Dysphagia is associated with increased mortality risk after hip fracture surgery.

PURPOSE: This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture. METHODS: A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality. RESULTS: Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006. CONCLUSIONS: This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

PURPOSE: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

A standardized method of measuring screw breach on postoperative computed tomography scans following percutaneous fixation of the posterior pelvic ring.

PURPOSE: To assess the reliability of a standardized measurement of screw breach on postoperative computed tomography (CT) scans following percutaneous fixation of the posterior pelvic ring. METHODS: Three orthopedic trauma surgeons independently utilized a standardized method of measuring posterior pelvic ring screw breaches on post-operative CT scan images. Breaches were measured as a continuous variable on sagittal images reformatted to be perpendicular to the screw on axial images. The inter-rater and intra-rater reliability of screw breach distance measurements was assessed. RESULTS: Measurements were performed on 42 screws in 20 patients. Screw types included S1-iliosacral (IS) (n = 16), S1-transsacral (TS) (n = 8), S2-IS (n = 2), and S2-TS (n = 16). Patients with varying degrees of screw breaches were chosen to test measurements across breach severities, including 0 mm (n = 10), ≤ 2 mm (n = 12), > 2 to 4 mm (n = 11), and > 4 mm (n = 9). The mean difference and 95% confidence interval (CI) between screw breach measurements between the three surgeons was - 0.13 mm (CI - 0.48 to 0.20), 0.05 mm (CI - 0.6 to 0.7), and 0.18 mm (CI - 0.47 to 0.85), respectively. The inter-rater reliability of the measurements was considered excellent (intraclass correlation coefficient (ICC), 0.93). The mean intra-rater reliability for the observers was considered good (ICC 88.5, CI 82 to 95). CONCLUSIONS: This simple standardized method of measuring screw breaches had excellent inter-rater reliability and would support comparisons of screw breach severity across studies. LEVEL OF EVIDENCE: Level III.

Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures.

PURPOSE: To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS: Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit. RESULTS: Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004). CONCLUSION: Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.

Treatment of intertrochanteric nonunion after sliding hip screw fixation with a short cephalomedullary nail.

Intertrochanteric femur fracture nonunions are a rare complication that can be difficult to treat with limited evidence regarding treatment options. Revision fixation is typically reserved for well-aligned nonunions with sufficient femoral head bone stock. The most common implant used for revision fixation is a sliding hip screw implant. The use of a short cephalomedullary nail (CMN) for revision fixation has not been previously reported. This article presents a technique for reamed short CMN revision fixation of well-aligned nonunions with sufficient bone stock that is a simpler and potentially less morbid treatment option compared to open procedures with fixed-angle devices. For nonunions with poor femoral head bone stock and/or malaligned fractures, a fixed-angle implant, with or without a valgus osteotomy, may be necessary, while arthroplasty is reserved for nonunions with poor proximal femur bone stock that are not amenable to fixed-angle implant fixation.

Predictors of Osteochondral Lesions of the Talus in Patients Undergoing Broström-Gould Ankle Ligament Reconstruction.

Chronic ankle instability is associated with intra-articular and extra-articular ankle pathologies, including osteochondral lesions of the talus. Patients with these lesions are at risk for treatment failure for their ankle instability. Identifying these patients is important and helps to guide operative versus nonoperative treatment. There is no literature examining which patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on patients (N = 192) who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging, and operative procedures were documented. Patients with and without a lesion were divided into 2 cohorts. Fifty-three (27.6%) patients had 1 lesion identified on preoperative magnetic resonance imaging. Forty (69.0%) of these lesions were medial, 18 (31.0%) were lateral, and 5 patients had both. Female sex was a negative predictor of a concomitant lesion (p = .013). Patients were less likely to have concomitant peroneal tendinopathy (30.2% vs 48.9%; p = .019) in the presence of a lesion. However, sports participation was a positive predictor of a concomitant lesion (p = .001). The remainder of the variables (age, body mass index, smoking, trauma, duration, contralateral instability, global laxity) did not show a significant difference. In patients who underwent lateral ankle ligament reconstruction, females were less likely to have a lesion than males. Patients with peroneal tendinopathy were less likely to have a lesion compared with patients without. Additionally, athletic participation was a positive predictor of a concomitant lesion.

