Acetabular fixation in total hip arthroplasty in the previously irradiated pelvis: a review of basic science and clinical outcomes.

Radiation therapy is a common primary, adjuvant, or palliative treatment for many intrapelvic tumors, including primary gastrointestinal, genitourinary, and hematopoietic tumors, as well as metastatic disease to bone. Radiation has well documented microbiologic and clinical effects on bone ranging from radiation osteitis to early degenerative changes of the hip joint and avascular necrosis of the femoral head. Conventional total hip arthroplasty methods have demonstrated high rates of failure in this population, with historical data describing aseptic loosening rates as high as 44-52%, as radiation have been shown to preferentially diminish osteoblast and osteocyte number and function and limit capacity for both cement interdigitation and biologic bony ingrowth. A review of the clinical literature suggests that patients with prior pelvic irradiation are at higher risk for both septic and aseptic loosening of acetabular components, as well as lower postoperative Harris Hip Score (HHS) when compared to historical controls. With limited evidence, trabecular metal shells with multi-screw fixation and cemented polyethene liners, as well as cemented cup-cage constructs both appear to be durable acetabular fixation options, though the indications for each remains elusive. Further prospective data are needed to better characterize this difficult clinical problem.

The Most Significant Risk Factors for Urinary Retention in Fast-track Total Joint Arthroplasty are Iatrogenic.

BACKGROUND: Postoperative urinary retention (POUR) remains a common complication after total joint arthroplasty (TJA). The objective of this study was to determine the incidence and risk factors for POUR in fast-track TJA emphasizing rapid mobilization, multimodal analgesia, and shorter hospital stay. METHODS: Our institutional joint registry was queried for patients who underwent primary TJA between January 2016 and November 2017. The primary outcome was the development of POUR. A panel of demographic, intraoperative, and postoperative variables was investigated. Multivariable regression analyses were performed to control for possible confounding factors. RESULTS: One hundred eighty-seven patients who underwent total hip arthroplasty (THA) and 191 patients who underwent total knee arthroplasty (TKA) were included in the study. Forty percent of TKA and 36% of THA patients developed POUR requiring bladder catheterization. Among THA patients, POUR was significantly associated with age >60 years, intraoperative fluid volume >1350 mL, and intraoperative placement of an indwelling bladder catheter (P = .016, P = .035, and P < .001, respectively). Among TKA patients, POUR was only significantly associated with intraoperative indwelling bladder catheter placement (P < .001). CONCLUSION: The most significant risk factors for POUR in modern-day fast-track TJA are iatrogenic. Routine intraoperative placement of an indwelling bladder catheter and fluid administration exceeding 1350 mL, especially in patients older than 60 years, are discouraged.

A novel supplementary anchor fixation technique for reinforcing fixation in bone grafting procedures for shoulder instability.

Bony stabilization procedures are a reliable solution for recurrent shoulder instability, but have a steep learning curve due to technical difficulties. Meticulous capsular closure is critical and can be augmented with suture anchor constructs. In addition, although fracture or fragmentation of the coracoid graft is relatively uncommon, it is devastating. Here, we describe the use of additional circumferential suture fixation to improve compression across the graft/glenoid interface and help mitigate the risk of fracture bony augmentation procedures.

Skeletal metastatic disease of the acetabulum: historical and evolving techniques for management.

The skeleton is the third most common organ system to be involved in the spread of metastatic carcinomas. More options for systemic therapies, surgeries and adjuvant treatments are providing longer survival for patients with known metastatic carcinoma to the bone. This means more patients are living with metastatic skeletal disease than ever before. If metastatic disease results in enough bone loss it can cause significant pain and dysfunction for patients. The acetabulum and pelvis are common sites of metastatic disease. The complex anatomy of the bony pelvis and acetabulum, as well as its proximity to important neurovascular and pelvic structures, can make surgical management of acetabular metastatic disease technically difficult. Decision making for patients with symptomatic skeletal metastatic disease is complex, and multidisciplinary teams can be helpful in providing appropriate care for these patients. Systemic chemotherapies, immunotherapies or targeted therapies may not adequately treat large areas of metastatic disease in the hip and pelvis. Radiation therapy is not successful for all patients. Fortunately, there are evolving therapies that are giving patients and providers more options for treatment. This review article will cover some of those new therapies and their outcomes, focusing on newer ablative, minimally invasive and surgical reconstruction techniques for metastatic disease involving the acetabulum. Decision making in the management of a patient's metastatic acetabular disease is still made on a case by case basis. This review article hopefully will remind clinicians of the variety of treatments available to these patients.

