Detroit Interventional Pain Assessment Scale: A Pain Score and Method for Measuring and Evaluating Post-Operative Pain Management-A Prospective Study.

Background and Objectives: Orthopedic surgeons commonly prescribe opioids, surpassing all medical specialties. Our objective was to develop a pain management scale that captures medication use, patient-reported pain scores, and helps orthopedic surgeons evaluate their post-operative prescribing practice. Materials and Methods: An IRB-approved prospective study followed 502 post-operative orthopedic surgery patients over a six-month period. All patients were surveyed in an orthopedic clinic at a Level 1 US Trauma Center, during a routine follow-up. Patient pain satisfaction was assessed using the validated Interventional Pain Assessment (IPA) scale, which uses three categories: 0 (no pain), 1 (tolerable pain), and 2 (intolerable pain). Daily narcotic use was translated to morphine milligram equivalents (MMEs) using the Michigan Automated Prescription System (MAPS) narcotics registry. When patient pain satisfaction and narcotic usage were combined, this scale was called the Detroit Interventional Pain Assessment (DIPA) scale. Results: The five classes based on common prescription and usage of narcotics in this cohort include the following: A (no pain medication), B (over-the-counter medication), C (occasional use of short-acting narcotics 1-30 MMEs), D (consistent/regular use of short-acting narcotics 31-79 MMEs), and E (long-duration or stronger short-acting narcotics 80+ MMEs). Patients were most satisfied with their pain management at six weeks (80.5%) and three months (75.65%), and least satisfied at two weeks (62.5%) and six months (60.9%). Additional information displayed on the DIPA graph revealed there was a significant decrease in the percentage of patients on narcotics at two weeks (65.2%) to six months (32.6%) at p < 0.001. Conclusions: The DIPA pain scale shows the relationship between patient pain perception and opioid prescription/usage, while also tracking prescriber tendencies. Providers were able to visualize their post-operative pain management progression at each designated clinic visit with corresponding alphabetical daily MME categories. In this study, results suggest that surgeons were not effective at managing the pain of patients at two weeks post-operative, which is attributed to an inadequate number of pain pills prescribed upon discharge. Overall, the DIPA graph signaled that better pain management interventions are necessitated in periods with lower efficiency scores.

Malunion of the Tibia: A Systematic Review.

Background and Objectives: Tibial malunions are defined as tibial fractures that have healed in a clinically unacceptable position, resulting in deformity such as shortening, lengthening, abnormal rotation, or angulation. These deformities can have adverse effects on patients, such as pain and gait disturbance, as well as long term development of post-traumatic arthritis. This paper seeks to highlight some of the options for surgical management of malunions and detail the strategies and approaches used to manage these complicated cases. Materials and Methods: An exhaustive search was conducted on PubMed using the key search terms "Tibial" OR "Tibia" AND "Malunion" to be included in the title. Exclusions to the search included any article with patients aged < 18 years, any nonhuman subjects, and any article not published or translated into English. Results: A systematic review of the literature revealed 26 articles encompassing 242 patients who had undergone surgical correction for tibia malunion. A total of 19 patients suffered from complications. Methods of treatment included osteotomies, with plate and screws, external fixator, angled blade plate, intramedullary nails, Ilizarov fixator, Taylor Spatial Frame, Precise nail, and total knee arthroplasty. Restoring alignment and the articular surface led to overwhelmingly positive patient outcomes. Conclusions: Tibial malunions take many forms, and as such, there are many approaches to correcting deformities. The literature supports the following radiological parameters to diagnose tibial malunion: 5−10 degrees angulation, 1−2 cm shortening, 10−15 degrees internal rotation, and 10−20 degrees external rotation. Surgical plans should be customized to each individual patient, as there are many approaches to tibial malunion that have been shown to be successful in delivering excellent clinical outcomes.

Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment.

Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were "malunion" AND "pelvic" OR "pelvis". Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.

Online Instruction to Measure Axial Alignment with the Bonesetter App.