Peroneal Nerve Dysfunction due to Multiligament Knee Injury: Patient Characteristics and Comparative Outcomes After Posterior Tibial Tendon Transfer.

OBJECTIVE: To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI). DESIGN: Retrospective cohort study with prospective follow-up. SETTING: Tertiary care institution. PATIENTS: Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury. INTERVENTIONS: Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent. MAIN OUTCOME MEASURES: The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure. RESULTS: Dorsiflexion was significantly reduced at initial contact and mid-late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results. CONCLUSIONS: Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?

BACKGROUND: Increased contact stresses after meniscectomy have led to an increased focus on meniscal preservation strategies to prevent articular cartilage degeneration. Platelet-rich plasma (PRP) has received attention as a promising strategy to help induce healing and has been shown to do so both in vitro and in vivo. Although PRP has been used in clinical practice for some time, to date, few clinical studies support its use in meniscal repair. QUESTIONS/PURPOSES: We sought to (1) evaluate whether PRP augmentation at the time of index meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; (2) determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and (3) examine whether PRP augmentation altered clinical and patient-reported outcomes. METHODS: Between 2008 and 2011, three surgeons performed 35 isolated arthroscopic meniscus repairs. Of those, 15 (43%) were augmented with PRP, and 20 (57%) were performed without PRP augmentation. During the study period, PRP was used for patients with meniscus tears in the setting of no ACL reconstruction. Complete followup at a minimum of 2 years (mean, 4 years; range, 2-6 years) was available on 11 (73%) of the PRP-augmented knees and 15 (75%) of the nonaugmented knees. Clinical outcome measures including the International Knee Documentation Committee (IKDC) score, Tegner Lysholm Knee Scoring Scale, and return to work and sports/activities survey tools were completed in person, over the phone, or through the mail. Range of motion data were collected from electronic patient charts in chart review. With the numbers available, a post hoc power calculation demonstrated that we would have expected to be able to discern a difference using IKDC if we treated 153 patients with PRP and 219 without PRP assuming an alpha rate of 5% and power exceeding 80%. Using the Lysholm score as an outcome measure, post hoc power estimate was 0.523 and effect size was -1.1 (-2.1 to -0.05) requiring 12 patients treated with PRP and 17 without to find statistically significant differences at p = 0.05 and power = 80%. RESULTS: There was no difference in the proportion of patients who underwent reoperation in the PRP group (27% [four of 15]) compared with the non-PRP group (25% [five of 20]; p = 0.89). Functional outcome measures were not different between the two groups based on the measures used (mean IKDC score, 69; SD, 26 with PRP and 76; SD, 17 without PRP; p = 0.288; mean, Tegner Lysholm Knee Scoring Scale, 66, SD, 32 with PRP and 89; SD, 10 without PRP; p = 0.065). With the numbers available there was no difference in the proportion of patients who returned to work in the PRP group (100% [six of six]) compared with the non-PRP group (100% [nine of nine]) or in the patients who returned to their regular sports/activities in the PRP group (71% [five of seven]) compared with the non-PRP group (78% [seven of nine]; p = 0.75). CONCLUSIONS: Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate. However, given the lack of power and nature of the study, modest size differences in outcome may not have been detected. Future larger prospective studies are needed to definitively determine whether PRP should be used with meniscal repair. Additionally, studies are needed to determine if PRP and other biologics may benefit complex tear types. LEVEL OF EVIDENCE: Level III, therapeutic study.

Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes?

