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Case: This clinical case report presents a 40-year-old male who sustained an ipsilateral hip and knee dislocation with ipsilateral femoral head fracture and incomplete femoral neck fracture following a motorcycle collision. Conclusion: This report describes acute and later definitive orthopedic care and management, with focus on urgent interventions and timing of immediate treatments. Given the presented patient's favorable clinical outcomes, return to baseline activities, and absence of significant sequelae following injury, the considerations from the acute management and surgical planning of this patient's injuries can be used as a reference for treating the rare injury of ipsilateral knee and hip dislocations.
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OBJECTIVES: Lateral compression type II pelvic ring injuries can be treated with fixation through open or percutaneous approaches depending on the injury pattern and available osseous fixation pathways. The start site of iliosacral screws to stabilize these injuries should be on the unstable posterior iliac fragment; however, our understanding of start sites for iliosacral screws has not been developed. The purpose of this study is to provide an analysis of iliosacral screw start sites on the posterior ilium to help guide treatment of pelvic ring injuries. METHODS: One-hundred and seventeen consecutive patients at an academic level I trauma center with pelvic ring injuries who underwent surgical treatment with iliosacral screws were included in the final analysis. The start sites of iliosacral screws with confirmed intraosseous placement on a postoperative computed tomography were mapped on the posterior ilium and analyzed according to the sacral segment and type of iliosacral screw. RESULTS: One-hundred and seventeen patients were included in the final analysis. Of the total of 272 iliosacral screw insertion sites analyzed, 145 (53%) were sacroiliac-style screws and 127 (47%) were transsacral screws. The insertion sites for sacroiliac-style screws and transsacral screws at different sacral segment levels can vary but have predictable regions on the posterior ilium relative to reliable osseous landmarks. CONCLUSIONS: Iliosacral screws start sites on the posterior ilium have reliable regions that can be used to plan posterior fixation of pelvic ring injuries.
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Tornillos Óseos , Fijación Interna de Fracturas , Fracturas Óseas , Ilion , Huesos Pélvicos , Sacro , Tomografía Computarizada por Rayos X , Humanos , Ilion/cirugía , Ilion/lesiones , Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/instrumentación , Fracturas Óseas/cirugía , Fracturas Óseas/diagnóstico por imagen , Huesos Pélvicos/lesiones , Huesos Pélvicos/cirugía , Huesos Pélvicos/diagnóstico por imagen , Masculino , Femenino , Sacro/cirugía , Sacro/lesiones , Sacro/diagnóstico por imagen , Adulto , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Centros Traumatológicos , AncianoRESUMEN
PURPOSE: To identify a cohort of isolated medial tibial plateau fractures treated with surgical fixation and to categorize them by Moore and Wahlquist classifications in order to determine the rate of complications with each fracture morphology and the predictive value of each classification system. We hypothesized there would be high rates of neurovascular injury, compartment syndrome, and complications overall with a higher incidence of neurovascular injury in Moore type III rim avulsion fractures and Wahlquist type C fractures that enter the plateau lateral to the tibial spines. METHODS: Patients who presented to six Level I trauma centers between 2010 and 2021 who underwent surgical fixation for isolated medial tibial plateau fractures were retrospectively reviewed. Data including demographics, radiographs, complications, and functional outcomes were collected. RESULTS: One hundred and fifty isolated medial tibial plateau fractures were included. All patients were classified by the Wahlquist classification of medial tibial plateau fractures, and 139 patients were classifiable by the Moore classification of tibial plateau fracture-dislocations. Nine percent of fractures presented with neurovascular injury: 5 % with isolated vascular injury and 6 % with isolated nerve injury. There were no significant differences in neurovascular injury by fracture type (Wahlquist p = 0.16, Moore p = 0.33). Compartment syndrome developed in two patients (1.3 %). The average final range of motion was 0.8-122° with no difference by Wahlquist or Moore classifications (p = 0.11, p = 0.52). The overall complication rate was 32 % without differences by fracture morphology. The overall rate of return to the operating room (OR) was 25 %. CONCLUSIONS: Isolated medial tibial plateau fractures often represent fracture-dislocations of the knee and should receive a meticulous neurovascular exam on presentation with a high suspicion for neurovascular injury. No specific fracture pattern was found to be predictive of neurovascular injuries, complications, or final knee range of motion. Patients should be counseled pre-operatively regarding high rates of return to the OR after the index surgery.
