Orthopedic surgeons' transition into full-time practice over the last 20 years: an analysis using Ministry of Health billing data.

BACKGROUND: Underemployment is a reality for many new graduates, who accept locum or part-time work as an alternative to unemployment because of lack of opportunities. We sought to analyze orthopedic surgeons' Ontario Health Insurance Program (OHIP) billing data over a 20-year period as a proxy of practice patterns and hypothesized that billing in the first 6 years of practice would be affected by underemployment and locum. METHODS: We analyzed the annual average billing totals of orthopedic surgeons, broken down by year of graduation, year of billings, and number of surgeons billing in that year. We analyzed public census data of the Ontario population size as a proxy of orthopedic demand. RESULTS: A 2019 cross-sectional analysis showed that around 15 surgeons per graduating year were billing in Ontario from the 1995 to 2016 cohorts, while 2017 and 2018 saw an increase to 30 and 36 actively billing surgeons, respectively. The number returned to more historical numbers in 2019, with 20 actively billing surgeons. For those surgeons billing in Ontario, billing trends have been roughly stable, with average billings increasing each year for the first 6 years in practice (p < 0.001). Year of graduation did not have an effect on the first 6 years of billings (p > 0.5). Billings were stable after 6 years in practice (p > 0.09). CONCLUSION: The Ontario health care system has not expanded to support more orthopedic surgeons despite the aging and growing population; despite our growing population, the number of surgeons being trained and retained has not matched this growth. Further research needs to be done to guide optimal health human resource decision-making.

Patient-clinician digital health interventions for the hip fracture population: a scoping review.

INTRODUCTION: Older adults with hip fracture often require extensive post-surgery care across multiple sectors, making follow-up care even more important to ensure an ideal recovery. With the increased adoption of technology, patient-clinician digital health interventions can potentially improve post-surgery outcomes of hip fracture patients by helping them and their caregivers better understand the various aspects of their care, post-hip fracture surgery. The purpose of this study was to examine the available literature on the impact of hip fracture-specific, patient-clinician digital health interventions on patient outcomes and health care delivery processes. We also aimed to identify the barriers and enablers to the uptake and implementation of these technologies and to provide strategies for improved use of these digital health interventions. METHODS: We conducted a scoping review following the six stages of Arksey and O'Malley's framework and following the PRISMA-ScR reporting format. Searches were conducted in five databases. In addition to hand searching for relevant studies from the references of all included studies, we also conducted a grey literature search to identify relevant primary studies. Screening of titles and abstracts as well as full texts were performed independently by two reviewers. Two reviewers also performed the data extraction of the included studies. RESULTS: After screening 3,638 records, 20 articles met the criteria and 1 article was identified through hand searching. Various patient-clinician digital health interventions were described including telehealth /telerehabilitation programs (n = 6), care transition /follow-up interventions (n = 5), online resources (n = 2), and wearable devices /sensor monitoring (n = 1). Outcomes were varied and included functional status, gait/mobility, quality of life, psychological factors, satisfaction, survival/complications, caregiver outcomes, compliance, technology-user interactions, and feedback on the use of the digital health interventions. For clinicians, a key barrier to the use of the digital health interventions was the acceptability of the technology. However, the usefulness of the digital health intervention by clinicians was seen as both a barrier and an enabler. For patients and caregivers, all the themes were seen as both a barrier and an enabler depending on the study. These themes included: 1) availability and access, 2) usability, 3) knowledge and skills, 4) acceptability, and 5) usefulness of the digital health intervention. CONCLUSION: Many behavioural factors affect the use of patient-clinician digital health interventions. However, a specific attention should be focused on the acceptability of the technology by the clinicians to encourage uptake of the digital health interventions. The results of this scoping review can help to better understand the factors that may be targeted to increase the use of these technologies by clinicians, patients, and caregivers.

Platform-Based Patient-Clinician Digital Health Interventions for Care Transitions: Protocol for a Scoping Review.