Why Rotationplasty? A Qualitative Study of Decision-Making by Families of Patients With Primary Bone Sarcoma.

Rotationplasty is an established technique that is indicated as part of the surgical reconstruction for certain patients with primary bone tumors around the knee who undergo tumor resection. There is considerable variation in the application of rotationplasty by surgeons as well as acceptance of the procedure by patients who may be candidates for this procedure. We qualitatively studied the decision-making process of families of patients who had undergone rotationplasty by interviewing 4 patients and their families using semi-structured interviews. Thematic analysis identified the following themes that were important in the decision-making process: (1) the desire for good information sources, (2) finding value in meeting with other patients who had been faced with a similar decision, (3) prioritizing function over cosmesis, (4) a desire to limit the need for revision surgeries, and (5) accepting that a return to normalcy is not an option with a surgery. Physicians and patients faced with a similar decision can benefit from a better understanding of the process, and by the normalization of anxieties and concerns that they may experience.

Bone and body characteristics of freestyle and non-freestyle skiers.

BACKGROUND: Freestyle skiers must optimize their aerial performance by maintaining the strength and coordination to propel themselves in the air and adapt to landings and take-offs on uneven surfaces. The purpose of this study was to investigate the differences in areal bone mineral density (aBMD) and body composition in freestyle skiers and non-freestyle skiing controls. We hypothesized that the unique demands and summation of forces experienced by freestyle athletes would manifest as greater femoral neck aBMD, lower percent body fat, and lower Body Mass Index (BMI) than non-freestyle skiing controls. This is a retrospective cohort study. METHODS: Eighteen freestyle skiers (14 M 4 F, [27.56±5.22 years]) and 15 controls (7 M 8 F, [26.93±3.54 years]) were measured with dual energy X-ray absorptiometry (DXA) to determine total body composition, hip and lumbar spine aBMD, and bone mineral composition (BMC). Height and weight were measured with an in-office stadiometer and scale. Questionnaires were used to determine physical activity and pertinent medical history. Between-group variations were analyzed with an analysis of variance (ANOVA) and stratified by sex. RESULTS: Percent body fat, hip and lumbar spine aBMD, BMC, and area were all similar between freeski and non-freeski athletes (P<0.05 for all). BMI was significantly lower in male freeski athletes (23.97 kg/m2, 95% CI: 22.75-25.18) compared to non-freestyle skiing controls (26.64 kg/m2, 95% CI: 24.43-28.86) (P=0.03). CONCLUSIONS: Freestyle skiers have a lower BMI than non-freestyle skiers. All skiers in this study have similar percent body fat, aBMD, and BMC. This pilot study supports that there are unique musculoskeletal adaptations based on type of skiing. Skiers endure a variety of intense physical forces yet remain understudied despite high orthopedic injury rates. This study serves to broaden the current sports health literature and explore the physical demands and subsequent physiology of freestyle skiers.

Bone Marrow Aspirate Concentrate for the Treatment of Knee Osteoarthritis: A Systematic Review.

