Treatment Failure After Repair of Displaced Femoral Neck Fractures in Patients Compared by "Decade of Life": An Analysis of 565 Cases in Adults Less Than 60 years of Age.

OBJECTIVES: To study the results of displaced femoral neck fractures (FNFs) in adults less than 60 years of age by comparing patients, injury, treatment, and the characteristics of treatment failure specifically according to patients' age at injury, that is, by their "decade of life" [ie, "under 30" (29 years and younger), "the 30s" (30-39 years), "the 40s" (40-49 years), and "the 50s" (50-59 years)]. DESIGN: Multicenter retrospective comparative cohort series. SETTING: Twenty-six North American Level 1 Trauma Centers. PATIENT SELECTION CRITERIA: Skeletally mature patients aged 18-59 years with operative repair of displaced FNFs. OUTCOME MEASURES AND COMPARISONS: Main outcome measures were treatment failures (fixation failure and/or nonunion, osteonecrosis, malunion, and the need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). These were compared across decades of adult life through middle age (<30 years, 30-39 years, 40-49 years, and 50-59 years). RESULTS: Overall, treatment failure was observed in 264 of 565 (47%) of all hips. The mean age was 42.2 years, 35.8% of patients were women, and the mean Pauwels angle was 53.8 degrees. Complications and the need for major secondary surgeries increased with each increasing decade of life assessed: 36% of failure occurred in patients <30 years of age, 40% in their 30s, 48% in their 40s, and 57% in their 50s (P < 0.001). Rates of osteonecrosis increased with decades of life (under 30s and 30s vs. 40s vs. 50s developed osteonecrosis in 10%, 10%, 20%, and 27% of hips, P < 0.001), while fixation failure and/or nonunion only increased by decade of life to a level of trend (P = 0.06). Reparative methods varied widely between decade-long age groups, including reduction type (open vs. closed, P < 0.001), reduction quality (P = 0.030), and construct type (cannulated screws vs. fixed angle devices, P = 0.024), while some variables evaluated did not change with age group. CONCLUSIONS: Displaced FNFs in young and middle-aged adults are a challenging clinical problem with a high rate of treatment failure. Major complications and the need for complex reconstructive surgery increased greatly by decade of life with the patients in their sixth decade experiencing osteonecrosis at the highest rate seen among patients in the decades studied. Interestingly, treatments provided to patients in their 50s were notably different than those provided to younger patient groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Optimal Fixation Strategies for Displaced Femoral Neck Fractures in Patients 18-59 Years of Age: An Analysis of 565 Cases Treated at 26 Level 1 Trauma Centers.

OBJECTIVES: The objective of this study was to determine the difference in failure rates of surgical repair for displaced femoral neck fractures in patients younger than 60 years of age according to fixation strategy. DESIGN: This is a retrospective, comparative cohort study. SETTING: Twenty-six Level 1 North American trauma centers. PATIENT SELECTION CRITERIA: Patients younger than 60 years of age with a displaced femoral neck fracture (OTA 31-B2, B3) undergoing surgical repair from 2005 to 2017. OUTCOME MEASURES AND COMPARISONS: Patient demographics, injury characteristics, repair methods used, and treatment failure (nonunion/failed fixation, avascular necrosis, and need for secondary surgery) were compared according to fixation strategy. RESULTS: Five hundred and sixty-five patients met inclusion criteria and were studied. The mean age was 42 years, 36% were female, and the average Pauwels' angle of fractures was 55 degrees. There were 305 patients treated with multiple cannulated screws (MCS) and 260 treated with a fixed-angle (FA) construct. Treatment failures were 46% overall, but was more likely to occur in MCS constructs versus FA devices (55% vs. 36%, P < 0.001). When FA constructs were substratified, the use of a sliding hip screw with addition of a medial femoral neck buttress plate (FNBP) and "antirotation" (AR) screw demonstrated better results than either FNBP or AR screw alone or neither with the lowest overall construct failure rate of 11% (P < 0.036). CONCLUSIONS: Historically used fixation constructs for femoral neck fractures (eg, multiple cannulated screws and sliding hip screw) in young and middle-aged adults performed poorly compared with more recently proposed constructs, including those using a medial femoral neck buttress plate and an antirotation screw. Fixed-angle constructs outperformed multiple cannulated screws overall, and augmentation of fixed-angle constructs with a medial femoral neck buttress plate and antirotation screw improved the likelihood of successful treatment. Surgeons should prioritize fixation decisions when repairing displaced femoral neck fractures in patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Neck Fractures With Associated Ipsilateral Femoral Shaft Fractures in Young Adults <50 Years Old: A Multicenter Comparison of 80 Cases Versus Isolated Femoral Neck Fractures.