BACKGROUND: With the increased adoption of technology, the use of digital health interventions in health care settings has increased. Patient-clinician digital health interventions have the potential to improve patient care, especially during important transitions between hospital and home. Digital health interventions can provide support to patients during these transitions, thereby leading to better patient outcomes. OBJECTIVE: This scoping review aims to explore the available literature, specifically (1) to examine the impact of platform-based digital health interventions focused on care transitions on patient outcomes, and (2) to identify the barriers to and enablers for the uptake and implementation of these digital health interventions. METHODS: This protocol was developed based on Arksey and O'Malley's, Levac and colleagues', and JBI scoping review methodologies, and it has been reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for the Scoping Reviews) format. The search strategies were developed for 4 databases: MEDLINE, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials by using key words such as "hospital to home transition" and "platform-based digital health." Studies involving patients 16 years or older that used a platform-based digital health intervention during their hospital to home transition will be included in this review. Two reviewers will independently screen articles for eligibility by using a 2-stage process (ie, title and abstract screening and full-text screening). We expect to refine the eligibility criteria during the title and abstract screening process as we anticipate retrieving a significant number of articles. In addition, we will also perform a targeted search of the grey literature, as well as data extraction. Data analysis will consist of a narrative and descriptive synthesis. RESULTS: The review is expected to identify research gaps that will inform the development of future patient-clinician digital health interventions. We have identified a total of 8333 articles. Screening began in September 2022, and data extraction is expected to commence in February 2023 and end by April 2023. Data analyses and final results will be submitted to a peer-reviewed journal in August 2023. CONCLUSIONS: We expect to find a wide variety of postcare interventions, some gaps in the quality of research evidence, as well as a lack of detailed information on digital health interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/42056.

Is Outcome of Total Hip Arthroplasty for Hip Fracture Inferior to That of Arthritis in a Contemporary Arthroplasty Practice?

BACKGROUND: Outcome of total hip arthroplasty (THA) for femoral neck fractures (FNF) has been associated with higher complication rates. However, THA for FNF is not always performed by arthroplasty surgeons. This study aimed to compare THA outcomes for FNF to osteoarthritis (OA). In doing so, we described contemporary THA failure modes for FNF performed by arthroplasty surgeons. METHODS: This was a retrospective, multisurgeon study from an academic center. Of FNFs treated between 2010 and 2020, 177 received THA by an arthroplasty surgeon [mean age 67 years (range, 42 to 97), sex: 64.4% women]. These were matched (1:2) for age and sex with 354 THAs performed for hip OA, by the same surgeons. No dual-mobilities were used. Outcomes included radiologic measurements (inclination/anteversion and leg length), mortality, complications, reoperation rates and patient-reported outcomes including Oxford Hip Score. RESULTS: Postoperative mean leg-length difference was 0 mm (range, -10 to -10 mm), with a mean cup inclination and anteversion of 41 and 26°, respectively. There was no difference in radiological measurements between FNF and OA patients (P = .3). At a 5-year follow-up, mortality rate was significantly higher in the FNF-THA group compared to the OA-THA group (15.3 versus 1.1%; P < .001). There was no difference in complications (7.3 versus 4.2%; P = .098) or reoperation rates (5.1 versus 2.9%; P = .142) between the groups. Dislocation rate was 1.7%. Oxford Hip Score at the final follow-up was similar [43.7 points (range, 10 to 48) versus 43.6 points (range, 10 to 48); P = .030]. CONCLUSION: THA for the treatment of FNF is a reliable option and is associated with satisfactory outcomes. Instability was not a common reason of failure, despite not using dual-mobility articulations in this at-risk population. This is likely due to THAs being performed by the arthroplasty staff. When patients live beyond 2 years, similar clinical and radiographic outcomes with low rates of revision can be expected compared to elective THA for OA. LEVEL OF EVIDENCE: III, case-control study.

Postsurgery paths and outcomes for hip fracture patients (POST-OP HIP PATHS): a population-based retrospective cohort study protocol.

INTRODUCTION: Hip fracture patients receive varying levels of support posthip fracture surgery and often experience significant disability and increased risk of mortality. Best practice guidelines recommend that all hip fracture patients receive active rehabilitation following their acute care stay, with rehabilitation beginning no later than 6 days following surgery. Nevertheless, patients frequently experience gaps in care including delays and variation in rehabilitation services they receive. We aim to understand the factors that drive these practice variations for older adults following hip fracture surgery, and their impact on patient outcomes. METHODS AND ANALYSIS: We will conduct a retrospective population-based cohort study using routinely collected health administrative data housed at ICES. The study population will include all individuals with a unilateral hip fracture aged 50 and older who underwent surgical repair in Ontario, Canada between 1 January 2015 and 31 December 2018. We will use unadjusted and multilevel, multivariable adjusted regression models to identify predictors of rehabilitation setting, time to rehabilitation and length of rehabilitation, with predictors prespecified including patient sociodemographics, baseline health and characteristics of the acute (surgical) episode. We will examine outcomes after rehabilitation, including place of care/residence at 6 and 12 months postrehabilitation, as well as other short-term and long-term outcomes. ETHICS AND DISSEMINATION: The use of the data in this project is authorised under section 45 of Ontario's Personal Health Information Protection Act and does not require review by a Research Ethics Board. Results will be disseminated through conference presentations and in peer-reviewed journals.

