Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall?

INTRODUCTION: Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial. MATERIALS AND METHODS: This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups. RESULTS: The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans. CONCLUSIONS: A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures.

Birth outcomes following pelvic ring injury: A retrospective study.

OBJECTIVE: To report obstetric outcomes in pregnant women with previous pelvic ring injury (PRI) and investigate the correlation between residual pelvic deformity and the mode of delivery. DESIGN: Retrospective cohort study. SETTING: Single medical centre in Taiwan. POPULATION: Forty-one women with PRI histories from 2000 to 2021 who subsequently underwent pregnancy and delivery. METHODS: All patients had complete PRI treatment and radiological follow up for at least 1 year. The demographic data, radiological outcomes after PRI and obstetric outcomes were collected to investigate the potential factors of delivery modes using non-parametric approaches and logistic regression. Caesarean section (CS) rates among different subgroups were reported. MAIN OUTCOME MEASURES: Comparisons of demographic data and radiological outcomes (Matta/Tornetta criteria and Lefaivre criteria) after PRI among patients who had subsequent pregnancy and underwent vaginal deliveries (VD) or CS. RESULTS: There were 14 VD and 27 CS in 41 patients. Nine patients underwent CS because of their PRI history, 12 patients underwent CS for other obstetric indications and 20 underwent trial of labour. Based on the logistic regression model, retained trans-iliosacral implants did not significantly increase the risk of CS (odds ratio [OR] 1.20; 95% CI 0.17-8.38). Higher pelvic asymmetry value by Lefaivre criteria was a potential risk factor for CS after previous PRI (OR 1.52; 95% CI 1.043-2.213). CONCLUSIONS: VD is possible after PRI. Retained trans-iliosacral implants do not affect the delivery outcome. Residual pelvic asymmetry after PRI by Lefaivre criteria is a potential risk factor for CS.

Causes of Increased Use of Closed Reduction and Internal Fixation for High-Energy-Related Traumatic Sacral Fractures.

BACKGROUND: Reasons for the increased use of closed reduction and internal fixation (CRIF) for traumatic sacral fractures (SFs) are unclear in the literature. Therefore, we aimed to report the annual changes in the number of patients, mechanisms of injury, fracture patterns, and fixation methods. METHODS: In this retrospective study, we extracted data of 271 patients (mean age, 37.5 years) from the trauma register over an 8-year period. Annual records regarding the number of patients, injury mechanisms, fracture types, and treatment options were statistically analyzed to examine the interactions among these factors. RESULTS: The number of patients with SFs increased significantly each year. The rate of admission to the intensive care unit after resuscitation was high (64.9%). Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C pelvic ring injury (PRI), Dennis zone II injury, Roy-Camille type 2 injury, and U/H-type injury were the most common fracture types. Trans-iliac trans-sacral screws were mainly used in AO type B PRI, and their use significantly increased each year. For AO type C PRI, open reduction and internal fixation (ORIF) with rigid fixation was the main treatment, and the use of CRIF with iliosacral screws decreased each year. Stepwise statistical analysis revealed that the increase in AO type B PRI and ORIF for anterior PRI were the factors contributing to the increased use of CRIF for SFs. CONCLUSIONS: While the use of osteosynthesis for SFs is increasing, an increased use of CRIF for traumatic SFs has also been observed in clinical practice. This increase can be attributed to the increase in AO type B PRIs and ORIF for anterior PRIs.

Sustained Release of Antifungal and Antibacterial Agents from Novel Hybrid Degradable Nanofibers for the Treatment of Polymicrobial Osteomyelitis.

This study aimed to develop a drug delivery system with hybrid biodegradable antifungal and antibacterial agents incorporated into poly lactic-co-glycolic acid (PLGA) nanofibers, facilitating an extended release of fluconazole, vancomycin, and ceftazidime to treat polymicrobial osteomyelitis. The nanofibers were assessed using scanning electron microscopy, tensile testing, water contact angle analysis, differential scanning calorimetry, and Fourier-transform infrared spectroscopy. The in vitro release of the antimicrobial agents was assessed using an elution method and a high-performance liquid chromatography assay. The in vivo elution pattern of nanofibrous mats was assessed using a rat femoral model. The experimental results demonstrated that the antimicrobial agent-loaded nanofibers released high levels of fluconazole, vancomycin, and ceftazidime for 30 and 56 days in vitro and in vivo, respectively. Histological assays revealed no notable tissue inflammation. Therefore, hybrid biodegradable PLGA nanofibers with a sustainable release of antifungal and antibacterial agents may be employed for the treatment of polymicrobial osteomyelitis.