OBJECTIVES: To analyze patients, injury patterns, and treatment of femoral neck fractures (FNFs) in young patients with FNFs associated with shaft fractures (assocFNFs) to improve clinical outcomes. The secondary goal was to compare this injury pattern to that of young patients with isolated FNFs (isolFNFs). DESIGN: Retrospective multicenter cohort series. SETTING: Twenty-six North American level-1 trauma centers. PATIENT SELECTION CRITERIA: Skeletally mature patients, <50 years old, treated with operative fixation of an FNF with or without an associated femoral shaft fracture. OUTCOME MEASURES AND COMPARISONS: The main outcome measurement was treatment failure defined as nonunion, malunion, avascular necrosis, or subsequent major revision surgery. Odds ratios for these modes of treatment were also calculated. RESULTS: Eighty assocFNFs and 412 isolFNFs evaluated in this study were different in terms of patients, injury patterns, and treatment strategy. Patients with assocFNFs were younger (33.3 ± 8.6 vs. 37.5 ± 8.7 years old, P < 0.001), greater in mean body mass index [BMI] (29.7 vs. 26.6, P < 0.001), and more frequently displaced (95% vs. 73%, P < 0.001), "vertically oriented" Pauwels type 3, P < 0.001 (84% vs. 43%) than for isolFNFs, with all P values < 0.001. AssocFNFs were more commonly repaired with an open reduction (74% vs. 46%, P < 0.001) and fixed-angle implants (59% vs. 39%) (P < 0.001). Importantly, treatment failures were less common for assocFNFs compared with isolFNFs (20% vs. 49%, P < 0.001) with lower rates of failed fixation/nonunion and malunion (P < 0.001 and P = 0.002, respectively). Odds of treatment failure [odds ratio (OR) = 0.270, 95% confidence interval (CI), 0.15-0.48, P < 0.001], nonunion (OR = 0.240, 95% CI, 0.10-0.57, P < 0.001), and malunion (OR = 0.920, 95% CI, 0.01-0.68, P = 0.002) were also lower for assocFNFs. Excellent or good reduction was achieved in 84.2% of assocFNFs reductions and 77.1% in isolFNFs (P = 0.052). AssocFNFs treated with fixed-angle devices performed very well, with only 13.0% failing treatment compared with 51.9% in isolFNFs treated with fixed-angle constructs (P = <0.001) and 33.3% in assocFNFs treated with multiple cannulated screws (P = 0.034). This study also identified the so-called "shelf sign," a transverse ≥6-mm medial-caudal segment of the neck fracture (forming an acute angle with the vertical fracture line) in 54% of assocFNFs and only 9% of isolFNFs (P < 0.001). AssocFNFs with a shelf sign failed in only 5 of 41 (12%) cases. CONCLUSIONS: AssocFNFs in young patients are characterized by different patient factors, injury patterns, and treatments, than for isolFNFs, and have a relatively better prognosis despite the need for confounding treatment for the associated femoral shaft injury. Treatment failures among assocFNFs repaired with a fixed-angle device occurred at a lower rate compared with isolFNFs treated with any construct type and assocFNFs treated with multiple cannulated screws. The radiographic "shelf sign" was found as a positive prognostic sign in more than half of assocFNFs and predicted a high rate of successful treatment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative Analysis of Supplemental Medial Buttress Plate Fixation for High-Energy Displaced Femoral Neck Fractures in Young Adults.