Comparing Intramedullary Nails Versus Dynamic Hip Screws in the Treatment of Intertrochanteric Hip Fractures on Post-operative Rehabilitation Outcomes:A Systematic Review Protocol.

Background: Intertrochanteric hip fractures are treated by fixation with either an intramedullary (IM) Nail or Dynamic Hip Screw (DHS). It is unknown whether one surgery type has better post-operative rehabilitative outcomes for the hip fracture population. This systematic review aims to compare post-operative rehabilitation outcomes of intertrochanteric hip fractures treated via IM Nails versus DHS. Methods: We will conduct a systematic review following the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format. A search strategy will be developed, and the following databases will be searched: MEDLINE, EMBASE, Cochrane Library, and Web of Science. Two reviewers will perform a two-step screening process and data extraction of included studies. Any disagreement will be resolved with a discussion or a third reviewer. Risk of bias and the quality of the studies will also be assessed. A narrative synthesis will be used for the data analysis. Conclusion: This systematic review will provide evidence for orthopaedic surgeons and rehabilitation clinicians to further improve patient rehabilitation outcomes post-hip fracture surgery.

Barriers and Enablers to the Use of Web-Based Applications for Older Adults and Their Caregivers Post-Hip Fracture Surgery: A Descriptive Qualitative Study.

Purpose: The purpose of this study was to describe the barriers and enablers to the use of web-based applications designed to help manage the personalized needs of older adults and their caregivers post-hip fracture surgery while transitioning from hospital to geriatric rehabilitation to home. Methods: This was a descriptive qualitative study consisting of semi-structured interviews informed by the Theoretical Domains Framework. The study took place between March 2021 and April 2022 on an orthopaedic unit in a large academic health sciences centre and in a geriatric rehabilitation service in Ontario, Canada. The transcripts were analyzed using a systematic 6-step approach. Results: Interviews were conducted with older adults (n = 10) and with caregivers (n = 8) post-hip fracture surgery. A total of 21 barriers and 24 enablers were identified. The top two barriers were a need for basic computer skills (n = 11, 61.1%) and a preference for direct verbal communication (n = 10, 55.6%). The top two enablers were having no concerns with using web-based applications (n = 12, 66.7%) and having ease of access to information (n = 10, 55.6%). Conclusion: We described the key barriers and enablers to the use of web-based applications from the perspectives of older adults and their caregivers. These factors will inform further developments of web-based applications aimed at improving the care transition from hospital to geriatric rehabilitation to home post-hip fracture surgery.

Protocol for a scoping review of patient-clinician digital health interventions for the population with hip fracture.

INTRODUCTION: Patient-clinician digital health interventions can potentially improve the care of patients with hip fracture transitioning from hospital to rehabilitation to home. Assisting older patients with a hip fracture and their caregivers in managing their postsurgery care is crucial for ensuring the best rehabilitation outcomes. With the increased availability and wide uptake of mobile devices, the use of digital health to better assist patients in their care has become more common. Among the older adult population, hip fractures are a common occurrence and integrated postsurgery care is key for optimal recovery. The overall aims are to examine the available literature on the impact of hip fracture-specific patient-clinician digital health interventions on patient outcomes and healthcare delivery processes; to identify the barriers and enablers to the uptake and implementation of these digital health interventions; and to provide strategies for improved use of digital health technologies. METHODS AND ANALYSIS: We will conduct a scoping review using Arksey and O'Malley's methodology framework and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for the Scoping Reviews reporting format. A search strategy will be developed, and key databases will be searched until approximately May 2022. A two-step screening process and data extraction of included studies will be performed by two reviewers. Any disagreement will be resolved by consensus or by a third reviewer. For the included studies, a narrative data synthesis will be conducted. Barriers and enablers identified will be mapped to the domains of the Theoretical Domains Framework and related strategies will be provided to guide the uptake of future patient-clinician digital health interventions. ETHICS AND DISSEMINATION: This review does not require ethics approval. The results will be presented at a scientific conference and published in a peer-reviewed journal. We will also involve relevant stakeholders to determine appropriate approaches for dissemination.

