Postoperative Computed Tomography Scans of Acetabular Fractures Routinely Identify Indications for Revision Surgery.

OBJECTIVES: To investigate the utility of postoperative computed tomography (CT) scans in identifying indications for revision surgery after surgical fixation of acetabular fractures. DESIGN: Retrospective cohort study. SETTING: Urban level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with surgically treated acetabular fractures with surgical fixation (open reduction and internal fixation or percutaneous fixation) with routine postoperative CT scans. OUTCOME MEASURES AND COMPARISONS: Primary outcome-revision surgery based on postoperative imaging, including intra-articular osteochondral fragments, implant complications, and malreductions. Secondary outcome-quality of reduction on radiographs versus CT scans. RESULTS: One hundred forty-eight patients were included. The revision surgery rate was 15.5% (23/148); indications included malpositioned implants (6.7%, n = 10), malreductions (5.4%, n = 8), and intra-articular loose bodies (3.4%, n = 5). Only 8.7% (2/23) of the indications for revision surgery were identified on postoperative radiographs, with the remainder being identified on CT scans. Revision surgeries were found to be associated with male gender (proportional difference: 19.6%, 95% confidence interval [CI]: 3.4%-29.4%; P = 0.04) and T-type fractures (PD 28.7%; CI, 9.0%-48.9%; P = 0.001). Revision surgery was not found to be associated with age, body mass index, posterior wall fractures, concurrent pelvic ring fractures, or surgical approach. On radiographs, 51.3% (n = 76/148) had anatomic reductions (<2 mm) compared with only 10.2% (n = 15/148) on CT scans. CONCLUSIONS: Indications for revision of acetabular fixation surgeries and poor reductions were frequently missed on plain radiography and identified on postoperative CT scans. This suggests that the use of advanced imaging such as intraoperative 3D imaging or postoperative CT scans may be beneficial. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Should a history of pelvic fracture fixation be an indication for cesarean section?

PURPOSE: To compare the success rate of a trial of labor (TOL) in a cohort of patients with pelvic fractures, with and without internal fixation, in order to better counsel patients and avoid unnecessary cesarean section (CS). METHODS: A retrospective review of 35 female patients with 28 pelvic ring, five acetabular, and two combined fractures that had subsequent pregnancy; 12 patients had operative fixation and 23 did not. Fracture classification, treatment, type of fixation, mode of deliveries, and reason for CS were documented. RESULTS: The rate of vaginal delivery, unscheduled CS, and scheduled CS across all patients was 80.0% (n = 28), 14.3% (n = 5), and 5.7% (n = 2), respectively, which was similar to institutional rates of 87.0, 12.0, and 1.0%. A TOL was attempted in 91.4% (32/35) and successful in 87.5% (28/32). Patients who failed a TOL were more likely to have Tile B/C pelvic fractures (100.0 vs. 30.4%, observed difference (OD) 69.6%, 95% confidence interval (CI) 16.4, 86.3%; p = 0.01) and more pelvic displacement (6.0 vs. 1.5 mm, OD 4.0, CI 1.0, 18.0; p = 0.01). The fixation and control groups had no observed difference in successful TOL (72.7% vs. 95.2%, OD 22.5%, - 49.7%, 5.5%; p = 0.10). CONCLUSIONS: A majority of women had successful vaginal deliveries after pelvic fractures, with or without fixation, suggesting that these patients should consider a TOL. LEVEL OF EVIDENCE: Diagnostic Level III.

Identifying Reasons for Nonmedical Delays in Fixation of Femur, Pelvis, and Acetabular Fractures at a Level 1 Trauma Center.