Anti-Adhesive Resorbable Indomethacin/Bupivacaine-Eluting Nanofibers for Tendon Rupture Repair: In Vitro and In Vivo Studies.

The treatment and surgical repair of torn Achilles tendons seldom return the wounded tendon to its original elasticity and stiffness. This study explored the in vitro and in vivo simultaneous release of indomethacin and bupivacaine from electrospun polylactide-polyglycolide composite membranes for their capacity to repair torn Achilles tendons. These membranes were fabricated by mixing polylactide-polyglycolide/indomethacin, polylactide-polyglycolide/collagen, and polylactide-polyglycolide/bupivacaine with 1,1,1,3,3,3-hexafluoro-2-propanol into sandwich-structured composites. Subsequently, the in vitro pharmaceutic release rates over 30 days were determined, and the in vivo release behavior and effectiveness of the loaded drugs were assessed using an animal surgical model. High concentrations of indomethacin and bupivacaine were released for over four weeks. The released pharmaceutics resulted in complete recovery of rat tendons, and the nanofibrous composite membranes exhibited exceptional mechanical strength. Additionally, the anti-adhesion capacity of the developed membrane was confirmed. Using the electrospinning technique developed in this study, we plan on manufacturing degradable composite membranes for tendon healing, which can deliver sustained pharmaceutical release and provide a collagenous habitat.

The double-plate fixation technique prevents varus collapse in AO type C3 supra-intercondylar fracture of the distal femur.

INTRODUCTION: Varus collapse followed by osteosynthesis for distal femoral fractures with conventional implants has been well documented but is seldom mentioned in fractures managed with locking plates. The purpose of this study was to assess the incidence of varus collapse after treating complex supra-intercondylar fractures of the distal femur (AO type C3) using a Single Plate (SP) or Double Plate (DP) fixation technique. MATERIALS AND METHODS: We retrospectively reviewed 357 patients with distal femoral fractures who were treated at our hospital between 2006 and 2017. After excluding cases of infection, malignancy, periprosthetic fracture, revision surgery, pediatric fracture, and extra-articular fracture, 54 patients were included in the study. All demographic data and radiological and clinical outcomes were reviewed and analyzed. RESULTS: There were 54 patients enrolled into this study with age from 15 to 85 years old (mean 41.6, SD = 19.9), and 32 of them were open fractures (59%). The patients were further divided into either an SP (n = 15) or a DP group (n = 39). Demographics, including age, sex, injury severity score, and open fracture type, were all compatible between the two groups. The overall nonunion rate was 25.9% (n = 14; 6 from the SP and 8 from the DP group; p = 0.175). The varus collapse rate was 9.3% (n = 5; 4 from the SP and 1 from the DP group (p = 0.018). CONCLUSIONS: The varus collapse rate after osteosynthesis with a single lateral locking plate could be as high as 26.7% in AO type C3 fractures of the distal femur, which would be decreased to 2.6% by adding a medial buttress plate. Surgeons should consider DP fixation to avoid varus collapse in severely comminuted complete intra-articular fractures of the distal femur.

Pararectus approach to the AO B2.2 pelvic fracture: early functional and radiological outcomes.

PURPOSE: The pararectus approach is used to treat acetabular fractures; however, it remains unclear whether it can be used to treat pelvic fractures. This study aimed to examine the outcomes of patients with a pelvic ring fracture treated with this approach. METHODS: Seven patients with AO B2.2 pelvic fractures treated with the pararectus approach were included. Patients' pain was assessed pre- and postoperatively with a numerical rating scale. Radiological evaluations included inlet and outlet ratios and pelvic symmetry. Functional outcomes, including Merle d'Aubigné and Majeed scores, were also recorded for 12 months. RESULTS: One patient experienced obturator nerve neuropraxia. Pain scores ranged from 2.3-8.0 to 2.0-3.1 points before and after surgery, respectively. Radiological findings revealed satisfactory outcomes. The maximal gap of the affected ilium reduced from 8.6-20.2 to 0-3.4 mm, from 6.8-17.9 to 0-4.4 mm, and from 3.7-20.3 to 0-3.2 mm in the axial, sagittal, and coronal views, respectively. Based on multiple evaluations, functional outcomes were improved for all patients. CONCLUSION: The pararectus approach can be used safely and satisfactorily to treat AO B 2.2 pelvic fractures.

