Unstable pelvic fractures in women: implications on obstetric outcome.

PURPOSE: Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery. METHOD: A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16-45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared. RESULTS: Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate. CONCLUSION: Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Incidence, risk factors and potential timing of occurrence of pulmonary embolism in fatal trauma: An autopsy based case-control study on 2705 victims.

BACKGROUND: Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities. METHODS: A case-control study on 9266 consecutive trauma fatalities (between 1996 and 2005) from a regional autopsy-based trauma registry. Injuries were classified according to the Abbreviated Injury Scale-1990 edition (AIS-90) and the Injury Severity Score (ISS) was calculated. Hospitalized victims were categorized according to the presence or absence of PE on autopsy. Univariate comparisons and multivariate logistic regression analysis for probabilities of association (odds ratios-OR) were performed. RESULTS: Out of 2705 subjects who met the inclusion criteria, 116 had autopsy findings of PE and constituted the PE group (incidence of 4,3%), while the remaining victims formed the control group. The survival time of the PE group ranged from 0.66 to 104.73 days. Victims in the PE group were older (median age 69.5 vs 59), had lower ISS values (median 16 vs 26) and longer post-injury survival times (median 13.6 vs 5.7 days). Positively associated risk factors were AIS2-5 pelvic ring injuries (OR:2.23) and secondary deaths following an uneventful hospital discharge (OR:3.97), while AIS2-5 head (OR:0.33) and abdominal injuries (OR:0.23) showed a reverse association. CONCLUSIONS: Trauma fatalities with autopsy findings of PE were associated with less severe trauma indicating that PE was likely detrimental to the fatal outcome. Both the early and delayed occurrence of PE was reaffirmed. Prophylactic measures should be initiated promptly and extended post discharge for high risk patients to prevent secondary deaths.

Femoral fractures are an indicator of increased severity of injury for road traffic collision victims: an autopsy-based case-control study on 4895 fatalities.

INTRODUCTION: The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs. PATIENTS AND METHODS: A case-control study based on forensic material from 4895 consecutive RTC-induced fatalities, between 1996 and 2005. Injuries were coded according to the Abbreviated Injury Scale-1990 Revision (AIS-90), and the Injury Severity Score (ISS) was calculated. Victims were divided according to the presence of femoral fractures in all possible anatomic locations or not. Univariate comparisons and logistic regression analysis for probabilities of association as odds ratios (OR) were performed. RESULTS: The FFx group comprised 788 (16.1%) victims. The remaining 4107 victims constituted the controls. The FFx group demonstrated higher ISS (median 48 vs 36, p < 0.001) and shorter post-injury survival times (median 60 vs 85 min, p < 0.001). Presence of bilateral fractures (15.5%) potentiated this effect (median ISS 50 vs 43, p = 0.006; median survival time 40 vs 65, p = 0.0025; compared to unilateral fractures). Statistically significant associations of FFx were identified with AIS2-5 thoracic trauma (OR 1.43), AIS2-5 abdominal visceral injuries (OR 1.89), AIS1-3 skeletal injuries of the upper (OR 2.7) and lower limbs (OR 3.99) and AIS2-5 of the pelvis (OR 2.75) (p < 0.001). In the FFx group, 218 (27.7%) victims survived past the emergency department and 116 (53.2%) underwent at least one surgical procedure. Complications occurred in 45.4% of hospitalized victims, the most common being pneumonia (34.8%). CONCLUSION: This study has documented that femoral fractures are associated with increased severity of injury, shorter survival times and higher incidence of associated thoracic, abdominal and skeletal extremity injuries, compared to controls. These findings should be considered for an evidence-based upgrading of trauma care.

Scoring systems for early prediction of tibial fracture non-union: an update.