Background and objectives: Alignment of the lower extremity is important when treating congenital deformities, fractures, and joint replacement. During the COVID-19 pandemic, AO North America offered an online course on deformity measurement and planning. The Bonesetter app is a deformity planning tool that is freely available online. The purpose of this study was to see how effective an online course was in teaching axial alignment measurement and to assess that skill using an online digital planning tool, the Bonesetter app. Materials and Methods: An online module on axial alignment was provided during the AONA osteotomy course as well as a tutorial on how to use an online digital planning tool (Bonesetter app). The tools within the Bonesetter app allow users to draw digital lines directly on the CT images and measure the exact angle between two planes. Participants in this study were directed to perform these measurements in four different cases that tested different variations of deformity. Results: The measurements were completed correctly in case 1 = 56%, case 2 = 61%, case 3 = 84%, and case 4 = 76%. The standard deviation of angular digital measurements between individuals was ±4.26 degrees. Measuring the angle directly vs. drawing angles to a horizontal line had smaller standard deviations per case (p < 0.005) and less incidents outside 1 standard deviation for each measurement. Errors in adding and subtracting were the most common errors, particularly in relation to femoral anteversion or retroversion. Conclusions: The online course successfully instructed a group of orthopedic surgeons to measure alignment and malalignment of lower limb axial deformities. The Bonesetter app helped participants to learn this skill and identify errors in measurement. The inability to differentiate between anteversion and retroversion of the femur is a common source of error when it occurs and should be a focus of instruction.

A pituitary cup biopsy is more accurate than reamings for histological diagnosis of intramedullary lesions during nailing of impending and pathologic fractures: a retrospective matched cohort analysis.

INTRODUCTION: Histologic diagnosis of the lesion is important while intramedullary nailing of a pathologic or impending fracture of a long bone. A biopsy can be performed extramedullary using a targeted sampling device such as a pituitary rongeur or intramedullary from the bone removed from the reamer during preparation of the intramedullary canal. The purpose of this study is to compare a cup pituitary rongeur vs. a reaming biopsy from the intramedullary canal during the treatment of pathologic bone lesions with an intramedullary nail. METHODS: An IRB approved retrospective case control study was performed on 46 consecutive patients who underwent an IMN for pathologic fracture or impending pathologic fracture with an obvious lytic lesion with a known metastatic primary. A laryngeal cup pituitary forceps' rongeur was used in 25 patients and the intramedullary reamer as it passed the lesion was used in 21 patients. Histopathology reports were assessed for (1) adequacy of bone sample (defined as containing sufficient bone and marrow-derived tissue to allow complete histological analysis) and (2) tumor tissue diagnosis. A standard approach for IMN was used. RESULTS: Twenty-three of 25 cup biopsy cases (92%) had positive pathology that corresponded to the primary cancer. Eleven of 21 reaming cases (52.4%) had positive pathology that corresponded to the primary cancer (p = 0.0117). CONCLUSION: The use of an intramedullary cup biopsy forceps is better than reamings to diagnose pathological lesions of impending and pathological fractures in long bones caused by metastatic lesions.

Elimination of the Femoral Neck in Measuring Femoral Version Allows for Less Variance in Interobserver Reliability.

Background and Objectives: Producing consistent measures of femoral version amongst observers are necessary to allow for an assessment of version for possible corrective procedures. The purpose of this study was to compare two computed tomography (CT)-based techniques for the reliability of measuring femoral version amongst observers. Materials and Methods: Review was performed for 15 patients post-femoral nailing for comminuted (Winquist III and IV) femoral shaft fractures where CT scanograms were obtained. Two CT-based techniques were utilized to measure femoral version by five observers. Results: The mean femoral version, when utilizing a proximal line drawn down the center of the femoral head-neck through CT, was 9.50 ± 4.82°, while the method utilizing the head and shaft at lesser trochanter centers produced a mean version of 18.73 ± 2.69°. A significant difference was noted between these two (p ≤ 0.001). The method of measuring in the center of the femoral head and neck produced an intraclass correlation coefficient (ICC) of 0.960 with a 95% confidence interval lower bound of 0.909 and upper bound of 0.982. For the method assessing version via the center of the head and shaft at the lesser trochanter region, the ICC was 0.993 with a 95% confidence interval lower bound of 0.987 and an upper bound of 0.996. Conclusions: The method of measuring version proximally through a CT image of the femoral head-neck versus overlaying the femoral head with the femoral shaft at the most prominent aspect of the lesser trochanter produces differing version measurements by roughly 10° while yielding an almost perfect interobserver reliability in the new technique. Both techniques result in significantly high interobserver reliability.