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Fijación Interna de Fracturas , Rango del Movimiento Articular , Fracturas de la Tibia , Humanos , Fracturas de la Tibia/cirugía , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/complicaciones , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Fijación Interna de Fracturas/métodos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Anciano , Lesiones del Sistema Vascular/fisiopatología , Lesiones del Sistema Vascular/cirugía , Síndromes Compartimentales/etiología , Síndromes Compartimentales/cirugía , Centros Traumatológicos , Radiografía , Fracturas de la Meseta TibialRESUMEN
PURPOSE: Operative fixation of femoral neck fractures (FNFs) remains challenging. Complications are not infrequent, especially in displaced patterns. Numerous fixation techniques have been previously described in the literature; however, there remains a paucity of data regarding outcomes of these injuries treated with the femoral neck system (FNS). METHODS: Patients with a displaced FNF (OTA/AO 31B) treated with the FNS at a single level 1 academic trauma center between 1/1/2019 and 1/1/2023 were identified. Radiographs were reviewed to assess fracture displacement, location, and characteristics. Patient records were further reviewed to assess for complications, reoperations, and osseous union. RESULTS: Forty-three patients (65% male) with 44 FNFs were identified with a mean age of 35.0 years (range, 13-61 years). Two patients developed a deep infection requiring surgical debridement, four patients underwent a total hip arthroplasty, and one patient underwent a valgus intertrochanteric osteotomy for nonunion. There were three cases of femoral head AVN. Mean follow-up was 482.5 days among all patients, and 36 fractures had at least 6 months of follow-up or reached bony union. CONCLUSIONS: Here, we present a series of patients treated with the FNS for internal fixation and report a 18% reoperation rate. This is lower than the average rate that has been previously reported in similar patient populations in the literature treated with alternative methods of internal fixation. Thus, the FNS appears to be a safe and effective option for treatment of these injuries.
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Fracturas del Cuello Femoral , Fijación Interna de Fracturas , Reoperación , Humanos , Fracturas del Cuello Femoral/cirugía , Reoperación/estadística & datos numéricos , Reoperación/métodos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Fijación Interna de Fracturas/métodos , Adolescente , Adulto Joven , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Curación de Fractura , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/efectos adversosRESUMEN
INTRODUCTION: Distal femur fractures account for 3-6% of all femur fractures. Internal fixation of most distal femur fractures with an anatomic lateral locking plate should permit some motion at the metaphyseal portion of the fracture when secondary bone healing is planned by the operating surgeon. While several studies have been performed evaluating union rates for distal femur fractures with stainless steel and titanium plates, the timing of callus formation between stainless steel and titanium implants used as bridge plates for distal femur fractures (AO/OTA 33-A and -C) has been investigated to a lesser extent. We hypothesize that callus will be visualized earlier with post-operative radiographs with titanium versus stainless steel bridge plates. METHODS: We retrospectively reviewed a consecutive cohort of patients over 18 years of age with acute AO/OTA 33-A and 33-C fracture patterns treated with an isolated stainless steel or titanium lateral bridge plate within 4 weeks of injury by a single fellowship-trained orthopedic trauma surgeon from 2011 to 2020 at one academic Level 1 trauma center. An independent, fellowship-trained orthopedic trauma attending surgeon reviewed anterior-posterior (AP) and lateral radiographs from every available post-operative clinic visit and graded them using the Modified Radiographic Score for Tibia (mRUST). RESULTS: Twenty-five subjects were included in the study with 10 with stainless steel and 15 with titanium plates. There were no significant differences in demographics between both groups, including age, sex, BMI, injury classification, open versus closed, mechanism, and laterality. Statistically significant increased mRUST scores, indicating increased callus formation, were seen on 12-week radiographs (8.4 vs. 11.9, p = 0.02) when titanium bridge plates were used. There were no statistically significant differences in mRUST scores at 6 or 24-weeks, but scores in the titanium group were higher in at every timepoint. DISCUSSION: In conclusion, we observed greater callus formation at 12 weeks after internal fixation of 33-A and 33-C distal femur fractures treated with titanium locked lateral distal femoral bridge plates compared to stainless steel plates. Our data suggest that titanium metallurgy may have quicker callus formation compared to stainless steel if an isolated, lateral locked bridge plate is chosen for distal femur fracture fixation.
