Iatrogenic Sciatic Nerve Injury in Posterior Acetabular Surgery: Surgeon More Predictive Than Position.

OBJECTIVES: To identify factors that contribute to iatrogenic sciatic nerve palsy during acetabular surgery through a Kocher-Langenbeck approach and to evaluate if variation among individual surgeons exists. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: Adults undergoing fixation of acetabular fractures (AO/OTA 62) through a posterior approach by 9 orthopaedic traumatologists between November 2010 and November 2022. OUTCOME MEASURES AND COMPARISONS: The prevalence of iatrogenic sciatic nerve palsy and comparison of the prevalence and risk of palsy between prone and lateral positions before and after adjusting for individual surgeon and the presence of transverse fracture patterns in logistic regression. Comparison of the prevalence of palsy between high-volume (>1 patient/month) and low-volume surgeons. RESULTS: A total of 644 acetabular fractures repaired through a posterior approach were included (median age 39 years, 72% male). Twenty of 644 surgeries (3.1%) resulted in iatrogenic sciatic nerve palsy with no significant difference between the prone (3.1%, 95% confidence interval [CI], 1.9%-4.9%) and lateral (3.3%, 95% CI, 1.3%-8.1%) positions (P = 0.64). Logistic regression adjusting for surgeon and transverse fracture pattern demonstrated no significant effect for positions (odds ratio 1.0, 95% CI, 0.3-3.9). Transverse fracture pattern was associated with increased palsy risk (odds ratio 3.0, 95% CI, 1.1-7.9). Individual surgeon was significantly associated with iatrogenic palsy (P < 0.02). CONCLUSIONS: Surgeon and the presence of a transverse fracture line predicted iatrogenic nerve palsy after a posterior approach to the acetabulum in this single-center cohort. Surgeons should perform the Kocher-Langenbeck approach for acetabular fixation in the position they deem most appropriate, as the position was not associated with the rate of iatrogenic palsy in this series. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Femoral and Tibial Shaft Fractures in Chronic Spinal Cord Injury Patients.

OBJECTIVES: To compare outcomes and complications between non-operative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI). METHODS: Design: Retrospective cohort study. SETTING: Three Level-1 Trauma centers. PATIENT SELECTION CRITERIA: All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from 01/01/2009 through 12/31/2019 were included. OUTCOME MEASURES AND COMPARISONS: Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion and treatment complications (infection, pressure ulcers, nonunion, DVT/PE, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome. RESULTS: Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the non-operative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and non-operative management for pressure ulcers (19% vs 52.9%, p=0.009) and mean VAS pain score at first follow-up (1.19 vs 3.3, p=0.03). No difference was seen for rates of infection, nonunion, DVT/PE, stroke, amputation, death, return to baseline activity, and range of motion. CONCLUSIONS: Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared to non-operative management. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Head Fractures: Evaluation, Management, and Outcomes.

Fractures of the femoral head typically occur after high-energy trauma. Radiographs and cross-sectional imaging are used to appropriately classify and identify associated injuries or morphologic characteristics that may influence management. Identification of the radiographic and clinical hallmarks of an irreducible variant is critical to optimizing the patient's outcome. Nonsurgical treatment can be used in the setting of small, infrafoveal femoral head fractures without hip instability. When surgical treatment is indicated, an anterior (Smith-Petersen), posterior (Kocher-Langenbeck), or surgical hip dislocation approach may be used depending on injury details and surgeon preference. The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and outcomes.