OBJECTIVES: To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures. DESIGN: Multicenter retrospective matched cohort comparative clinical study. SETTING: Twenty-seven North American Level 1 trauma centers. PATIENTS: Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture. INTERVENTION: Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP. MAIN OUTCOME MEASUREMENTS: Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty. RESULTS: Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001). CONCLUSIONS: The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning . LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of Technical Errors on the Outcomes of Operatively Managed Femoral Neck Fractures in Adults Less than 50 Years of Age.

OBJECTIVE: To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults. DESIGN: Multicenter retrospective clinical study. SETTING: 26 North American Level 1 Trauma Centers. PATIENTS: Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017. INTERVENTION: Operative repair of femoral neck fracture. MAIN OUTCOME MEASUREMENTS: The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis. RESULTS: Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001). CONCLUSIONS: TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Trans-sacral screw fixation of posterior pelvic ring injuries: review and expert opinion.

Posterior pelvic ring injuries (i.e., sacro-iliac joint dislocations, fracture-dislocations, sacral fractures, pelvic non-unions/malunions) are challenging injury patterns which require a significant level of surgical training and technical expertise. The modality of surgical management depends on the specific injury patterns, including the specific bony fracture pattern, ilio-sacral joint involvement, and the soft tissue injury pattern. The workhorse for posterior pelvic ring stabilization has been cannulated iliosacral screws, however, trans-sacral screws may impart increased fixation strength. Depending on injury pattern and sacral anatomy, trans-sacral screws can potentially be more beneficial than iliosacral screws. In this article, the authors will briefly review pelvic mechanics and discuss their rationale for ilio-sacral and/or trans-sacral screw fixation.

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers.

OBJECTIVES: To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. DESIGN: Large multicenter retrospective cohort series. SETTING: Twenty-six North American Level 1 trauma centers. PATIENTS: Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. INTERVENTION: Operative repair of FNF. MAIN OUTCOME MEASUREMENTS: The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. RESULTS: Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure. CONCLUSIONS: FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quantitative Analysis of Growth Factors From Cancellous Bone Graft Collected With a Reamer-Irrigator-Aspirator System From Native Long Bones Versus Previously Reamed Long Bones.

OBJECTIVE: Collection of bone graft with the Reamer-Irrigator-Aspirator (RIA) system has become common practice across the field of orthopaedic surgery. While RIA bone graft is typically obtained from native long bones, grafting material can likewise be harvested from long bones that have previously undergone the placement and removal of an intramedullary nail, a process termed re-reamed RIA (RRR). The purpose of this study was to evaluate the total protein and growth factor concentrations present in native-RIA (NR) compared with RRR samples. METHODS: NR and RRR bone grafts were collected intraoperatively with the RIA system and processed to evaluate both the aqueous and the hard tissue components. Total protein concentration and specific growth factors were analyzed using standard bicinchoninic acid and multiplex assays, respectively. Analyte levels were then normalized to the total amount of protein detected. RESULTS: Total protein levels were comparable between NR and RRR samples for both the aqueous filtrate and the hard tissue samples. When normalized, while levels of bone morphogenic protein-2 and vascular endothelial growth factor were comparable in the hard tissue component, the aqueous filtrate from the RRR sample was found to have elevated levels of growth factors, with bone morphogenic protein-2 reaching statistical significance. CONCLUSIONS: This study demonstrates that ample protein is found within both NR and RRR samples, with comparable or elevated levels of osteogenic growth factors found within RRR samples. Future, larger, prospective studies will be required to evaluate the osteogenic potential and clinical efficacy of NR and RRR cancellous bone grafts to validate their equivalency.

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study.

OBJECTIVE: To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model. METHODS: A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch. RESULTS: In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches. CONCLUSION: The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.

Radiographic Evaluation of the Tibial Intramedullary Nail Entry Point.