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Placas Óseas , Callo Óseo , Fracturas del Fémur , Fijación Interna de Fracturas , Acero Inoxidable , Titanio , Humanos , Fracturas del Fémur/cirugía , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/fisiopatología , Estudios Retrospectivos , Fijación Interna de Fracturas/instrumentación , Fijación Interna de Fracturas/métodos , Masculino , Callo Óseo/diagnóstico por imagen , Femenino , Persona de Mediana Edad , Adulto , Radiografía , Curación de Fractura/fisiología , Anciano , Fracturas Femorales DistalesRESUMEN
PURPOSE: Obesity is an epidemic which increases risk of many surgical procedures. Previous studies in spine and hip arthroplasty have shown that fat thickness measured on preoperative imaging may be as or more reliable in assessment of risk of post-operative infection and/or wound complications than body mass index (BMI). We hypothesized that, similarly, increased local fat thickness at the surgical site is a predictor of wound complication in acetabulum fracture surgery. METHODS: Patients who underwent open reduction and internal fixation (ORIF) of an acetabulum fracture through a Kocher-Langenbeck (K-L) approach at a single institution from 2013 to 2020 were identified. Pre-operative CT scans were used to measure fat thickness from the skin to the greater trochanter in line with the surgical approach. Post-operative infections and wound complications were recorded and associated with fat thickness and BMI. RESULTS: 238 patients met inclusion criteria. 12 patients had either infection or a wound complication (5.0%). There was no significant association with BMI or preoperative fat thickness on post-operative infection or wound complication (p-value 0.73 and 0.86). CONCLUSIONS: There is no statistically significant association of post-operative infection or wound complications in patients with increased soft tissue thickness or increased BMI. ORIF of acetabulum fractures through a K-L approach can be performed safely in patients with large subcutaneous fat thickness and high BMI with low risk of infection or wound complications.
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Acetábulo , Tejido Adiposo , Índice de Masa Corporal , Fijación Interna de Fracturas , Fracturas Óseas , Reducción Abierta , Infección de la Herida Quirúrgica , Humanos , Acetábulo/cirugía , Acetábulo/diagnóstico por imagen , Acetábulo/lesiones , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Masculino , Femenino , Infección de la Herida Quirúrgica/etiología , Fracturas Óseas/cirugía , Fracturas Óseas/diagnóstico por imagen , Persona de Mediana Edad , Reducción Abierta/efectos adversos , Reducción Abierta/métodos , Adulto , Tejido Adiposo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Estudios Retrospectivos , Obesidad/complicaciones , Factores de RiesgoRESUMEN
PURPOSE: Intra-articular distal femur fractures in patients with a lower extremity amputation can present a technical challenge for the treating surgeon in what may be otherwise considered a routine procedure in non-amputees. Difficulties with positioning, fracture reduction, limb contractures, and stump osteoporosis can present challenges with treatment. Here, we describe the surgical technique and outcome of a case series of amputee patients with AO/OTA 33C femur fractures. METHODS: Retrospective case series of five patients with a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation treated with retrograde intramedullary nail at a single Level 1 trauma center from January 1, 2021, to January 1, 2023. Baseline demographic and clinical data were recorded. Rate of bony union and complications were documented. RESULTS: Five patients (three females and two males) with a mean age of 48 years who were treated for a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation were identified. At the time of final follow-up (mean 109.3 days, range 29-183 days), all patients had healed their incisions and were progressing to return of function with their prosthesis. All patients were treated with the surgical technique described in this article, and no postoperative complications were reported. CONCLUSION: This is an effective and safe technique for surgical treatment of comminuted intra-articular distal femur fractures in patients with an ipsilateral below-knee amputation. We believe that this technique can be utilized by any orthopedic surgeon taking trauma call and can avoid unnecessary transfers or delays to care.
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Amputación Quirúrgica , Fracturas del Fémur , Fijación Intramedular de Fracturas , Fracturas Conminutas , Humanos , Fracturas del Fémur/cirugía , Femenino , Masculino , Fijación Intramedular de Fracturas/métodos , Fijación Intramedular de Fracturas/efectos adversos , Fijación Intramedular de Fracturas/instrumentación , Persona de Mediana Edad , Estudios Retrospectivos , Adulto , Fracturas Conminutas/cirugía , Amputación Quirúrgica/métodos , Clavos Ortopédicos , Resultado del Tratamiento , Curación de Fractura , AncianoRESUMEN
CASE: The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts. CONCLUSION: Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.
