Surgical complications after fixation of minimally displaced lateral compression type 1 pelvic ring injuries.

PURPOSE: To review surgical complications after fixation of stress-positive minimally displaced (< 1 cm) lateral compression type 1 (LC1) pelvic ring injuries. METHODS: A retrospective study at a level one trauma center identified patients who received surgical fixation of isolated LC1 pelvic ring injuries. Surgical complications and additional procedures were reviewed. RESULTS: Sixty patients were included. The median age was 61 years (Interquartile range 40-70), 65% (n = 39) were women, and 57% (n = 34) had high-energy mechanisms. Anterior-posterior, posterior-only, and anterior-only fixation constructs were used in 77% (n = 46), 15% (n = 9), and 8% (n = 5) of patients. Anterior fixation was performed with rami screw fixation in 82% (49/60), external fixation in 2% (1/60), and open reduction and plate fixation in 2% (1/60). There were 15 surgical complications in 23% (14/60), and 12 additional procedures in 17% (10/60). Complications included loss of reduction ≥ 1 cm (8%), symptomatic hematomas (8%), symptomatic backout of unicortical retrograde rami screws (5%), deep infection of the pelvic space after a retrograde rami screw (1.6%), and iatrogenic L5 nerve injury (1.6%). All losses of reduction involved geriatric females with distal rami fractures sustained in ground-level falls. Loss of reduction was found to be more likely in patients with low energy mechanisms (proportional difference (PD) 62%, 95% confidence interval (CI) 18% to 76%; p = 0.01) and 2 versus 1 posterior pelvic screws (PD 36%; CI 0.4% to 75%; p = 0.03). CONCLUSIONS: Surgical complications and additional procedures routinely occurred after fixation of LC1 injuries. Patients should be appropriately counseled on the risks of surgical fixation of these controversial injuries. LEVEL OF EVIDENCE: Diagnostic, Level III.

Variables Associated With Loss of Fixation of Retrograde Rami Screws in Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries.

OBJECTIVES: To evaluate variables associated with loss of fixation of retrograde rami screws in the treatment of stress-positive minimally displaced lateral compression type 1 (LC1) injuries. DESIGN: Retrospective comparative study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Stress-positive minimally displaced (<1 cm) LC1 pelvic ring injuries treated with retrograde rami screws. OUTCOME MEASURES AND COMPARISONS: Loss of fixation, defined as >5 mm of pelvic fracture displacement based on the radiographic tear-drop distance or >5 mm of implant displacement on follow-up radiographs; revision surgery for loss of fixation. RESULTS: Thirty-eight patients with 40 retrograde rami screws were analyzed. Median patient age was 64 years (interquartile range 42.5-73.3 years), 71.1% (n = 27/38) were female, and 52.6% (n = 20/38) of injuries were secondary to low-energy mechanisms. Loss of fixation occurred in 17.5% (n = 7/40) of screws with 10% (n = 4/40) requiring revision surgery. On univariate analysis, patients who had a loss of fixation were more likely to have greater dynamic displacement on stress radiographs (22.0 vs. 15.2 mm; median difference 5.6 mm, confidence interval [CI] -19.2 to 10.3; P = 0.04), unicortical rami screws (71.4% vs. 9.1%; proportional difference 62.3%, CI 8.8%-22.6%; P = 0.001), and partially threaded rami screws (71.4% vs. 21.2%; proportional difference 50.2%, CI 10.0%-77.6%; P = 0.01). The remaining variables had no observed association ( P ≥ 0.05) with loss of fixation, including age, sex, body mass index, energy of injury mechanism, tobacco use, American Society of Anesthesiologist score, sacral fracture type, distal rami fractures, rami comminution, number of sacral screws, fully threaded sacral screws, transsacral screws, or rami screw diameter. On multivariate analysis, only unicortical rami screws ( P = 0.01) remained associated with loss of fixation. CONCLUSIONS: Retrograde rami screws had a high rate of loss of fixation in minimally displaced LC1 pelvic ring injuries, and this was associated with unicortical screws. These screws should be avoided when possible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Trends of impact factor contributors to the Injury Journal: A bibliometric analysis.

