The "Well-Cap" Technique: Screw Insertion for Pelvic Nutrient Foramen Hemostasis.

Several approaches to the pelvis and acetabulum involve subperiosteal dissection of the iliacus from the internal iliac fossa.Typically bleeding is encountered from the nutrient foramen located near the sacroiliac joint. Bone wax and electrocautery have traditionally been used to achieve hemostasis from this foramen but produce inconsistent results.The authors of this technical tip describe a novel technique of inserting a cortical screw directly into the foramen tocontrol osseous hemorrhage.This technique has been consistently effective at achieving hemostasis in cases of refractory bleeding and has produced no complications. (Journal of Surgical Orthopaedic Advances 27(3):246-250, 2018).

Treatment of Calcaneal Fracture With Severe Soft Tissue Injury and Osteomyelitis: A Case Report.

Advancements in surgical technique have resulted in the ability to reconstruct lower extremity injuries that would have previously been treated by amputation. Currently, a paucity of data is available specifically addressing limb amputation versus reconstruction for calcaneal fractures with severe soft tissue compromise. Reconstruction leaves the patient with their native limb; however, multiple surgeries, infections, chronic pain, and a poor functional outcome are very real possibilities. We present the case of a complex calcaneal fracture complicated by soft tissue injury and osteomyelitis that highlights the importance of shared decision-making between patient and surgeon when considering reconstruction versus amputation. This case exemplifies the need for open communication concerning the risks and benefits of treatment modalities while simultaneously considering the patient's expectations and desired outcomes.

Is preoperative radiation therapy as effective as postoperative radiation therapy for heterotopic ossification prevention in acetabular fractures?

BACKGROUND: Prophylactic approaches to prevent heterotopic ossification after acetabular fracture surgery have included indomethacin and/or single-dose external beam radiation therapy administered after surgery. Although preoperative radiation has been used for heterotopic ossification prophylaxis in the THA population, to our knowledge, no studies have compared preoperative and postoperative radiation therapy in the acetabular fracture population. QUESTIONS/PURPOSES: We determined whether heterotopic ossification frequency and severity were different between patients with acetabular fracture treated with prophylactic radiation therapy preoperatively and postoperatively. METHODS: Between January 2002 and December 2009, we treated 320 patients with a Kocher-Langenbeck approach for acetabular fractures, of whom 50 (34%) were treated with radiation therapy preoperatively and 96 (66%) postoperatively. Thirty-four (68%) and 71 (74%), respectively, had 6-month radiographs available for review and were included. For hospital logistical reasons, patients who underwent operative treatment on a Friday or Saturday received radiation therapy preoperatively, and all others received it postoperatively. The treatment groups were comparable in terms of most demographic parameters, injury severity, and fracture patterns. Six-month postoperative radiographs were reviewed and graded according to Brooker. Followup ranged from 6 to 93 months and 6 to 97 months for the preoperative and postoperative groups, respectively. Post hoc power analysis showed our study was powered to detect a difference of 22% or more between patients with severe heterotopic ossification. Sample size calculations showed 915 subjects would be needed to detect a 5% relative difference in severe heterotopic ossification status between groups. RESULTS: We detected no difference in heterotopic ossification frequency between the preoperative (eight of 36, 22%) and postoperative (19 of 71, 27%) groups (p=0.609). There was also no difference in heterotopic ossification severity between groups (p=0.666). Two of 36 (6%) in the preoperative group and three of 71 (4%) in the postoperative group developed clinically significant Grade III heterotopic ossification. No patients developed Grade IV heterotopic ossification. CONCLUSIONS: We found no difference in heterotopic ossification frequency or severity when comparing preoperative and postoperative radiation therapy. However, given the relatively low frequency of heterotopic ossification in this population, in particular the frequency of severe or symptomatic heterotopic ossification, the possibility of a Type II error must be considered. Larger, prospective studies are required to confirm our no-difference finding, but insofar as the result in this fracture population mirrors that of the THA population, unless our finding is disproven, we believe radiation therapy can be given either before or after surgery, as dictated by the clinical scenario. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