Altering polymerization temperature of antibiotic-laden cement can increase porosity and subsequent antibiotic elution.

PURPOSE: To examine the role of polymerization temperature on the cement porosity and antibiotic elution to optimize antibiotic release from antibiotic-laden cement (ABLC). METHODS: Elution profiles of vancomycin and tobramycin from ABLC discs prepared with low- and high-dose antibiotic dosages, cured at 8, 21, and 37 °C, and placed in phosphate buffered saline (PBS) at 37 °C were examined. Samples were collected at one, four, eight, 24, 72, 168, 336, and 1008 hours to calculate the quantity of antibiotic eluted. Porosity was determined by MicroCT analysis. RESULTS: ABLC porosity and antibiotic elution were increased up to five times the amount eluted from room temperature discs (p < 0.05). Low-dose ABLC group saw decreased but similar porosity at 8 °C and 21 °C compared to cement cured at 37 °C (p < 0.001). High-dose ABLC group porosities were all significantly different (p < 0.02). CONCLUSIONS: Altering the polymerization temperature of ABLC led to more porous constructs yielding increased antibiotic elution.

INFIX versus plating for pelvic fractures with disruption of the symphysis pubis.

PURPOSE: The purpose of this study is to compare INFIX to plating in the treatment of unstable pelvic ring injuries with disruption of the symphysis. METHODS: Twenty-four patients treated with INFIX were compared to 28 patients fixed by plating. All patients had anterior and posterior fixation. Injuries were classified using the Young and Burgess and AO/OTA classification systems. Reductions of the pelvic ring were assessed using the pelvic deformity index (PDI) and symphyseal widening. Patients were contacted to get functional outcomes using the Majeed scoring system and complications were tabulated . RESULTS: INFIX was inferior to plating at reducing symphyseal widening (INFIX 10.72± 5.0 Plates 6.97 ± 3.39 P = 0.012) but similar in reducing the pelvic deformity index. (INFIX 0.0221± .015 Plates 0.0190 ± .0105 P = 0 .38). Majeed scores were similar 83.95 ± 15.2 (median 89, range 51-100) for INFIX and 77.67± 16.7 (median 79, range 54-100) for plating. Complications included infection (1 (4%) INFIX , 4 (14%) plates), improper hardware placement or failure (2 (8%) INFIX, 3 (11%) plates), and heterotopic ossification (11 (46%) INFIX, 16 (57.1%) plates). Infection in the plated patients was related to urological injury in 3/4 cases. CONCLUSIONS: Plating provides better reduction of the pubic symphysis and requires only one surgery. Outcomes scores were similar. INFIX may be preferable in obese patients, young women of childbearing age or those with urological injury.

Accuracy of Low Dose Computed Tomography Scanogram for Measurement of Femoral Version after Locked Intramedullary Nailing.