BACKGROUND: Bone marrow aspirate concentrate (BMAC) has emerged as a therapeutic option for symptomatic knee osteoarthritis (OA). PURPOSE: To systematically review the literature to evaluate the efficacy of isolated BMAC injection in the treatment of OA of the knee joint. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was performed by searching the PubMed, Embase, and Cochrane Library databases up to July 2020 to identify human studies that assessed the clinical outcomes of isolated BMAC injection for the treatment of knee OA. The electronic search strategy used was "bone marrow aspirate concentrate knee osteoarthritis." RESULTS: Eight studies met the inclusion criteria, including a total of 299 knees with a mean follow-up of 12.9 months (range, 6-30 months). Of all patient-reported outcomes assessed across studies, 34 of 36 (94.4%) demonstrated significant improvement from baseline to latest follow-up (P < .05). Five studies evaluating numerical pain scores (visual analog scale and Numeric Rating Scale) reported significant improvements in pain level at final follow-up (P < .01). However, 3 comparative studies evaluating BMAC in relation to other therapeutic injections failed to demonstrate the clinical superiority of BMAC. CONCLUSION: The BMAC injection is effective in improving pain and patient-reported outcomes in patients with knee OA at short- to midterm follow-up. Nevertheless, BMAC has not demonstrated clinical superiority in relation to other biologic therapies commonly used in the treatment of OA, including platelet-rich plasma and microfragmented adipose tissue, or in relation to placebo. The high cost of the BMAC injection in comparison with other biologic and nonoperative treatment modalities may limit its utility despite demonstrable clinical benefit.

Supracondylar femur fracture following multiligament knee reconstruction with Internal Brace® augmentation: A case report.

This a case report of a 40-year-old male with left knee dislocation Type III and associated peroneal nerve palsy underwent delayed allograft reconstruction of his multiligament knee injury (MKI) with Internal Brace augmentation. The patient returned to work at 6 months postoperatively. He then fell and sustained a displaced supracondylar left femur fracture at the site of the internal brace augmentation of his lateral collateral ligament (LCL) reconstruction for which he underwent placement of a retrograde femoral nail. At 2 years of follow-up the patient had no evidence of knee instability. Level of evidence: V.

Osteoid osteoma of the femoral neck mistaken as a synovial herniation pit.

A 36-year-old man presented with 1 year of atraumatic left lateral thigh, groin, and hip pain, and imaging consistent with the diagnosis of femoroacetabular impingement and a labral tear. Imaging concurrently demonstrated a synovial herniation pit. The patient underwent hip arthroscopy, which included femoroplasty, acetabuloplasty, labral debridement, and synovectomy. His pain persisted and further workup confirmed an osteoid osteoma that was mimicking a synovial herniation pit. The osteoid osteoma was treated with radiofrequency ablation. At 18 months follow-up, the patient reported complete resolution of his symptoms. We present the case to highlight distinguishing imaging and clinical findings of these similar-appearing lesions. While neither condition is particularly rare individually, the misidentification of osteoid osteoma as a synovial herniation pit is a unique feature of this case that lead to the patient's protracted clinical course.

Chondrosarcoma Arising in Synovial Chondromatosis of the Hip: A Case Report.

CASE: Synovial chondromatosis (SC) is a rare condition involving the proliferation of cartilage within the synovial membrane secondary to subsynovial connective tissue metaplasia. Malignant transformation to chondrosarcoma is rare. We cite a case of SC of the hip refractory to arthroscopic debridement, found to have secondary chondrosarcoma on aborted total hip arthroplasty, in which curative treatment was ultimately obtained with external hemipelvectomy. CONCLUSION: SC has the potential to undergo malignant transformation to chondrosarcoma. The consequences of not recognizing such transformation can significantly impact patient outcomes and limit options for local control surgery and limb salvage.

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery.

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation-7 a.m. to 4 p.m.; (2) night operation-4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19-33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities.

Five-Year Surveillance of Vitamin D Levels in NCAA Division I Football Players: Risk Factors for Failed Supplementation.