OBJECTIVE: The objective of this study was to determine whether time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. DESIGN: Retrospective review. SETTING: Three level 1 trauma centers at 2 academic institutions. PATIENT SELECTION CRITERIA: Adult (18 years or older) patients with no pre-existing coagulopathy treated for an acetabular fracture via an AIP approach. Excluded were those with other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). OUTCOME MEASURES AND COMPARISONS: Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL) by Gross and Hgb balance methods, and packed red blood cell (PRBC) transfusion requirement. Outcomes were evaluated based on time to surgery. RESULTS: 195 patients were studied. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross method, P = 0.003; -0.440 g of Hgb per hour by Hgb balance method, P = 0.003) and 3 days (-1.69 mL per hour by Gross method, P = 0.013; -0.497 g of Hgb per hour by Hgb balance method, P = 0.010) postoperative, but not EBL or PRBC transfusion. Using 48 hours from admission to surgery to define early versus delayed surgery, CBL was significantly greater in the early group compared to the delayed group (453 [IQR 277-733] mL early versus 364 [IQR 160-661] delayed by Gross method, P = 0.017; 165 [IQR 99-249] g of Hgb early versus 143 [IQR 55-238] g Hgb delayed by Hgb balance method, P = 0.035), but not EBL or PRBC transfusion. In addition, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative ( P > 0.05). CONCLUSION: There was higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic Acid and Holding Venous Thromboembolism Prophylaxis Morning of Surgery Do Not Decrease Transfusion Requirements in Patients Undergoing Anterior Intrapelvic Approach for Acetabular Open Reduction and Internal Fixation.

INTRODUCTION: The objective of this study was to determine factors that may affect transfusion rates for patients requiring an anterior intrapelvic (AIP) approach for an acetabulum fracture. METHODS: This was a multicenter retrospective comparison study (3 trauma centers at two urban academic centers). Patients who had an AIP approach for an acetabulum fracture without other notable same-day procedures (irrigation and débridement and/or external fixation were only other allowed procedures) were included. One hundred ninety-five adult (18 and older) patients had adequate records to complete analysis with no preexisting coagulopathy. The main outcome evaluated was the number of units transfused at the time of surgery and up to 7 days after surgery. RESULTS: Factors that were found to affect intraoperative transfusion rates were older age, lower preoperative hematocrit, longer surgery duration, and requiring increased intraoperative intravenous fluids. Factors that did not affect transfusion rate included sex, body mass index, hip dislocation at the time of injury, fracture pattern, AIP approach alone or with lateral window ± distal extension, Injury Severity Score, preoperative platelet count, use of tranexamic acid, and venous thromboembolism prophylaxis received morning of surgery. When followed out through the remainder of a week after surgery, the results for any factor did not change. DISCUSSION: In this large multicenter retrospective study of patients requiring an AIP approach, tranexamic acid and use of venous thromboembolism prophylaxis (or holding it the morning of surgery) did not affect transfusion rates either during surgery or up to a week after surgery. Older age, lower preoperative hematocrit level, longer surgery time, and increased intraoperative intravenous fluids were associated with higher transfusion rates. DATA AVAILABILITY AND TRIAL REGISTRATION NUMBERS: Data are available on request. LEVEL OF EVIDENCE: Level 3, retrospective case-control study.

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.

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.

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.

Risk of Postoperative Sciatic Nerve Palsy After Posterior Acetabular Fracture Fixation: Does Patient Position Matter?

