An international survey of pelvic trauma surgeons on the management of pelvic ring injuries.

INTRODUCTION: There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS: A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS: Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION: This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.

Is immediate weight bearing safe for periprosthetic distal femur fractures treated by locked plating? A feasibility study in 52 consecutive patients.

BACKGROUND: Periprosthetic distal femur fractures associated with total knee replacement are increasing in incidence. We hypothesized that a standardized management protocol would result in few implant failures and a low rate of postoperative complications. METHODS: Retrospective observational cohort study at an urban level 1 trauma center and academic level 2 trauma center. Consecutive patients with periprosthetic distal femur fractures and stable total knee arthroplasty were included between January 1, 2011 and December 31, 2014. Patients were managed by a standardized protocol of co-management by a hospitalist service, fracture fixation within 24 h of admission by less-invasive locked bridge plating, and immediate unrestricted postoperative weight bearing. The primary outcome measure was the rate of postoperative complications. Secondary outcome measures included time to surgery, intraoperative blood loss, duration of surgery, length of hospital stay, time to full weight bearing, and time to radiographic fracture healing. RESULTS: Fifty four fractures were treated in 52 patients. There were three implant failures, one deep infection, one nonunion and two patients with symptomatic malunion. One patient had knee pain due to patellar component instability associated with valgus alignment. There were ten thromboembolic complications despite consistent anticoagulation. Two patients died within 12 months of injury. Thirty-eight patients had returned to their pre-injury ambulation status at 1 year follow-up. CONCLUSION: A standardized approach of less-invasive locked plating fixation and immediate unrestricted weight bearing appears safe and feasible in the management of this vulnerable patient cohort. TRIAL REGISTRATION NUMBER: This is a retrospective observational study without a Trial registration number.

Prophylactic antibiotics in open fractures: a pilot randomized clinical safety study.

OBJECTIVE: To develop preliminary data on Staphylococcus aureus colonization and surgical site infections (SSIs) in patients with open fractures who received standard antibiotic prophylaxis compared with a regimen including targeted methicillin-resistant Staphylococcus aureus (MRSA) coverage. DESIGN: Randomized prospective clinical trial. PATIENTS: Adult patients who presented to the emergency department with an open fracture between April 2009 and July 2011. INTERVENTIONS: One hundred thirty patients were randomized to receive prophylaxis with either cefazolin alone (control arm) or vancomycin and cefazolin (experimental arm) from presentation to the emergency department until 24 hours after the surgical intervention. Screening for S. aureus carriage was performed with nares swabs and predebridement and postdebridement open fracture wound swabs. Patients underwent prospective assessment for the development of SSI for no less than 30 days and up to 12 months. RESULTS: Nasal colonization of methicillin-sensitive S. aureus and MRSA among the sample was 20% and 3%, respectively. No significant difference in the rates of SSI was observed between the study arms (15% vs 19%, respectively, P = 0.62). Staphylococcus aureus caused 55% of the deep incisional/organ space SSI, with 18% attributed to MRSA. A significantly higher rate of MRSA SSIs was observed among MRSA carriers compared with noncarriers (33% vs 1%, respectively, P = 0.003). CONCLUSIONS: Staphylococcus aureus nasal colonization in trauma patients with open fractures is similar to that of the general community. In this pilot study, the addition of vancomycin to standard antibiotic prophylaxis was found safe, but its efficacy should be evaluated in a larger multiinstitutional trial.

Early complications of anterior supine intermuscular total hip arthroplasty.

Anterior supine intermuscular total hip arthroplasty (THA) performed on a fracture table has been increasingly used for primary THA. Accurate cup placement, low incidence of dislocation, shorter hospital stay, and faster return of function are potential benefits of the technique. However, a high complication rate, particularly during a surgeon's learning curve, has been reported. A retrospective analysis of 61 consecutive anterior supine intermuscular primary THAs with at least 6-month follow-up was performed. All procedures were performed using the anterior supine intermuscular approach with cementless implants under fluoroscopic guidance on a fracture table. Prospectively collected data were retrospectively reviewed to evaluate the early complication rate and radiographic accuracy of implant placement. Five (8.2%) intraoperative complications were observed: including 3 trochanteric fractures and 2 calcar fractures, 4 of which required cable fixation during the index procedure. One nondisplaced trochanteric fracture was treated conservatively. One patient sustained an injury of the lateral femoral cutaneous nerve. Postoperative complications included 1 anterior dislocation, 1 infected superficial hematoma, 1 stem subsidence, and 1 loose stem, with the latter 2 presenting as increasing thigh pain postoperatively and requiring stem revision. The overall complication rate was 16.4% (10/61). Overall, 3 patients (4 hips; 6.5%) required reoperation. No femoral or sciatic nerve injuries occurred, and no patient was diagnosed with venous thromboembolism. All intraoperative fractures occurred during the first 32 cases, and none during the last 29 cases. A potentially high incidence of complications with the anterior supine intermuscular THA exists during a surgeon's learning curve in an academic setting.