INTRODUCTION: Tibia fractures are common injuries that can often be effectively treated with intramedullary nail (IMN) fixation. The ideal starting point for IMN reaming and nail placement is well described and regarded as a crucial aspect in the technique. The purpose of this study is to determine the accuracy and precision with which the starting point is established and if this is maintained after nail insertion during fracture fixation. METHODS: Fifty consecutive tibia fractures treated by IMN fixation sized 9 to 13 mm through an infrapatellar or medial parapatellar approach and 50 treated with a suprapatellar approach were evaluated. The starting point for reaming and IMN placement was measured using intraoperative fluoroscopy. Postoperative radiographs were used to determine the center of the IMN after placement. The distance between the measured points and the ideal starting point was measured. RESULTS: Deviation from the ideal entry point on intraoperative fluoroscopy averaged 4.6 ± 4.0 mm medially, 2.9 ± 3.7 mm anteriorly, and 2.7 ± 3.3 mm distally. In 30% of cases, the final IMN position varied from the entry point by greater than one SD in the coronal or sagittal plane. No difference between approaches was appreciated. DISCUSSION: Although the ideal starting point for tibial IMN fixation is known, this is frequently not the starting point accepted in practice. Final position of the IMN is independent of IMN size or approach and is not markedly different than the obtained starting point. LEVEL OF EVIDENCE: Therapeutic level III.

Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure.

OBJECTIVE: To characterize the presentation and outcomes of calcaneal avulsion fractures. DESIGN: Case series. SETTING: Two ACS Level I trauma centers. PATIENTS/PARTICIPANTS: Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period. MAIN OUTCOME MEASUREMENTS: We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation. RESULTS: Forty-one patients were treated operatively, and 6 were treated without surgery. Twenty-one patients (44.7%) had either soft-tissue compromise or an open fracture necessitating urgent treatment at the time of presentation. Of those patients treated operatively with 3-month follow-up (n = 39), 28.2% of patients (11/39) had evidence of implant failure or fracture displacement. Age was the only predictor of catastrophic fixation failure (P = 0.01). The use of washer(s), suture anchor(s), or addition of soft-tissue procedures (eg, Strayer) did not have a significant effect on failure rate. Neither the number of screws used nor size of screw impacted the failure rate. Fourteen patients (35.9%) underwent a secondary operation. DISCUSSION: Avulsion fractures of the calcaneus commonly present with soft-tissue compromise and have a significant rate of treatment failure and reoperation. This injury should be identified early and approached thoughtfully, acknowledging that risks are high. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement.

BACKGROUND: Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement. METHODS: This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs. RESULTS: Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks. CONCLUSIONS: A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Deformity and Malunion of the Anterior Pelvic Ring.

Pelvic fractures are common after high-energy trauma and are often associated with ligamentous injury. Treatment is guided by assessing stability of the pelvic ring, and unstable injuries frequently require surgery to achieve a desirable outcome. Assessment of pelvic ring stability is often possible with physical examination and standard imaging studies (plain radiographs and computed tomography); however, these "static" imaging modalities may not adequately identify dynamically unstable pelvic injuries that require surgery. Cadaveric and clinical data suggest that the injured pelvis may recoil significantly from the point of maximal displacement, and some unstable injuries may not be recognized until patients present with clinical symptoms. This article presents the case of a patient who sustained a minimally displaced pelvic ring injury that was stable on bedside examination and static imaging, but ultimately was unstable. She developed a substantial pelvic malunion with significant pain and activity limitations. The patient subsequently underwent successful pelvic ring reconstruction, and she remains asymptomatic at 2 years.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

OBJECTIVES: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. DESIGN: Retrospective cohort. SETTING: American College of Surgeons Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. MAIN OUTCOME MEASUREMENTS: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. RESULTS: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risks to the Superior Gluteal Neurovascular Bundle During Iliosacral and Transsacral Screw Fixation: A Computed Tomogram Arteriography Study.

