patients?

BACKGROUND: Patients with pelvic ring displacement and instability can benefit from surgical reduction and instrumentation to stabilize the pelvis and improve functional outcomes. Current treatments include iliosacral screw or transsacral-transiliac screw, which provides greater biomechanical stability. However, controversy exists regarding the effects of placement of a screw across an uninjured sacroiliac joint for pelvis stabilization after trauma. QUESTIONS/PURPOSES: Does transsacral-transiliac screw fixation of an uninjured sacroiliac joint increase pain and worsen functional outcomes at minimum 1-year followup compared with patients undergoing standard iliosacral screw fixation across the injured sacroiliac joint in patients who have sustained pelvic trauma? METHODS: All patients between ages 18 and 84 years who sustained injuries to the pelvic ring (AO/OTA 61 A, B, C) who were surgically treated between 2011 and 2013 at an academic Level I trauma center were identified for selection. We included patients with unilateral sacroiliac disruption or sacral fractures treated with standard iliosacral screws across an injured hemipelvis and/or transsacral-transiliac screws placed in the posterior ring. Transsacral-transiliac screws were generally more likely to be used in patients with vertically unstable sacral injuries of the posterior ring as a result of previous reports of failures or in osteopenic patients. We excluded patients with bilateral posterior pelvic ring injuries, fixation with a device other than a screw, previous pelvic or acetabular fractures, associated acetabular fractures, and ankylosing spondylitis. Of the 110 patients who met study criteria, 53 (44%) were available for followup at least 12 months postinjury. Sixty patients were unable to be contacted by phone or mail and seven declined to participate in the study. Outcomes were obtained by members of the research team using the visual analog scale (VAS) pain score for both posterior sacroiliac joints, Short Musculoskeletal Functional Assessment (SMFA), and Majeed scores. Patients completed the forms by themselves when able to return to the clinic. A phone interview was performed for others after they received the outcome forms by mail or email. RESULTS: There were no differences between iliosacral and transsacral-transiliac in terms of VAS injured (2.9 ± 2.9 versus 3.0 ± 2.8, mean difference = 0.1 [95% confidence interval, -1.6 to 1.7], p = 0.91), VAS uninjured (1.8 ± 2.4 versus 2.0 ± 2.6, mean difference = 0.2 [-1.3 to 1.6], p = 0.82), Majeed (80.3 ± 19.9, 79.3 ± 17.5, mean difference = 1.0 [-11.6 to 9.6], p = 0.92), SMFA Function (22.8 ± 22.2, 21.0 ± 17.6, mean difference = 1.8 [-13.2 to 9.6], p = 0.29, and SMFA Bother (24.3 ± 23.8, 29.7 ± 23.4, mean difference = 5.4 [-7.8 to 18.6], p = 0.42). CONCLUSIONS: Placement of fixation across a contralateral, uninjured sacroiliac joint resulted in no differences in pain and function when compared with standard iliosacral screw placement across an injured hemipelvis at least 1 year after instrumentation. When needed for biomechanical stability, transsacral-transiliac fixation across an uninjured sacroiliac joint can be used without expectation of positive or negative effects on pain or functional outcomes at minimum 1-year followup. LEVEL OF EVIDENCE: Level III, therapeutic study.

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

BACKGROUND: Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture. QUESTIONS/PURPOSES: (1) After the Kocher-Langenbeck approach and gluteus minimus débridement, is single-dose radiotherapy associated with a decreased risk of HO? (2) Does addition of single-dose radiotherapy prolong length of stay after a Kocher-Langenbeck approach and gluteus minimus débridement as compared with patients without radiotherapy? METHODS: After institutional review board approval, all adult patients treated for acetabular fracture by a single surgeon with a Kocher-Langenbeck approach between August 2011 and October 2014 were identified (n = 60). Débridement of gluteus minimus muscle caudal to the superior gluteal bundle was standard in all patients. Radiotherapy was given with a single dose of 700 cGy within 72 hours of surgery from August 2011 until April 2013. Patients treated subsequently did not receive radiotherapy. Patients treated with indomethacin (n = 1) and with fewer than 10 weeks followup were excluded (n = 12) because several studies suggest that most HO that develops is visible by that point in time. Our study group totaled 46 patients with 24 in the radiotherapy and débridement group and 22 in the débridement group. Charts were reviewed to determine length of stay. Attending orthopaedic trauma surgeons who were blinded to the patient's treatment group graded all followup radiographs according to the Brooker system, and Classes III and IV HO were considered clinically important Fisher's exact test was used to analyze clinically significant differences HO between the two groups. Length of stay was compared using a t-test. RESULTS: Single-dose radiotherapy is associated with a decreased risk of clinically important (Brooker III-IV) HO after a Kocher-Langenbeck approach and gluteus minimus débridement (radiotherapy: one of 24 [4%], no radiotherapy: seven of 22 [32%], relative risk: 0.131 [95% confidence interval {CI}, 0.018-0.981], p = 0.020). Addition of single-dose radiotherapy did not result in increased length of stay (radiotherapy: 12 ± 7.0 days; no radiotherapy: 11 ± 7.2 days; mean difference: 1.0 [95% CI, -3.2 to 5.2] days, p = 0.635). CONCLUSIONS: Single-dose radiation in combination with gluteus minimus débridement decreases the risk of clinically important HO compared with gluteus minimus débridement alone after a Kocher-Langenbeck approach for acetabular fracture. No differences in length of stay were seen. Surgeons who chose not to use radiotherapy as a result of concern for future sarcoma may see higher rates of clinically significant HO after a Kocher-Langenbeck approach for acetabular fracture fixation. LEVEL OF EVIDENCE: Level III, therapeutic study.

"Push-past" reaming as a reduction aid with intramedullary nailing of metadiaphyseal and diaphyseal femoral shaft fractures.

Eccentric reaming of cortical bone near a fracture site can introduce malalignment when an intramedullary nail is placed. The authors describe a technique of reaming metadiaphyseal and diaphyseal femur fractures in which maintaining reduction at the fracture site is not necessary to obtain an excellent alignment of long bone fractures after intramedullary nailing. They have found that central reaming proximal and distal to, but not at, the fracture site allows for excellent reduction of long bone fractures when the intramedullary nail is passed. The reamer is stopped just before the fracture site and then "pushed" across the fracture prior to resumption of reaming. The authors present "push-past" reaming as a technical trick to facilitate reduction of femoral fractures treated with intramedullary nails and a consecutive series of 18 cases in which excellent postoperative alignment was achieved.