Three-year functional outcome after open pelvic fracture treatment: a retrospective case series from a level I trauma center.

PURPOSE: Open pelvic fractures have high mortality rates, and survivors may have ongoing functional deficits from severe trauma and invasive life-saving procedures. However, there are limited reports regarding the functional status evaluation following open pelvic fractures. We aimed to report the treatment experiences and short-term functional outcomes of patients with open pelvic fractures. METHODS: We retrospectively reviewed the data of 19 consecutive patients with pelvic fractures who underwent treatment at a single institute between January 2014 and June 2018. The resuscitation protocol, osteosynthesis strategy, reduction quality of the pelvic ring, and functional outcomes were analyzed. RESULTS: The incidence and mortality rates in patients with open pelvic fractures were 4.9 and 21.6%, respectively. Ten, one, and seven of the open wounds related to the pelvic fractures were located in Faringer zones I, II, and III, respectively. Fractures of four patients were categorized as classes 1 and 2, and those of 11 patients as class 3, according to the Jones-Powell classification. Eleven of 19 (57.9%) and 9 of 19 (47.5%) revealed excellent reduction quality by Matta/Torenetta and Lefaivre criteria, respectively. The Merle d'Aubigné score improved at each evaluation but stagnated after 24 months. The Majeed hip score also improved at the 12-month evaluation but the improvement stopped thereafter. At a 3-year follow-up, the patients with excellent reduction of the pelvic ring showed the highest functional performances. CONCLUSION: Improvements in functional status of patients with open pelvic fractures can be anticipated based on the reduction quality of the pelvis ring.

Simultaneous reduction and fixation of concomitant acetabular fracture and ipsilateral sacroiliac joint injury through the pararectus approach: a technical report and early radiological outcome.

PURPOSE: Osteosynthesis for acetabular fractures with ipsilateral sacroiliac joint (SIJ) injuries remains challenging for orthopedic surgeons, despite the evolution of surgical approaches, such as the pararectus approach, and treatment sequences. The study aimed to describe the details of the treatment of acetabular fracture with ipsilateral SIJ injury by the pararectus approach and to report its surgical outcomes. METHODS: We retrospectively assessed patients with acetabular fractures and ipsilateral SIJ injuries undergoing osteosynthesis by the pararectus approach over a three-year period. Evaluation parameters of the quality of reduction of both acetabulum and pelvis injuries were, among others, Matta's criteria, Lefaivre's criteria, inlet/outlet ratios, and maximal gap measured on computed tomography (CT) scans. RESULTS: Ten patients (seven men and three women) were enrolled. Pelvic ring injuries classified as AO B2.3 and acetabular fractures involving two columns were the most common fractures, accounting for 70% and 60%, respectively. Radiological evaluation for pelvic ring injury revealed three excellent and seven good results according to Matta's criteria, as well as five excellent, three good, and one fair results according to Lefaivre's criteria. Inlet and outlet ratios were between 0.84-1.06 and 0.93-1.60, respectively. The distance of the sacroiliac joints significantly improved postoperatively in both axial and coronal views (P = 0.002). Further, the maximal articular gap and step-off of acetabular fractures on axial, coronal, and sagittal view CT scans showed statistically significant improvements after osteosynthesis. CONCLUSION: Simultaneous reduction and fixation of acetabular fractures with ipsilateral SIJ injuries using the pararectus approach achieved satisfactory radiological outcomes. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION: Retrospectively registered.

Higher pelvic incidence values are a risk factor for trans-iliac trans-sacral screw malposition in sacroiliac complex fracture treatment.