PURPOSE: To evaluate the available tibial fracture non-union prediction scores and to analyse their strengths, weaknesses, and limitations. METHODS: The first part consisted of a systematic method of locating the currently available clinico-radiological non-union prediction scores. The second part of the investigation consisted of comparing the validity of the non-union prediction scores in 15 patients with tibial shaft fractures randomly selected from a Level I trauma centre prospectively collected database who were treated with intramedullary nailing. RESULTS: Four scoring systems identified: The Leeds-Genoa Non-Union Index (LEG-NUI), the Non-Union Determination Score (NURD), the FRACTING score, and the Tibial Fracture Healing Score (TFHS). Patients demographics: Non-union group: five male patients, mean age 36.4 years (18-50); Union group: ten patients (8 males) with mean age 39.8 years (20-66). The following score thresholds were used to calculate positive and negative predictive values for non-union: FRACTING score ≥ 7 at the immediate post-operative period, LEG-NUI score ≥ 5 within 12 weeks, NURD score ≥ 9 at the immediate post-operative period, and TFHS < 3 at 12 weeks. For the FRACTING, LEG-NUI and NURD scores, the positive predictive values for the development of non-union were 80, 100, 40% respectively, whereas the negative predictive values were 60, 90 and 90%. The TFHS could not be retrospectively calculated for robust accuracy. CONCLUSION: The LEG-NUI had the best combination of positive and negative predictive values for early identification of non-union. Based on this study, all currently available scores have inherent strengths and limitations. Several recommendations to improve future score designs are outlined herein to better tackle this devastating, and yet, unsolved problem.

Fixation of periprosthetic or osteoporotic distal femoral fractures with locking plates: a pilot randomised controlled trial.

INTRODUCTION: We hypothesised that the use of a polyaxial locking plate design offers the same clinical benefits as a monoaxial locking plate system following distal femoral osteoporotic/periprosthetic fracture fixation. METHOD: A multicentre prospective randomised pilot trial was conducted. Inclusion criteria were patients over 60 years with a displaced osteoporotic or periprosthetic distal femoral fracture. Details documented included time to union, complications, reinterventions and functional outcomes according to the Oxford knee score and EuroQol EQ-5D. Analysis of factors influencing an early fracture healing response was performed between those with clear features of radiological callus formation at three months. Statistical analysis was performed using a logistic regression model with multiple covariates assessed for each plate system (1:1 ratio) over a follow-up period of one year. RESULTS: Forty patients (34 females) with a mean age of 77 (60-99) were recruited. Four patients deceased within the first six months. Twenty-five patients united by the six month follow-up. Six more patients progressed to union between six and nine months. Five patients developed non-union (two patients had implant failure; one in each group) and all underwent revision surgery. Malunion was evident in two cases, one with 15° of valgus (monoaxial plate), and one with 12° of recurvatum (polyaxial plate). Between the two plate systems, statistical analysis revealed no significant differences in most of the recorded parameters. Radiological features of early bone healing were present when the surgical approach was smaller (p = 0.015), and when a greater working length of the bridging plate was present (p = 0.016). CONCLUSION: Both plate systems demonstrated good union rates and limited implant related complications. Good reduction, mechanically sound construct and respect of the local fracture biology was more important than the particular plate design characteristics.

Implementation of a standardized protocol to manage elderly patients with low energy pelvic fractures: can service improvement be expected?

PURPOSE: The incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve the quality of services provided to these patients. METHODS: A cohort study was contacted to test the impact of (1) using a specific clinical algorithm and (2) using different antiosteoporotic drugs. Multivariate regression analysis was used to determine prognostic factors. Study endpoints were the time-to-healing, length-of-stay, return to pre-injury mobility, union status, mortality and complications. RESULTS: A total of 132 elderly patients (≥65 years) admitted during the period 2012-2014 with FPFs were enrolled. High-energy fractures, acetabular fractures, associated trauma affecting mobility, pathological pelvic lesions and operated FPFs were used as exclusion criteria. The majority of included patients were females (108/132; 81.8%), and the mean age was 85.8 years (range 67-108). Use of antiosteoporotics was associated with a shorter time of healing (p = 0.036). Patients treated according to the algorithm showed a significant protection against malunion (p < 0.001). Also, adherence to the algorithm allowed more patients to return to their pre-injury mobility status (p = 0.039). CONCLUSIONS: The use of antiosteoporotic medication in elderly patients with fragility pelvic fractures was associated with faster healing, whilst the adherence to a structured clinical pathway led to less malunions and non-unions and return to pre-injury mobility state.

The use of buttress plates in the management of acetabular fractures with quadrilateral plate involvement: is it still a valid option?