PURPOSE: This study aims to analyse papers concerning journal impact factors published in the Injury-International Journal of the Care of the Injured between 1997 and 2022. Through this analysis, the research offers valuable insights into the publication performance and contributors to the journal impact factor, encompassing papers, authors, institutions, and countries. METHODS: Articles and reviews published in the Injury between 1995 and 2021 were examined using the Science Citation Index Expanded database. The study employed the journal impact factor contributing indicator to compare highly cited and high journal impact factor papers across various aspects, including papers, authors, institutions, and countries. RESULTS: A notable correlation exists between prolific authors, institutions, and countries, alongside those who contribute to high journal impact factors. However, a less distinct connection was observed between highly cited papers/authors and high journal impact factor contributors. The Injury serves as a well-regarded international journal. Notably, editorial members of the journal play a substantial role, serving as model editors and contributing significantly to the journal's success. Out of the Top 25 IF contributing papers with the CN of 34 or more the following themes were noted to dominate: bone healing/tissue regeneration (40 %) of papers, covid-19 pandemic (24 %), polytrauma/coagulopathy (12 %) and infection (8 %). CONCLUSIONS: Utilizing the journal impact factor to assess research performance at the individual, institutional, or national levels appears not to be the most appropriate method. The results show that highly cited authors did not hold the distinction of being the primary contributors to the IF. Analysis revealed a low significant relationship among the primary contributors to the IF, highly cited papers, and the most influential papers in 2022. A more effective indicator could involve considering the total number of citations a publication receives from its year of publication up to the end of the most recent year.

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.

Open Fixation After Preperitoneal Pelvic Packing Is Associated With a High Surgical Site Infection Rate.

OBJECTIVES: To evaluate the incidence of pelvic space surgical site infection (SSI) after preperitoneal pelvic packing (PPP) for persistent hemodynamic instability. DESIGN: Retrospective comparative study. SETTING: Urban Level 1 trauma center. PATIENTS/PARTICIPANTS: 83 patients who received PPP and 55 patients who had open reduction and internal fixation (ORIF) of the anterior pelvic ring without PPP. INTERVENTION: Operative fixation. MAIN OUTCOME MEASUREMENTS: Pelvic space SSI. RESULTS: The SSI rate in the PPP group was 31.3% (26/83) compared with 10.9% (6/55) in the control group (proportional difference 20.4%, confidence interval (CI) 6.4-32.5, P = 0.007). Patients in the PPP group (n = 43) were 1:1 propensity score matched with patients in the control group to account for differences in Injury Severity Score and American Society of Anesthesiologists score. In this matched cohort, the rate of pelvic space SSI remained higher in the PPP group compared with that in the control group (30.2% vs. 9.3%; proportional difference 20.9%, CI, 3.7-36.3; P = 0.02). On multivariate analysis of the PPP group, anterior ORIF (odds ratio 6.56, CI, 2.00-21.47, P = 0.002) was found to be independently associated with SSI. CONCLUSIONS: PPP is an independent risk factor of space SSI. The likelihood of SSI after PPP is increased with anterior ORIF. The morbidity of SSI after PPP must be weighed against the risk of exsanguination. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Disconnected: Electronic Patient-Reported Outcome Measure Collection in Orthopaedic Patients is Less Successful Than In-Person Collection at an Urban Safety Net Trauma Center.