BACKGROUND: When associated with a knee dislocation, management of the medial ligamentous injury is challenging, with little literature available to guide treatment. QUESTIONS/PURPOSES: We (1) compared MRI findings of medial ligament injuries between Schenck KDIIIM and KDIV injuries, (2) compared clinical outcomes and health-related quality of life as determined by Lysholm and Veterans Rand 36-Item Health Survey (VR-36) scores, respectively, of reconstructed KDIIIM and KDIV injured knees, and (3) determined reoperation rates of reconstructed KDIIIM and KDIV injured knees. METHODS: Over a 12-year period, we treated 65 patients with knee dislocations involving bicruciate ligament injury and concomitant medial ligament injuries, without or with posterolateral corner injuries (Schenck KDIIIM and KDIV, respectively); 57% were available for followup at a mean of 6.2 years (range, 1.1-11.6 years). These patients were contacted, and prospectively measured clinical outcomes scores (Lysholm and VR-36) were obtained and compared between subsets of patients. Preoperative MRIs (available for review on 49% of the patients) were rereviewed to characterize the medial ligament injuries. RESULTS: KDIIIM injuries more frequently had complete deep medial collateral ligament tears and posterior oblique ligament tears compared to KDIV injuries. KDIIIM knees had better Lysholm scores (88 versus 67, p = 0.027) and VR-36 scores (88 versus 70, p = 0.022) than KDIV knees. Female sex (Lysholm: 55 versus 85, p = 0.005; VR-36: 59 versus 85, p = 0.003) and an ultra-low-velocity mechanism (injury that occurs during activity of daily living in obese patients) (Lysholm: 55 versus 80-89, p = 0.002-0.013; VR-36: 60 versus 79-88, p = 0.001-0.017) were associated with worse outcomes. The overall reoperation rate was 28%, and the most common indication for reoperation was stiffness. CONCLUSIONS: Medial ligament injury is common in knee dislocations. Females who sustain these injuries and patients who have an ultra-low-velocity mechanism should be counseled at the time of injury about the likelihood of inferior outcomes. As ROM deficits are the most commonly encountered complication, postoperative rehabilitation should focus on early ROM exercises as stability and wound healing allow. Future prospective studies are needed to definitively determine whether operative or nonoperative management is appropriate for particular medial ligamentous injury patterns.

Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes.

PURPOSE: To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population. METHODS: For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes. RESULTS: A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts. CONCLUSIONS: Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Patient age is a factor in early outcomes after shoulder arthroplasty.

BACKGROUND: Elderly and young patients alike are undergoing shoulder replacement at increased rates. In an era of outcomes reporting, risk adjustment, and cost containment, identifying patients likely to have adverse events is increasingly important. Our objective was to determine whether patient age is independently associated with postoperative in-hospital complications or increased hospital charges after shoulder arthroplasty. METHODS: We used the Nationwide Inpatient Sample to analyze 58,790 patients undergoing total shoulder arthroplasty or hemiarthroplasty between 2000 and 2008. Multivariate analysis with logistic regression modeling was used to compare groups. Our objective was to determine whether age had an independent impact on the likelihood of postoperative in-hospital complications, mortality rate, length of stay, or charges after shoulder arthroplasty. RESULTS: Patients aged 80 years or older had an increased in-hospital mortality rate (0.5%) compared with patients aged 50 to 79 years (0.1%) and patients aged younger than 50 years (0.1%). Predictors of death included female gender, total shoulder arthroplasty versus hemiarthroplasty, and Deyo score. Increased age was associated with slightly increased hospital charges. Length of stay was longer in patients aged 80 years or older compared with younger patients. After shoulder arthroplasty, postoperative anemia occurred more often in patients aged 80 years or older. Other postoperative complications including pulmonary embolism, infection, and cardiac complications were similar among groups. CONCLUSION: Older patients tend to have longer hospital stays, an increased incidence of postoperative anemia, and slightly higher charges after shoulder arthroplasty. Advanced age is not associated with an increased incidence of pulmonary embolism, infection, and cardiac complications. Further research is warranted to explain the relationship between age and early postoperative outcomes.

Traumatic brain injury is common and undertreated in the orthopaedic trauma population.