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Fracturas del Cuello Femoral , Fijación Interna de Fracturas , Humanos , Fijación Interna de Fracturas/métodos , Fracturas del Cuello Femoral/diagnóstico por imagen , Fracturas del Cuello Femoral/cirugía , Fijación de Fractura/métodos , FluoroscopíaRESUMEN
OBJECTIVES: To determine the incidence of infection in nonoperative versus operative management of extraperitoneal bladder ruptures in patients with pelvic ring injuries. DESIGN: A retrospective cohort study of 2 prospectively collected trauma registries. SETTING: Two Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients with operative pelvic ring injuries, 68 (6%) had extraperitoneal bladder ruptures. OUTCOME MEASURES AND COMPARISONS: The primary outcome was the incidence and associated risk factors of deep pelvic infection requiring return to OR for surgical debridement. Secondary outcomes included quality of reduction, other complications, and radiographic union. Comparisons were made based on the status of any associated bladder injury. RESULTS: Of 1127 patients with operative pelvic ring injuries, 68 patients had extraperitoneal bladder ruptures, 55 had bladder repair and 13 did not. Of those 13 without repair, none had ORIF of the anterior pelvic ring. Patients without bladder repair had an increased odds of infection 17-fold compared to patients who did have a repair performed (OR 16.9, 95% CI 1.75 - 164, P = 0.01). Other associated factors for deep pelvic infection included use of suprapubic catheter ( p < 0.02) and a closed reduction of the anterior ring ( p < 0.01). Patients undergoing anterior ring ORIF and bladder repair had improved reductions and no increased infection risk. CONCLUSIONS: Operative repair of extraperitoneal bladder ruptures decreases risk of infection in patients with pelvic ring injuries. Additionally, ORIF of the anterior pelvic ring does not increase the risk of infection and results in better reductions compared to closed reduction. Treatment algorithms for these combined injuries should consider recommending early bladder repair and anterior pelvic ORIF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas Óseas , Huesos Pélvicos , Infección Pélvica , Humanos , Fracturas Óseas/cirugía , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesiones , Estudios Retrospectivos , Vejiga Urinaria/cirugía , Vejiga Urinaria/lesiones , Desbridamiento , Infección Pélvica/etiología , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/métodos , Resultado del TratamientoRESUMEN
PURPOSE: To describe U-type sacral fracture characteristics amenable to percutaneous sacral screw fixation. METHODS: U-type sacral fractures were identified from a trauma registry at a level 1 trauma center from 2014 to 2020. Patient demographics, injury mechanism, fracture characteristics, and fixation construct were retrospectively retrieved. Associations between fracture pattern and surgical fixation were identified. RESULTS: 82 U-type sacral fractures were reviewed. Six treated with lumbopelvic fixation (LPF) and 76 were treated with percutaneous sacral screws (PSS) alone. Patients receiving LBF had greater sacral fracture displacement in coronal, sagittal, and axial planes compared to patients receiving PSS alone (P < 0.05), negating osseous fixation pathways. All patients went onto sacral union and there were no implant failures or unplanned reoperations for either group. CONCLUSION: If osseous fixation pathways are present, U-type sacral fractures can be successfully treated with percutaneous sacral screws. LPF may be indicated in more displaced fractures with loss of spinopelvic alignment. Both techniques for U-type sacral fractures result in reliable fixation and healing without reoperations.
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SUMMARY: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.
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Fracturas Óseas , Fracturas de Cadera , Huesos Pélvicos , Fracturas de la Columna Vertebral , Humanos , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Fijación Interna de Fracturas/métodos , Tornillos Óseos , Pelvis/cirugía , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Acetábulo/lesiones , Fluoroscopía/métodos , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesionesRESUMEN
Pelvic ring injuries and acetabular fractures are complex injuries and are often challenging to treat for a number of reasons. Orthopaedic trauma surgeons critically evaluate pelvic radiographs and CT images to generate an appropriate detailed injury and patient-specific preoperative plan. There are numerous crucial osseous details that surgeons should be aware of. Often, some of the most important factors that affect patients in treatment timing decisions, assessing reduction strategies, and deciding and inserting fixation constructs may be subtle on preoperative imaging. The radiographic and CT imaging findings covered subsequently should be sought out and appreciated preoperatively. Combining all the available osseous information helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Ensuring a methodical and meticulous imaging review allows for the development of a detailed preoperative plan and helps avoid intraoperative missteps. This process will inherently streamline the surgical procedure and optimize the patient's surgical care. Maximizing the accuracy of the preoperative planning process can streamline the treatment algorithm and ultimately contribute to the best possible clinical outcome.