PURPOSE: This prospective study was performed to compare the accuracy of femoral version measurements following repair of femoral shaft fractures using computed tomography (CT) scanograms with 10 % of the standard dose of ionizing radiation versus standard-dose scanograms. METHODS: CT scanogram protocols that used 90 and 10 % of the usual dose of ionizing radiation were developed. Ten patients with comminuted femoral shaft fractures repaired with either an intramedullary (IM) nail or plate were imaged with both high- and low-dose CT scanograms. Postoperative version of both femurs was measured and compared between the two dose scans using the Bonesetter application. This was a prospective blinded controlled study at a level 1 trauma centre. Statistical analysis was performed, including standard deviation (SD) and paired t test. Significance was set at p < 0.05. RESULTS: Comparison of femoral version measurements between the 90 and 10 % dose scanograms on the native and repaired sides were insignificant (p = 0.870 and p = 0.737, respectively). The difference between native and repaired femurs had an average error of 2.0 ± 1.1° for both the high- and low-dose scans and was insignificant (p = 0.742). CONCLUSIONS: Reducing the dose of ionizing radiation in a CT scanogram by 90 % has no significant effect on the accuracy of femoral version measurement. This simple change can significantly reduce patient radiation exposure while accurately measuring femoral version and length.

Functional Outcomes After Both Bone Forearm Fractures in Adults.

The purpose of this study was to evaluate midterm outcomes after both bone forearm fractures. A retrospective review of patients treated with open reduction and internal fixation (ORIF) at three level 1 trauma centers was completed. Eligible patients were sent three questionnaires: Disabilities of the Arm, Shoulder and Hand (DASH), Short Form-12 (SF-12), and questions about postinjury experience. Twenty-nine patients with an average age of 45 years returned the materials. The forms were completed an average of 60 months after ORIF. The mean DASH was 22 for all respondents. Twenty-one subjects participated in physical therapy (72%). Eight patients (28%) screened positive for posttraumatic stress disorder (PTSD). The mean SF-12 physical component score was 39 and the SF-12 mental component score was 40, both of which were lower than the non-PTSD group, indicating a lower subjective level of health (p < .05). The data suggest that, years after surgery, patients have decreased functional outcomes.

Septic arthritis in intravenous drug abusers: a historical comparison of habits and pathogens.

BACKGROUND: Intravenous drug abuse (IVDA) is a common problem; there were more than 16 million users worldwide in 2008. Numerous reports highlight the infectious skeletal complication associated with IVDA. OBJECTIVE: To determine septic arthritis pathogens in IVDA in a U.S. hospital and compare the current causative organisms to a cohort from the 1980s at the same institution. METHODS: An institutional review board-approved retrospective cohort study compared a consecutive series of IVDA septic arthritis patients over a 10-year period, 1999-2008 (Group B), with an IVDA septic arthritis database that was collected in the 1980s (Group A). Endpoints were: bacterial species and staph species antibiotic susceptibility. RESULTS: Group B included 58 patients (35 men, 23 women) with a median age of 46.5 years. Group A included 38 patients (30 men, 8 women), with a median age of 32.5 years. The sets were significantly different in pathogens (p = 0.0443). The most common organisms were Staphylococcus (staph) species (B 74.51%, A 52.63%), followed by Streptococcus (strep) species (B 7.84%, A 31.58%), Pseudomonas (B 13.73%, A 13.16%), and Serratia (B 3.92%, A 2.63%). Of the total number of septic joints, methicillin-resistant Staphylococcus aureus (MRSA) made up 39% of Group B and 34% of Group A. However, within the staph species, MRSA made up 53% of Group B and 65% of Group A. Strep species made up 7.84% (Group B) vs. 31.58% (Group A), and Pseudomonas (13%) and Serratia (3-4%) were similar. In the Group B cohort, methicillin-susceptible Staphylococcus aureus (MSSA) had a predilection to infect the knee (94.4%), whereas MRSA was found more often in the hip (57.1%). CONCLUSIONS: In IVDAs, MRSA is the most common pathogen causing septic arthritis. The ratio of staph species in septic joints is increasing, and the ratio of MRSA to MSSA remains high (>50%). Strep species are much less common.

Antibiotic cement nails manufactured with threaded rods or cannulated intramedullary nails are better than those made with guidewires and do not debond.