The Effect of Extracorporeal Membrane Oxygenation in Patients With Multiple Orthopaedic Injuries.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) plays a vital role in providing life support for patients with reversible cardiac or respiratory failure. Given the high rate of complications and difficulties associated with caring for ECMO patients, the goal of this study was to compare outcomes of orthopaedic surgery in polytrauma patients who received ECMO with similar patients who have not. This will help elucidate the timing and type of fixation that should be considered in patients on ECMO. METHODS: A retrospective cohort was collected from the electronic medical record of two level I trauma centers over an 8-year period (2015 to 2022) using Current Procedural Terminology codes. Patients were matched with a similar counterpart not requiring ECMO based on sex, age, American Society of Anesthesiologists score, body mass index, injury severity score, and fracture characteristics. Outcomes measured included length of stay, number of revisions, time to definitive fixation, infection, amputation, revision surgery to promote bone healing, implant failure, bleeding requiring return to the operating room, and mortality. RESULTS: Thirty-two patients comprised our ECMO cohort with a patient-matched control group. The ECMO cohort had an increased length of stay (40 versus 17.5 days, P = 0.001), number of amputations (7 versus 0, P = 0.011), and mortality rate (19% versus 0%, P = 0.024). When comparing patients placed on ECMO before definitive fixation and after definitive fixation, the group placed on ECMO before definitive fixation had significantly longer time to definitive fixation than the group placed on ECMO after fixation (14 versus 2.0 days, P < 0.001). CONCLUSION: ECMO is a lifesaving measure for trauma patients with cardiopulmonary issues but can complicate fracture care. Although it is not associated with an increase in revision surgery rates, ECMO was associated with prolonged hospital stay and delays in definitive fracture surgery when initiated before definitive fixation. LEVEL OF EVIDENCE: III.

Evaluating ChatGPT's Ability to Answer Common Patient Questions Regarding Hip Fracture.

INTRODUCTION: ChatGPT is an artificial intelligence chatbot software programmed for conversational applications using reinforcement learning techniques. With its growing popularity and overall versatility, it is likely that ChatGPT's applications will expand into health care especially because it relates to patients researching their injuries. The purpose of this study was to investigate ChatGPT's ability to accurately answer frequently asked questions regarding hip fractures. METHODS: Eleven frequently asked questions regarding hip fractures were posed to ChatGPT, and the responses were recorded in full. Five of these questions were determined to be high-yield based on the likelihood that a patient would ask the question to a chatbot software. The chatbot's responses were analyzed by five fellowship-trained orthopaedic trauma surgeons for their quality and accuracy using an evidence-based approach. The chatbot's answers were rated as "Excellent response requiring no clarification", "Satisfactory response requiring minimal clarification", "Satisfactory response requiring moderate clarification", or "Unsatisfactory response requiring significant clarification." RESULTS: Of the five high-yield questions posed to the chatbot, no question was determined to be unsatisfactory requiring significant clarification by the authors. The remaining responses were either satisfactory requiring minimal clarification (n = 3) or satisfactory requiring moderate clarification (n = 2). DISCUSSION: The chatbot was generally found to provide unbiased and evidence-based answers that would be clearly understood by most orthopaedic patients. These findings suggest that ChatGPT has the potential to be an effective patient education tool especially because it continues to grow and improve as a chatbot application. LEVEL OF EVIDENCE: Level IV study.

Lumbopelvic fixation in the treatment of spinopelvic dissociation: union, complications, and neurologic outcomes of a multicenter case series.

PURPOSE: To review outcomes of spinopelvic dissociation treated with open lumbopelvic fixation. METHODS: We reviewed all cases of spinopelvic dissociation treated at three Level-I trauma centers with open lumbopelvic fixation, including those with adjunctive percutaneous fixation. We collected demographic data, associated injuries, pre- and postoperative neurologic status, pre- and postoperative kyphosis, and Roy-Camille classification. Outcomes included presence of union, reoperation rates, and complications involving hardware or wound. RESULTS: From an initial cohort of 260 patients with spinopelvic dissociation, forty patients fulfilled inclusion criteria with a median follow-up of 351 days. Ten patients (25%) had a combination of percutaneous iliosacral and open lumbopelvic repair. Average pre- and postoperative kyphosis was 30 degrees and 26 degrees, respectively. Twenty patients (50%) had neurologic deficit preoperatively, and eight (20%) were unknown or unable to be assessed. All patients presenting with bowel or bladder dysfunction (n = 12) underwent laminectomy at time of surgery, with 3 patients (25%) having continued dysfunction at final follow-up. Surgical site infection occurred in four cases (10%) and wound complications in two (5%). All cases (100%) went on to union and five patients (13%) required hardware removal. CONCLUSION: Open lumbopelvic fixation resulted in a high union rate in the treatment of spinopelvic dissociation. Approximately 1 in 6 patients had a wound complication, the majority of which were surgical site infections. Bowel and bladder dysfunction at presentation were common with the majority of cases resolving by final follow-up when spinopelvic dissociation had been treated with decompression and stable fixation.