PURPOSE: The primary aim of this study was to report on the mid-term outcomes after quadrilateral plate reconstruction of acetabular fractures using a buttress/spring plate through an ilioinguinal approach. METHODS: Between 2003 and 2011, 30 adult patients (25 males) with mean age 54 years (range 17-80) who underwent surgical fixation for an acetabular fracture and had minimum follow up of 24 months (mean 46.2, range 24-78.6) were retrospectively reviewed. Standard demographics, admission and hospitalization data (concomitant injuries, number of operative procedures, time to operating theatre, early and late complications) were correlated to the clinical (Harris Hip Score) and radiological (Matta Reduction Score and Matta Arthritis Score) outcome. RESULTS: Three patients underwent a Total Hip Replacement. Functional score was excellent in 17 (56.6 %), good in 4 (13.3 %), fair in 6 (20 %) and poor in 3 (10 %) cases. Surgery-related complications included two patients with temporary lateral femoral cutaneous palsy and three with heterotopic ossification. The quality of the postoperative reduction was associated to Harris Hip Score (p = 0.015) and postoperative arthritis (p = 0.010). Strong association was evident between age and both post-operative reduction (p = 0.010) and arthritis (p = 0.014). The presence of quadrilateral plate comminution and gull-sign were associated to poor post-operative reduction (p = 0.016) and low Harris Hip Score (p = 0.049) respectively. CONCLUSION: Quadrilateral plate reconstruction with a buttress plate though the ilioinguinal approach remains a valid method of fixation in acetabular surgery. Additional studies are needed to compare the efficiency of this method to new surgical approaches and fixation implants.

A cohort study on the incidence and outcome of pulmonary embolism in trauma and orthopedic patients.

BACKGROUND: This study aims to determine the incidence of pulmonary embolism (PE) in trauma and orthopedic patients within a regional tertiary referral center and its association with the pattern of injury, type of treatment, co-morbidities, thromboprophylaxis and mortality. METHODS: All patients admitted to our institution between January 2010 and December 2011, for acute trauma or elective orthopedic procedures, were eligible to participate in this study. Our cohort was formed by identifying all patients with clinical features of PE who underwent Computed Tomography-Pulmonary Angiogram (CT-PA) to confirm or exclude the clinical suspicion of PE, within six months after the injury or the surgical procedure.Case notes and electronic databases were reviewed retrospectively to identify each patient's venous thromboembolism (VTE) risk factors, type of treatment, thromboprophylaxis and mortality. RESULTS: Out of 18,151 patients admitted during the study period only 85 (0.47%) patients developed PE (positive CT-PA) (24 underwent elective surgery and 61 sustained acute trauma). Of these, only 76% of the patients received thromboprophylaxis. Hypertension, obesity and cardiovascular disease were the most commonly identifiable risk factors. In 39% of the cases, PE was diagnosed during the in-hospital stay. The median time of PE diagnosis, from the date of injury or the surgical intervention was 23 days (range 1 to 312). The overall mortality rate was 0.07% (13/18,151), but for those who developed PE it was 15.29% (13/85). Concomitant deep venous thrombosis (DVT) was identified in 33.3% of patients. The presence of two or more co-morbidities was significantly associated with the incidence of mortality (unadjusted odds ratio (OR) = 3.52, 95% confidence interval (CI) (1.34, 18.99), P = 0.034). Although there was also a similar clinical effect size for polytrauma injury on mortality (unadjusted OR = 1.90 (0.38, 9.54), P = 0.218), evidence was not statistically significant for this factor. CONCLUSIONS: The incidence of VTE was comparable to previously reported rates, whereas the mortality rate was lower. Our local protocols that comply with the National Institute for Health and Clinical Excellence (NICE) guidelines in the UK appear to be effective in preventing VTE and reducing mortality in trauma and orthopedic patients.

Severely injured patients: modern management strategies.

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which dictates a clear understanding of the existing nomenclature. What is defined nowadays as polytrauma or major trauma, together with other essential terms used in the orthopaedic trauma literature, is described in this instructional review. Furthermore, an analysis of contemporary management strategies (early total care (ETG), damage control orthopaedics (DCO), early appropriate care (EAC), safe definitive surgery (SDS), prompt individualised safe management (PRISM) and musculoskeletal temporary surgery (MuST)) advocated over the last two decades is presented. A focused description of new methods and techniques that have been introduced in clinical practice recently in all different phases of trauma management will also be presented. As the understanding of trauma pathophysiology and subsequently the clinical practice continuously evolves, as the means of scientific interaction and exchange of knowledge improves dramatically, observing different standards between different healthcare systems and geographic regions remains problematic. Positive impact on the survivorship rates and decrease in disability can only be achieved with teamwork training on technical and non-technical skills, as well as with efficient use of the available resources.

Biological aspects to enhance fracture healing.

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role. For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.