Purpose: The purpose of this study was to comparatively evaluate cement debonding at the time of removal of antibiotic cemented coated nails (ABNs) with cores made with a guidewire ($120), a regular intramedullary nail ($1100) or a threaded rod from a circular frame external fixator set ($60). Methods: A retrospective study was performed on 32 ABNs that had been implanted for long bone infections after intramedullary nailing. All ABNs were manufactured intraoperatively by the treating surgeon using 2 grams of vancomycin and single package of Tobramycin Simplex Cement (Stryker, Kalamazoo, MI). The powder, antibiotics, and polymer were mixed and then injected into an ABN cement mold (Bonesetter Holdings USA). Debonding was assessed at time of removal by the operating surgeon. Rates of cement debonding between the 3 groups were statistically compared. Results: Debonding occurred in 0/12 of the cement nails manufactured with an intramedullary nail, 0/7 threaded rod ABNs, and 6/13 guidewire ABNs. There was a significant difference in the rate of debonding between the 3 groups (P < 0.01). Removal of the remnant cement was accomplished with thin osteotomes, long pituitary rongeurs, or reamers. The canal was visualized using an arthroscope to ensure complete removal of the cement. Conclusion: ABNs fabricated with standard intramedullary nails or threaded rods did not lead to any debonding. Debonding of the cement from the inner core of an antibiotic nail often requires significant effort to remove the remnant cement. Given that threaded rods are often cheaper than guidewires, we recommend that ABNs be fabricated with either threaded rods or interlocking nails, but not guidewires, depending on the level of stability required.

Analyzing the Accuracy of Digital Sizing on Long-Leg Alignment X-rays by Using a 1-Inch Ball Bearing: A Cheap and Effective Method.

Background and objective Sizing on digital films is important for implants and planning deformity correction. CT is the most accurate digital measurement method. We use a 1-inch ball bearing (cost: $1) to size our long-leg standing films (LLSFs) when planning deformity correction. In this study, we aimed to assess the accuracy of digital measurements calibrated by this method. Methods We conducted An IRB-approved study involving 25 patients having both an LLSF with a 1-inch ball bearing taped to the inner mid-thigh and a CT scanogram. The longest distance in the axial cut of the bilateral ankle, knee, and femoral heads of the CT images were compared to the same anatomic locations on LLSFs calibrated with the ball bearing using the online digital planning software DetroitBonesetter (DBS) and measurements from our Picture Archiving Communication Software (PACS). Five observers performed each measurement. Results The average measurement differences between the gold standard CT scan and LLSFs calibrated with DBS were as follows: 0.110 ± 0.432 mm (femoral head); 2.173 ± 0.0619 mm (knee); and 3.671 ± 0.30 mm (ankle). In PACS, they were as follows: 5.470 ± 0.381 mm (femoral head); 6.248 ± 0.712 mm (knee); and 1.806 ± 0.548 mm (ankle). The intraclass correlation coefficient for 600 measurements by five observers was 0.972. Conclusions The $1 ball-bearing sizing on DBS using LLSFs provides accuracy to <1 mm for the femoral head, 2 mm at the knee, and 3.7 mm at the ankle. It was significantly better than the PACS system for both the femoral head and knee (<0.001), while PACS was better at the ankle (<0.001).

Long-Term Prevention of Arthroplasty Infections via Incorporation of Activated AgNbO3 Nanoparticles in PMMA Bone Cement.

We investigated the possibility of loading PMMA bone cement with antimicrobial nanostructured AgNbO3 particles to counter biofilm formation at the cement-tissue interface. We found that a formulation containing (1-4)% AgNbO3 showed high antibacterial activity against Gram-positive Staphylococcus aureus and Gram-negative Pseudomonas aeruginosa while not showing any toxicity against THP1 human cell lines. In addition, loading the particles did not impact the mechanical properties of the cement. The results thus obtained illustrate the potential of the approach to replace the current technique of mixing cement with conventional antibiotics, which is associated with shortcomings such as efficacy loss from antibiotic depletion.

A Novel Digital Templating Method for Total Hip Arthroplasty in Patients With Unilateral Hip Arthrosis.