Percutaneous Posterior Pelvic Fixation of Spinopelvic Dissociation: A Multicenter Series of Displaced Patterns.

OBJECTIVE: To characterize the success and complications of percutaneous posterior pelvic fixation in the treatment of displaced spinopelvic dissociation patterns. DESIGN: Retrospective cohort study. SETTING: Three Level I trauma centers. PATIENTS: 53 patients with displaced spinopelvic patterns were enrolled. INTERVENTION: Percutaneous iliosacral screw fixation was used. MAIN OUTCOME MEASURES: Main outcome measures include incidence of union, fixation failure, and soft tissue complications. RESULTS: All patients had displaced, unstable patterns with a mean preoperative kyphosis of 29.7 ± 15.4 degrees (range, 0-70). Most of the patients treated were neurologically intact (72%) or had an unknown examination at the time of fixation (15%). The median follow-up was 254 days (interquartile range, 141-531). The union rate was 98%. Radiographic and clinical follow-up demonstrated 1 case (2%) of nonunion. Two patients (4%) had radiographic evidence of screw loosening at the final follow-up, both of whom had fixation with a single sacroiliac-style screw placed bilaterally and went on to uneventful union. Neurologic recovery occurred at an average of 195 ± 114 days (range, 82-363 days). When present, long-term neurologic sequelae most commonly consisted of radicular pain and paresthesias at the final follow-up (n = 3, 6%). CONCLUSIONS: Percutaneous posterior pelvic fixation of select displaced spinopelvic dissociation seems to be safe with a low complication rate and reliable union. In a cohort of displaced fractures that were fixed in situ, we found a 2% rate of fixation failure/nonunion. Although rare, radicular pain and paresthesias were the most common long-term neurologic sequela. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparative Analysis of Supplemental Medial Buttress Plate Fixation for High-Energy Displaced Femoral Neck Fractures in Young Adults.

OBJECTIVES: To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures. DESIGN: Multicenter retrospective matched cohort comparative clinical study. SETTING: Twenty-seven North American Level 1 trauma centers. PATIENTS: Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture. INTERVENTION: Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP. MAIN OUTCOME MEASUREMENTS: Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty. RESULTS: Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001). CONCLUSIONS: The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning . LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Non-osseous considerations in diagnostic imaging for pelvic and acetabular trauma.

High-quality imaging is crucial for orthopedic traumatologists in the evaluation and management of pelvic and acetabular fractures. Computed tomography (CT) plays an essential role in the diagnosis and treatment of patients with these complex injuries. A thoughtful evaluation of associated soft tissues can reveal additional details about the patient and their injury that may impact treatment. This review aims to highlight soft tissue findings that should be identified when evaluating the initial diagnostic imaging after pelvic and acetabular trauma.

Comparing Calcaneus Fracture Radiographic Outcomes and Complications after Percutaneous Pin versus Screw Fixation.

Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Although screws are thought to provide greater stability, limited data exists directly comparing fixation success of these implants. Medical record data from 53 patients (62 total fractures) surgically treated with percutaneous screws (28 fractures) or K-wires (34 fractures) for joint-depression calcaneus fractures at a large tertiary hospital were retrospectively reviewed. Bohler's angle and calcaneal varus were assessed from available radiographs at time of injury, postoperatively, and at final follow-up, and joint congruity was assessed postoperatively and at final follow-up. Complications were also extracted. There were no statistical differences in patient characteristics between surgical groups although a higher proportion of patients treated with K-wires compared to screws had other associated injuries (79% vs 42%, p = .01). A higher proportion of fractures treated with screws compared to K-wires maintained joint congruity at the final follow-up (69% vs 32%, p = .005). However, there were no statistically detectable differences in other postoperative radiographic metrics (p > .05). In conclusion, joint congruity was more often maintained with screw fixation although there was no statistical difference in restoration and maintenance of Bohler's angle or varus alignment. The difference in radiographic metrics was not correlated with secondary procedures, namely subtalar arthrodesis, and may not be clinically significant. Neither group was completely effective in attaining and maintaining reduction, and additional fixation strategies should be considered if feasible based on patient, injury, and soft tissue characteristics.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Neurologic injury after spinopelvic dissociation: Incidence, outcome, and predictors.

