Treatment of an Impending Pathologic Sacral Fracture with a Novel Iliosacral Fusion Construct: A Case Report.

CASE: A 49-year-old woman presented with left leg radiculopathy and posterior pelvic pain. Subsequent evaluation demonstrated metastatic multiple myeloma with an impending left S1 sacral fracture. Immediate posterior pelvic ring stabilization was recommended to prevent fracture and disruption of her oncologic recovery. This was performed percutaneously with computer-assisted navigation using a novel cannulated screw design. CONCLUSION: The patient was treated with prophylactic percutaneous posterior pelvic ring fixation with a novel cannulated screw design that provided a durable construct for immediate weight-bearing. The fixation prevented a pathologic fracture and allowed immediate return to activity.

Iliac dysmorphism: defining radiographic characteristics and association with pelvic osseous corridor size.

INTRODUCTION: Insertion of iliac wing implants requires understanding of the curvilinear shape of the ilium. This study serves to quantitatively identify the area of iliac inner-outer table convergence (IOTC), characterize the iliac wing osseous corridor, and define the gluteal pillar osseous corridor. METHODS: Computed tomography scans of 100 male and 100 female hemipelves were evaluated. The iliac wing was studied using manual best-fit analysis of the bounds of the inner and outer cortices. The IOTC was defined as the location of the iliac wing with an intercortical width less than 5 mm. The shortest distance from the apex of the iliac crest to the superior border of the IOTC was defined as the iliac wing osseous corridor. Finally, the width of the gluteal pillar corridor from the gluteus medius tubercle to the ischial tuberosity was measured. RESULTS: The IOTC is an elliptical area measuring 22.3 cm2. All ilia had an area where the inner and outer cortices converged to an intercortical width of less than 5 mm; 48% converged to a single cortex. The shortest mean distance from the superior edge of the iliac crest to the beginning of the IOTC was 20.3 mm in men and 13.8 mm in women (p < 0.001). The gluteal pillar diameter averaged 5.3 mm in men and 4.3 mm in women (p < 0.001). DISCUSSION: All ilia converge to a thin and frequently unicortical central region. A 4.5 mm iliac wing lag screw will not breach the cortex if it remains within 20 mm or 14 mm distal to the cranial aspect of the iliac crest in males and females, respectively. Not only is the gluteal pillar smaller than previously thought, in 41% of males and 73% of females, it is not be large enough for 5 mm implants. CONCLUSION: This study quantitatively assesses the dimensions of the IOTC, the iliac crest osseous corridor, and the gluteal pillar. Overall, our findings provide improved understanding of the limits for implant use in the iliac wing as well as better appreciation of the complex osteology of the ilium. This will help surgeons to identify safe areas for implant placement and avoid inadvertent cortical penetration.

Intramedullary Nail and Plate Combination Technique for Peri-Implant Both-Bone Forearm Fractures.

A 35-year-old female patient with cerebellar ataxia presented with a right periprosthetic both-bone forearm fracture after a ground-level fall. Her surgical history was significant for multiple both-bone forearm fractures treated by open reduction and internal fixation. Subsequent treatment with a combination of intramedullary nailing and plate fixation for each bone provided successful fracture union while allowing immediate return to weight-bearing and range of motion. This case report demonstrates that intramedullary nailing and plate fixation of both-bone forearm fractures provides complete protection of the radius and ulna in recurrent, peri-implant both-bone forearm fractures. This technique is a valuable treatment option in the setting of a patient at risk for recurrent injury of the forearm.

Defining the iliac wing osseous fixation pathways: anatomy and implant constriction points.