BACKGROUND: Identification of the hip center of rotation (HCOR) before total hip arthroplasty (THA) is crucial for achieving optimal implant position and size, and for restoring native biomechanics around the hip joint. Current techniques for determining the HCOR in cases of abnormal hip anatomy are limited and unreliable. This study presents a novel technique using open-access software for preoperative THA templating for patients with significantly abnormal hip anatomy due to unilateral hip arthrosis. The aim is to reliably predict the HCOR and acetabular implant size compared with a traditional intraoperative method. MATERIALS AND METHODS: This retrospective study involved 20 patients with unilateral hip arthrosis who underwent THA. Preoperative templating was performed using the experimental technique, and the position of the HCOR was measured on preoperative and postoperative radiographs. The positions of the predicted and actual HCOR were compared, along with the inclination and size of the acetabular component. RESULTS: The difference between the predicted and actual HCOR positions was insignificant (0.43±0.22 mm vertically and 0.18±0.20 mm horizontally), and there was a positive correlation between them (r=0.78, P<.005; r=0.72, P<.005). The agreement between the predicted and actual acetabular implant sizes was 85%, with near-perfect interobserver agreement (Cohen's kappa=0.827). CONCLUSION: This novel technique provides a reliable method for predicting HCOR and acetabular implant size for THA in cases of unilateral hip arthrosis. This technique may help optimize biomechanics and improve outcomes in challenging cases. Further research and validation are warranted to establish its broader applicability. [Orthopedics. 2024;47(3):e139-e145.].

Characterizing Trauma Patients with Delays in Orthopaedic Process Measures.

INTRODUCTION: Early operative intervention in orthopaedic injuries is associated with decreased morbidity and mortality. Relevant process measures (e.g. femoral shaft fixation <24 hours) are used in trauma quality improvement programs to evaluate performance. Currently, there is no mechanism to account for patients who are unable to undergo surgical intervention (i.e. physiologically unstable). We characterized the factors associated with patients who did not meet these orthopaedic process measures. METHODS: A retrospective cohort study of patients from 35 ACS-COT verified Level 1 and Level 2 trauma centers was performed utilizing quality collaborative data (2017-2022). Inclusion criteria were adult patients (≥18 years), ISS ≥5, and a closed femoral shaft or open tibial shaft fracture classified via the Abbreviated Injury Scale version 2005 (AIS2005). Relevant factors (e.g. physiologic) associated with a procedural delay >24 hours were identified through a multivariable logistic regression and the effect of delay on inpatient outcomes was assessed. A sub-analysis characterized the rate of delay in "healthy patients". RESULTS: We identified 5,199 patients with a femoral shaft fracture and 87.5% had a fixation procedure, of which 31.8% had a delay, and 47.1% of those delayed were "healthy." There were 1,291 patients with an open tibial shaft fracture, 92.2% had fixation, 50.5% had an irrigation and debridement and 11.2% and 18.7% were delayed, respectively. High ISS, older age and multiple medical comorbidities were associated with a delay in femur fixation, and those delayed had a higher incidence of complications. CONCLUSIONS: There is a substantial incidence of surgical delays in some orthopaedic trauma process measures that are predicted by certain patient characteristics, and this is associated with an increased rate of complications. Understanding these factors associated with a surgical delay, and effectively accounting for them, is key if these process measures are to be used appropriately in quality improvement programs. LEVEL OF EVIDENCE: Level III; Therapeutic/Care Management.

Lead toxicity and management of gunshot wounds in the lumbar spine.

INTRODUCTION: Gunshot wounds are one of the commonest causes of spinal injury. Management of these patients differs from other blunt trauma injuries to the spine. We present a case of a gunshot wound to the lumbar spine that occurred in 1985 which was treated non-operatively. METHODS: In the last 10 years, the patient was admitted multiple times for confusion and lead toxicity with blood levels over 100 µg/dl. Inpatient chelation therapy was implemented. After multiple recommendations for surgery, the patient agreed to have as much of the bullet removed as possible. The patient successfully underwent decompression and fusion from both anterior and posterior approaches. Lead levels subsequently declined. CONCLUSION: The purpose of this paper is to show a case of a gunshot wound to the spine that ultimately caused plumbism and required surgery. Technical aspects of the surgery are described as well as pre- and post-procedural imaging. Recommendations for the general management of spine gunshot wounds are also described.