BACKGROUND: Traumatic spinopelvic dissociation is a rare injury pattern resulting in discontinuity between the spine and bony pelvis. This injury is associated with a known risk of neurologic compromise which can impact the clinical outcome of these patients. We sought to determine incidence and characteristics of neurologic injury, outcomes following treatment, and predictive factors for neurologic recovery. METHODS: We reviewed the clinical documentation and imaging of 270 patients with spinopelvic dissociation from three Level-1 trauma centers treated over a 20-year period. From this cohort, 137 patients fulfilled inclusion criteria with appropriate follow-up. Details surrounding patient presentation, incidence of neurologic injury, and outcome variables were collected for each injury. Neurologic injuries were categorized using the Gibbons criteria. Multivariate analysis was performed to assess for patient and injury factors predictive of neurologic injury and recovery. RESULTS: The overall incidence of neurologic injury in spinopelvic dissociation injuries was 33% (45/137), with bowel and/or bladder dysfunction (n=16) being the most common presentation. Complete neurologic recovery was seen in 26 cases (58%) and two patients (4%) improved at least one Gibbon stage in clinical follow-up. The most common long-term neurologic sequela at final follow-up was radiculopathy (n=12, 9%). Increased kyphosis was found to be associated with neurologic injury (p=0.002), while location of transverse limb and Roy-Camille type were not predictive of neurologic injury (p=0.31 and p=0.07, respectively). There were no factors found to be predictive of neurologic recovery in this cohort. CONCLUSION: Neurologic injury is commonly seen in patients with spinopelvic dissociation and complete neurologic recovery was seen in the majority of patients at final follow-up. When present, long term neurologic dysfunction is most commonly characterized by radiculopathy. While increasing kyphosis was shown to be associated with neurologic injury, no patient or injury factors were predictive of neurologic recovery.

Sacral Insufficiency Fractures.

¼: Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. ¼: The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. ¼: Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. ¼: Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. ¼: The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Treatment Failure in Femoral Neck Fractures in Adults Less Than 50 Years of Age: Analysis of 492 Patients Repaired at 26 North American Trauma Centers.

OBJECTIVES: To assess the operative results of femoral neck fractures (FNFs) in young adults in a large multicenter series, specifically focusing on risk factors for treatment failure. DESIGN: Large multicenter retrospective cohort series. SETTING: Twenty-six North American Level 1 trauma centers. PATIENTS: Skeletally mature patients younger than 50 years with displaced and nondisplaced FNFs treated between 2005 and 2017. INTERVENTION: Operative repair of FNF. MAIN OUTCOME MEASUREMENTS: The main outcome measure is treatment failure: nonunion and/or failed fixation, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (arthroplasty or proximal femoral osteotomy). Logistic regression models were conducted to examine factors associated with treatment failure. RESULTS: Of 492 patients with FNFs studied, a major complication and/or subsequent major reconstructive surgery occurred in 45% (52% of 377 displaced fractures and 21% of 115 nondisplaced fractures). Overall, 23% of patients had nonunion/failure of fixation, 12% osteonecrosis type 2b or worse, 15% malunion (>10 mm), and 32% required major reconstructive surgery. Odds of failure were increased with fair-to-poor reduction [odds ratio (OR) = 5.29, 95% confidence interval (CI) = 2.41-13.31], chronic alcohol misuse (OR = 3.08, 95% CI = 1.59-6.38), comminution (OR = 2.63, 95% CI = 1.69-4.13), multiple screw constructs (vs. fixed-angle devices, OR = 1.95, 95% CI = 1.30-2.95), metabolic bone disease (OR = 1.77, 95% CI = 1.17-2.67), and increasing age (OR = 1.03, 95% CI = 1.01-1.06). Women (OR = 0.57, 95% CI = 0.37-0.88), Pauwels angle ≤50 degrees (type 1 or 2; OR = 0.64, 95% CI = 0.41-0.98), or associated femoral shaft fracture (OR = 0.19, 95% CI = 0.10-0.33) had lower odds of failure. CONCLUSIONS: FNFs in adults <50 years old remain a difficult clinical and surgical problem, with 45% of patients experiencing major complications and 32% undergoing subsequent major reconstructive surgery. Risk factors for complications after treatment of displaced FNFs were numerous. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Statistical Literacy in the Orthopaedic Trauma Population.