OBJECTIVES: To determine whether the prone or lateral position is associated with postoperative sciatic nerve palsy in posterior acetabular fracture fixation. DESIGN: Retrospective cohort study. SETTING: Three Level I trauma centers. PATIENTS: Patients with acetabular fractures treated with a posterior approach (n = 1045). INTERVENTION: Posterior acetabular fixation in the prone or lateral positions. OUTCOME MEASUREMENTS: The primary outcome was the prevalence of postoperative sciatic nerve palsy by position. Secondary outcomes were risk factors for nerve palsy, using multiple regression analysis and propensity scoring. RESULTS: The rate of postoperative sciatic nerve palsy was 9.5% (43/455) in the prone position and 1.5% (9/590) in the lateral position ( P < 0.001). Intraoperative blood loss and surgical duration were significantly higher for patients who developed a postoperative sciatic nerve palsy. Subgroup analysis showed that position did not influence palsy prevalence in posterior wall fractures. For other fracture patterns, propensity score analysis demonstrated a significantly increased odds ratio of palsy in the prone position [aOR 7.14 (2.22-23.00); P = 0.001]. CONCLUSIONS: With the exception of posterior wall fracture patterns, the results of this study suggest that factors associated with increased risk for postoperative sciatic nerve palsy after a posterior approach are fractures treated in the prone position, increased blood loss, and prolonged operative duration. These risks should be considered alongside the other goals (eg, reduction quality) of acetabular fracture surgery when choosing surgical positioning. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Analysis of 101 Mechanical Failures in Distal Femur Fractures Treated with 3 Generations of Precontoured Locking Plates.

OBJECTIVES: To evaluate mechanical treatment failure in a large patient cohort sustaining a distal femur fracture treated with a distal femoral locking plate (DFLP). DESIGN: This retrospective case-control series evaluated mechanical treatment failures of DFLPs. SETTING: The study was conducted at 8 Level I trauma centers from 2010 to 2017. PATIENTS AND PARTICIPANTS: One hundred one patients sustaining OTA/AO 33-A and C distal femur fractures were treated with DFLPs that experienced mechanical failure. INTERVENTION: The intervention included the treatment of a distal femur fracture with a DFLP, affected by mechanical failure (implant failure by loosening or breakage). MAIN OUTCOME MEASURE: The main outcome measures included injury and DFLP details; modes and timing of failure were studied. RESULTS: One hundred forty-six nonunions were found overall (13.4%) including 101 mechanical failures (9.3%). Failures occurred in different manners, locations, and times depending on the DFLPs. For example, 33 of 101 stainless steel (SS) plates (33%) failed by bending or breaking in the working length, whereas no Ti plates failed here ( P < 0.05). Eleven of 12 failures with titanium-Less Invasive Stabilization System (92%) occurred by lost shaft fixation, mostly by the loosening of unicortical screws (91%). Sixteen of 44 variable -angled-LCP failures (36%) occurred at the distal plate-screw junction, whereas only 5 of 61 other DFLPs (8%) failed this way ( P < 0.05). Distal failures occurred on average at 23.7 weeks compared with others that occurred at 38.4 weeks ( P < 0.05). Variable -angled-LCP distal screw-plate junction failures occurred earlier (mean 21.4 weeks). CONCLUSION: Nonunion and mechanical failure occurred in 14% and 9% of patients, respectively, in this large series of distal femur fracture treated with a DFLP. The mode, location, presence of a prosthesis, and timing of failure varied depending on the characteristics of DFLP. This information should be used to optimize implant usage and design to prolong the period of stable fixation before potential implant failures occur in patients with a prolonged time to union. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of extra-articular fractures of the distal tibia: intramedullary nailing versus plate fixation.

Intramedullary nailing and plate fixation represent two viable approaches to internal fixation of extra-articular fractures of the distal tibia. Although both techniques have demonstrated success in maintaining reduction and promoting stable union, they possess distinct advantages and disadvantages that require careful consideration during surgical planning. Differences in soft-tissue health and construct stability must be considered when choosing between intramedullary nailing and plating of the distal tibia. Recent advances in intramedullary nail design and plate-and-screw fixation systems have further increased the options for management of these fractures. Current evidence supports careful consideration of the risk of soft-tissue complications, residual knee pain, and fracture malalignment in the context of patient and injury characteristics in the selection of the optimal method of fixation.