Safe surgical technique for associated acetabular fractures.

Associated acetabular fractures are challenging injuries to manage. The complex surgical approaches and the technical difficulty in achieving anatomical reduction imply that the learning curve to achieve high-quality care of patients with such challenging injuries is extremely steep. This first article in the Journal's "Safe Surgical Technique" section presents the standard surgical care, in conjunction with intraoperative tips and tricks, for the safe management of all subgroups of associated acetabular fractures.

Are conventional reconstruction plates equivalent to precontoured locking plates for distal humerus fracture fixation? A biomechanics cadaver study.

BACKGROUND: The optimal plate type and configuration for distal humerus fracture fixation has yet to be defined. Available biomechanical studies show conflicting results. No existing studies compare conventional reconstruction plates to newer precontoured distal humerus locking plates in both parallel and perpendicular configurations. METHODS: Three groups of humerus specimens were compared via biomechanical testing in a cadaver model simulating metaphyseal comminution. Group 1 consisted of conventional reconstruction plates in a perpendicular configuration. Group 2 used precontoured locking plates in a perpendicular configuration. Group 3 used precontoured locking plates in a parallel configuration. Each group was tested for stiffness in anterior bending, posterior bending, axial compression, and torsion. The specimens then underwent cyclic loading followed by single load to failure in posterior bending. FINDINGS: There was no significant difference between the three groups for anterior bending, posterior bending, axial compression, or torsional stiffness. There was no significant difference in load to failure for any of the three groups. Screw loosening was significantly higher in Group 1 when compared to Groups 2 and 3 after cyclic loading. INTERPRETATION: In the early postoperative period, less expensive perpendicular conventional reconstruction plate constructs provide similar stiffness and load to failure properties to newer precontoured locking plate systems regardless of plate configuration.

The dangers of damage control orthopedics: a case report of vascular injury after femoral fracture external fixation.

BACKGROUND: Placement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma. CASE REPORT: We present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion. CONCLUSION: This case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.

Hemodynamically unstable pelvic fracture management by advanced trauma life support guidelines results in high mortality.

The purpose of this study was to examine the acute outcomes and mortality rates of an Advanced Trauma Life Support guideline approach for managing hemodynamically unstable pelvic ring injuries. We retrospectively reviewed the acute outcomes of 48 consecutive patients with hemodynamically unstable pelvic fractures. Patients underwent treatment via the advanced trauma life support protocol, with primary angiography based on trauma surgeon preference. Mean patient age was 51.2 years, with a mean injury severity score of 43.2±14.3. Mean systolic blood pressure was 74.8±16.1 mm Hg at presentation. Patients received an average of 7.0±6.6 units of red blood cells and 4.2±2.3 units of fresh frozen plasma in the first 6 hours. Fourteen patients underwent emergent angiography, and 12 patients were treated with embolization. Mean time to angiography was 3 hours and 55 minutes (range, 2-19 hours). Twenty patients died during hospitalization, with an overall mortality rate of 41.7%; 13 (27.1%) of them died within 24 hours. Advanced Trauma Life Support guidelines with angiography are not adequate for the management of hemodynamically unstable pelvic ring injuries and result in unacceptably high mortality rates compared with more specific approaches using transfusion protocols and interventions, such as pelvic packing.

Influence of preoperative 7.5% hypertonic saline on neutrophil activation after reamed intramedullary nailing of femur shaft fractures: a prospective randomized pilot study.

