Primary Closure of External Fixator Pin Sites Is Safe After Orthopaedic Trauma Surgery.

OBJECTIVES: To determine if rates of pin site infection and surgical site infection among patients managed with primary closure after external fixator removal were similar to those allowed to heal secondarily. DESIGN: Retrospective cohort. SETTING: Urban/Suburban Academic Level I Trauma Center. PATIENT SELECTION CRITERIA: Patients who had received a lower extremity external fixator for provisional management before definitive fixation of lower extremity fractures were included with pin site wounds closed primarily or allowed to heal by secondary intention. OUTCOME MEASURES AND COMPARISONS: The rate of pin tract infection and surgical site infection following primary closure of external fixator pin sites relative to patients whose pin sites were allowed to heal through secondary intention. RESULTS: In total, 256 patients were evaluated: 143 patients (406 pin sites) in the primary closure group and 113 patients (340 in sites) in the secondary closure group. The average age was 49 ± 16 years. Sixty-five percent of included patients were male. There was no difference in pin tract infections between cohorts (primary = 0.5%, secondary = 1.5%, P = 0.26). External fixator duration in the primary closure group was 11.5 ± 8.4 days and 13.0 ± 8.1 days in the secondary closure group (P = 0.15). There was a greater rate of surgical site infections in the secondary intention cohort (15.9% vs. 7.7%, P = 0.047). CONCLUSIONS: There was no difference in pin site infection rate after primary pin site closure relative to patients who were allowed to heal through secondary intention. Furthermore, there was a lower rate of surgical site infection after primary closure. These results challenge the dogma of secondary closure for ex fix pin sites, suggesting that debridement and primary closure is a safe option for management of external fixator pin sites and may impart benefit in decreasing infection risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Locked plates reduce displacement of vertically unstable pelvic fractures in a Mechanical Testing Model.

BACKGROUND: The purpose of this study is to compare a locked screw construct to a single iliosacral screw for fixation of a vertically unstable pelvic ring injury in a transforaminal sacral fracture model. METHODS: Orthopaedic Trauma Association type 61-C1.3a2c5 fractures were created in 10 fresh frozen cadaveric pelvis specimens. Specimens were divided into two groups of five. In both groups, the anterior ring was stabilized with a six-hole 3.5-mm reconstruction plate. In the locked plate (LP) group, the posterior injury was stabilized using a two-hole locking plate with one solid 5.0-mm locking iliosacral screw directed onto the S1 body and a second locking screw directed into the lateral sacral ala. In the iliosacral screw group, the posterior injury was stabilized using a single cannulated 7.3-mm screw. Testing was conducted on a Materials Testing System. Values for displacement and rotation were recorded. Each pelvis was axially loaded with a compressive sine wave from 175 N to 350 N for 10,000 cycles to simulate limited weight bearing, with data recorded at 1,000 cycle increments. RESULTS: Two specimens in the iliosacral screw group displaced more than 1 cm during the first 1,000 cycles. These two specimens displayed gross fracture motion in all planes. All five specimens in the LP group completed 10,000 cycles of testing with less than 1 cm of displacement. A vector displacement calculation from the plane displacement data revealed that the LP group had significantly less displacement (median 1.9 mm) than the specimens in the iliosacral group (median 6.7 mm; p = 0.008) after 10,000 cycles. CONCLUSIONS: A two-hole plate locked head screw construct resulted in less displacement than a single iliosacral screw in a transforaminal sacral fracture model.

Surgical management of U/H type sacral fractures: outcomes following iliosacral and lumbopelvic fixation.

BACKGROUND: U and H-type sacral fractures are under diagnosed injuries resulting from significant axial loading that are often associated with neurological deficits. No studies to date have compared two common methods of surgical fixation, iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF). METHODS: Patients with sacral fractures from 2009-2015 at one level 1 trauma center were identified by current procedural terminology (CPT) code and imaging reviewed for U/H type sacral fractures. RESULTS: Four hundred and fifty-three sacral fractures were identified during the study period, of which sixteen patients met inclusion criteria for the study. Six patients had the presence of a documented neurological injury at the time of presentation, 9 patients had concurrent spine fractures and 10 patients had concurrent pelvic fractures. Eight patients underwent ISF and 8 patients underwent LPF. There was no significant difference between the two groups in regards to age, intensive care unit (ICU) requirement, length of stay, or estimated blood loss. There was a significant increase in surgical time in the LPF group (P=0.002). In addition, there was a significant difference between those patients that underwent ISF that were discharged to a rehab facility compared to those treated with LPF (P=0.04). CONCLUSIONS: Patients with U/H type sacral fractures can be treated with ISF or LPF without an expected increase in hospital length of stay (LOS) or need for ICU. Treatment with LPF may increase operative time however; the patient is more likely to be discharged to home instead of a rehab facility.

Radiographic Review of Helical Blade Versus Lag Screw Fixation for Cephalomedullary Nailing of Low-Energy Peritrochanteric Femur Fractures: There is a Difference in Cutout.

