Accuracy and Reliability of Computed Tomography and Magnetic Resonance Imaging Compared With True Anatomic Femoral Version.

BACKGROUND: Abnormal torsion of the femur is correlated to lower extremity pathologies. Although computed tomography (CT) scan is the gold standard torsional measurement, magnetic resonance imaging (MRI) is proposed as a viable alternative. Our aim was to determine the accuracy and consistency of MRI and CT femur rotational studies based on 4 described protocols. METHODS: Twelve cadaveric femora were stripped of soft tissue before imaging and physical assessment of torsion. Four advanced imaging series were obtained for each specimen: CT with axial cuts of the femoral neck (CT-axial); CT with oblique cuts of the femoral neck (CT-oblique); MRI with axial cuts of the femoral neck (MR-axial); MRI with oblique cuts of the femoral neck (MR-oblique). Anatomic specimens were placed with the posterior femoral condyles flat on a dissection table for assessment of true torsion with digital images. Three independent reviewers performed all measurements, including true torsion, using imaging software. Bland-Altman analysis was repeated with the data from each reviewer. RESULTS: Interobserver repeatability for all groups was high at 0.95, 0.87, 0.90, 0.97, and 0.92 for CT-axial, CT-oblique, MR-axial, MR-oblique, and true torsion, respectively. CT-axial had the lowest mean difference from clinical imaging for all three observers (all <1 degree) and held the tightest 95% limits of agreement for 2/3 observers. As torsion increases from neutral, MR-oblique linearly overestimates the rotation compared with true torsion. CT-oblique and MR-axial showed slightly greater differences from true torsion compared with CT-axial, but did not reach clinical significance. CONCLUSIONS: CT-axial was both most accurate and reproducible when compared with true torsion of the femur and should be the gold standard imaging modality; however, both MR-axial and CT-oblique were accurate to a level that is likely less than clinical significance. MR-axial images should be used in clinical situations where radiation exposure needs to be limited. MR-oblique images can overestimate true antetorsion and should not be used. CLINIC SIGNIFICANCE: CT-axial followed by MRI-axial is the most accurate and consistent in measuring true torsion of the femur.

Continuous femoral nerve block using 0.125% bupivacaine does not prevent early ambulation after total knee arthroplasty.

BACKGROUND: Continuous femoral nerve block has been shown to decrease opioid use, improve postoperative pain scores, and decrease length of stay. However, several studies have raised the concern that continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period. QUESTIONS/PURPOSES: This study sought to determine whether continuous femoral nerve block with a single-shot sciatic block prevented early ambulation after total knee arthroplasty (TKA) and whether the technique was associated with adverse effects. METHODS: Between January 2011 and January 2013, 77 consecutive patients undergoing primary TKAs at an orthopaedic specialty hospital received a continuous femoral nerve block for perioperative analgesia. The femoral block was placed preoperatively with an initial bolus and 76 (99%) patients received a single-shot sciatic nerve block performed at the same time. Fifty-eight percent (n = 45) received an initial bolus of 0.125% bupivacaine and 42% (n = 32) received 0.25% bupivacaine. All 77 patients received 0.125% bupivacaine infusion postoperatively with the continuous femoral nerve block. All patients were provided a knee immobilizer that was worn while they were out of bed and was used until 24 hours after removal of the block. All patients also used a front-wheeled walker to assist with ambulation. All 77 patients had complete records for assessing the end points of interest in this retrospective case series, including distance ambulated each day and whether in-hospital complications could be attributed to the patients' nerve blocks. RESULTS: Thirty-five patients (45%) ambulated for a mean distance of 19 ± 22 feet on the day of surgery. On postoperative Days 1 and 2, all 77 patients successfully ambulated a mean of 160 ± 112 and 205 ± 123 feet, respectively. Forty-eight patients (62%) had documentation of ascending/descending stairs during their hospital stay. No patient fell during the postoperative period, required return to the operating room, or readmission within 90 days of surgery. One patient experienced a transient foot drop related to the sciatic nerve block, which resolved by postoperative Day 1. CONCLUSIONS: Continuous femoral nerve block with dilute bupivacaine (0.125%) can be successfully used after TKA without preventing early ambulation. By taking active steps to prevent in-hospital falls, including the use of a knee immobilizer for ambulation while the block is in effect, patients can benefit from the analgesia provided by the block and still ambulate early after TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The effect of insertion angle on the pullout strength of threaded suture anchors: a validation of the deadman theory.

PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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." CLINICAL RELEVANCE: 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.

Early weight bearing after lower extremity fractures in adults.

Weight-bearing protocols should optimize fracture healing while avoiding fracture displacement or implant failure. Biomechanical and animal studies indicate that early loading is beneficial, but high-quality clinical studies comparing weight-bearing protocols after lower extremity fractures are not universally available. For certain fracture patterns, well-designed trials suggest that patients with normal protective sensation can safely bear weight sooner than most protocols permit. Several randomized, controlled trials of surgically treated ankle fractures have shown no difference in outcomes between immediate and delayed (≥6 weeks) weight bearing. Retrospective series have reported low complication rates with immediate weight bearing following intramedullary nailing of femoral shaft fractures and following surgical management of femoral neck and intertrochanteric femur fractures in elderly patients. For other fracture patterns, particularly periarticular fractures, the evidence in favor of early weight bearing is less compelling. Most surgeons recommend a period of protected weight bearing for patients with calcaneal, tibial plafond, tibial plateau, and acetabular fractures. Further studies are warranted to better define optimal postoperative weight-bearing protocols.

Age-related patterns of spine injury in children involved in all-terrain vehicle accidents.

BACKGROUND: With increases in use and power of all-terrain vehicles (ATVs), there have been dramatic increases in both the number and severity of ATV-related injuries. The KIDS database showed a 240% increase in the number of children admitted to a hospital for an ATV-related injury between 1997 and 2006. Over the same time period, there was a 476% increase in the number of children with ATV-related spine injuries. To better understand the nature of these injuries, a series of pediatric ATV-related spine fractures at a regional pediatric trauma center were analyzed. METHODS: Records and radiographs of children and adolescents who presented to a regional pediatric trauma center with a spine injury as a result of an ATV accident were reviewed. In addition to demographic data, information was collected regarding length of stay, Glasgow Coma Score, Pediatric Trauma Score, treatment type, associated injuries, and hospital charges. Patients were divided into 2 groups based on age and American Academy of Orthopaedic Surgeons guidelines for ATV use: younger children (age, 0 to 15 y) and older children (age, 16 to 18 y). RESULTS: Fifty-three spine injuries were identified in 29 children (mean, 1.8 injuries/child) with an average age of 15.7 years; 16 (55%) had associated nonspine injuries and 13 had multiple spine injuries, contiguous in 9 and noncontiguous in 4. Four patients, all in the younger age group, had neurological injuries. Children older than 16 years had significantly lower Pediatric Trauma Scores and were more likely to have a thoracic spine fracture than younger children, who were more likely to have a lumbar fracture. Fourteen patients required surgery for their injuries, 7 for spine injuries and 7 for nonspine injuries; the mean hospital charge was almost $75,000 per patient. CONCLUSIONS: ATV-related spine injuries in children and adolescents are high-energy injuries with a high rate of associated spine and nonspine injuries. ATV-related spine injuries are different from other ATV-related injuries in children in that they are more common in older children and in females. As musculoskeletal injuries are the most common ATV-related injuries in children, orthopaedic surgeons need to be aware of these differences, and have a high index of suspicion for associated injuries, including additional and often noncontiguous spine injuries.

Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes.

BACKGROUND: Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS: Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS: One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION: Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE: Prognostic study, Level IV.

Validated Radiographic Scoring System for Lateral Compression Type 1 Pelvis Fractures.