Stabilization of Tibial Fractures at Risk of Complications With the Bactiguard Intramedullary Nail: Early to Medium Results With a Novel Metal-Coated Device.

OBJECTIVES: The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. DESIGN: This is a retrospective case series with prospectively collected data. SETTING: Level I Trauma Centre in the United Kingdom. PATIENTS AND INTERVENTION: Thirty-one patients who were managed with the Bactiguard-coated Natural Nail and achieved a minimum of a 12-month follow-up. MAIN OUTCOME MEASUREMENTS: The main outcomes of this study were the incidence of adverse events (related to implant safety), complications (particularly infection), and reinterventions. RESULTS: Thirty-one patients with a mean age of 41.6 years were included in this study. Active heavy smokers or intravenous drug users were 25.8% and 9.7% of them were diabetic. Five fractures were open while 13 had concomitant soft-tissue involvement (Tscherne grade 1 or 2). Twenty-seven patients healed with no further intervention in a mean time of 3.3 months. Three patients developed nonunion and required further intervention. The overall union rate was 96.7%. One patient developed deep infection after union (infection incidence 3.2%). Six patients (6/31; [19.3%]) required reinterventions [2 for the treatment of nonunion, 3 for removal of screws soft-tissue irritation, and 1 for the management of infection). CONCLUSIONS: The management of tibial shaft fractures with a noble metal-coated titanium tibial nail demonstrates encouraging outcomes. Further studies are desirable to gather more evidence in the performance of this innovative implant. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Severe trauma with associated pelvic fractures: The impact of regional trauma networks on clinical outcome.

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are notoriously linked with hypovolemic shock or even death from excessive blood loss. The aim of this prospective cohort study is to compare the profile of severely injured patients with combined pelvic fractures and their mortality between two different distinct eras of an advanced healthcare system. Anonymized consecutive patient records submitted to TARN UK between 2002 and 2017 by NHS England hospitals were analyzed. Records of patients without a pelvic fracture, or with isolated pelvic fractures (no other serious injury with abbreviated injury scale AIS >2) were excluded. All patients with known outcomes were included and were divided into 2 distinct periods (pre-RTN era: between January 2002 and March 2008 (control group); and RTN era April 2013 to June 2017 (study group)). Data from the transition period from April 2008 to March 2013 were excluded to minimize the effect of variations between the developing networks and MTCs during that era. Overall, the study group included 10,641 patients, whereas the control group was 3152 patients, with a median age of 52.4 and 35.1 years and an ISS of 24 and 27 respectively. A systolic blood pressure below 90mmHg was observed in 7.2% of patients in the study group and 10.4% in the control group. A significant increase of the median time to death (from 8hrs to 188hrs) was observed between the two eras. The cumulative mortality of severely injured patients with pelvic fractures decreased significantly from 17.8% to 12.4% (p<0.0001). The recorded improvement of survivorship in the subgroup of severely injured patients with a pelvic fracture (32% lower in the post-RTN than in the pre-RTN period: OR 1.32  (95% CI 1.21 - 1.44), following the first 5 years of established regional trauma networks in NHS England, is encouraging, and should be attributed to a wide range of factors that translate to all levels of trauma care.

Surgical fixation of ipsilateral femoral neck and shaft fractures: a matter of debate?

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are employed. Definitive fixation consists of either single-implant (reconstruction femoral nails) or dual-implant constructs. There is no consensus in favour of one of these two strategies. At present, there is no high-quality comparative evidence between the various methods of treatment. The development of advanced design nailing and plating systems has offered fixation constructs with improved characteristics. A comprehensive review of the existing evidence with a step-by-step description of these different definitive fixation strategies based on three case examples was conducted. Furthermore, the rationale for using single vs dual-implant strategy in its case is presented with supportive references. The prevention of complications relies mainly on the strict adherence to basic principles of fracture fixation with an emphasis on careful preoperative planning, the quality of the reduction, and the application of soft tissue-friendly surgical methods.

Treatment of tibial bone defects: pilot analysis of direct medical costs between distraction osteogenesis with an Ilizarov frame and the Masquelet technique.