INTRODUCTION: Insertion of iliac wing implants requires understanding of the curvilinear shape of the ilium. This study serves to quantitatively identify the area of iliac inner-outer table convergence (IOTC), characterize the iliac wing osseous corridor, and define the gluteal pillar osseous corridor. METHODS: Computed tomography scans of 100 male and 100 female hemipelves were evaluated. The iliac wing was studied using manual best-fit analysis of the bounds of the inner and outer cortices. The IOTC was defined as the location of the iliac wing with an intercortical width less than 5 mm. The shortest distance from the apex of the iliac crest to the superior border of the IOTC was defined as the iliac wing osseous corridor. Finally, the width of the gluteal pillar corridor from the gluteus medius tubercle to the ischial tuberosity was measured. RESULTS: The IOTC is an elliptical area measuring 22.3 cm2. All ilia had an area where the inner and outer cortices converged to an intercortical width of less than 5 mm; 48% converged to a single cortex. The shortest mean distance from the superior edge of the iliac crest to the beginning of the IOTC was 20.3 mm in men and 13.8 mm in women (p < 0.001). The gluteal pillar diameter averaged 5.3 mm in men and 4.3 mm in women (p < 0.001). DISCUSSION: All ilia converge to a thin and frequently unicortical central region. A 4.5 mm iliac wing lag screw will not breach the cortex if it remains within 20 mm or 14 mm distal to the cranial aspect of the iliac crest in males and females, respectively. Not only is the gluteal pillar smaller than previously thought, in 41% of males and 73% of females, it is not be large enough for 5 mm implants. CONCLUSION: This study quantitatively assesses the dimensions of the IOTC, the iliac crest osseous corridor, and the gluteal pillar. Overall, our findings provide improved understanding of the limits for implant use in the iliac wing as well as better appreciation of the complex osteology of the ilium. This will help surgeons to identify safe areas for implant placement and avoid inadvertent cortical penetration.

Supraacetabular osseous corridor: defining dimensions, sex differences, and alternatives.

INTRODUCTION: The supraacetabular (SA) corridor extends from the anterior inferior iliac spine to the posterior ilium and can safely accommodate implants to stabilize pelvic and acetabular fractures. However, quantitative analysis of its dimensions and characteristics have not been thoroughly described. This study seeks to define the dimensions, common constriction points, and any alternative trajectories that would maximize the corridor diameter. METHODS: Computed tomography of 100 male and 100 female hemipelves without osseous trauma were evaluated. The corridor boundaries were determined through manual best-fit analysis. The largest intercortical cylinder within the pathway was created and measured. Alternative trajectories were tested within the SA boundaries to identify another orientation that maximized the diameter of the intercortical cylinder. RESULTS: The traditional SA corridor had a mean diameter of 8.3 mm in men and 6.2 mm in women. This difference in diameter is due to a more S-shaped ilium in women. A larger alternative SA corridor was found that had a less limited path through the ilium and measured 11.3 mm in men and 9.9 mm in women. These dimensions are significantly different compared to those of the traditional SA corridor in both men and women. CONCLUSIONS: In men, the SA corridor allows for the safe passage of most hardware used in pelvic and acetabular fractures. However, in women, the SA corridor is restricted by a more S-shaped ilium. An alternative trajectory was found that has a significantly larger mean diameter in both sexes. Ultimately, the trajectory of hardware will be dictated by the clinical scenario. When large implants are needed, especially in women, we recommend considering the alternative SA corridor.

Business Modeling of Orthopaedic Trauma in the Emergency Department: An Untapped Revenue Stream.

INTRODUCTION: Emergency departments (EDs) and emergency medicine and orthopaedic residencies can be faced with financial challenges while caring for patients. Procedures performed by residents are a potentially viable source of revenue that may make orthopaedic coverage of the ED a financially viable service line. METHODS: A custom text-mining program was created and validated, which allowed evaluation of all orthopaedic resident notes. Procedures performed in the ED were quantified, allowing for the calculation of professional fee billing data. The patients with distal radius fractures were followed after fracture reduction through final outpatient clinic follow-up to identify additional professional fee billing. RESULTS: Over a 1-year period, more than $445,000 in uncaptured professional fees charged was identified in the 12 most common Current Procedural Terminology codes for splint application and fracture reduction in the ED. More than $395,000 of outpatient professional revenue was received for patients who had reduction of distal radius fractures in the ED. CONCLUSION: A notable, previously unrecognized and uncaptured source of revenue was identified and quantified. Professional fee billing for distal radius fracture reduction in the ED did not have a negative effect on outpatient professional fee revenue received for these patients.