Radiographic changes of implant failure after plating for pubic symphysis diastasis: an underappreciated reality?

BACKGROUND: Implant failure after symphyseal disruption and plating reportedly occurs in 0% to 21% of patients but the actual occurrence may be much more frequent and the characteristics of this failure have not been well described. QUESTIONS/PURPOSES: We therefore determined the incidence and characterized radiographic implant failures in patients undergoing symphyseal plating after disruption of the pubic symphysis. METHODS: We retrospectively reviewed 165 adult patients with Orthopaedic Trauma Association (OTA) 61-B (Tile B) or OTA 61-C (Tile C) pelvic injuries treated with symphyseal plating at two regional Level I and one Level II trauma centers. Immediate postoperative and latest followup anteroposterior radiographs were reviewed for implant loosening or breakage and for recurrent diastasis of the pubic symphysis. The minimum followup was 6 months (average, 12.2 months; range, 6-65 months). RESULTS: Failure of fixation, including screw loosening or breakage of the symphyseal fixation, occurred in 95 of the 127 patients (75%), which resulted in widening of the pubic symphyseal space in 84 of those cases (88%) when compared with the immediate postoperative radiograph. The mean width of the pubic space measured 4.9 mm (range, 2-10 mm) on immediate postoperative radiographs; however, on the last radiographs, the mean was 8.4 mm (range, 3-21 mm), representing a 71% increase. In seven patients (6%), the symphysis widened 10 mm or more; however, only one of these patients required revision surgery. CONCLUSIONS: Failure of fixation with recurrent widening of the pubic space can be expected after plating of the pubic symphysis for traumatic diastasis. Although widening may represent a benign condition as motion is restored to the pubic symphysis, patients should be counseled regarding a high risk of radiographic failure but a small likelihood of revision surgery. LEVEL OF EVIDENCE: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Patient-Reported Outcomes for Fractures of the Acetabulum: A Comparison Between Patient-Reported Outcomes Information System and Traditional Instruments.

INTRODUCTION: The objective of this study was to compare instruments from the Patient-Reported Outcomes Information System (PROMIS) with previously validated acetabulum fracture outcome instruments. METHODS: This study included adult patients presenting for routine follow-up at least 3 months after surgical treatment of an acetabulum fracture. Participants completed four different patient-reported outcomes in a randomized order: PROMIS Mobility, PROMIS Physical Function, Short Form 36 (SF-36), and Short Musculoskeletal Functional Assessment (SMFA). Primary outcomes were the correlations between instruments, floor/ceiling effects, and survey completion time. The effects of age, education, and race on survey completion time were also evaluated. RESULTS: Overall strong correlations were observed between PROMIS instruments and the SMFA/SF-36 (r = 0.73 to 0.86, P < 0.05) with weaker, more moderate correlations in those with >18 months of follow-up (r = 0.41 to 0.76, P < 0.05). No instruments demonstrated notable floor or ceiling effects. The PROMIS outcomes required less time to complete (PROMIS [56 to 59 seconds] than SF-36 [5 minutes 22 seconds] and SMFA [6 minutes 35 seconds]; P < 0.001). Older individuals required more time to complete the PROMIS PF (0.5 s/yr, P = 0.03), SF-36 (2.35 s/yr, P = 0.01), and SMFA (3.85 s/yr, P < 0.01). Level of education did not affect completion time; however, African Americans took significantly longer than Caucasians to complete the SMFA and SF-36 by 151 and 164 seconds (P < 0.01). CONCLUSION: This study supports that the PROMIS Mobility and Physical Function surveys are much more efficient instruments for evaluating patients with acetabulum fractures when compared with the SMFA and SF-36. Convergent validity of the PROMIS instruments was overall strong but weaker and more moderate in those with a long-term follow-up, and additional study is suggested for longer-term outcomes. Level of education did not influence survey completion time; however, it took markedly longer time for older individuals and African Americans to complete the SMFA and SF-36.

Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures.

OBJECTIVE: To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS: Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. INTERVENTION: The study intervention included retrospective review of patients' charts and radiographs. MAIN OUTCOME MEASUREMENT: Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. RESULTS: Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. CONCLUSIONS: Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smart fracture plate for quantifying fracture healing: Preliminary efficacy in a biomechanical model.

The diagnosis of fracture nonunion following plate osteosynthesis is subjective and frequently ambiguous. Initially following osteosynthesis, loads applied to the bone are primarily transmitted through the plate. However, as callus stiffness increases, the callus is able to bear load proportional to its stiffness while forces through the plate decrease. The purpose of this study was to use a "smart" fracture plate to distinguish between phases of fracture healing by measuring forces transmitted through the plate. A wireless force sensor and small adapter were placed on the outside of a distal femoral locking plate. The adapter converts the slight bending of the plate under axial load into a transverse force which is measurable by the sensor. An osteotomy was created and then plated in the distal femur of biomechanical Sawbones. Specimens were loaded to simulate single-leg stance first with the osteotomy defect empty (acute healing), then sequentially filled with silicone (early callus) and then polymethyl methacrylate (hard callus). There was a strong correlation between applied axial load and force measured by the "smart" plate. Data demonstrate statistically significant differences between each phase of healing with as little as 150 N of axial load applied to the femur. Forces measured in the plate were significantly different between acute (100%), early callus (66.4%), and hard callus (29.5%). This study demonstrates the potential of a "smart" fracture plate to distinguish between phases of healing. These objective data may enable early diagnosis of nonunion and enhance outcomes for patients.

Pediatric and Adolescent Fractures of the Acetabulum Treated With ORIF: What Are Their Functional Outcomes?

OBJECTIVES: To evaluate the functional outcomes of pediatric and adolescent patients (<18 year old) who sustained acetabulum fractures that were treated with open reduction internal fixation (ORIF). DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Thirty-four pediatric and adolescent patients underwent acetabulum fracture ORIF between 2001 and 2018. Of the operatively treated patients, 21 patients had sufficient follow-up (>6 months), one died after fixation secondary to other traumatic injuries, and 12 patients were lost to follow-up. INTERVENTION: Acetabulum fracture ORIF. MAIN OUTCOME MEASUREMENT: The SF-36 Health Survey and Short Musculoskeletal Functional Assessment (SMFA) were compared with population norms. The modified Merle d'Aubigné clinical hip score, Matta radiologic outcome, and postoperative complications were also documented. RESULTS: Functional outcome data were available at a mean of 5 years 2 months. Mean SF-36 scores were 44.8 and 50.1 for the physical component score and mental component scores, respectively, which did not differ significantly from US population norms (physical component score mean: 50, P = 0.061 and mental component score mean: 50, P = 0.973). Furthermore, the mean SMFA Bother Index score was 18.6, which is not significantly different from the population norm mean of 13.8 (P = 0.268). However, the function index mean was 31.9, which was significantly worse than the population norm mean of 12.7 (P = 0.001). Two patients with a delayed reduction (>6 hours) of an acetabulum fracture dislocation had poor outcomes related to the development of avascular necrosis and post-traumatic osteoarthritis. CONCLUSION: In this small cohort, 86% (18/21) of these patients had a favorable functional outcome with the exception of the SMFA Functional Index that was significantly less than population norms. Although long-term follow-up is needed, we advocate for operative management of pediatric and adolescent acetabulum fractures when adult displacement and instability criteria are present. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reamer Irrigator Aspirator Versus Iliac Crest Bone Grafting and Proximal Tibial Curettage: Is There a Difference in Blood Loss and Transfusion Rates?