OBJECTIVES: To develop a radiographic fracture scoring system for lateral compression type 1 (LC-1) pelvic fractures based on OTA/AO survey data and to preliminarily evaluate this system within an LC-1 pelvis fracture cohort. DESIGN: Survey study with validation patient cohort. SETTING: Two Level 1 academic trauma centers. PATIENTS/PARTICIPANTS: Attendings (n=111) at the 2013 OTA/AO national meeting 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: The 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/AO attendees' operative recommendations and (2) LC-1 cohort treatment and outcomes. RESULTS: Operative tendency of OTA/AO survey respondents-defined as the percent of "yes" responses to recommend surgical stabilization-was highly correlated with radiographic findings: sacral displacement {odds ratio (OR) = 18.9 [95% confidence interval (CI): 11.7-30.6]}; sacral column 2-3 versus 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)]; and 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.

Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed Through the Kocher-Langenbeck Approach.

OBJECTIVE: To determine whether an injectable thrombin product [thrombin hemostatic matrix (THM)] at closure of a Kocher-Langenbeck approach reduces the risk of heterotopic ossification (HO) formation after an acetabular fracture. DESIGN: Case control. SETTING: Two Level 1 trauma centers. PATIENTS: Patients with operatively treated acetabulum fractures fixed through Kocher-Langenbeck from 2013 to 2018. INTERVENTION: Records were reviewed for demographics, history of traumatic brain injury, HO medication or radiation prophylaxis, THM (Surgiflo, Ethicon, Bridgewater New Jersey) administration, and length of follow-up. Radiographs were reviewed for dislocation, fracture, Letournel and Orthopaedic Trauma Association classifications, HO, and Brooker grade if applicable. Patients receiving HO prophylaxis (eg, nonsteroidal anti-inflammatory drugs and radiation) were excluded. Remaining patients were divided into 2 groups: THM administration (intervention) and no THM. Continuous variables were compared using t-tests and categorical variables with chi-square or Fisher's exact tests. MAIN OUTCOME MEASUREMENTS: Risk ratios for the association between HO occurrence and THM administration. RESULTS: Three-hundred and twenty-eight acetabular fractures met inclusion criteria (126 intervention, 202 control) in patients with a mean age of 38.7 ± 15.9 years; 62.2% were male, and 42.1% were African American. Traumatic brain injury and posterior dislocation rates were equivalent between groups (P = 0.505, 0.754, respectively). HO rate in the control group was 42.6% compared with 21.4% in the THM group (P < 0.001). Booker grade 3/4 in control group was 17.3% versus 3.2% in the THM group (P < 0.001). Patients receiving THM had a 50% reduced risk of HO (95% confidence interval 0.35-0.73) compared to those who did not; adjustment for age, gender, ethnicity, and traumatic brain injury did not meaningfully change the association (risk ratio 0.46; 95% confidence interval 0.29-0.73; P < 0.001). CONCLUSION: The use of a surgiflo product at closure of a KO approach may reduce the risk of HO formation by 50% after an acetabular fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis.

OBJECTIVES: To evaluate the rate of, and reasons for, conversion of closed treatment of humeral shaft fractures using a fracture brace, to surgical intervention. DESIGN: Multicenter, retrospective analysis. SETTING: Nine Level 1 trauma centers across the United States. PATIENTS: A total of 1182 patients with a closed humeral shaft fracture initially managed nonoperatively with a functional brace from 2005 to 2015 were reviewed retrospectively from 9 institutions. INTERVENTION: Functional brace. MAIN OUTCOME MEASUREMENTS: Conversion to surgery. RESULTS: A total of 344 fractures (29%) ultimately underwent surgical intervention. Reasons for conversion included nonunion (60%), malalignment beyond acceptable parameters (24%), inability to tolerate functional bracing (12%), and persistent signs of radial nerve palsy requiring exploration (3.7%). Univariate comparisons showed that females and whites were significantly (P < 0.05) more likely to be converted to surgery. The multivariate logistic regression identified females as being 1.7 times more likely and alcoholics to be 1.4 times more likely to be converted to surgery (P < 0.05). Proximal shaft as well as comminuted, segmental, and butterfly fractures were also linked to a higher rate of conversion. CONCLUSIONS: This large multicenter study identified a 29% surgical conversion rate, with nonunion as the most common reason for surgical intervention after the failure of functional brace. These results are markedly different than previously reported. These results may be helpful in the future when counseling patients on the choice between functional bracing and surgical intervention in managing humeral shaft fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

New Imaging, Diagnostic, and Assessment Techniques in Orthopedic Trauma.