OBJECTIVES: Electronic patient-reported outcome measure (E-PROM) collection is a technological advancement that has the potential to facilitate PROM collection in orthopaedic trauma. The purpose of this study was to compare E-PROM versus in-person PROM collection. DESIGN: This is a retrospective comparative study. SETTING: Urban Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and fifty consecutive operative orthopaedic trauma patients. INTERVENTION: The Percent of Normal single assessment numerical evaluation and patient-reported outcomes measurement information system physical function were collected through automated e-mails from an online patient-engagement platform (PatientIQ, Chicago, IL) 2-week, 6-week, 3-month, and 6-month postoperatively. The Percent of Normal was also administered to patients in clinic at the same time intervals. MAIN OUTCOME MEASUREMENTS: Completion of PROMs; Loss to follow-up. RESULTS: The median clinical follow-up time was 4 months (interquartile range: 1.3-6 months), and 42.7% (64/150) were lost to follow-up. Loss to follow-up was associated with a more disadvantaged area deprivation index [observed difference, 7.0, 95% confidence interval, 1.0 to 13.0; P = 0.01] and noncommercial/no insurance (observed difference 34.8%, confidence interval, 20.9%-45.5%; P < 0.0001). In-person PROM collection was more successful than E-PROM collection at all intervals [2-week (51.3% vs 20.7), 6-week (46.7% vs 20.0%), 3-month (50.0% vs 18.7%), and 6-month (38.0% vs 18.7%), P < 0.0001]. Patients who completed 3-month E-PROMs had longer clinical follow-up (5.2 vs. 3.0 months, P = 0.004) and a trend of being less likely to be lost to follow-up (28.6% vs 45.9%, P = 0.13). CONCLUSION: E-PROMs were less successful than in-person PROM collection in trauma patients at an urban safety net trauma center. LEVEL OF EVIDENCE: Diagnostic Level III.

Use of 3D Printing Technology in Fracture Management: A Review and Case Series.

SUMMARY: Three-dimensional (3D) offers exciting opportunities in medicine, particularly in orthopaedics. The boundaries of 3D printing are continuously being re-established and have paved the way for further innovations, including 3D bioprinting, custom printing refined methods, 4D bioprinting, and 5D printing potential. The quality of these applications have been steadily improving, increasing their widespread use among clinicians. This article provides a review of the current literature with a brief introduction to the process of additive manufacturing, 3D printing, and its applications in fracture care. We illustrate this technology with a case series of 3D printing used for correction of complex fractures/nonunion. Factors limiting the use of this technology, including cost, and potential solutions are discussed. Finally, we discuss 4D bioprinting and 5D printing and their potential role in fracture surgery.

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement.

PURPOSE: Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. METHODS: Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm. RESULTS: As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively). CONCLUSION: Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively. LEVEL OF EVIDENCE: Level III, prognostic retrospective cohort study.

Percutaneous pelvic fixation model: an affordable and realistic simulator for pelvic trauma training.

PURPOSE: To describe the construction and use of a percutaneous pelvic fixation model, evaluate its translational validity among fellowship-trained orthopedic trauma surgeons, and investigate the importance of specific criteria for effective competency-based assessment of pelvic fixation techniques. METHODS: Five orthopedic trauma surgeons were asked to place percutaneous wires on a pelvic fixation model, including anterior column (antegrade/retrograde), posterior column (antegrade/retrograde), supra-acetabular, transsacral, and iliosacral. Evaluation criteria included successful wire placement, redirections, cortical breaches, procedure duration, radiation exposure, and quality of fluoroscopic views. Following completion, participants were provided a survey to rate the model. RESULTS: There were no differences between approaches on successful screw placement, wire redirections, or fluoroscopic quality. Antegrade approaches to the anterior and posterior columns took longer (p = 0.008) and used more radiation (p = 0.02). There was also a trend toward more cortical breaches with the antegrade anterior column approach (p = 0.07). Median ratings among surgeons were 4 out of 5 for their overall impression and its accuracy in tactile response, positioning constraints, and fluoroscopic projections. Learning parameters considered most important to the progression of trainees (most to least important) were successful screw placement, corridor breaches, wire redirections, quality of fluoroscopic views, radiation exposure, and procedure duration. CONCLUSION: In being affordable, accessible, and realistic, this percutaneous pelvic fixation model represents an opportunity to advance orthopedic surgery education globally. Future research is needed to validate the findings of this pilot study and to expand upon how trainees should be evaluated within simulations and the operating room to optimize skill progression.

Postfasciotomy Classification System for Acute Compartment Syndrome of the Leg.