OBJECTIVE: To evaluate the baseline level and demographic predictors of statistical literacy in orthopaedic patients who sustained traumatic injuries. DESIGN: Prospective observational. SETTING: Level 1 trauma center. PATIENTS: One hundred ninety-eight patients presenting to the orthopaedic trauma clinic. INTERVENTION: Berlin Numeracy Test (BNT) and General Health Numeracy Test-6 (GHNT-6). RESULTS: When assessed using the BNT, 67% of patients had results that placed them into the lowest quartile of objective numeracy skills. Only 3.5% of patients had results that scored in the top quartile. Our multivariate ordinal regression model demonstrated lower education level ( P = 0.01), and older age ( P = 0.03) were significant predictors of poor performance on the BNT. The mean score on the GHNT-6 was 36% (SD 30%). CONCLUSIONS: In a cohort of traumatically injured patients, poor statistical literacy was common, occurring in more than two-thirds of patient surveyed. Older age and lower levels of education were predictive of poor BNT performance and should be considered when discussing surgical options, associated risks, and likelihood of potential complications.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

SUMMARY: Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes.

OBJECTIVE: To characterize the associated injuries, fixation constructs, and outcomes of extra-articular unstable iliac fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Thirty-three extra-articular unstable iliac fractures treated over a 20-year period. INTERVENTION: Percutaneous or open fixation of iliac fractures at the pelvic brim AND/OR iliac crest. MAIN OUTCOME MEASURES: Incidence of union, fixation failure, and angiography at the time of injury. RESULTS: Twenty-five patients were treated operatively with appropriate follow-up. Four patients had fixation failure with displacement, all in the group with only brim OR crest fixation (4/8 patients, 50% rate). In patients with both crest AND brim fixation (n = 17), there were no cases of implant failure or late displacement. In displaced fractures (n = 22), 4 patients (18%) required embolization by interventional radiology. In all 4 cases, the superior gluteal artery was embolized. In patients with both crest AND brim fixation, all went on to uneventful union with an average Visual Analog Scale (VAS) pain score of 0.9 (range, 0-5) at final follow-up. CONCLUSIONS: Extra-articular unstable iliac fractures are high-energy injuries that demonstrate a high rate of union when both pelvic brim AND iliac crest fixation is used. Approximately 1 in 5 patients with a displaced iliac fracture presented with a superior gluteal artery disruption requiring embolization. Pelvic brim OR iliac crest fixation used in isolation was associated with a fixation failure rate of 50%, supporting previous biomechanical work. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clamp Assisted Reduction of the Transverse Acetabular Fracture With Anterior Column Screw Fixation and Posterior Plating: A Technical Trick and Case Series.

SUMMARY: Displaced transverse acetabular fractures are unstable injuries that frequently require repair. Although multiple approaches, techniques, and fixation constructs have been described to treat this pattern, achieving an anatomical reduction and applying fixation to maintain this until union remains the goal of treatment. We present a surgical technique for transverse or transverse/posterior wall acetabular fractures repaired using a clamp-assisted reduction through the sciatic notch, followed by anterior column screw fixation and subsequent posterior column plating through a Kocher-Langenbeck exposure. We review a case series of 55 patients treated with this technique and evaluate reduction quality using postoperative computed tomogram scans to assess for any residual step-off.

Outcomes of periprosthetic distal femur fractures following total knee arthroplasty: Intramedullary nailing versus plating.

BACKGROUND: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating. MATERIALS AND METHODS: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs. RESULTS: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9). CONCLUSION: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.