OBJECTIVE: To identify reasons for nonmedical delays in femur, pelvis, and acetabular fracture fixation at an institution with a dedicated orthopaedic trauma room (DOTR) and an early appropriate care practice model. DESIGN: Retrospective review of a prospective registry. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundred ninety-four patients undergoing 313 procedures for 226 femur, 63 pelvis, and 42 acetabular fractures. INTERVENTION: Definitive fixation. MAIN OUTCOME MEASUREMENTS: Reasons for delays in fixation after hospital day 2. RESULTS: Delays occurred in 12.5% of procedures (39/313), with 7.7% (24/313) having medical delays and 4.8% (15/313) having nonmedical delays. Nonmedical delays were most commonly due to the operating room being at-capacity (n = 6) and nonpelvic trauma specialists taking weekend call (n = 5). Procedures with nonmedical delays were associated with younger age (median difference -16.0 years, 95% confidence interval [CI], -28 to -5.0; P = 0.006), high-energy mechanisms (proportional difference [PD] 58.5%, 95% CI, 37.0-69.7; P < 0.0001), Thursday through Saturday hospital admission (PD 30.3%, 95% CI, 5.0-50.0; P < 0.0001), pelvis/acetabular fractures (PD 51.8%, 95% CI, 26.7-71.0%; P < 0.0001), and external fixation (PD 33.0%, 95% CI, 11.8-57.3; P < 0.0001). CONCLUSION: Only 4.8% of procedures experienced nonmedical delays using an early appropriate care model and a DOTR. Nonmedical delays were most commonly due to 2 modifiable factors-the DOTR being at-capacity and nonpelvis trauma specialists taking weekend call. Patients with nonmedical delays were more likely to be younger, with pelvis/acetabular fractures, high-energy mechanisms, external fixation, and to be admitted between Thursday and Saturday. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pelvic ring injuries after alpine ski and snowboard accidents.

PURPOSE: The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. METHODS: Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. RESULTS: Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. CONCLUSION: The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

The interobserver reliability of clinical relevance in orthopaedic research.

PURPOSE: A ratio of observed difference (OD) over the 95% confidence interval (CI) has been shown to be strongly associated with the perceived clinical relevance (CR) of medical research results. The purpose of this study was to evaluate the association between the OD/CI ratio and perceived CR in orthopaedic research. METHODS: Sixty-seven orthopaedic surgeons completed a survey with 15 study outcomes (mean difference and CI) and were asked if they perceived the findings as clinically relevant. The interobserver reliability of perceived CR and the association between CR and the OD/CI ratio and p-value were assessed. RESULTS: The interobserver reliability of CR between respondents was moderate (kappa = 0.46, CI 0.45 to 0.48). P-values did not differ between results with and without CR (median difference (MD) - 0.12, CI - 0.74 to 0.0009, p = 0.07). The OD/CI ratio, however, was greater for results with CR (MD 1.01, CI 0.3 to 3.9, p = 0.004). The area under the curve (AUC) for the p-value and OD/CI ratio receiver operating characteristic (ROC) curves was 0.80 (p = 0.01) and 0.97 (p = 0.0003). The cutoff p -value and OD/CI ratio that maximized the sensitivity (SN) and specificity (SP) for CR were 0.001 (SN 80%, SP 80%) and 0.84 (SN 100%, SP 90%). The SN and SP of a p-value cutoff of 0.05 was 100% and 50%. CONCLUSION: The interobserver reliability of the perceived CR of orthopaedic research findings was moderate. The OD/CI ratio, in contrast to the p-value, was strongly associated with perceived CR making it a potentially useful measure to evaluate research results.

A standardized method of measuring screw breach on postoperative computed tomography scans following percutaneous fixation of the posterior pelvic ring.

PURPOSE: To assess the reliability of a standardized measurement of screw breach on postoperative computed tomography (CT) scans following percutaneous fixation of the posterior pelvic ring. METHODS: Three orthopedic trauma surgeons independently utilized a standardized method of measuring posterior pelvic ring screw breaches on post-operative CT scan images. Breaches were measured as a continuous variable on sagittal images reformatted to be perpendicular to the screw on axial images. The inter-rater and intra-rater reliability of screw breach distance measurements was assessed. RESULTS: Measurements were performed on 42 screws in 20 patients. Screw types included S1-iliosacral (IS) (n = 16), S1-transsacral (TS) (n = 8), S2-IS (n = 2), and S2-TS (n = 16). Patients with varying degrees of screw breaches were chosen to test measurements across breach severities, including 0 mm (n = 10), ≤ 2 mm (n = 12), > 2 to 4 mm (n = 11), and > 4 mm (n = 9). The mean difference and 95% confidence interval (CI) between screw breach measurements between the three surgeons was - 0.13 mm (CI - 0.48 to 0.20), 0.05 mm (CI - 0.6 to 0.7), and 0.18 mm (CI - 0.47 to 0.85), respectively. The inter-rater reliability of the measurements was considered excellent (intraclass correlation coefficient (ICC), 0.93). The mean intra-rater reliability for the observers was considered good (ICC 88.5, CI 82 to 95). CONCLUSIONS: This simple standardized method of measuring screw breaches had excellent inter-rater reliability and would support comparisons of screw breach severity across studies. LEVEL OF EVIDENCE: Level III.