OBJECTIVES: Iliosacral (IS) and transsacral (TS) screws are popular techniques to repair complicated injuries to the pelvis. The anatomy of the superior gluteal neurovasculature (SG NV bundle) is well described as running along the posterior ilium, providing innervation and perfusion to important abductor muscles. The method of pelvis fixation least likely to injure the SG NV bundle is unknown. METHODS: Twenty uninjured patients with a contrasted computed tomogram of the pelvis and lower extremities (CTA) were evaluated. Starting points for an S1 IS screw and S1 and S2 TS screws were estimated on the "ghost" lateral CTA image for those pelvi with safe corridors (>9 mm diameter). The distance from the projected screw to the SG artery was measured. A distance of <3.65 mm (half of a 7.3-mm screw's diameter) was considered likely for NV bundle injury. RESULTS: Of 40 pelvi CTAs (single sides), 10 pelvi (25%) were determined to be inappropriate for an S1 TS screw. The average distances from the screw starting point and the artery were 25.3 mm (±9.2) for S1 IS, 12.4 mm (±9.0) for S1 TS, and 23.5 mm (±10.7) for S2 TS screws, respectively. Ten S1 TS screws (25%) and no S1 IS or S2 TS screws were projected to have caused injury to the SG NV bundle (P < 0.001). CONCLUSIONS: Inserting S1 IS and S2 TS screws put the SG NV anatomy at significantly less risk than S1 TS screws. This information may aid in choosing the "best" fixation option for patients with pelvic ring trauma requiring surgery.

No Incidence of Postoperative Knee Sepsis With Suprapatellar Nailing of Open Tibia Fractures.

OBJECTIVE: To evaluate the incidence of knee sepsis after suprapatellar (SP) nailing of open tibia fractures. DESIGN: Retrospective; Setting: ACS level 1 trauma center. PATIENTS/PARTICIPANTS: We reviewed 139 open tibia fractures that underwent SP nailing as definitive treatment over a 5-year period (January 1, 2011 to January 1, 2016). Most patients (90%, n = 126) underwent intramedullary nailing at the time of their initial surgery. We defined knee sepsis as intra-articular infection requiring operative debridement, either open or arthroscopically, within 1 month's time. INTERVENTION: Open tibia fractures treated with an SP tibial nail. MAIN OUTCOME MEASUREMENTS: Demographic data, fracture characteristics, Gustilo and Anderson classification of open fractures, and occurrence of knee sepsis. RESULTS: In 139 open tibia fractures, there were no cases of knee sepsis in the 30 days after treatment with an SP intramedullary nail. Eighty-seven percent of our cohort had Gustilo and Anderson type II (41%) or type III (46%) open fractures. Most open fractures (83%) underwent primary wound closure during the index procedures. Twenty-five limbs (18%) had evidence of infection at the open fracture site of their open fracture necessitating operative intervention and/or antibiotics: none, however, developed knee sepsis. CONCLUSIONS: Although the SP approach carries intra-articular risks, we found a low risk of knee sepsis using this technique in the treatment of open tibia fractures. Our data suggest that there is no greater risk of intra-articular infection using an SP portal as compared with an infrapatellar one. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Posterior to Anteriorly Directed Screws for Management of Talar Neck Fractures.

BACKGROUND: Screws placed from posterior to anterior have been shown to be biomechanically and anatomically superior in the fixation of talar neck and neck-body fractures, yet most surgeons continue to place screws from an anterior start point. The safety and efficacy of percutaneously applied posterior screws has not been clinically defined, and functional outcomes after their use is lacking. METHODS: After institutional review board approval, we performed a retrospective review of 24 consecutive talar neck fractures treated by a single surgeon that utilized posterior-to-anterior screw fixation. Clinical, radiographic, and functional outcomes were assessed at a minimum follow-up of 12 months. Functional outcomes including the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, Olerud-Molander Scores, and the Short Form 36 (SF-36) measurement were collected and reviewed. Average patient follow-up was 44 months. RESULTS: According to the classification system of Canale and Kelly, there were 4 type I fractures, 15 type II fractures, 4 type III fractures, and 1 type IV fracture. Four patients had open fractures. One superficial wound infection occurred, 1 patient reported FHL stiffness, and 6 complained of numbness or paresthesias in the distribution of the sural nerve (5 transient, 1 permanent). One reoperation was required to exchange a screw impinging on the talonavicular joint. Radiographically, 44% developed a positive Hawkins sign, and the specificity of this finding was 100% for talar dome viability. Avascular necrosis developed in 43% of patients, with 33% revascularizing and none going on to collapse. Subtalar arthrosis developed in 62% of patients. CONCLUSION: Screws placed from posterior to anterior are a useful technique in the treatment of talar neck fractures. Functional outcomes following their use appear favorable compared with recent reports with minimal risk to local structures. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Adverse cardiac events in 56,000 orthopaedic trauma patients: Does anatomic area make a difference?