BACKGROUND: Percutaneous iliosacral (IS) screw fixation and trans-iliac trans-sacral (TITS) screw fixation are clinically effective treatments of posterior pelvic sacroiliac fractures. In order to accurately assess the sacrum position relative to the pelvis, pelvic incidence (PI) is a commonly utilized radiographic parameter in sagittal view. This study aimed to investigate and compare the surgical outcomes and radiographic parameters of IS or TITS screw fixations for the treatment of posterior sacroiliac complex fractures with different PI values. MATERIALS AND METHODS: The data on patients with posterior pelvic sacroiliac fractures who underwent percutaneous IS or TITS screw fixations, or both, at a single level I trauma center between January 2017 and June 2020 were reviewed. We documented the patient characteristics and fracture types, reviewed surgical records, and measured the radiographic parameters via plain films and multi-planar computed tomography (mpCT) images. Radiographic variations in PI, sacral slope, pelvic tilt, sacral dysmorphism, pelvic ring reduction quality, screw deviation angles, screw malposition grading, and iatrogenic complications were documented and analyzed. RESULTS: A total of 85 patients were included, and 65 IS and 70 TITS screws were accounted for. Patients were divided into two groups according to screw fixation method and further divided into four sub-groups based on baseline PI values. The PI cutoff values were 49.85° and 48.05° in the IS and TITS screw groups, respectively, according to receiver operating characteristic analysis and Youden's J statistic. Smaller PI values were significantly correlated with sacral dysmorphism (p = 0.027 and 0.003 in the IS and TITS screw groups, respectively). Patients with larger PI values were at a significantly increased risk of screw malposition in the TITS screw group (p = 0.049), with no association in the IS screw group. Logistic regression confirmed that a larger PI value was a significant risk factor for screw malposition in the TITS screw group (p = 0.010). The post-operative outcomes improved from poor/fair (at 6 months) to good/average (at 12 months) based on the Postel Merle d'Aubigné and Majeed scores, with no significant differences between subgroups. CONCLUSIONS: Both percutaneous IS and TITS screw fixations are safe and effective treatments for posterior pelvic sacroiliac fractures. Due to the higher risk of screw malposition in patients with larger PI values, it is crucial to identify potential patients at risk when performing TITS screw fixation surgery. LEVEL OF EVIDENCE: Level III.

Postoperative Reduction Quality May Be the Most Important Factor That Causes Worse Functional Outcomes in Open and Closed Pelvic Fractures.

BACKGROUND: Data on the functional outcomes of patients with open pelvic fractures after osteosynthesis are limited, and whether open fracture is a risk factor for worse outcomes, as compared with closed fracture, remains unclear. This study aimed to compare the functional outcomes of patients with open and closed pelvic fractures and evaluate potential factors that might affect outcomes. METHODS: Overall, 19 consecutive patients with open pelvic fractures and 78 patients with closed pelvic fractures between January 2014 and June 2018 were retrospectively reviewed. All fractures were surgically treated, with a minimal follow-up period of three years. Patients' demographic profile, associated injuries, management protocol, quality of reduction, and outcomes were recorded and analyzed. RESULTS: Patients with open pelvic fractures had higher new injury severity score, higher incidence of diverting colostomy, and longer length of stay. Both radiological and functional evaluations revealed no significant differences between the two groups at 1-year and 3-year evaluations. Multiple logistic regression analysis identified poor radiological outcomes (using Lefaivre criteria) and longer length of stay as risk factors for worse short-term functional outcomes. At 3-year evaluation, fair-to-poor radiological outcomes (using Matta/Tornetta and Lefaivre criteria) and the presence of diverting colostomy were potential risk factors. CONCLUSIONS: Compared with closed pelvic fracture, open pelvic fracture was not an indicator of worse functional outcomes. Functional outcomes may be comparable between patients with open and closed pelvic fractures at different time points within three years postoperatively. Achieving anatomical reduction in a fracture is crucial, because it might affect patient satisfaction.

Influence of associated femoral head fractures on surgical outcomes following osteosynthesis in posterior wall acetabular fractures.