PURPOSE: The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis-Ilizarov method (ILF), or with Masquelet technique (MIF). METHODS: Data of 20 random patients treated in a single centre were analysed. Inclusion criteria included acute tibial defects, or post-debridement of nonunions with complete follow-up and successful union. The endpoint of clinical efficacy was the time-to-defect union. Comparisons were made between equally sized subgroups (ILF vs. MIF). RESULTS: The average defect length was 5.6 cm (2.6-9.6 cm). The overall cost of 20 cases reached £452,974 (mean £22,339, range £13,459-£36,274). Statistically significant differences favoring the MIF were found regarding the average time-to-union; number of surgeries, of admissions and follow-up visits, as well as the mean intraoperative cost (£8857 vs. £14,087). These differences lead to significant differences of the mean cost of the overall treatment (MIF £18,131 vs. ILF £26,126). Power analysis based on these data indicated that 35 patients on each group would allow detection of a 25% difference, with an alpha value of 0.05 and probability (power) of 0.9. CONCLUSIONS: The results and analysis presented highlight factors affecting the high financial burden, even in a best-case scenario, this type of surgery entails. Larger pivotal studies should follow to improve the cost efficiency of clinical practice.

Operative management of acetabular fractures in the elderly: a case series.

BACKGROUND: Our objective was to identify acetabular fractures in the elderly population (over 60 years of age), treated with open reduction and internal fixation (ORIF), and to examine their outcomes, primarily the risk for need for further surgery in the form of a total hip arthroplasty (THA), and factors associated with it. Additional outcomes such as infection, avascular necrosis (AVN) of the femoral head, and heterotopic ossification (HO) were also investigated. METHODS: Following institutional review board (IRB) approval, a retrospective analysis of all consecutive patients presenting to a Level I Trauma Centre over a 13-years period (January 2003-February 2016) was conducted. Patients were excluded if their initial treatment was conservative or simultaneous ORIF with THA. RESULTS: A total of 62 patients with an age of 71.5 ± 8.04 years were included (14 female; follow-up 54.2 months, range 1-195 months). Sixteen patients required a THA as a secondary procedure due to symptomatic post-traumatic arthritis (25.8%), five (8.1%) of whom having a THA within a year from the original trauma (three patients presenting with loss of reduction and two patients with early AVN). No associations with progression to THA were identified. Surgical approach (ilioinguinal) was the only factor associated with increased risk of development of HO (p = 0.010). The median post-operative survival following an acetabular fracture treated with ORIF was calculated at 90.1 months (95% CI 72.9-107.2). CONCLUSION: Acetabular fractures ORIF in the elderly, is a safe and reliable option. The relatively incidence of development of severe post-operative arthritis was 45.2%. Conversion to THA was 25.8%, with 8.1% having the arthroplasty procedure within a year of the original trauma surgery. LEVEL OF EVIDENCE: III.

Reconstruction of iliac crest with bovine cancellous allograft after bone graft harvest for symphysis pubis arthrodesis.

PURPOSE: The aim of this study was to evaluate the safety and efficiency, as well as the incorporation characteristics of a specific type of xenograft used for iliac crest defects post-harvesting tri-cortical iliac crest bone graft. METHODS: Sixteen patients diagnosed with chronic anterior pelvic pain were operated for pubic symphysis fusion. The tri-cortical graft harvested from the iliac crest was inserted into the pubic symphysis and compressed with a reconstruction plate. The defect in the iliac crest was filled with a block of cancellous bovine substitute (Tutobone®). The length of iliac crest defect, time to fusion of pubic symphysis, time to incorporation of the graft and complications were recorded. The postoperative pain and patients' satisfaction were evaluated. RESULTS: The median age of patients was 36.5 years (range 27-75). Fusion was obtained in 15 patients (94 %). The median time to fusion was four months (range three to seven). The length of the iliac crest bone defect ranged from 40 to 70 mm. Integration of the bovine substitute was achieved in 15 patients (94 %) over a median period of three months (range two to six). The postoperative median pain score was 2 (range 1-5). Twelve patients (75 %) reported good satisfaction. No major complications or allergic reactions were observed. CONCLUSIONS: The xenograft used in this study provided a safe and effective method of reconstruction of iliac crest donor site defects. It has satisfactory incorporation, high biocompatibility and no signs of inflammatory reactions. This new technique is simple and easily reproducible in routine clinical practice.

Surgical Treatment of Marginal Impaction Injuries of The Acetabulum Associated with Posterior Wall Fractures.