INTRODUCTION: Traumatic brain injuries (TBIs) can be difficult to diagnose and are often marginalized when compared to more obvious physical injuries. Despite this, recognition and early treatment can lead to improved outcomes. Even mild TBIs have the potential to cause significant long-term consequences for patients, which may affect their physical recovery from orthopaedic injuries. The objective of this study was to examine the incidence and treatment of TBI within the orthopaedic trauma population. METHODS: Inclusion criteria were all patients presenting after an acute trauma with an orthopaedic surgery consult over a continuous 3 month timeframe (n = 187). A retrospective review was completed at an academic tertiary referral trauma center. The primary outcome was the rate of TBI. Secondary outcomes included rate of TBI listed as a discharge diagnosis and rate of follow up plan. Several secondary variables were noted and their associations with TBI evaluated. RESULTS: 27 % of the 187 patients had an acute TBI. 61 % of TBI patients had the diagnosis listed in their discharge summary. 6 % had a follow up plan. The positive TBI group was associated with more high energy injuries (p = 0.032), average limbs involved (p = 0.007), upper extremity injury (p < 0.001), bilateral lower extremity injury (p = 0.004), and Injury Severity Score (p < 0.001). 82 % of patients with an acute TBI had an occupational therapy consult and 39 % had a neurosurgery consult. 24 % of patients with a TBI were admitted to the orthopaedic primary service. CONCLUSIONS: Patients presenting after an acute trauma with orthopaedic injuries have high rates of TBI, but low rates of diagnosis and treatment. This lack of diagnosis and treatment can negatively impact recovery from orthopaedic injuries. Orthopaedic providers should be aware of the diagnostic criteria and initial treatment steps for TBI to ensure prompt and effective treatment, which has been shown to improve outcomes.

Peripheral Nerve Blocks for Hip Fractures.

The incidence of hip fractures has continued to increase as life expectancy increases. Hip fracture is one of the leading causes of increased morbidity and mortality in the geriatric population. Early surgical treatment (<48 h) is often recommended to reduce morbidity/mortality. In addition, adequate pain management is crucial to optimize functional recovery and early mobilization. Pain management often consists of multimodal therapy which includes non-opioids, opioids, and regional anesthesia techniques. In this review, we describe the anatomical innervation of the hip joint and summarize the commonly used peripheral nerve blocks to provide pain relief for hip fractures. We also outline literature evidence that shows each block's efficacy in providing adequate pain relief. The recent discovery of a nerve block that may provide adequate sensory blockade of the posterior capsule of the hip is also described. Finally, we report a surgeon's perspective on nerve blocks for hip fractures.

Identifying Reasons for Nonmedical Delays in Fixation of Femur, Pelvis, and Acetabular Fractures at a Level 1 Trauma Center.

OBJECTIVE: To identify reasons for nonmedical delays in femur, pelvis, and acetabular fracture fixation at an institution with a dedicated orthopaedic trauma room (DOTR) and an early appropriate care practice model. DESIGN: Retrospective review of a prospective registry. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred ninety-four patients undergoing 313 procedures for 226 femur, 63 pelvis, and 42 acetabular fractures. INTERVENTION: Definitive fixation. MAIN OUTCOME MEASUREMENTS: Reasons for delays in fixation after hospital day 2. RESULTS: Delays occurred in 12.5% of procedures (39/313), with 7.7% (24/313) having medical delays and 4.8% (15/313) having nonmedical delays. Nonmedical delays were most commonly due to the operating room being at-capacity (n = 6) and nonpelvic trauma specialists taking weekend call (n = 5). Procedures with nonmedical delays were associated with younger age (median difference -16.0 years, 95% confidence interval [CI], -28 to -5.0; P = 0.006), high-energy mechanisms (proportional difference [PD] 58.5%, 95% CI, 37.0-69.7; P < 0.0001), Thursday through Saturday hospital admission (PD 30.3%, 95% CI, 5.0-50.0; P < 0.0001), pelvis/acetabular fractures (PD 51.8%, 95% CI, 26.7-71.0%; P < 0.0001), and external fixation (PD 33.0%, 95% CI, 11.8-57.3; P < 0.0001). CONCLUSION: Only 4.8% of procedures experienced nonmedical delays using an early appropriate care model and a DOTR. Nonmedical delays were most commonly due to 2 modifiable factors-the DOTR being at-capacity and nonpelvis trauma specialists taking weekend call. Patients with nonmedical delays were more likely to be younger, with pelvis/acetabular fractures, high-energy mechanisms, external fixation, and to be admitted between Thursday and Saturday. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress Radiographs.