OBJECTIVES: Femoral reaming and intramedullary nailing (IMN) primes polymorphonuclear leukocytes (PMNL) and thereby increases the posttraumatic systemic inflammatory response. Resuscitation with hypertonic saline (HTS) attenuates PMNL activation after trauma-hemorrhage. We hypothesized that preoperative administration of 7.5% HTS attenuates PMNL priming after IMN of unilateral femur shaft fractures compared with 0.9% normal saline. DESIGN: Prospective, randomized, double-blind study. SETTING: Level I trauma center. PATIENTS: Twenty patients between 18 and 80 years of age with an Injury Severity Score less than 25 and a unilateral femur shaft fracture amenable to IMN fixation within 24 hours after injury. INTERVENTION: Patients were allocated to equally sized HTS or normal saline treatment groups (n = 10) before surgery. Solutions were administered in a blinded bag as a single bolus of 4 mL/kg body weight immediately before surgery. Whole blood samples were collected directly before saline application (t0) and at 6, 12, and 24 hours after surgery. MAIN OUTCOME MEASUREMENTS: PMNL surface expression of CD11b and CD62L, as determined by flow cytometry analysis. RESULTS: Demographic characteristics of both treatment groups were comparable. Baseline expression of CD11b and CD62L cell markers was in a similar range in the two cohorts. The expression levels of CD11b were comparable between the two groups throughout the observation time, whereas CD62L levels were significantly higher in the HTS group at 6 and 24 hours after surgery. CONCLUSION AND SIGNIFICANCE: Preoperative infusion of HTS appears to exert an anti-inflammatory effect by attenuating the extent of postoperative PMNL activation after reamed IMN for femoral shaft fractures.

Deep vein thrombosis prophylaxis in trauma patients.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients.

Modality of wound closure after total knee replacement: are staples as safe as sutures? A retrospective study of 181 patients.

BACKGROUND: Surgical site wound closure plays a vital role in post-operative success. This effect is magnified in regard to commonly performed elective procedures such as total knee arthroplasty. The use of either sutures or staples for skin re-approximation remains a contested subject, which may have a significant impact on both patient safety and surgical outcome. The literature remains divided on this topic. METHODS: Two cohorts of patients at a level one trauma and regional referral center were reviewed. Cohorts consisted of consecutive total knee arthroplasties performed by two surgeons who achieved surgical wound re-approximation by either staples or absorbable subcuticular sutures. Outcome variables included time of surgery, wound dehiscence, surgical site infection per Center for Disease Control criteria and repeat procedures for debridement and re-closure. RESULTS: 181 patients qualified for study inclusion. Staples were employed in 82 cases (45.3% of total) and sutures in 99 cases (54.7%). The staples group had no complications while the sutures group had 9 (9.1%). These consisted of: 4 infections (2 superficial, one deep, one organ/space); three patients required re-suturing for dehiscence; one allergic type reaction to suture material; and one gout flare resulting in dehiscence. The mean surgical time with sutures was 122.3 minutes (sd = 33.4) and with staples was 114 minutes (sd = 24.4). CONCLUSION: This study demonstrated significantly fewer complications with staple use than with suture use. While all complications found in this study cannot be directly attributed to skin re-approximation method, the need for further prospective, randomized trials is established.

The role of prophylactic antibiotics in open fractures in an era of community-acquired methicillin-resistant Staphylococcus aureus.

Infection is a feared complication and a common cause of loss of function following open fractures. Despite the evidence supporting the administration of prophylactic antibiotics after open fractures, data demonstrating the optimal regimen is lacking. We reviewed the data supporting the current prophylaxis recommendations and the changing epidemiology of Staphylococcus aureus, the most common cause of surgical site infection in patients with open fractures. Although widespread emergence of methicillin-resistant Staphylococcus aureus (MRSA) has been described in both hospital and community settings, to date, no studies have addressed the need for prophylaxis against MRSA in patients with open fractures. Until well-designed randomized trials are conducted, we recommend that providers consider selecting antibiotics active against MRSA for open fracture prophylaxis based on the local prevalence of MRSA carriage and individualized risk factors.

Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a "safe" surgical corridor for sacro-iliac screw placement.