Retrograde versus antegrade intramedullary nailing of gunshot diaphyseal femur fractures.

BACKGROUND: The use of retrograde nailing for gunshot wound femur fractures is controversial due to concerns of knee sepsis after this procedure since the knee is entered to introduce the nail into the canal. QUESTIONS/PURPOSES: We compared retrograde and antegrade nailing for gunshot femur fractures to determine whether (1) knee sepsis or other adverse events were more likely to complicate procedures using retrograde nails, (2) there were differences in surgical time or blood loss, and (3) there were differences in radiographic union. METHODS: We retrospectively reviewed our prospective trauma database from 1999 to 2012 for patients with a diagnosis of gunshot and femur fracture. We performed a detailed review of medical records and radiographs for those patients with OTA Classification Type 32 femur fractures secondary to gunshot injury treated with either retrograde or antegrade femoral nailing. Eighty-one patients were treated with intramedullary nailing (53 retrograde and 28 antegrade). We reviewed elements of the operative treatment (procedure, anesthesia time, operative time, and estimated blood loss) for all 81 patients. For clinical and radiographic review, followup was adequate for 43 and 25 patients with retrograde and antegrade nailing, respectively. Minimum followup was 3 months for both groups (retrograde: mean, 41 months; range, 3-148 months; antegrade: 26 months: range, 3-112 months). RESULTS: No patients in either group developed knee sepsis. No significant differences were found between groups with regard to operative time, blood loss, or radiographic union. CONCLUSIONS: With the numbers available, immediate retrograde nailing appears as safe and effective as antegrade nailing for gunshot femur fractures. Immediate retrograde nailing is as safe as antegrade nailing for gunshot femur fractures.

The traumatic lower extremity amputee: surgical challenges and advances in prosthetics.

The mangled lower extremity is a challenging injury to treat. Orthopaedic surgeons treating patients with these severe injuries must have a clear understanding of contemporary advantages and disadvantages of limb salvage versus amputation. It is helpful to review the acute management of mangled extremity injuries in the civilian and military populations, to be familiar with current postoperative protocols, and to recognize recent advances in prosthetic devices.

Anterior internal fixator versus a femoral distractor and external fixation for sacroiliac joint compression and single stance gait testing: a mechanical study in synthetic bone.

PURPOSE: The purpose of this study was to evaluate the biomechanical stability and compressive forces across the sacroiliac (SI) joint of an anterior internal fixator compared to the femoral distractor and external fixator for vertically unstable pelvic fractures. METHODS: Five composite pelvises with a simulated APC type III injury fixed with a femoral distractor, external fixator, or anterior internal fixator were tested. A pressure-sensitive film (Tekscan) was placed in the disrupted SI joint recording the magnitude of force. Then, in a single-leg stance model (Instron machine), a load was applied through the sacrum. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Peak load and displacement were measured, and axial stiffness was calculated. Values were compared using a Student's t-test (p < 0.05). RESULTS: The SI joint was compressed significantly (p < 0.001) more using the anterior internal fixator (18.9 N) and femoral distractor (18.6 N) than the two-pin external fixator (2.5 N). There was no significant difference between the anterior internal fixator and the femoral distractor in displacement at the SI joint. The pubic symphysis displaced less with the femoral distractor than the anterior internal fixator (5.5 mm vs. 4.1 mm; p < 0.05). CONCLUSIONS: The anterior pedicle screw internal fixator allows for indirect compression across the sacroiliac joint that is superior to two-pin external fixation and comparable to the femoral distractor. The anterior internal fixator may be an option for temporary anterior pelvic fixation in situations where external fixation or the femoral distractor have otherwise been used.