The interobserver reliability of clinical relevance in medical research.

BACKGROUND: A measure of effect size, such as observed difference (OD) and its 95% confidence interval (CI), is necessary to determine clinical relevance (CR) of research findings. The purpose of this paper is to (1) determine the interobserver reliability (IOR) of determining CR when presented with only the OD and CI and (2) to determine if a ratio of OD over CI (OD/CI) had a stronger association with CR than the p-value. METHODS: A survey including the OD and CI results from 21 studies was sent to 36 physicians, of which 21 responded. Respondents were asked to determine if the results were clinically relevant or not clinically relevant. RESULTS: Twenty-one (58%) physicians responded. The IOR of interpreting CR based on OD and the CI was weak (kappa=0.13, CI 0.10 to 0.15). The p-value did not differ between CR and non-CR results (median difference -0.001, CI -0.005 to 0.0, p = 0.07). The OD/CI however, was greater for CR vs. non-CR results (median difference 0.5, CI 0.09 to 0.95, p = 0.02). The area under the curve for the p-value and OD/CI receiver-operator characteristic curve was 0.70 and 0.80. The p-value and OD/CI that maximized the sensitivity (SN) and specificity (SP) for identifying CR was 0.001 (SN 88%, SP 59%) and 0.95 (SN 88%, SP 84%). CONCLUSION: Determining CR from the OD and CI alone had weak interobserver reliability. The OD/CI ratio had a stronger association with CR than the p-value making it potentially useful in evaluating the CR of research findings.

Antegrade versus retrograde nailing of proximal femur fractures: A cortical diameter based study.

Background: Retrograde nailing of proximal femoral shaft fractures is controversial. The purpose of this study was to compare patients with proximal femur fractures undergoing antegrade versus retrograde intramedullary nailing (AIMN vs RIMN) and determine the safety and efficacy of RIMN. Methods: A retrospective review was performed on 54 patients undergoing femoral IMN for proximal femoral shaft fractures at an urban level one trauma institution between January 2016 and July 2021.Fracture distance from the lesser trochanter (LT) was recorded and used to calculate the number of cortical diameters (NCD) from the LT. Proximal femur fractures were defined as < 3 NCD. AIMN and RIMN fixation was utilized in 31 (57.4%) and 23 (42.6%) patients, respectively. Outcomes measures included pre-/postoperative true translational and angular displacement (TTD and TAD), operative time, estimated blood loss (EBL), union rate, time to union, complications, and reoperations. Results: AIMN and RIMN groups were similar in terms of age, sex, BMI, tobacco use, diabetes, ASA classification >2, AO/OTA classification, preoperative TTD or TAD, open fractures, or ballistic fractures. The AIMN group, had a shorter measured distance from the LT (47.0 vs. 66.1 mm, p = 0.04) but the difference in NCD was not significant (1.4 vs. 2.0, p = 0.07). Among patients with isolated IMN procedures, the RIMN group had shorter operative times (142.3 vs. 178.5 min, p = 0.01) and less EBL (100 vs. 250 mL, p = 0.008). There was no observed intergroup difference in terms of postoperative TTD/TAD, union rate, time to union, complications, or reoperations. Conclusion: RIMN is a viable treatment option for proximal femoral shaft fractures that results in less operative time, less blood loss, and no detectable differences in union, reoperations, or complications. Level of evidence: Level III, Retrospective cohort study.

Risk factors for screw breach and iatrogenic nerve injury in percutaneous posterior pelvic ring fixation.