This article examines new imaging, diagnostic, and assessment techniques that may affect the care of patients with orthopedic trauma and/or infection. Three-dimensional imaging has assisted in fracture assessment preoperatively, whereas improvement in C-arm technology has allowed real-time evaluation of implant placement and periarticular reduction before leaving the operating room. Advances in imaging techniques have allowed earlier and more accurate diagnosis of nonunion and infection. Innovations in bacteriologic testing have improved the sensitivity and specificity of perioperative and peri-implant infections. It is critical that surgeons remain up to date on the options available for optimal patient care.

Intramedullary Nails Yield Superior Results Compared With Plate Fixation When Using the Masquelet Technique in the Femur and Tibia.

OBJECTIVES: To determine the optimal fixation method [intramedullary nail (IMN) vs. plate fixation (PF)] for treating critical bone defects with the induced membrane technique, also known as the Masquelet technique. DESIGN: Retrospective cohort study. SETTING: Four Level 1 Academic Trauma Centers. PATIENTS/PARTICIPANTS: All patients with critical bone defects treated with the induced membrane technique, or Masquelet technique, between January 1, 2005, and January 31, 2018. INTERVENTION: Operative treatment with a temporary cement spacer to induce membrane formation, followed by spacer removal and bone grafting at 6-8 weeks. MAIN OUTCOME MEASUREMENTS: Time to union, number/reason for reoperations, time to full weight-bearing, and any complications. RESULTS: One hundred twenty-one patients (56 tibias and 65 femurs) were treated with a mean follow-up of 22 months (range 12-148 months). IMN was used in 57 patients and plates in 64 patients. Multiple grafting procedures were required in 10.5% (6/57) of those with IMN and 28.1% (18/64) of those with PF (P = 0.015). Reoperation for all causes occurred in 17.5% (10/57) with IMN and 46.9% (30/64) with PF (P = 0.001). Average time to weight-bearing occurred at 2.44 versus 4.63 months for those treated with IMN and plates, respectively (P = 0.002). The multivariable adjusted analysis showed that PF is 6.4 times more likely to require multiple grafting procedures (P = 0.017) and 7.7 times more likely to require reoperation (P = 0.003) for all causes compared with IMN." CONCLUSIONS: This is the largest study to date evaluating the Masquelet technique for critical size defects in the femur and tibia. Our results indicate that patients treated with IMN had faster union, fewer grafting procedures, and fewer reoperations for all causes than those treated with plates, with differences more evident in the femur. The authors believe this is a result of both the development of an intramedullary canal and circumferential stress on the graft with early weight-bearing when using an IMN, as opposed to a certain degree of stress shielding and delayed weight-bearing when using PF. We, therefore, recommend the use of an IMN whenever possible as the preferred method of fixation for tibial and femoral defects when using the Masquelet technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Extreme Nailing: Is It Safe to Allow Immediate Weightbearing After Intramedullary Nail Fixation of Extra-articular Distal Tibial Fractures (OTA/AO 43-A)?

OBJECTIVES: To determine whether immediate weightbearing after intramedullary (IM) fixation of extra-articular distal tibial fractures (OTA/AO 43-A) results in a change in alignment before healing. DESIGN: Retrospective review. SETTING: Level 1 trauma center. INTERVENTION: IM nailing of distal tibial fractures. PATIENTS/PARTICIPANTS: Fifty-three patients with 54 fractures, all of whom could bear weight as tolerated postoperatively. Eighteen fractures were OTA/AO 43-A1, 20 OTA/AO 43-A2, and 16 OTA/AO 43-A3; 20 fractures were open. MAIN OUTCOME MEASUREMENTS: Change in fracture alignment or loss of position. RESULTS: Average change from initial angulation at final follow-up was 0.52 ± 1.49 degrees of valgus and 0.48 ± 3.14 degrees of extension. Final alignment was excellent in 14, acceptable in 28, and poor in 12; 2 fractures went from acceptable initial alignment to poor final alignment; and 2 fractures went from excellent to acceptable alignment. Seven fractures had an improvement in alignment over time. Two fractures required free-flap coverage and 4 required staged grafting because of bone loss. Ten fractures had an unplanned return to the operating room (5 for infected nonunion requiring implant exchange, 3 for infection requiring debridement without implant revision, and 2 for aseptic nonunion). No patient had revision for implant failure. CONCLUSIONS: Immediate weightbearing after IM fixation of extra-articular distal tibial fractures (OTA/AO 43-A) led to minimal change in alignment and seems to be safe for most patients. Complications were consistent with those reported in previous non-weightbearing cohorts. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short Versus Long Cephalomedullary Nails for Fixation of Stable Versus Unstable Intertrochanteric Femur Fractures at a Level 1 Trauma Center.