BACKGROUND: To date, no study has compared the surgical outcomes between posterior wall acetabular fractures with and without associated femoral head fractures. Therefore, we evaluated whether an associated femoral head fracture increases the incidence of fracture sequelae, including post-traumatic osteoarthritis (PTOA) and osteonecrosis of the femoral head (ONFH), following osteosynthesis for posterior wall acetabular fractures. METHODS: This retrospective clinical study enrolled 183 patients who underwent osteosynthesis for posterior wall acetabular fractures between 2009 and 2019 at a level-1 trauma center. The incidence of PTOA, ONFH, and conversion to total hip arthroplasty (THA) was reviewed. RESULTS: The incidence of PTOA, ONFH, and conversion to THA following osteosynthesis were 20.2%, 15.9%, and 17.5%, respectively. The average time for conversion to THA was 18.76 ± 20.15 months (range, 1-82). The results for the comparison of patients with associated femoral head fractures and isolated posterior wall acetabular fractures were insignificant (PTOA: 27.3% vs. 15.7%, p = 0.13; ONFH: 18.2% vs. 14.3%, p = 0.58; conversion to THA: 20.4% vs. 15.7%, p = 0.52). Upon evaluating other variables, only marginal impaction negatively affected ONFH incidence (odds ratio: 2.90). CONCLUSIONS: Our methods failed to demonstrate a significant difference in the rate of PTOA, ONFH, or conversion to THA in posterior wall acetabular fractures with and without an associated femoral head fracture. Beyond femoral head fractures, the marginal impaction of the acetabulum could have led to early sequelae. LEVEL OF EVIDENCE: Level III.

Comparison of the clinical outcomes between vascularized bone graft and the Masquelet technique for the reconstruction of Gustilo type III open tibial fractures.

BACKGROUND: Gustilo type III tibial fractures commonly involve extensive soft tissue and bony defects, requiring complex reconstructive operations. Although several methods have been proposed, no research has elucidated the efficacies and differences between vascular bone graft (VBG) and the Masquelet technique (MT) to date. We aimed to evaluate and compare the clinical effectiveness of VBG and the MT for the reconstruction of Gustilo type III tibial fractures. METHODS: This retrospective cohort study enrolled patients who underwent reconstruction for Gustilo type III tibial fractures using VBG or the MT in a single center from January 2000 to December 2020. The patients' demographics, injury characteristics, and surgical interventions were documented for analysis. The clinical outcomes including union status, time to union, postoperative infections, and the causes of union failure were compared between the two groups. RESULTS: We enrolled 44 patients: 27 patients underwent VBG, and 17 underwent MT. The average union time was 20.5 ± 15.4 and 15.1 ± 9.0 months in the VBG and MT groups, respectively (p = 0.232). The postoperative deep infection rates were 70.4% and 47.1% in the VBG and MT groups (p = 0.122), respectively. Though not statistically significant, the VBG group had a shorter union time than did the MT group when the bone defect length was > 60 mm (21.0 ± 17.0 versus 23.8 ± 9.4 months, p = 0.729), while the MT group had a shorter union time than did the VBG group when the bone defect was length < 60 mm (17.2 ± 5.6 versus 10.7 ± 4.7 months, p = 0.067). CONCLUSIONS: VBG and MT are both promising reconstruction methods for Gustilo type III tibial fractures. VBG appears to have more potential in reconstructing larger bone defects, while MT may play an important role in smaller bone defects, severe surgical site infections, and osteomyelitis. Therefore, flexible treatment strategies are required for good outcomes in Gustilo type III open tibial fractures.

A retrospective study of hip posterior fracture-dislocation: closed reduction at the emergency department or in the operation theater?

BACKGROUND: For hip posterior fracture-dislocation, the current consensus is to perform joint reduction within 6 h to prevent sequelae. However, whether a closed reduction (CR) should be performed at the emergency department (ED) or in the operation theater (OT) remains debatable. We aimed to assess the incidence and factors predictive of CR failure at the ED in patients with hip posterior fracture-dislocation. METHODS: Patients with hip posterior fracture-dislocation between 2009 and 2019 were included. Age, sex, body mass index (BMI), injury severity score, new injury severity score, time from injury to first reduction attempt (TIR), presence of associated femoral head fracture, posterior wall marginal impaction, and posterior wall fragment size were compared between patients with CR success and patients with CR failure at the ED. RESULTS: Fifty-five patients with hip posterior fracture-dislocation experienced CR attempts at the ED and were enrolled in the study. Thirty-eight (69.1%) hips were reduced successfully at the ED, and 17 (30.9%) experienced failure. No significant differences in age, sex, BMI, presence of femoral head fracture, marginal impaction, or size of the posterior wall fragment were found between the groups. TIR was significantly shorter in the successful CR group (2.24 vs. 4.11 h, p = 0.01). According to receiver operating characteristic curve analysis, 3.5 h was the cut-off time. CONCLUSIONS: For patients with hip posterior fracture-dislocation, TIR was a critical factor for successful CR. If the time interval exceeds 3.5 h from injury, the success rate of bedside CR at the ER is likely to decrease, and the OT should be prepared in case of failed bedside CR.