BACKGROUND: Monitoring vitamin D levels in athletes and determining their response to supplementation in cases of deficiency is thought to be necessary to modulate the risks associated with vitamin D deficiency. HYPOTHESIS/PURPOSE: To report the results of a 5-year-long surveillance program of vitamin D in the serum of football players on a National Collegiate Athletic Association (NCAA) Division I team and to examine whether factors including age, body mass index (BMI), race, position played, and supplement type would affect the response to 12-month oral vitamin D replacement therapy in athletes with deficiency. We hypothesized that yearly measurements would decrease the proportion of athletes with vitamin D insufficiency over the years and that the aforementioned factors would affect the response to the supplementation therapy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We measured serum 25(OH)D levels (25-hydroxyvitamin D) in 272 NCAA Division I football players from our institution annually between 2012 and 2017. Athletes with insufficient vitamin D levels (<32 ng/mL) received supplementation with vitamin D3 alone or combined vitamin D3/D2. The percentage of insufficient cases between the first 2 years and last 2 years of the program was compared, and yearly team averages of vitamin D levels were calculated. Associations between player parameters (age, BMI, race, team position, supplement type) and failed supplementation were evaluated. RESULTS: The prevalence of vitamin D insufficiency decreased significantly during the study period, from 55.5% in 2012-2013 to 30.7% in 2016-2017 (P = .033). The mean 25(OH)D level in 2012 was 36.3 ng/mL, and this increased to 40.5 ng/mL in 2017 (P < .001); however, this increase was not steady over the study period. Non-Hispanic athletes and quarterbacks had the highest average 25(OH)D levels, and Black players and running backs had the lowest overall levels. There were no significant differences in age, BMI, race, or playing position between athletes with and without failed vitamin D supplementation. Athletes receiving vitamin D3 alone had a more successful rate of conversion (48.15%) than those receiving combined vitamin D3/D2 (22.22%; P = .034). CONCLUSION: To decrease the prevalence of vitamin D deficiency in football players, serum vitamin D measurements should be performed at least once a year, and oral supplementation therapy should be provided in cases of deficiency. Black players might be at increased risk of vitamin D insufficiency. Oral vitamin D3 may be more effective in restoring vitamin D levels than combined vitamin D3/D2 therapy.

Biomechanical Testing of Suture Anchor Versus Transosseous Tunnel Technique for Quadriceps Tendon Repair Yields Similar Outcomes: A Systematic Review.

PURPOSE: To systematically review the literature to evaluate the biomechanical properties of the suture anchor (SA) versus transosseous tunnel (TO) techniques for quadriceps tendon (QT) repair. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase using PRISMA guidelines to identify studies that evaluated the biomechanical properties of SA and TO techniques for repair of a ruptured QT. The search phrase used was "quadriceps tendon repair biomechanics". Evaluated properties included ultimate load to failure (N), displacement (mm), stiffness (N/mm), and mode of failure. RESULTS: Five studies met inclusion criteria, including a total of 72 specimens undergoing QT repair via the SA technique and 42 via the TO technique. Three of 4 studies found QTs repaired with SA to have significantly less elongation upon initial cyclic loading when compared to QTs repaired with the TO technique (P < .05). Three of 5 studies found QTs repaired with SA to have significantly less elongation upon final cyclic loading when compared to QTs repaired with the TO technique (P < .05). The pooled analysis from 4 studies reporting on initial displacement showed a statistically significant difference in favor of the SA group compared to the TO group (P = .03). The pooled analysis from studies reporting on secondary displacement and ultimate load to failure showed no significant difference between the SA and TO groups (P > .05). The most common mode of failure in both groups was suture slippage. CONCLUSION: On the basis of the included cadaveric studies, QTs repaired via the SA technique have less initial displacement upon cyclic testing when compared to QTs repaired via the TO technique. However, final displacement and ultimate load to failure outcomes did not reveal differences between the two fixation strategies. Knot slippage remains a common failure method for both strategies.

Brain metastases from Truncal and extremity bone and soft tissue sarcoma: Single institution study of oncologic outcomes.