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Fracturas Óseas , Fracturas de Cadera , Huesos Pélvicos , Humanos , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesiones , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Acetábulo/lesiones , Fijación Interna de Fracturas/métodos , Pelvis , Estudios RetrospectivosRESUMEN
OBJECTIVES: To compare debridement, antibiotics, and implant retention (DAIR) and intramedullary nail (IMN) removal with subsequent strategy for fracture stabilization in the treatment of tibia fracture-related infections (FRIs) occurring within 90 days of initial IMN placement. DESIGN: Retrospective case-control. SETTING: Four academic, Level 1 trauma centers. PATIENTS: Sixty-six patients who subsequently received unplanned operative treatment for FRI diagnosed within 90 days of initial tibia IMN. INTERVENTION: DAIR versus IMN removal pathways. MAIN OUTCOME MEASUREMENTS: Fracture union. RESULTS: Twenty-eight patients (42.4%) were treated with DAIR and 38 (57.6%) via IMN removal with subsequent strategy for fracture stabilization. Mean follow-up was 16.3 months. At final follow-up, ultimate bone healing was achieved in 75.8% (47/62), whereas 24.2% (15/62) had persistent nonunion or amputation. No significant difference was observed in ultimate bone healing ( P = 0.216) comparing DAIR and IMN removal. Factors associated with persistent nonunion or amputation were time from injury to initial IMN ( P < 0.001), McPherson systemic host grade B ( P = 0.046), and increasing open-fracture grade, with Gustilo-Anderson IIIB/IIIC fractures being the worst ( P = 0.009). Fewer surgeries after initial FRI treatment were positively associated with ultimate bone healing ( P = 0.029). CONCLUSIONS: Treatment of FRI within 90 days of tibial IMN with DAIR or IMN removal with subsequent strategy for fracture stabilization results in a high rate, nearly 1 in 4, of persistent nonunion or amputation, with neither appearing superior for improving bone healing outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Pelvic ring injuries and acetabular fractures can be complex and challenging to treat. Orthopaedic trauma surgeons scrutinize pelvic radiographs and accompanying CT images for the osseous details that help create a thorough patient-specific preoperative plan. While the osseous details are incredibly important, the surrounding soft-tissue structures are equally as critical and can have a tremendous effect on both the patient and the surgeon. These findings may change surgery timing, dictate the need for additional surgeons or multidisciplinary teams, and determine the treatment sequence. The structures and potential clinical findings reviewed and demonstrated through example images should be sought out during physical examination and correlative preoperative imaging review. Combining all the available osseous and nonosseous information with a detailed approach helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Maximizing the accuracy of the preoperative planning process can streamline treatment algorithm development and ultimately contribute to the best possible clinical patient outcome.
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Fracturas Óseas , Fracturas de Cadera , Huesos Pélvicos , Humanos , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Acetábulo/lesiones , Fijación Interna de Fracturas/métodos , Pelvis , Radiografía , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/cirugía , Huesos Pélvicos/lesionesRESUMEN
Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities.
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INTRODUCTION: The purpose of this study is to (1) describe a pre-operative planning technique using non-reformatted CT images for insertion of multiple transiliac-transsacral (TI-TS) screws at a single sacral level, (2) define the parameters of a sacral osseous fixation pathway (OFP) that will allow for insertion of two TI-TS screws at a single level, and (3) identify the incidence of sacral OFPs large enough for dual-screw insertion in a representative patient population. METHODS: Retrospective review at a level-1 academic trauma center of a cohort of patients with unstable pelvic injuries treated with two TI-TS screws in the same sacral OFP, and a control cohort of patients without pelvic injuries who had CT scans for other reasons. RESULTS: Thirty-nine patients had two TI-TS screws at S1. Eleven patients, all with dysmorphic osteology, had two TI-TS screws at S2. The average pathway size in the sagittal plane at the level the screws were placed was 17.2 mm in S1 vs 14.4 mm in S2 (p = 0.02). Twenty-one patients (42%) had screws that were intraosseous and 29 (58%) had part of a screw that was juxtaforaminal. No screws were extraosseous. The average OFP size of intraosseous screws was 18.1 mm vs. 15.5 mm for juxtaforaminal screws (p = 0.02). Fourteen millimeters was used as a guide for the lower limit of the OFP for safe dual-screw fixation. Overall, 30% of S1 or S2 pathways were ≥ 14 mm in the control group, with 58% of control patients having at least one of the S1 or S2 pathways ≥ 14 mm. CONCLUSIONS: OFPs ≥ 7.5 mm in the axial plane and 14 mm in the sagittal plane on non-reformatted CT images are large enough for dual-screw fixation at a single sacral level. Overall, 30% of S1 and S2 pathways were ≥ 14 mm and 58% of control patients had an available OFP in at least one sacral level.