Matta's criteria may be useful for evaluating and predicting the reduction quality of simultaneous acetabular and ipsilateral pelvic ring fractures.

BACKGROUND: Although the incidence, types, and radiological outcomes of simultaneous ipsilateral pelvic ring and acetabular fractures have been reported, there have been no reports on factors that may affect the quality of acetabular fracture reduction. Here, we evaluate the radiological outcomes of patients treated for simultaneous ipsilateral pelvic and acetabular fractures and analyze the factors that affect the quality of acetabular fracture reduction. METHODS: We conducted a retrospective review of patients treated for simultaneous ipsilateral pelvic ring and acetabular fractures between 2016 and 2020. Factors that may predict inadequate reduction of the acetabular fracture were analyzed. RESULTS: Data from 27 hips of 26 patients were collected. AO B2.2 and anterior columnar fractures were the most common types of pelvic ring and acetabular fractures, respectively. Univariate analysis revealed that Matta's criteria for pelvic ring fracture may be useful for predicting fair to poor quality of acetabular fracture reduction on X-rays. Furthermore, associated fractures identified by Letournel's classification system on computed tomography may be predictive of greater step-offs. CONCLUSIONS: Associated fractures identified via Letournel's classification may contribute to inadequate reduction of acetabular fractures. Matta's criteria for pelvic ring fractures may also be useful for predicting the risk of inadequate reduction of the acetabulum on X-ray scans. These findings may be assessed intraoperatively by fluoroscopy before beginning osteosynthesis for acetabular fractures.

Predictors of Acute Mortality After Open Pelvic Fracture: Experience From 37 Patients From A Level I Trauma Center.

BACKGROUND: Open pelvic fractures are caused by high-energy traumas and are accompanied by organ injuries. Despite improvements in pre-hospital care, the acute mortality rate following open pelvic fractures remains high. This study aimed to report experiences in managing open pelvic fractures, identify potential independent predictors that contribute to acute mortality in such patients, and generate a scoring formula to predict mortality rate. METHODS: Open pelvic fracture patients managed during a 42-month period were retrospectively studied. Logistic regression analysis was used to determine predictors of acute mortality. Using the Youden index, threshold values of predictors were selected. Significant predictors were weighted to create a scoring formula. The area under the curve (AUC) was tested in this specific group. RESULTS: The incidence of open pelvic fractures in all pelvic fractures was 4.9% (37/772), and the overall mortality rate was 21.6% (8/37). All the successfully resuscitated patients entered the reconstruction stage survived and underwent the complete treatment course. Univariate and multivariate logistic regression analyses revealed that the revised trauma score (RTS) was the single independent predictor of acute mortality. A scoring formula was generated following the statistical analysis. The probability of mortality was 0% and 100% when the score was above and below -2, respectively. This model predicted mortality with an AUC of 0.948 (95% confidence interval 0.881-1.000, P < 0.01). CONCLUSION: The RTS may be a potential predictor of acute mortality in open pelvic fracture patients. Further work would be required to validate the clinical efficacy of the generated scoring formula.

High incidence of surgical site infection may be related to suboptimal case selection for non-selective arterial embolization during resuscitation of patients with pelvic fractures: a retrospective study.