BACKGROUND: Percutaneous sacro-iliac (SI) screw fixation represents a widely used technique in the management of unstable posterior pelvic ring injuries and sacral fractures. The misplacement of SI-screws under fluoroscopic guidance represents a critical complication for these patients. This study was designed to determine the prevalence of sacral dysmorphia and the radiographic anatomy of surgical S1 and S2 corridors in a representative trauma population. METHODS: Prospective observational cohort study on a consecutive series of 344 skeletally mature trauma patients of both genders enrolled between January 1, 2007, to September 30, 2007, at a single academic level 1 trauma center. Inclusion criteria included a pelvic CT scan as part of the initial diagnostic trauma work-up. The prevalence of sacral dysmorphia was determined by plain radiographic pelvic films and CT scan analysis. The anatomy of sacral corridors was analyzed on 3 mm reconstruction sections derived from multislice CT scan, in the axial, coronal, and sagittal plane. "Safe" potential surgical corridors at S1 and S2 were calculated based on these measurements. RESULTS: Radiographic evidence of sacral dysmorphia was detected in 49 patients (14.5%). The prevalence of sacral dysmorphia was not significantly different between male and female patients (12.2% vs. 19.2%; P = 0.069). In contrast, significant gender-related differences were detected with regard to radiographic analysis of surgical corridors for SI-screw placement, with female trauma patients (n = 99) having significantly narrower corridors at S1 and S2 in all evaluated planes (axial, coronal, sagittal), compared to male counterparts (n = 245; P < 0.01). In addition, the mean S2 body height was higher in dysmorphic compared to normal sacra, albeit without statistical significance (P = 0.06), implying S2 as a safe surgical corridor of choice in patients with sacral dysmorphia. CONCLUSIONS: These findings emphasize a high prevalence of sacral dysmorphia in a representative trauma population and imply a higher risk of SI-screw misplacement in female patients. Preoperative planning for percutaneous SI-screw fixation for unstable pelvic and sacral fractures must include a detailed CT scan analysis to determine the safety of surgical corridors.

Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess.

BACKGROUND: Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been adequately studied. We hypothesized that implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess would decrease antibiotic and health care resource utilization. METHODS: A retrospective preintervention-postintervention study was performed to compare management before and after implementation of the guideline (January 1, 2007-December 31, 2007, and July 9, 2009-July 8, 2010). RESULTS: A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased from 13 days (interquartile range [IQR], 10-15 days) to 10 days (IQR, 9-12 days) (P < .001). Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases (P = .93), respectively. CONCLUSION: Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.

Traction table-related complications in orthopaedic surgery.

Traction tables are used in numerous procedures about the hip and femur, including fracture fixation, hip arthroscopy, and less invasive arthroplasty. The use of a traction table is not without risks, however, and significant complications have been described, including injury to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. The orthopaedic surgeon who uses a traction table for the surgical management of femur fracture must be familiar with the associated potential dangers and risks and must develop a plan to avoid traction table-associated complications, such as use of a radiolucent flat-top operating table for obese patients, adequate patient positioning, and the minimum possible surgical time.

Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries.

BACKGROUND: The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury. METHODS: During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but <2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images. RESULTS: The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of >2.5 cm during the stress examination, which changed their treatment from nonoperative to operative. CONCLUSIONS: Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.

Safety and efficacy of conversion from external fixation to plate fixation in humeral shaft fractures.

OBJECTIVE: Immediate external fixation and planned conversion to internal fixation of humeral shaft fractures is an option in the treatment of associated severe soft-tissue injuries and severely injured patients. The purpose of this study was to evaluate the outcome and complications of patients who sustained humeral shaft fractures and were treated with initial unilateral external fixation followed by plate fixation. DESIGN: Retrospective analysis of a prospective database. SETTING: Academic level I trauma center. PATIENT/PARTICIPANTS: We identified 17 patients treated between June 2003 and August 2007 with immediate unilateral external fixation followed by planned conversion to internal plate fixation. All patients were seen for follow-up until bony union occurred, with a minimum follow-up of 6 months. MAIN OUTCOME MEASUREMENTS: Initial patient condition, local and systemic complications, and short-term outcomes were evaluated. RESULTS: The main reason for immediate placement of an external fixator was multiple trauma in nine patients (damage control orthopedics group); six open fractures with massive soft-tissue injury; one temporarily decreased perfusion to the forearm and hand; and one associated compartment syndrome of the upper arm. The average timing of the conversion to internal fixation was 6.2 (range, 2-14) days from the time of external fixation. There were no iatrogenic nerve injuries after either the external fixation or the conversion to internal fixation. Fifteen of 17 fractures united with an average time to healing of 11.1 (range, 8-14) weeks. Two fractures failed to heal after conversion from external to internal fixation. Both were open fractures from the non-damage control orthopedics group that developed a deep infection. There were no systemic complications after conversion from external to internal fixation. CONCLUSIONS: Immediate external fixation with planned conversion to plate fixation within 2 weeks proved to be a safe and effective approach for the management of humeral shaft fractures in selected patients with multiple injuries or severe soft-tissue injuries that preclude early plate fixation.

Technical problems and complications in the removal of the less invasive stabilization system.