Background: Percutaneous screw fixation of the posterior pelvic ring is technically demanding and can result in cortical breach. The purpose of this study was to examine risk factors for screw breach and iatrogenic nerve injury. Methods: A retrospective review at a single level-one trauma center identified 245 patients treated with 249 screws for pelvic ring injuries with postoperative computed tomography (CT) scans. Cortical screw breach, iatrogenic nerve injury, and associated risk factors were evaluated. Results: There were 86 (35%) breached screws. The breach rate was similar between screw types (33% S1-iliosacral (S1-IS), 44% S1-transsacral (S1-TS), 31% S2-IS, and 30% S2-TS) and was not associated with patient characteristics, Tile C injuries, or corridor size or angle. The overall rate of screw revision for screw malpositioning was 1.2% (3/249). Iatrogenic nerve injuries occurred in 8 (3.2%) of the 249 screws. Screws that caused iatrogenic nerve injuries had greater screw breach distances (5.4 vs. 0 mm, MD 5, CI 2.3 to 8.7, p < 0.0001), were more likely to be S1-IS screws (88% vs. 47%, PD 40%, CI 7 to 58%, p = 0.006), more likely to be placed in Tile C injuries (75% vs. 44%, PD 31%, CI -3 to 55%, p = 0.04), and there was a trend for having a screw corridor size <10 mm (75% vs. 47%, PD 28, CI -6 to 52%, p = 0.06). Of the 7 iatrogenic nerve injuries adjacent to screw breaches, two nerve injuries recovered after screw removal, three recovered with screw retention, and two did not recover with screw retention. Conclusion: Screw breaches were common and iatrogenic nerve injuries were more likely with S1-IS screws. Surgeons should maintain a high degree of caution when placing these screws and consider removal of any breached screw associated with nerve injury.

Orthopaedic Injuries After Introduction of Electric Scooters to Denver, Colorado.

INTRODUCTION: Cost and efficiency have made electric scooters (e-scooters) popular in urban areas, but many orthopaedic injuries are associated with their use. METHODS: A retrospective review of e-scooter-related injuries at a level one trauma center identified injury patterns and hospital-associated costs before and after widespread commercial introduction of e-scooters. RESULTS: Twenty-three and 197 patients were included in preimplementation and postimplementation groups, respectively. Hospital admission increased from 11% to 62% after commercial introduction. Cost of care increased from $1.8 million to $7.6 million, and 61% of orthopaedic injuries required surgery. The most common orthopaedic injuries were distal radius fractures. Seventy-three percent of the patients tested were intoxicated at the time of injury. DISCUSSION: This study categorizes injury patterns and highlights increased hospital-related admissions and surgeries associated with e-scooters. The high rate of intoxicated rider injuries emphasizes the need for laws guiding operation of e-scooters.

Defining Sacral Dysmorphism: What Size Corridor Precludes Transsacral Screw Placement.

OBJECTIVE: To determine what size S1-transsacral (TS) corridor is amenable to TS screw placement, as this is commonly used to identify sacral dysmorphism, and to determine if gender, ethnicity, or screw breach is associated with narrow corridors. DESIGN: Retrospective review. SETTING: Urban level-1 trauma center. PATIENTS: Two hundred ninety patients with pelvic ring injuries and preoperative computed tomography (CT) scans. INTERVENTION: Percutaneous posterior pelvic ring fixation. MAIN OUTCOME MEASUREMENTS: The width of the S1-TS corridor was measured on the axial (inlet) and coronal (outlet) reformatted CT images. Patients with S1-TS screw fixation and postoperative CT scans were identified. Corridor size, gender, ethnicity, and screw breach were documented. RESULTS: S1-TS screws were placed in 55 of the 290 patients. No S1-TS screws were placed in corridors less than 8 mm. Corridors of <8 mm were present in 114 (39%) of the 290 patients and were not associated with gender or ethnicity. S1-TS screws placed in small (<10 mm) versus large (≥10 mm) corridors did not have a detectable difference in screw breaches (5 of 8, 62% versus 19 of 47 40%; difference, 22%, 95% confidence interval -14% to 52%) or median (interquartile range) screw breach distance [3 mm (2.5-4.8) versus 3 mm (1.2-4.8); difference, 0.9 mm; confidence interval -1.6 to 2.2]. CONCLUSION: These data are useful for the standardization of sacral dysmorphism reporting based on corridor size. Screw breaches were common irrespective of TS corridor size, emphasizing the small degree of error allowed by this procedure. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lateral Stress Radiographs of Lateral Compression Type 1 Pelvic Injuries, With the Injured Side Down or Up, Reliably Measure Occult Instability.