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Fracturas Óseas , Huesos Pélvicos , Humanos , Fijación Interna de Fracturas/métodos , Tornillos Óseos , Sacro/diagnóstico por imagen , Sacro/cirugía , Sacro/lesiones , Tomografía Computarizada por Rayos X , Estudios Retrospectivos , Ilion/cirugía , Ilion/lesiones , Huesos Pélvicos/lesiones , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugíaRESUMEN
OBJECTIVES: To determine the infection and nonunion rates for open tibia fracture treatment over the past 4 decades since the introduction of the Gustilo-Anderson (GA) open fracture classification. DATA SOURCES: PubMed, Scopus, CINAHL, and Cochrane databases were reviewed using the PRISMA checklist for articles between 1977 and September 2018. STUDY SELECTION: One hundred sixty-one articles meeting the following inclusion criteria: English language, published between 1977 and 2018, reported infection rates, reported nonunion rates, and fractures classified by the GA open fracture criteria were selected. DATA EXTRACTION: All articles were thoroughly evaluated to extract infection and nonunion data for open tibia fractures. DATA SYNTHESIS: Due to variability in the data reviewed, statistical evaluation could not be reliably done. RESULTS: 11,326 open tibia fractures were reported with 17% type I, 25.2% type II, 25.3% type IIIA, and 32.5% type IIIB/C. The average infection rate over 4 decades was 18.3%, with 24.3% superficial, 11.2% deep, and 14.7% pin tract. The infection rate by decade was 14% for 1977-1986, 16.2% for 1987-1996, 20.5% for 1997%-2006%, and 18.1% from 2007 to 2017. The overall nonunion rate was 14.1%. The nonunion rate was 13% for 1977-1986, 17% for 1987-1996, 12.8% for 1997%-2006%, and 12.3% for 2007-2017. CONCLUSIONS: This in-depth summary has demonstrated that the percentage rate for infections and nonunion has remained similar over the past 40 years. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Fracturas Abiertas , Fracturas de la Tibia , Humanos , Tibia , Fracturas Abiertas/epidemiología , Fracturas Abiertas/cirugía , Estudios Retrospectivos , Fracturas de la Tibia/epidemiología , Fracturas de la Tibia/cirugía , Resultado del TratamientoRESUMEN
SUMMARY: Intra-articular glenoid displacement is an indication for open reduction and internal fixation of scapular fractures. However, direct visualization of the glenoid is limited, and articular reductions are typically performed and assessed using extra-articular cortical reduction reads and fluoroscopic imaging. In this technique, we describe the application of a distractor for direct visualization of the glenoid articular surface. In this way, anatomic reduction of the glenoid articular surface can be assessed and achieved. In addition, we discuss the use of a portable, dry arthroscopy when needed. This technique has resulted in good-to-excellent articular reductions by adjusting extra-articular reads that seemed adequate before intra-articular visualization. This technique is safe, requires minimal extra set-up or instruments, and results in good-to-excellent articular reductions.
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OBJECTIVE: To quantify the posterior acetabular exposure achieved with the Kocher-Langenbeck (K-L) with gluteus minimus debridement and Gibson approaches. METHODS: A Kocher-Langenbeck approach and a subsequent Gibson approach on the contralateral hip were performed in the prone position on 9 fresh frozen cadavers. Calibrated digital images were obtained of the Kocher-Langenbeck exposure, Kocher-Langenbeck exposure after gluteus minimus debridement, and Gibson exposure. The surface area of the posterior hip and pelvis visualized with each approach was calculated and compared with the contralateral side to assess for the difference between exposures. RESULTS: In 5 of the 9 cadavers, the Kocher-Langenbeck exposure before gluteus minimus debridement yielded an increased exposure in comparison with the Gibson approach, and the exposure was equivocal in 3 specimens. An increase of greater than 10% was considered significant. The exposure increased anteriorly and cranially by an average of 13.1 cm 2 after debridement of the gluteus minimus caudal to the superior gluteal neurovascular bundle in the Kocher-Langenbeck approach. CONCLUSIONS: Debridement of the gluteus minimus caudal to the level of the superior gluteal neurovascular bundle can significantly increase anterior and cranial exposure in the Kocher-Langenbeck approach and provide similar areas of access when compared with that in the Gibson approach.