Posterior-wall acetabular fractures have been reported to be associated with marginal impaction characteristics in approximately 16% to 38% of cases1-3. Early recognition of this special entity of joint impaction is essential for effective preoperative planning, intraoperative execution, and favorable outcomes. The 2-level reconstruction technique is safe and effective in experienced hands. Description: The procedure is performed with the patient under general anesthesia, placed under traction in either the prone or lateral position with use of a radiolucent flat-top fracture table and fluoroscopic guidance. The Kocher-Langenbeck approach is utilized. The big posterior wall fracture is identified and reflected in order to visualize the joint surface. Subsequently, traction is applied to facilitate visualization of the marginal impaction area(s). With use of an osteotome, the impacted fragments are disimpacted and elevated. The femoral head is utilized as a template for accurate reduction of the impacted fragments to the acetabular joint surface. The resultant subchondral void is assessed and may be grafted with use of a variety of bone graft materials. The 2-level reconstruction technique may also be considered when the surgeon desires to optimize stability of the impacted fragments and maintain anatomical reduction. The big posterior wall fragment is reduced and fixed with use of the standard posterior-wall reconstruction technique. Finally, irrigation and wound closure in layers is performed. Alternatives: Treatment alternatives include either delayed or acute primary total hip arthroplasty in elderly patients >70 years old. Rationale: Preoperative identification of the marginal impaction is critical because articular incongruency leads to the development of early posttraumatic osteoarthritis. Achieving joint congruency is especially important in the young population in order to avoid an otherwise unnecessary early total hip arthroplasty. Expected Outcomes: Expected radiographic outcomes are excellent or good in 82% of cases, as measured with use of the Matta radiographic score1-3. Expected function outcomes are good to excellent in 67.5% of patients, as measured with use of the Modified Merle d'Aubigné system1-3. Total hip arthroplasty has been reported as a secondary procedure within 2 years postoperatively in 7.6% of patients1-3. Important Tips: Joint irrigation is crucial in order to clarify the details of the fragmentation and facilitate removal of debris. Impacted articular cartilage fragments are often rotated and face away from the femoral head. Utilize osteotomes to elevate the impacted area, taking care to mobilize adequate subchondral bone and the accompanying cartilage in case the 2-level reconstruction technique is needed and can be successfully applied. Utilize the femoral head as a template after traction is released to facilitate anatomical reduction. A 1.6-mm Kirschner wire should be available in case it is needed to temporarily stabilize the impacted fragments. Avoid overstuffing the void with bone graft because this may subsequently hinder successful reduction of the posterior wall fragment. Acronyms and Abbreviations: CT = computed tomographyAP = anteroposteriorK wire = Kirschner wirePDS = polydioxanone sutureAVN = avascular necrosis.

A technical note: How to extract broken Reamer-Irrigator-Aspirator (RIA) metal intramedullary debris.

The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick as a bailout in this difficult situation.

Induced membrane technique for acute bone loss and nonunion management of the tibia.

Objectives: To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects. Design: Retrospective study of prospectively collected data (Level IV). Setting: Level I trauma center in the UK. Patients/Participants: Consecutive patients with tibial nonunions and open fractures associated with bone loss.Intervention: Two-stage Masquelet Procedure for the tibia. Main Outcome Measurements: Clinical and imaging assessment at 6 weeks, 3,6,9,12 months, or until pain-free mobilization and union. Results: There were 17 eligible patients, with a mean size of bone defect of 6 cm (range, 4-8 cm) and an 88.2% union rate at a mean of 8 months (range 5-18 months). Mean range of motion was 95 degrees of knee flexion (range 80°-130°). All patients but 2 returned to their previous occupation. Conclusions: The Masquelet technique is simple, effective, and has a high rate of success for the management of a variety of situations including acute bone loss or infected nonunions and is associated with a low incidence of complications.

Trauma networks: present and future challenges.

In England, trauma is the leading cause of death across all age groups, with over 16,000 deaths per year. Major trauma implies the presence of multiple, serious injuries that could result in death or serious disability. Successive reports have documented the fact that the current ad hoc unstructured management of this patient group is associated with considerable avoidable death and disability. The reform of trauma care in England, especially of the severely injured patient, has already begun. Strong clinical leadership is embraced as the way forward. The present article summarises the steps that have been made over the last decade that led to the recent decision to move towards a long anticipated restructure of the National Health Service (NHS) trauma services with the introduction of Regional Trauma Networks (RTNs). While, for the first time, a genuine political will and support exists, the changes required to maintain the momentum for the implementation of the RTNs needs to be marshalled against arguments, myths and perceptions from the past. Such an approach may reverse the disinterest attitude of many, and will gradually evolve into a cultural shift of the public, clinicians and policymakers in the fullness of time.