OBJECTIVES: To determine whether displacement on lateral stress radiographs (LSRs) in patients with minimally displaced lateral compression type 1 pelvic ring injuries is associated with any demographic and/or injury characteristics. DESIGN: Retrospective comparative cohort. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Ninety-three consecutive patients with minimally displaced lateral compression type 1 injuries. INTERVENTION: Displacement of pelvic ring injury on LSR (≥10 mm vs. <10 mm). MAIN OUTCOME MEASUREMENTS: Demographic and injury characteristics (mechanism of injury, Nakatani rami classification, rami comminution, Denis zone, complete/incomplete sacral fracture, sacral comminution). RESULTS: 65.6% of patients (n = 61) had ≥10 mm of displacement on LSR. On univariate analysis, displacement was associated with increased age [median difference 11: confidence interval (CI), 2-23], female sex [proportional difference (PD): 25.1%, CI, 3.9%-44.4%], Nakatani classification (type I PD: 27.9%, type II PD: -19.5%), and rami comminution (PD: 55.6%, CI, 35.4%-71.3%). On multivariate analysis, displacement was only associated with rami comminution (odds ratio: 16.48, CI, 4.67-58.17). Displacement was not associated with energy of injury mechanism, sacral fracture Denis zone, complete sacral fracture, sacral comminution, or bilateral rami fractures. CONCLUSIONS: Although rami comminution was the only variable found to be independently associated with displacement ≥10 mm on LSR, no single variable perfectly predicted displacement. Future studies are needed to determine whether displacement on stress radiographs should change the management of these injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lateral Stress Radiographs of Lateral Compression Type 1 Pelvic Injuries, With the Injured Side Down or Up, Reliably Measure Occult Instability.

OBJECTIVES: To evaluate the interobserver reliability of measured displacement and occult instability of minimally displaced lateral compression type 1 (LC1) fractures on lateral stress radiographs (LSRs) and to compare differences in displacement between LSR with the injured side down (ID) and up (IU). DESIGN: Retrospective review. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: Twenty-three adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Three orthopaedic surgeons measured the distance between the radiographic teardrops on LSR and supine anteroposterior pelvic radiographs to calculate dynamic fracture displacement. The interobserver reliability of the measured displacement, a continuous variable, was assessed by calculating the intraclass correlation coefficient. The interobserver reliability of occult instability (≥10 mm of displacement on LSR), a categorical variable, was assessed by calculating the kappa value. Matched-pairs analysis was performed to calculate the mean difference of measurements between observers and between ID and IU LSR. RESULTS: The interobserver reliability of the measured displacement was excellent (intraclass correlation coefficient 0.93). The mean difference in measurements between observers ranged from -1.8 to 0.96 mm. The mean difference in the measured displacement between ID and IU LSRs for each observer ranged from -0.6 to 0.3 mm. There was 83% (19/23 cases) agreement on the presence of occult instability (≥10 mm of displacement on LSR) on both ID and IU LSRs. The interobserver reliability of occult instability was moderate (kappa 0.76). CONCLUSIONS: Measured fracture displacement and occult instability of minimally displaced LC1 injuries were reliably measured and identified on LSR, regardless of the laterality.

Risk factors for screw breach and iatrogenic nerve injury in percutaneous posterior pelvic ring fixation.