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.].

Symptomatic Iliosacral Screw Removal After Pelvic Trauma-Incidence and Clinical Impact.

OBJECTIVE: To calculate the incidence of symptomatic iliosacral (SI) screw removal following pelvic trauma and to determine the clinical impact of the secondary intervention. DESIGN: Retrospective chart review. SETTING: Level 1 and Level 2 trauma centers. PATIENTS: Four hundred seventy-one consecutive patients undergoing percutaneous posterior pelvic fixation over 10 years, with 7 excluded for spinopelvic fixation,and 7 excluded due to age <16 year old. INTERVENTION: Implant removal. MAIN OUTCOME MEASUREMENT: Secondary intervention. RESULTS: A total of 25/457 patients underwent screw removal (5.4%). Two patients were lost to follow-up, leaving 23 for analysis. There were 13 male patients and 10 female patients. There were 13 SI and 10 trans-sacral screws removed. Four screws were loose before removal (17%). Average time to screw removal was 10.7 months (4-26 minutes). Fifteen (83.3%) patients had subjective improvement, and 3 (16.7%) had no notable improvement. CONCLUSION: The incidence of symptomatic SI screws necessitating removal is low (5.4%). When removed, there is a high likelihood (83%) that the secondary intervention will result in subjective symptomatic improvement. Routine screw removal is unnecessary because most patients tolerate the implants without symptoms necessitating subsequent surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Role of Implant Removal in Orthopedic Trauma.

Although implant removal is common after orthopedic trauma, indications for removal remain controversial. There are few data in the literature to allow evidence-based decision-making. The risk of complications from implant removal must be weighed against the possible benefits and the likelihood of improving the patient's symptoms.

Bone Morphogenetic Protein: Is There Still a Role in Orthopedic Trauma in 2017?

Approximately 10 years ago bone morphogenic protein (BMP) was seen as a miraculous adjuvant to assist with bone growth. However, in the face of an increasing number of complications and a lack of understanding its long-term effects, it is unclear what role BMP has in the current treatment of orthopedic trauma patients. This article reviews the current recommendations, trends, and associated complications of BMP use in fracture care.

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures.

OBJECTIVE: To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS). DESIGN: Retrospective review of prospectively collected database. SETTING: Single Level 1 academic trauma center. PATIENTS: All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients. METHODS: After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS. RESULTS: ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS. CONCLUSIONS: In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates.

OBJECTIVE: To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures. DESIGN: Retrospective review. SETTING: Multiple trauma centers. PATIENTS: Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device. INTERVENTION: Intramedullary fixation with closed, percutaneous, or open reduction. MAIN OUTCOME MEASUREMENTS: Superficial wound complication, deep infection, nonunion. RESULTS: A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492). CONCLUSIONS: This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Hip Dislocations and Associated Injuries: Current State of Care.

Hip dislocations, most often caused by motor vehicle accidents or similar high-energy trauma, traverse a large subset of distinct injury patterns. Understanding these patterns and their associated injuries allows surgeons to provide optimal care for these patients both in the early and late postinjury periods. Nonoperative care requires surgeons to understand the indications. Surgical care requires the surgeon to understand the benefits and limitations of several surgical approaches. This article presents the current understanding of hip dislocation treatment, focusing on anatomy, injury classifications, nonoperative and operative management, and postinjury care.

Prospective Assessment of the Oncogenic Risk to Patients From Fluoroscopy During Trauma Surgery.

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.