OBJECTIVES: To evaluate the interobserver reliability of measured displacement and occult instability of minimally displaced lateral compression type 1 (LC1) fractures on lateral stress radiographs (LSRs) and to compare differences in displacement between LSR with the injured side down (ID) and up (IU). DESIGN: Retrospective review. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: Twenty-three adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Three orthopaedic surgeons measured the distance between the radiographic teardrops on LSR and supine anteroposterior pelvic radiographs to calculate dynamic fracture displacement. The interobserver reliability of the measured displacement, a continuous variable, was assessed by calculating the intraclass correlation coefficient. The interobserver reliability of occult instability (≥10 mm of displacement on LSR), a categorical variable, was assessed by calculating the kappa value. Matched-pairs analysis was performed to calculate the mean difference of measurements between observers and between ID and IU LSR. RESULTS: The interobserver reliability of the measured displacement was excellent (intraclass correlation coefficient 0.93). The mean difference in measurements between observers ranged from -1.8 to 0.96 mm. The mean difference in the measured displacement between ID and IU LSRs for each observer ranged from -0.6 to 0.3 mm. There was 83% (19/23 cases) agreement on the presence of occult instability (≥10 mm of displacement on LSR) on both ID and IU LSRs. The interobserver reliability of occult instability was moderate (kappa 0.76). CONCLUSIONS: Measured fracture displacement and occult instability of minimally displaced LC1 injuries were reliably measured and identified on LSR, regardless of the laterality.

Analysis of Postoperative Gait, Hip Strength, and Patient-Reported Outcomes After OTA/AO 61-B and 61-C Pelvic Ring Injuries.

OBJECTIVES: To examine clinical gait parameters, hip muscle strength, pelvic functional outcomes, and psychological outcomes after surgical fixation of OTA/AO 61-B and 61-C pelvic ring injuries. DESIGN: Retrospective review identified 10 OTA/AO 61-B patients and 9 OTA/AO 61-C patients for recruitment who were between 1 and 5 years after pelvic fixation. Gait and strength assessments, and patient-reported outcome scores were performed/collected and analyzed. SETTING: Outpatient clinical motion performance laboratory. PATIENTS/PARTICIPANTS: Patients with OTA/AO 61-B and OTA/AO 61-C fractures who were between 1 and 5 years after pelvic fixation. MAIN OUTCOME MEASUREMENTS: Hip strength, kinetics, and spatial-temporal outcomes; Majeed Pelvic Outcome Score; Short Form 36; Hamilton Anxiety/Depression Rating Scales. RESULTS: There were no differences in age, body mass index, or time since definitive fixation between OTA/AO 61-B and 61-C groups. The OTA/AO 61-C group had higher median injury severity scores, longer length of stay, and greater postoperative pelvic fracture displacement. There was no difference in bilateral hip strength, bilateral peak hip moments, peak hip power, and walking speed between groups. Patients with OTA/AO 61-C fractures had lower scores on Short Form 36 General Health and Majeed Work, with a trend toward a lower Total Majeed score. There were no differences in self-reported total anxiety and depression symptoms. CONCLUSIONS: This study did not identify any gait, strength, or psychological differences between OTA/AO 61-B and 61-C injuries at 1-5 years of follow-up. However, increased injury severity in OTA/AO 61-C patients may have residual consequences on perceived general health and ability to work. This pilot study establishes a template for future research into functional recovery of patients with severe pelvic ring trauma. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Oral Versus Intravenous Antibiotics for Residual Osteomyelitis After Amputation in the Diabetic Foot.