Brain metastases are a rare occurrence in patients with sarcoma. The prognosis for patients is poor, and treatment can contribute to considerable morbidity. We sought to examine the experience of our institution in managing these patients over a period of 17 years. We performed a retrospective cohort study of patients managed for sarcoma of the extremity or trunk who developed brain metastases from 2000 to 2017. Clinical data were analyzed and we assessed survival outcomes. 14 patients presenting at a mean age of 46.7 years were included. All patients were treated with radiotherapy for their brain metastases. 3 patients underwent surgical excision of their intracranial metastases. Two patients were treated with radium-223 dichloride. Kaplan-Meier survival analysis and the log rank test were used to calculate the survival probability, and to compare patient subgroups. All patients in this study developed lung or bone metastases at a mean interval of 13.3 months prior to the development of brain metastasis. The median interval from diagnosis of a brain metastasis to death was 3.6 months. The Kaplan-Meier survival probability at 6 months was 28.6%, and 14.3% at 1 year. Surgery was not found to be associated with increased survival. Patients with cerebellar metastasis had increased survival probability as compared to those with cerebral metastasis. Patients with extremity or trunk sarcoma who develop brain metastases frequently develop lung or bone metastases in the year preceding their diagnosis of brain metastasis. Patients with cerebellar metastasis may have better survival than those with cerebral metastasis, and an aggressive treatment approach should be considered. Despite aggressive treatment, the prognosis is grim.

The Prevention of Infections in Older Adults: Oral Health.

The oral cavity is exposed to the external environment and from a very young age is colonized by infectious agents. Under certain circumstances including poor oral hygiene, dry mouth, trauma, and the use of antibiotics, oral infections can occur. They can result in damage to the oral cavity including teeth and their support structures. Oral infections can also lead to the extension of infection into surrounding tissues and to systemic infections. Chronic oral infection is a recognized risk factor for heart disease. Older adults are at high risk for oral infections and associated complications. Tooth loss, for which infection is the most significant cause, leads to cosmetic changes and a decreased ability to masticate certain foods that can lead to malnutrition. Chronic oral infections and the manipulation of teeth and supporting structures can lead to the hematogenous spread of infection including the infection of artificial joints and endocardial implants. Good oral hygiene, the use of fluoride, regular dental care, and the appropriate use of antibiotics can all reduce oral infections and their associated complications. J Am Geriatr Soc 68:411-416, 2020.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment.

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

Management of a Tibial Plafond Lung Cancer Metastasis Using an Intramedullary Hindfoot Fusion Nail.

Metastatic disease to the tibial plafond is rare with few reports in the literature. No consensus exists regarding surgical reconstruction of large structural defects of the ankle due to these lesions, as each treatment must be tailored to the individual patient's goals and prognosis. Cancer metastases pose a unique challenge to limb salvage as there is often bone loss and poor soft tissue quality combined with the need for postoperative adjuvant therapy. The goal of surgery is to obtain early weightbearing, pain relief, and a durable reconstruction that will outlive the patient. In this report, we present the case of an intraarticular fracture of the tibial plafond with severe bone loss due to a lung carcinoma metastasis. The patient was successfully treated with en bloc tumor excision, curettage, argon beam coagulation, tibiotalocalcaneal arthrodesis using an intramedullary hindfoot fusion nail, and bone cementation with postoperative chemotherapy and radiation. One year after surgery, the patient was able to bear full weight on the extremity without a brace or assistive device and had no pain in the ankle with no local tumor recurrence. LEVELS OF EVIDENCE: Level V: Expert opinion.

Periosteal Osteosarcoma: A Single-Institutional Study of Factors Related to Oncologic Outcomes.