Feasibility, acceptability, and preliminary effects of PATH FOR timely transfer of geriatric HIP fracture patients from hospital to rehabilitation to home (PATH4HIP): a protocol for a mixed method study.

BACKGROUND: Hip fractures in older adults are significant contributors to severe functional decline and disability as well as hospitalization and increased health care costs. Research shows that timely referral to geriatric rehabilitation leads to better patient outcomes. Currently, a wide variability in the timing, the frequency, and the choice of appropriate setting for rehabilitation of hip fracture patients exists. AIM: Evaluate the feasibility, acceptability, and preliminary effectiveness of PATH4HIP, a pathway intervention for timely transfer of post-operative geriatric hip fracture patients from hospital to rehabilitation to home. METHODS: This is a single-arm, pragmatic feasibility study to measure reach, effectiveness, adoption, implementation, and maintenance of PATH4HIP, a pathway for post-operative hip fracture patients from a large academic health science center to a geriatric rehabilitation service in Ottawa, Canada. During a 6-month period, all hip fracture patients, 65 years of age or older who have undergone surgery and have met the eligibility criteria (n = 96), will be transferred to the geriatric rehabilitation service no later than post-operative day 6. Patients (n = 10-12) and clinicians who are working on the orthopedic team (n = 10-12) and on the geriatric rehabilitation service (n = 10-12) will be invited to participate in an interview to share their feedback on the intervention's feasibility and acceptability and to provide suggestions to improve PATH4HIP. Descriptive statistics will be used to summarize results of the quantitative data and content analysis will be used to analyze the qualitative data. The study will be open for recruitment from January to July 2022. DISCUSSION: If feasible, PATH4HIP will result in the reduction of the post-operative acute care length of stay to less than or equal to 6 days, while having no detrimental effect on rehabilitation outcomes such as functional gains, or discharge destination.

Barriers and Enablers to Early Identification, Referral and Access to Geriatric Rehabilitation Post-Hip Fracture: A Theory-Based Descriptive Qualitative Study.

Background: Geriatric hip fracture patients often experience gaps in care including variability in the timing and the choice of an appropriate setting for rehabilitation following hip fracture surgery. Many guidelines recommend standardized processes, including timely access of no later than day 6 to rehabilitation services. A pathway for early identification, referral and access to geriatric rehabilitation post-hip fracture was created to facilitate the implementation. The study aimed to describe the barriers and enablers prior to the implementation of this pathway. Methods: We conducted a qualitative descriptive study consisting of semi-structured interviews with geriatric hip fracture patients (n = 8), caregivers (n = 1), administrators (n = 12) and clinicians (n = 17) in 2 orthopaedics units and a geriatric rehabilitation service. Responses were analysed using a systematic approach, and overarching themes describing the barriers and enablers were identified. Results: The clinicians' and administrators' top barriers to implementation of the pathway were competing demands (n = 24); lack of bed availability, community resources and funding (n = 19); and the need for extended hours and increased staff (n = 16). The top 3 enablers were clear communication with patients (n = 27), awareness of the benefits of geriatric rehabilitation (n = 24) and the need for education and resources to properly use the pathway (n = 15). Common barriers among patients and caregivers included lack of care coordination, overcoming some of their own specific challenges during their transition, gaps in the information they received before discharge, not knowing what questions to ask and lack of resources. Despite these barriers, patients were generally pleased with their transition from the hospital to geriatric rehabilitation. Conclusion: We identified and described key barriers and enablers to early identification, referral and access to geriatric rehabilitation post-hip fracture. These influencing factors provide a basis for the development of a standardized pathway aimed at improving access to rehabilitative care for geriatric hip fracture patients.

Posterior malleolus exposure.