PURPOSE: Postoperative cardiac events in orthopaedic trauma patients constitute severe morbidity and mortality. It is therefore increasingly important to determine patient risk factors that are predictive of postoperative myocardial infarctions and cardiac arrests. This study sought to assess if there is an association between anatomic area and cardiac complications in the orthopaedic trauma patient. PATIENTS AND METHODS: From 2006-2013, a total of 361,402 orthopaedic patients were identified in the NSQIP database using Current Procedural Terminology (CPT) codes. Of these, 56,336 (15.6%) patients were identified as orthopaedic trauma patients broken down by anatomic region: 11,905 (21.1%) upper extremity patients (UE), 29,009 (51.5%) hip/pelvis patients (HP), and 15,422 (27.4%) lower extremity patients (LE) using CPT codes. Patients were defined as having adverse cardiac events if they developed myocardial infarctions or cardiac arrests within 30days after surgery. Chi-squared analysis was used to determine if there was an association between anatomic area and rates of cardiac events. Multivariate logistical analysis was used with over 40 patient characteristics including age, gender, history of cardiac disease, and anatomic region as independent predictors to determine whether anatomic area significantly predicted the development of cardiac complications. RESULTS: There were significant differences in baseline demographics among the three groups: HP patients had the greatest average age (77.6 years) compared to 54.8 years for UE patients and 54.1 years in LE patients (p<0.001). HP patients also had the highest average ASA score (3.0) (p<0.001). There was a significant difference in adverse cardiac events based on anatomic area: 0.27% (32/11,905) UE patients developed cardiac complications compared to 2.15% (623/29,009) HP patients and 0.61% (94/15,422) LE patients. After multivariate analysis, HP patients were significantly more likely to develop cardiac complications compared to both UE patients (OR: 6.377, p=0.014) and LE patients (OR: 2.766, p=0.009). CONCLUSION: There is a significant difference in adverse cardiac events following orthopaedic trauma based on anatomic region. Hip/Pelvis surgery appeared to be a significant risk factor in developing an adverse cardiac event. Further studies should investigate why hip/pelvic patients are at a higher risk of adverse cardiac events.

Unstable Proximal Femur Fractures Treated With Proximal Femoral Locking Plates: A Retrospective, Multicenter Study of 111 Cases.

OBJECTIVES: A few small case series have found that proximal femur fractures treated with a proximal femur locking plate (PFLP) have experienced more failures than expected. The purpose of this study was to review the clinical results of patients with acute, unstable proximal femur fractures treated with proximal femoral locking plates in a large, multicenter patient cohort. DESIGN: This is a retrospective clinical study. SETTING: The study included patients from 12 regional trauma centers and tertiary referral hospitals. PATIENTS: One hundred eleven consecutive patients with unstable proximal femur fractures stabilized with a PFLP and having required clinical and radiographic follow-up at a minimum of 12 months after injury. INTERVENTION: Surgical repair of an unstable proximal femur fracture with a PFLP. MAIN OUTCOME MEASUREMENTS: Treatment failures (failure of fixation, nonunion, and malunion) and need for revision surgery. RESULTS: Forty-six patients (41.4%) experienced a major treatment failure, including failed fixation with or without nonunion (39), surgical malalignment or malunion (18), deep infection (8), or a combination of these. Thirty-eight (34%) patients underwent secondary surgeries, including 30 for failed fixation, nonunion, or both. Treatment failure was found to occur at a significantly higher rate in patients with major comorbidities, in femurs repaired in varus malalignment, and using specific plate designs. CONCLUSIONS: Proximal femoral locking plates are associated with a high complication rate, frequently requiring revision or secondary surgeries in the treatment of unstable proximal femur fractures. Given the high complication rate with PFLPs, careful attention to reduction, use of a PFLP implant, and consideration should be given to alternative implants or fixation techniques when appropriate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.