OBJECTIVES: To compare blood loss and transfusion rates among reamer irrigator aspirator (RIA), iliac crest bone graft (ICBG), and proximal tibial curettage (PTC) for autograft harvest. DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: The study included 139 adult patients treated between 2011 and 2018. INTERVENTIONS: Nonunion repair of the femur or tibia using either RIA (n = 64), ICBG (n = 59), or PTC (n = 16) for autograft. MAIN OUTCOME MEASUREMENTS: Estimated blood loss and transfusion rates. RESULTS: Patient demographics, surgical indications, and medical comorbidities that affect bleeding did not differ among the groups. Estimated blood loss (mL) was significantly higher in the RIA group [RIA: 388 ± 368 (50-2000), ICBG: 286 ± 344 (10-2000), PTC: 196 mL ± 219 (10-700), P < 0.01]. The transfusion rate was also significantly higher in the RIA group (RIA 14%, ICBG 0%, PTC 0%, P < 0.01). The amount of graft obtained was higher in the RIA group (RIA = 48.3 mL, ICBG = 31.0 mL, PTC = 18.8 mL, P < 0.01), and the operative time (hours) was longer in the RIA group (RIA = 2.8, ICBG = 2.6, PTC = 1.9, P = 0.04). CONCLUSION: Estimated blood loss and transfusion rates were significantly higher in patients undergoing RIA compared with those in patients undergoing ICBG and PTC; however, the incidence of transfusion after RIA (14%) was considerably lower than previous reports. These findings suggest that the risk of transfusion after RIA is present and clinically significant but lower than previously believed, and it is likely affected by the amount of graft obtained and complexity of the nonunion repair. The risk of transfusion should be discussed with patients and the choice of RIA carefully evaluated in patients who have anemia or risk factors of bleeding. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Low interobserver and intraobserver reliability using the Matta radiographic system for intraoperative assessment of reduction following acetabular ORIF.

INTRODUCTION: The system described by Matta for rating acetabular fracture quality of reduction following ORIF has been used extensively throughout the literature. However, the reliability of this system remains to be validated. We sought to determine the interobserver and intraobserver reliability of this system when used by fellowship-trained pelvic and acetabular surgeons to evaluate intraoperative fluoroscopy. METHODS: This is a retrospective evaluation of a prospectively collected acetabular fracture database at an academic level I trauma center. The quality of reduction of all acetabular fractures treated with open reduction internal fixation (ORIF) between May 2013 and December 2015 was assessed using three standard intraoperative fluoroscopic views (anteroposterior and two 45˚ oblique Judets). Displacement of ≤1 mm was considered to be an anatomic reduction, 2-3 mm imperfect, and >3 mm poor according to the system described by Matta. A total of 107 acetabular fractures treated with ORIF with complete intraoperative fluoroscopic images during that time period were available for review. Acetabular fracture reductions were reviewed by the operative surgeon at the time of surgery and subsequently reviewed by two fellowship-trained pelvic and acetabular surgeons. All reduction assessments were performed in a blinded fashion. The primary outcome measure was interobserver reliability for assessing reduction quality. This was evaluated using a weighted kappa (κw) statistic between each evaluator and the operative surgeon and a generalized kappa (κg) for all 3 surgeons. After a 6-week "washout interval," the surgeons reviewed the images again and intraobserver agreement was calculated using a weighted kappa statistic. RESULTS: Interobserver reliability based on the initial assessment was low (κg = 0.09); however, did slightly improve with the second assessment to fair (κg = 0.24). Intraobserver reliability ranged from slight (κw = 0.20) to moderate (κw = 0.53) among the surgeons. DISCUSSION: Low interobserver and intraobserver reliability was found when quality of reduction was assessed with intraoperative fluoroscopic images by the operative and two other pelvic and acetabular surgeons using the Matta system. Given the importance of an anatomic reduction on functional and radiographic outcomes, an accurate and reliable system for assessing intraoperative quality of reduction is essential.

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.