BACKGROUND: In most institutions, arterial embolization (AE) remains a standard procedure to achieve hemostasis during the resuscitation of patients with pelvic fractures. However, the actual benefits of AE are controversial. In this study, we aimed to explore AE-related outcomes following resuscitation at our center and to assess the predictive value of contrast extravasation (CE) during computed tomography (CT) for patients with hemodynamically unstable closed pelvic fractures. METHODS: We retrospectively reviewed data from patients who were treated for closed pelvic fractures at a single center between 2014 and 2017. Data regarding the AE and clinical parameters were analyzed to determine whether poor outcomes could be predicted. RESULTS: During the study period, 545 patients were treated for closed pelvic fractures, including 131 patients who underwent angiography and 129 patients who underwent AE. Nonselective bilateral internal iliac artery embolization (nBIIAE) was the major AE strategy (74%). Relative to the non-AE group, the AE group had higher values for injury severity score, shock at hospital arrival, and unstable fracture patterns. The AE group was also more likely to require osteosynthesis and develop surgical site infections (SSIs). Fourteen patients (10.9%) experienced late complications following the AE intervention, including 3 men who had impotence at the 12-month follow-up visit and 11 patients who developed SSIs after undergoing AE and osteosynthesis (incidence of SSI: 11/75 patients, 14.7%). Nine of the 11 patients who developed SSI after AE had undergone nBIIAE. The positive predictive value of CE during CT was 29.6%, with a negative predictive value of 91.3%. Relative to patients with identifiable CE, patients without identifiable CE during CT had a higher mortality rate (30.0% vs. 11.0%, p = 0.03). CONCLUSION: Performing AE for pelvic fracture-related hemorrhage may not be best practice for patients with no CE detected during CT or for unstable patients who do not respond to resuscitation after exclusion of other sources of hemorrhage. Given the high incidence of SSI following nBIIAE, this procedure should be selected with care. Given their high mortality rate, patients without CE during imaging might be considered for other hemostasis procedures, such as preperitoneal pelvic packing.

Augmentative antirotational plating provided a significantly higher union rate than exchanging reamed nailing in treatment for femoral shaft aseptic atrophic nonunion - retrospective cohort study.

BACKGROUND: Atrophic nonunion of femoral shaft fracture after intramedullary (IM) nailing is uncommon. The treatment for femoral shaft aseptic atrophic non-union remained controversial. The aim of this study was to compare the surgical results between exchanging reamed nailing (ERN) and augmentative antirotational plating (AAP) for femoral shaft aseptic atrophic nonunion. METHODS: We retrospectively reviewed the patients with femoral shaft nonunion between the year of 2014 and 2015. The patients with nonunion after plate osteosynthesis, septic nonunion, hypertrophic nonunion, additional surgery during revision surgery were excluded. All the patients were followed up at least 12 months. RESULTS: Overall, the union rate after revision surgery was 70.8%. The union rate was significantly higher in the AAP group than in the ERN group. Operating time was also significantly shorter in the AAP group. Regarding the location of nonunion, the union rate was comparable between groups for isthmic nonunions. However, for non-isthmic nonunions, the union rate was significantly higher and operating time was significantly shorter in the AAP group. CONCLUSION: AAP showed an overall higher union rate for management of femoral shaft aseptic atrophic nonunion compared with ERN. Especially for non-isthmic femoral shaft atrophic nonunions, AAP provided a significantly higher union rate and significantly shorter operating time.

Sustained relief of pain from osteosynthesis surgery of rib fracture by using biodegradable lidocaine-eluting nanofibrous membranes.

Various effective methods are available for perioperative pain control in osteosynthesis surgery, but they are seldom applied intraoperatively. The aim of this study was to evaluate a biodegradable poly([d,l]-lactide-co-glycolide) (PLGA)/lidocaine nanofibrous membrane for perioperative pain control in rib fracture surgery. Scanning electron microscopy showed high porosity of the membrane, and an ex vivo high-performance liquid chromatography study revealed an excellent release profile for both burst and controlled release of lidocaine within 30days. Additionally, the PLGA/lidocaine nanofibrous membrane was applied in an experimental rabbit rib osteotomy model. Implantation of the membrane around the osteotomized rib during osteosynthesis surgery resulted in a significant increase in weight gain, food and water consumption, and daily activity compared to the study group without the membrane. In addition, all osteotomized ribs were united. Thus, application of the PLGA/lidocaine nanofibrous membrane may be effective for sustained relief of pain in oeteosynthesis surgery.