The standard management for residual osteomyelitis following amputation in a diabetic foot infection includes a prolonged course of intravenous antibiotic agents. The purpose of this analysis was to investigate whether oral antibiotic therapy led to treatment failure more than intravenous antibiotic therapy for this indication. The primary endpoint was treatment failure within one year of the initial amputation, defined by re-operation for residual osteomyelitic infection or a remaining nonhealing wound at the surgical site. All patients received at least 4 weeks of antibiotics and were chosen for oral or intravenous route of administration by infectious disease specialists. Characteristics including age, sex, hemoglobin A1c, BMI, tobacco use, PVD, homelessness and IDSA classification were also assessed for influence on antibiotic success and failure. Of the 65 patients meeting inclusion criteria, treatment failure occurred in 32 and treatment success occurred in 33. Of the treatment failures, 17 (53%) were in the intravenous group, and 15 (47%) were in the oral group. The differences between the modalities of antibiotic administration and their failure rates were not found to be statistically significant (p = .28 (proportional difference: -14%, 95% confidence interval [CI]:-36% to 10%)).

Nonoperative Management of Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries With and Without Occult Instability.

OBJECTIVES: To determine the association of pelvic fracture displacement on lateral stress radiographs (LSRs) with the hospital course of patients with minimally displaced lateral compression type 1 (LC1) pelvic injuries. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Twenty-eight adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION: Nonoperative management. MAIN OUTCOME MEASUREMENTS: Delayed operative fixation, days to clear physical therapy, mobilization, hospital length of stay, and total hospital opioid morphine equivalent dose. RESULTS: LSR displacement was correlated with delayed operative fixation [r = 0.23, 95% confidence interval (CI) 0.05-1.11; P = 0.01], days to clear PT (r = 0.13, CI 0.01-0.28; P = 0.02), length of stay (r = 0.13, CI 0.006-0.26; P = 0.02), and opioid morphine equivalent dose (r = 19.4, CI 1.5-38.1; P = 0.03). A receiver operating characteristic curve for delayed operative fixation over LSR displacement had an area under the curve of 0.87. The LSR displacement threshold that maximized sensitivity and specificity for detecting patients who required delayed fixation was 10 mm (100% sensitivity and 78% specificity). Ten of the 15 patients with ≥10 mm of displacement on LSRs underwent delayed operative fixation for pain with mobilization at a median of 6 days (interquartile range 3.7-7.5). Patients with ≥10 mm of displacement on LSRs took longer to clear PT, took longer to walk 15 feet, had longer hospital stays, and used more opioids. CONCLUSIONS: LC1 fracture displacement on LSRs is associated with delayed operative fixation, difficulty mobilizing secondary to pain, longer hospital stays, and opioid use. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Using Reformatted Axial Computed Tomography Images in Isolation Will Miss Narrow S1 Transsacral Screw Corridors.

OBJECTIVE: To evaluate S1 transsacral (TS) corridors on reformatted and nonreformatted computed tomography (CT) images to determine which most reliably identifies narrow corridors. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Two hundred forty-five patients with operative pelvic ring injuries. INTERVENTION: CT scan review. MAIN OUTCOME MEASUREMENTS: Preoperative CT scans were evaluated to determine the width of the S1 TS corridor on standard axial nonreformatted (ANR), axial reformatted (AR), and coronal reformatted images. Sensitivity and specificity of each format to detect a narrow corridor (<10 mm on AR or coronal reformatted) were calculated. Patients with S1 TS screws were evaluated to determine the rate of screw breach with narrow corridors. RESULTS: The axial width of the S1 TS corridor was consistently smaller on ANR versus AR images (mean difference 1.4mm, 95% confidence interval 1.1-1.5). The corridor width on ANR images was on average 86% of the AR measurement. ANR images had the highest sensitivity and specificity (100% and 98%) for detecting S1 TS corridors <10 mm. Fifty-three S1 TS screws were placed in corridors ranging 10-23 mm on AR images and 7-19 mm on ANR images. Four (57%) of the 7 screws placed in corridors less than 10 mm in width on ANR images breached the sacral cortex. CONCLUSION: Using ANR images to measure the S1 TS corridor consistently measured smaller widths than AR images and identified all narrow corridors. A high rate of screw breach was noted with screw placement in narrow corridors. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Urinary Bladder Matrix Grafting: A Simple and Effective Alternative to Flap Coverage for Wounds in High-Risk Orthopaedic Trauma Patients.