BACKGROUND: Periosteal osteosarcoma is a rare surface-based variant with a lower propensity to metastasis and better prognosis than conventional osteosarcoma. The literature supporting survival benefit with adjuvant chemotherapy is lacking. Our institutional practice is for chemotherapy to be offered to patients with high-grade disease. METHODS: We conducted a retrospective cohort study of patients managed for periosteal osteosarcoma from 1970 to 2015 analyzing the survival outcomes and assessing for any relationship of survival to patient- or treatment-related factors. 18 patients were included. The study population presented at a mean of 20.8 years and was followed for a mean of 10.7 years. Factors assessed for an association with survival included age, size of tumor, use of chemotherapy, presence of medullary involvement, presence of high-grade disease, local recurrence, and site of disease. Kaplan-Meier survival analysis and Cox proportional hazard regression were performed to calculate the survival rates and to assess for the effect of any factor on survival. RESULTS: 10-year overall survival rate was 77.1%, and 10-year event-free survival rate was 66.4%. No factor was found to have an association with overall or event-free survival. CONCLUSION: These findings add to the available evidence which has failed to find any survival benefit from chemotherapy; patients with this rare disease and their families should be counselled regarding the unclear role of chemotherapy in this rare subtype of osteosarcoma.

Treatment of Sarcoma Lung Metastases with Stereotactic Body Radiotherapy.

BACKGROUND: The most common site of sarcoma metastasis is the lung. Surgical resection of pulmonary metastases and chemotherapy are treatment options that have been employed, but many patients are poor candidates for these treatments for multiple host or tumor-related reasons. In this group of patients, radiation might provide a less morbid treatment alternative. We sought to evaluate the efficacy of radiotherapy in the treatment of metastatic sarcoma to the lung. METHODS: Stereotactic body radiotherapy (SBRT) was used to treat 117 pulmonary metastases in 44 patients. Patients were followed with serial computed tomography imaging of the chest. The primary endpoint was failure of control of a pulmonary lesion as measured by continued growth. Radiation-associated complications were recorded. RESULTS: The majority of patients (84%) received a total dose of 50 Gy per metastatic nodule utilizing an image-guided SBRT technique. The median interval follow-up was 14.2 months (range 1.6-98.6 months). Overall survival was 82% at two years and 50% at five years. Of 117 metastatic nodules treated, six nodules showed failure of treatment (95% control rate). Twenty patients (27%) developed new metastatic lesions and underwent further SBRT. The side effects of SBRT included transient radiation pneumonitis (n=6), cough (n=2), rib fracture (n=1), chronic pain (n=1), dermatitis (n=1), and dyspnea (n=1). CONCLUSION: Stereotactic body radiotherapy is an effective and safe treatment for the ablation of pulmonary metastasis from sarcoma. Further work is needed to evaluate the optimal role of SBRT relative to surgery or chemotherapy for treatment of metastatic sarcoma.

Is Closed Reduction and Percutaneous Fixation of Unstable Posterior Ring Injuries as Accurate as Open Reduction and Internal Fixation?

OBJECTIVES: The objective of this retrospective review was to determine whether a closed reduction technique for unstable pelvic ring injuries is as accurate as an open technique. DESIGN: Retrospective review. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: We reviewed the records of 113 patients who had unilateral unstable pelvic ring injuries (Bucholz type 3, OTA type 61-C1) treated with closed reduction and percutaneous fixation (CRPF) or open reduction with internal fixation (ORIF). INTERVENTION: Sixty patients were treated at one institution with open reduction and percutaneous iliosacral screw fixation. This involved prone positioning and a gluteus maximus sparing approach for direct visualization and reduction of the fracture. A second cohort of 53 patients was treated at a separate institution with closed reduction and percutaneous iliosacral screw fixation. This involved supine positioning and skeletal traction. MAIN OUTCOME MEASURES: Preoperative and postoperative plain radiographs of the pelvis were reviewed and standardized measurements were made to compare quality of reduction. RESULTS: We were able to measure displacement within 0.1 mm. Overall reduction quality was slightly better for the CRPF group. The largest average difference in postoperative displacement was seen at the iliac wing height on anteroposterior pelvis radiographs with 6.3 mm (range 0-19.6) in the ORIF group versus 1.9 mm (range 0-4.7) in the CRPF group. CONCLUSIONS: The closed reduction technique described here is as effective as the ORIF technique in obtaining reduction of unstable pelvic ring injuries (Bucholz type 3, OTA type 61-C1). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.