Objectives: Posterior malleolus (PM) fractures are common in rotational ankle injuries, tibial plafond fractures, and distal third tibia fractures. Surgical indications continue to evolve as we improve our understanding of ankle and syndesmotic stability. These fractures remain technically challenging with respect to both exposure and fixation. Our biomechanical cadaveric study compared posterolateral versus modified posteromedial surgical approaches to define the following: maximal surface area exposed, and maximal screw trajectory obtainable for fixation. Methods: Twelve fresh-frozen cadaver limbs were thawed at room temperature. Posterolateral and modified posteromedial approaches were performed on each limb. Margins of exposure were marked. A 2.5 mm drill was advanced at the extreme medial and lateral extents of each exposure, standardized at 1 cm proximal to the joint line and perpendicular to the bone. Computed tomography (CT) scans were performed to identify the maximal trajectory. Limbs were stripped of soft tissue, and the exposed bony surface area was measured using a validated laser surface-scanning technique. Results: The modified posteromedial approach allowed for a larger exposed surface area compared to the posterolateral exposure (median 99% vs 64%, respectively; P < .05). The modified posteromedial approach allowed for instrumentation of up to a median of 77% of the posterior distal tibia as opposed to 46% through the posterolateral approach (P < .05). Conclusion: The modified posteromedial approach allowed for increased exposure and wider access for instrumentation of the PM when compared to the posterolateral approach. We advocate use of this approach when addressing complex PM fractures, in particular the Haraguchi type 2 fracture pattern.

Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol.

BACKGROUND: Proximal humerus fractures are the third most common fracture in the elderly population and are expected to increase due to the aging population. Surgical fixation with locking plate technology has increased over the last decade despite a lack of proven superiority in the literature. Three previous randomized controlled trials have not shown a difference in patient-centered outcomes when comparing non-operative treatment with open reduction and internal fixation. Low patient enrollment and other methodological concerns however limit the generalizability of these conclusions and as a result, management of these fractures remains a controversy. By comparing the functional outcomes of locked plate surgical fixation versus non-operative treatment of displaced three and four-part proximal humerus fractures in the elderly population with a large scale, prospective, multi-centered randomized controlled trial, the optimal management strategy for this common injury may be determined. METHODS: We will conduct a prospective, single blind randomized controlled parallel arm trial to compare non-operative management of proximal humerus fractures with open reduction and internal fixation using locked plating technology. One-hundred and sixty patients > age 60 with acute 3- or 4- part proximal humerus fractures will be randomized to either open reduction and internal fixation with locked plating technology or non-operative management treatment arms. The primary outcome measure is the Constant Score at 24 months post-operative. Secondary outcome measures include the American Shoulder and Elbow Surgeon's Score (ASES), EuroQol EQ-5D-5 L Health Questionnaire Score, short form PROMIS upper extremity score and IPAQ for the elderly score. Further outcome measures include assessment of the initial classification, displacement and angulation and the quality of surgical reduction via a standard computed tomography (CT) scan; rates of non-union, malunion, arthrosis, osteopenia or other complications including infection, nerve injury, intra-articular screw penetration, reoperation rates and hospital re-admission rates. DISCUSSION: The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population. TRIAL REGISTRATION: ClinicalTrials.gov NCT02362100 . Registered 5 Feb 2015.

Acetabular fractures in the elderly: evaluation and management.

Acetabular fracture patterns in the elderly, with increased involvement of the anterior column, quadrilateral plate comminution, medialization of the femoral head, and marginal impaction, differ from those noted among a younger cohort. Poor prognostic factors for open reduction and internal fixation (ORIF) are posterior wall comminution, marginal impaction of the acetabulum, a femoral head impaction fracture, a so-called gull sign, and hip dislocation. The rate of conversion to total hip arthroplasty following formal ORIF has been reported to be 22% at a mean of twenty-nine months. Total hip replacement after an acetabular fracture generally yields good clinical results; however, in the acute setting, it must be combined with proper stable fracture fixation.

Outcomes following surgical treatment of periprosthetic femur fractures: a single centre series.

BACKGROUND: Periprosthetic femoral fracture after total hip arthroplasty (THA) is an increasing clinical problem and a challenging complication to treat surgically. The aim of this retrospective study was to review the treatment of periprosthetic fractures and the complication rate associated with treatment at our institution. METHODS: We reviewed the cases of patients with periprosthetic femoral fractures treated between January 2004 and June 2009. We used the Vancouver classification to assess fracture types, and we identified the surgical interventions used for these fracture types and the associated complications. RESULTS: We treated 45 patients with periprosthetic femoral fractures during the study period (15 men, 30 women, mean age 78 yr). Based on Vancouver classification, 2 patients had AL fractures, 9 had AG, 15 had B1, 24 had B2, 2 had B3 and 4 had C fractures. Overall, 82% of fractures united with a mean time to union of 15 (range 2-64) months. Fourteen patients (31%) had complications; 11 of them had a reoperation: 6 to treat an infection, 6 for nonunion and 2 for aseptic femoral component loosening. CONCLUSION: Periprosthetic fractures are difficult to manage. Careful preoperative planning and appropriate intraoperative management in the hands of experienced surgeons may increase the chances of successful treatment. However, patients should be counselled on the high risk of complications when presenting with this problem.