SUMMARY: Complex traumatic and/or infected wounds and their sequelae are a significant burden for high-volume trauma centers. Local or free flap coverage options are well described; however, they may be high risk in poor hosts with multiple comorbidities and active infections. In addition, flap coverage can result in delays in wound coverage depending on specialist availability. Porcine urinary bladder matrix grafting has been shown to be a simple definitive wound coverage option that can be performed without delay in multiple patient populations for wounds that would otherwise require flap coverage. The purpose of this article was to describe a technique for urinary bladder matrix grafting and report on a series of orthopaedic trauma patients treated with this technique.

Sacral Fracture Completeness in Lateral Compression Type 1 Pelvic Ring Injuries Has Weak Interobserver Reliability.

OBJECTIVES: To determine the agreement between fellowship-trained orthopaedic trauma surgeons in evaluating sacral fracture completeness in the setting of minimally displaced lateral compression type 1 pelvic ring injuries. DESIGN: Survey study. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: This study included 10 fellowship-trained orthopaedic trauma surgeons reviewing 10 cases of minimally displaced lateral compression type 1 injuries with proven occult instability (≥10 mm of fracture displacement on lateral stress radiographs). Sacral fractures were considered complete (n = 5; fracture line exiting posterior cortex of sacrum) or incomplete (n = 5). INTERVENTION: Participants reviewed videos of all axial computed tomography images of the sacrum and were asked if the sacral fracture was complete or incomplete. MAIN OUTCOME MEASUREMENTS: Interobserver reliability of completeness of sacral fracture. RESULTS: Interobserver reliability among surgeons for completeness of sacral fractures was considered to be weak (k = 0.46) with a 95% confidence interval that ranged from minimal (k = 0.37) to weak (k = 0.55). None of the 5 unstable sacral fractures that were considered to be complete garnered 100% agreement among surgeons. Agreement for each of these cases ranged from 40% to 90%. In contrast, 4 of the 5 unstable sacral fractures considered to be incomplete had 100% agreement. CONCLUSIONS: Completeness of sacral fractures had weak interobserver reliability among fellowship-trained orthopaedic trauma surgeons. Sacral fractures that were considered incomplete by all surgeons did have occult instability. These results highlight the large potential for error created by using sacral fracture completeness as a criterion to rule out occult instability. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

PURPOSE: External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. METHODS: This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. RESULTS: Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85 cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5 cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4 min; 95% CI, - 32 to 22; p = 0.68). CONCLUSIONS: In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

Percent of Normal: A Pragmatic Patient-Reported Outcome Measure for the Orthopaedic Trauma Clinic.

OBJECTIVES: To compare a single numerical patient-reported outcome measure (PROM) to general health and injury-specific PROMs. DESIGN: Retrospective cohort. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: The study included 175 patients with 34 humerus, 54 pelvis, 31 acetabular, and 56 ankle fractures. MAIN OUTCOME MEASUREMENTS: Patients were administered 3 PROMs: the 12-item short-form (SF-12), an injury-specific PROM (QuickDASH-humerus; Majeed Pelvic Outcome Score (Majeed)-pelvis; modified Merle d'Aubigne score (Merle)-acetabular; Foot and Ankle Disability Index (FADI)-ankle, and the Percent of Normal (PON) PROM, a single numerical PROM, which asked, "How would you rate yourself, if 100% is back to normal?" Floor/ceiling effect, convergent validity, and responsiveness of PROMs were assessed. RESULTS: None of the PROMs demonstrated a floor effect. The Merle was the only PROM with a ceiling effect (19%). The PON had a strong correlation with the QuickDASH (r = 0.78) and Majeed (r = 0.78); a moderate association with the SF-12 physical component score (r = 0.63), Merle (r = 0.67), and FADI (r = 0.55); and a weak association with the SF-12 mental component score (r = 0.22). The regression coefficient for change in PROM over time, a measure of responsiveness, was greater for the PON compared with the SF-12 physical component score/mental component score, Majeed, Merle, and FADI, but not the QuickDASH. CONCLUSIONS: The PON is a pragmatic PROM that can be easily administered in clinic by the physician to quickly assess and manage a variety of fractures, avoiding the disadvantages of nonrelative general or region-specific PROMs.