OBJECTIVES: To compare the rate of cutout of helical blades and lag screws in low-energy peritrochanteric femur fractures treated with a cephalomedullary nail (CMN). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: Overall, this study included 362 patients with an average age of 83 year old, a majority of whom were women, and had sustained a low-energy peritrochanteric femur fracture treated with a CMN. All patients had at least 3 months of clinical and radiographic follow, with an average follow-up of 11 months and a range of 3-88 months follow-up. INTERVENTION: Cephalomedullary nailing with the use of a helical blade or single lag screw for proximal fixation. MAIN OUTCOME MEASUREMENTS: Cutout of the helical blade or lag screw. RESULTS: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients with helical blades and 8 (3.0%) of 269 patients with lag screws. Cutout with the helical blade was significantly more frequent than with the lag screw (P = 0.0001). The average tip-apex distance (TAD) was significantly greater for those patients who experienced cutout both for the helical blades (23.5 vs. 19.7 mm; P = 0.0194) and lag screws (24.5 vs. 20.0 mm; P = 0.0197). An absolute TAD predictive of cutout could not be determined. CONCLUSIONS: When the helical blade was used, implant cutout occurred at a significantly higher rate compared with lag screw fixation. There was not a threshold TAD that was predictive of cutout for either implant. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Interobserver reliability of a CT-based fracture classification system.

OBJECTIVES: This study was designed to determine whether the interobserver reliability of a fracture classification scheme applied based on a single, carefully defined, computed tomography (CT) cut is greater than those previously reported for systems designed for use with plain radiographs. DESIGN: Observer review of selected cases. SETTING: Four, level one, trauma centers. PATIENTS: Pretreatment CT scans of patients with calcaneus fractures were screened by the authors. Thirty cases were selected that had an appropriate semicoronal CT image. Ten orthopaedic traumatologists who were members of the Orthopaedic Trauma Association and had a minimum of 5 years postresidency experience were selected as reviewers. INTERVENTION: The reviewers were provided with a digital CT image for each case as well as written and diagrammatic representations of the Sanders classification system. The observers then classified each fracture according to the Sanders classification. RESULTS: : The mean kappa value for interobserver reliability for fracture types I-IV was 0.41 +/- 0.02 (mean +/- standard error of the mean; range, 0.07-0.64). Observers disagreed by more than 1 fracture type (ie, I vs. III or II vs. IV) in 10% of the cases. Observers agreed on the location of the fracture lines (A, B, C) in 90% of type II fractures and 52% of type III fractures. CONCLUSIONS: The results indicate that in a carefully controlled paradigm, the interobserver reliability with a classification system based on interpretation of a single, carefully defined CT image was no better than the results reported for the same classification system used with full CT data or for other classification systems used for various fractures in the skeleton. Agreement in identifying the location of the fracture lines was very good for simple fractures but much worse for complex injuries. Additional study may determine whether the use of a full complement of CT images can improve reliability in classification of complex injuries.

Fragility fractures requiring special consideration: pelvic insufficiency fractures.

Fractures of the pelvis and acetabulum in osteoporotic bone represent an important subset of fragility fractures. Pelvic fractures in the elderly patient carry a significant 1-year mortality risk, comparable to that of hip fractures. Patients often lose their ability to function independently in the community. In this group, treatment of their bone density is essential to reducing their risk of further fractures. A thorough discussion of the likely course of recovery, the prolonged need for pain medications, and the risks and benefits of intervention can help patients and their families cope with the disability.

Murine model of oligotrophic tibial nonunion.

OBJECTIVES: This study aimed to use modified distraction osteogenesis techniques to develop a reliable mouse fracture nonunion model with an oligotrophic phenotype. METHODS: Twenty-six 10- to 14-week-old C57BL/6 male mice underwent a proximal diaphyseal tibial osteotomy with a 2-mm bone resection. An external fixation device was applied to the tibia using cerclage wires. A total of 2.25 mm of distraction was applied over 3 days, resulting in an average distraction gap of 4.28 mm. Plain radiographs were taken at regular intervals until euthanasia at 7 (n = 9), 10 (n = 13), or 12 (n = 4) weeks. After euthanasia, all samples were fixed in formalin, scanned with microcomputed tomography, decalcified in formic acid, prepared in paraffin, and stained with Alcian blue/Mayer's hematoxylin. RESULTS: In the distraction groups, five mice were prematurely euthanized as a result of wound complications stemming from loss of distal fixation. Of the remaining 21, two healed, resulting in a 90% nonunion rate. These nonunions radiographically resembled clinical nonunions with tapered, cone-like fracture ends and histologically demonstrated evidence of attempted healing as seen with cartilage capping. Additionally, the plain radiographic appearance of those nonunions from mice euthanized at 10 and 12 weeks did not change over the final 4 to 6 weeks. CONCLUSIONS: The use of 2-mm tibial resection osteotomy with 2-mm distraction provides a predictable model for fracture nonunion in mice with the oligotrophic phenotype closely resembling the clinical correlate. This model offers a promising means for characterization of the molecular events that occur during the development of fracture nonunion and for evaluation of noninvasive methods of nonunion rescue.