CONTEXTE: La fracture périprothétique du fémur après prothèse totale de la hanche (PTH) est un problème clinique croissant et une complication difficile à traiter chirurgicalement. Le but de cette étude rétrospective était de passer en revue le traitement des fractures périprothétiques et le taux de complications associées à leur traitement dans notre établissement. MÉTHODES: Nous avons passé en revue les cas de fractures périprothétiques du fémur traitées entre janvier 2004 et juin 2009. Nous avons utilisé la classification de Vancouver pour évaluer les types de fractures et nous avons recensé les interventions chirurgicales utilisées pour corriger ces types de fractures et leurs complications respectives. RÉSULTATS: Nous avons traité 45 patients victimes de fractures périprothétiques du fémur durant la période de l'étude (15 hommes, 30 femmes, âge moyen de 78 ans). Selon la classification de Vancouver, la répartition des fractures était la suivante : 2 patients avaient une fracture de type AL; 9, un type AG; 15, un type B1; 24, un type B2; 2, un type B3; et 4 un type C. Dans l'ensemble, 82 % des fractures ont repris dans un intervalle de temps moyen de 15 mois (entre 2 et 64 mois). Quatorze patients (31 %) ont présenté des complications; 11 ont dû être réopérés : 6 pour traiter une infection, 6 pour non soudure et 2 pour descellement aseptique de la composante fémorale. CONCLUSION: Les fractures périprothétiques sont difficiles à soigner. Une planification préopératoire soigneuse et une prise en charge peropératoire appropriée par des chirurgiens d'expérience peuvent augmenter les chances de succès. Toutefois, il faut informer les patients du risque élevé de complications lorsqu'ils se présentent avec ce type de problème.

Scapula fractures.

Fractures of the scapula are rare and the diagnosis and treatment may be unfamiliar to some surgeons. This article outlines a diagnostic work-up and treatment approach for the various types of scapular fractures. The approach helps guide decision making on operative versus nonoperative treatment based on what is known regarding prognosis and outcomes of management. Operative technique and fixation strategies are discussed for the common fracture patterns along with guidelines for postsurgical shoulder rehabilitation.

Comparative radiographic and clinical outcome of two-hole and multi-hole symphyseal plating.

OBJECTIVES: To report on the radiographic and clinical outcome of symphyseal plating techniques, with specific attention to the incidence of implant failure, reoperation secondary to implant complication, and ability to maintain reduction of the pelvic ring. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 trauma center. PATIENTS: A total of 229 skeletally mature patients with traumatic pelvic disruptions associated with pubic symphysis diastasis requiring open reduction internal fixation. INTERVENTION: Symphyseal plating: (1) group THP, a two-hole plate; (2) group MHP, a multi-hole plate (minimum 2 holes/screws on either side of the symphysis). Patients were analyzed with respect to technique of anterior ring fixation and posterior ring injury pattern and fixation. MAIN OUTCOME MEASUREMENT: Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. Analysis included pelvic ring injury, type of anterior and/or posterior fixation, maintenance of postoperative reduction, rate of implant failure, and need for reoperation secondary to implant complication. Additionally, logistic regression analysis was performed to detect correlation between any other variable (posterior injury pattern, presence or absence of posterior fixation, time to surgery) and failure or malunion. Statistical analyses were performed using SPSS software. RESULTS: A total of 92 complete data sets were available for review. There were 51 patients in group THP and 41 patients in group MHP. When comparing the results of the 2 different methods of anterior fixation (THP versus MHP), the rate of fixation failure was greater in group THP (17 of 51; 33%) than group MHP (5 of 41; 12%). This was statistically significant (P = 0.018). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (29 of 51; 57%) than in the MHP group (6 of 41; 15%). Again, this was highly statistically significant (P = 0.001). Although the reoperation rate was slightly higher in the THP group (16%) as compared to the MHP group (12%), this was not statistically significant (P = 0.67). Logistic regression analysis did not reveal any other variables to correlate as a risk factor for failure or malunion in this group of patients. CONCLUSIONS: In this group of patients, the two-hole symphyseal plating technique group had a higher implant failure rate and, more importantly, a significantly higher rate of pelvic malunion. On the basis of these findings, we recommend multi-hole plating of unstable pubic symphyseal disruptions.