OBJECTIVES: This study was designed to evaluate the frequency of intraoperative problems and complications involved with Less Invasive Stabilization System (LISS) plate removal. DESIGN: Retrospective study. SETTING: Single academic level I trauma center. METHODS: Medical records were reviewed for demographics, surgical technique, plate length, number and position of screws, time from internal fixation to plate removal, reason for removal, operating time for removal, and perioperative complications. Pre- and post-op radiographs were also reviewed to confirm plate and screw positions. The independent factors including age, sex, plate site, plate screws placed/available holes, union status, and time from internal fixation to removal were compared between patients in whom screw removal was complicated to those in whom screw removal proceeded without difficulty. Mann-Whitney and Fisher Exact tests were calculated with the level of significance at P < 0.05. RESULTS: There were 33 patients (24 men and 9 women) that underwent LISS plate removal from 36 extremities (15 tibias and 21 femurs). The average time from internal fixation to removal was 13.2 months. The plates removed were 13-hole plates (16 cases), 9-hole plates (18 cases), and 5-hole plates (2 cases), which included a total of 349 screws. The specific reasons for plate removal were symptomatic implants after bone union (21 cases), nonunion requiring additional fixation (12 cases), early loss of fixation (2 cases), and a peri-implant fracture after bone union (1 case). The average operating time for plate removal was 71.3 minutes (range, 28-180 minutes). Five cases required more than 120 minutes. Difficulty with screw removal was encountered in 37 screws (10.6%) from 14 cases (38.9%). Two plates and 11 screw heads required cutting using a carbide or diamond tipped burr. Six cases required tearing the plate off bone by levering with a total of 10 screws still attached. Five screws were cut using a large bolt cutter. The other screws were stripped and removed with a stripped screw removal tap. Two patients developed a postoperative superficial wound infection that required treatment with oral antibiotics. One patient had a postoperative peroneal nerve palsy that recovered spontaneously. There were no statistical differences in predictors for patients with screw removal difficulty. CONCLUSIONS: Difficulty with removal due to cold welding or screw head stripping is common in locking LISS plate screws. LISS plate removal can often require prolonged operating time and the use of specialized removal tools. Surgeons should anticipate the possibility of difficulties when removing these implants and be appropriately prepared.

Combined injuries of the pelvis and acetabulum: nature of a devastating dyad.

OBJECTIVES: To describe the clinical characteristics of combined injuries of the pelvis and acetabulum, which have not been previously described. We hypothesize that this combination of injuries affects not only the postinjury hemodynamics of the patient, but the outcome of subsequent acetabular fracture treatment. DESIGN: Retrospective study. SETTING: Level I trauma center. METHODS: The data collected included patient demographics, fracture classification, Injury Severity Score, systolic blood pressure on arrival, amount of packed red blood cells transfused, time to operation, perioperative complications, and radiographic outcomes. Age- and sex-matched control groups of patients with pure pelvic fractures and pure acetabular fractures were compared with the combined injury group to assess injury severity characteristics. To determine the independent factors influencing the postoperative residual displacement of the acetabulum, multiple linear regression analysis was used. RESULTS: Between January 1, 1998, and December 31, 2007, there were 1612 patients with either pelvic or acetabular fractures requiring admission to our institution, of which 82 (5.1%) had the combination of an unstable pelvic injury (Orthopaedic Trauma Association [OTA] 61 Types B/C) and a displaced acetabular fracture (OTA 62). Eighty-two patients with an isolated unstable pelvic injury and 82 patients with an isolated displaced acetabular fracture were chosen from the same study period to act as control groups. Patients in the combined group were significantly more injured as compared with the displaced acetabular fracture control group with regard to Injury Severity Score (P < 0.001), systolic blood pressure (P < 0.001), and packed red blood cells (P < 0.001). In the combined group, the most common pelvic fracture patterns were OTA 61.B1 and B2. Transverse-type acetabular fractures patterns (OTA 62.B1 and B2) accounted for 61.2% of all acetabular fractures in the combined group. The most frequent injury combination was a transverse-type acetabular fracture with an associated ipsilateral anterior disruption of the sacroiliac joint. Sixty-eight patients underwent surgical intervention at a mean time of 5.7 days. The mean postoperative displacement of acetabular fracture reduction was 2.2 mm as evaluated by radiographs. Multiple regression analysis revealed that the amount of postoperative posterior pelvic displacement, Type B2 acetabular fractures, and patient age were significant predictors of the amount of residual acetabular displacement found postoperatively. CONCLUSION: Patients with combined pelvic and acetabular fractures represent a serious injury that includes the resuscitative challenges of pelvic injuries coupled with the difficulties of precise reduction of acetabular fractures. To obtain optimal reduction of the acetabulum, initial accurate reduction of the posterior pelvic lesion appears to be necessary.