Background: Percutaneous screw fixation of the posterior pelvic ring is technically demanding and can result in cortical breach. The purpose of this study was to examine risk factors for screw breach and iatrogenic nerve injury. Methods: A retrospective review at a single level-one trauma center identified 245 patients treated with 249 screws for pelvic ring injuries with postoperative computed tomography (CT) scans. Cortical screw breach, iatrogenic nerve injury, and associated risk factors were evaluated. Results: There were 86 (35%) breached screws. The breach rate was similar between screw types (33% S1-iliosacral (S1-IS), 44% S1-transsacral (S1-TS), 31% S2-IS, and 30% S2-TS) and was not associated with patient characteristics, Tile C injuries, or corridor size or angle. The overall rate of screw revision for screw malpositioning was 1.2% (3/249). Iatrogenic nerve injuries occurred in 8 (3.2%) of the 249 screws. Screws that caused iatrogenic nerve injuries had greater screw breach distances (5.4 vs. 0 mm, MD 5, CI 2.3 to 8.7, p < 0.0001), were more likely to be S1-IS screws (88% vs. 47%, PD 40%, CI 7 to 58%, p = 0.006), more likely to be placed in Tile C injuries (75% vs. 44%, PD 31%, CI -3 to 55%, p = 0.04), and there was a trend for having a screw corridor size <10 mm (75% vs. 47%, PD 28, CI -6 to 52%, p = 0.06). Of the 7 iatrogenic nerve injuries adjacent to screw breaches, two nerve injuries recovered after screw removal, three recovered with screw retention, and two did not recover with screw retention. Conclusion: Screw breaches were common and iatrogenic nerve injuries were more likely with S1-IS screws. Surgeons should maintain a high degree of caution when placing these screws and consider removal of any breached screw associated with nerve injury.

Percutaneous Reduction of Intra-Articular Posterior Wall Acetabular Rim Fragment: Surgical Technique and Case Series With an Average Follow-Up of 2 Years.

SUMMARY: Small posterior wall rim fractures are typically stable; however, if incarcerated in the joint, they must be removed. It is possible to reduce the morbidity associated with open approaches by addressing these incarcerated fragments in a percutaneous manner. This allows the restoration of joint congruity and removal of the osteochondral fragment from the joint space. The following report details the surgical technique to accomplish this, and the results of a case series of patients who underwent this technique. The advantages include limiting the morbidity of an open approach. However, the surgeon must be prepared to convert to an open approach if percutaneous removal does not accomplish the goals of surgery-a concentric, stable hip joint.

The Antibiotic Cement Bead Rouleaux: A Technical Trick to Maximize the Surface Area to Volume Ratio of Cement Beads to Improve the Elution of Antibiotics.

SUMMARY: The use of antibiotic-impregnated cement as a local antibiotic delivery system is well-established as an adjunctive treatment for chronic osteomyelitis. Because the elution of antibiotics is a surface area phenomenon, the geometry of the cement is an important consideration. The antibiotic cement bead rouleaux technique is a simple and efficient method of bead fabrication that requires only 10 minutes of preparation time and readily available operating room supplies. The discoid structure of the beads provides 3 times the surface-area-to-volume ratio of a spherical bead, which facilitates antibiotic elution. Given the speed and ease of fabrication, along with optimized geometry, the antibiotic cement bead rouleaux is a useful addition to the surgeon's repertoire.

Urinary Bladder Matrix Grafting: A Simple and Effective Alternative to Flap Coverage for Wounds in High-Risk Orthopaedic Trauma Patients.

SUMMARY: Complex traumatic and/or infected wounds and their sequelae are a significant burden for high-volume trauma centers. Local or free flap coverage options are well described; however, they may be high risk in poor hosts with multiple comorbidities and active infections. In addition, flap coverage can result in delays in wound coverage depending on specialist availability. Porcine urinary bladder matrix grafting has been shown to be a simple definitive wound coverage option that can be performed without delay in multiple patient populations for wounds that would otherwise require flap coverage. The purpose of this article was to describe a technique for urinary bladder matrix grafting and report on a series of orthopaedic trauma patients treated with this technique.