OBJECTIVE: Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy. METHODS: Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses. RESULTS: The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency. CONCLUSION: This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Disconnected: Electronic Patient-Reported Outcome Measure Collection In Orthopaedic Patients at an Urban Safety-Net Hospital.

INTRODUCTION: Collection of patient-reported outcome measures (PROMs) in orthopaedic patients at safety-net hospitals is challenging. The purpose of this study was to evaluate the success of electronic PROM (E-PROM) collection in this setting. METHODS: A retrospective review identified 207 consecutive orthopaedic patients undergoing 77 elective arthroplasty procedures and 130 trauma procedures. E-PROMs were collected through automated e-mails from an online patient engagement platform (PatientIQ) at 2 weeks, 6 weeks, and 3 months postoperatively. Patients with trauma received the percentage of normal Single Assessment Numerical Evaluation (SANE) and Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF). Arthroplasty patients received the Hip/Knee SANE, Hip/Knee Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS Jr/KOOS Jr), PROMIS Global Physical Health (PROMIS-G-PH), and Veterans RAND 12-Item (VR-12) Health Survey. RESULTS: Compared with patients with trauma, arthroplasty patients were older (median difference 18.0 years; 95% confidence interval [CI] 12.0-22.0; P < 0.0001), more likely to be Hispanic/Black (proportional difference 16.9%; CI 2.8-30.3%; P = 0.02), more likely to have noncommercial or no insurance (proportional difference 34.0%; CI 23.2-43.0%; P < 0.001), and did not differ in Area Deprivation Index or E-PROM completion at each time point. E-PROMs were completed at 2 weeks, 6 weeks, and 3 months by 25.1% (52 of 207), 24.6% (51 of 207), and 21.7% (45 of 207) of all patients, respectively. Trauma and arthroplasty patients had a similar rate of partial E-PROM completion. Patients who completed 3-month E-PROMs were less likely to be Hispanic/Black (PD -16.4%; CI -31.0 to -0.2%; P < 0.04); less likely to have noncommercial/no insurance (PD -20.0%; CI -35.5 to -4.5%; P = 0.01); and did not differ in age, sex, Area Deprivation Index, or procedure type. DISCUSSION: The low collection rate of E-PROMs from orthopaedic patients at safety-net hospitals should be weighed against their costs. E-PROM collection may exacerbate disparities in PROM collection among certain patient populations. LEVEL OF EVIDENCE: Diagnostic Level III.

Early Outcomes of Operative Versus Nonoperative Management of Stress-Positive Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries.

OBJECTIVES: To compare the early outcomes of patients with stress-positive minimally displaced lateral compression type 1 (LC1b) pelvic ring injuries managed with or without operative fixation. DESIGN: Retrospective comparison study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-three patients with LC1b injuries. INTERVENTION: Operative versus nonoperative. MAIN OUTCOME MEASUREMENTS: Discharge to subacute rehabilitation (SAR); 2- and 6-week pain visual analog score, opioid use, assistive device use, percentage of normal single assessment numerical evaluation, SAR status; fracture displacement; and complications. RESULTS: The operative group did not differ in age, gender, body mass index, high-energy mechanism, dynamic displacement stress radiographs, complete sacral fractures, Denis sacral fracture classification, Nakatani rami fracture classification, follow-up length, or American Society of Anesthesiologists classification. The operative group was less likely to be using an assistive device at 6 weeks [observed difference (OD) -53.9%, 95% confidence interval (CI) -74.3% to -20.6%, OD/CI 1.00, P = 0.0005], less likely to remain in an SAR at 2 weeks (OD -27.5%, CI, -50.0% to -2.7%, OD/CI 0.58, P = 0.02), and had less fracture displacement at follow-up radiographs (OD -5.0 mm, CI, -9.2 to -1.0 mm, OD/CI 0.61, P = 0.02). There were no other differences in outcomes between treatment groups. Complications occurred in 29.6% (n = 8/27) of the operative group compared with 25.0% (n = 4/16) of the nonoperative group resulting in 7 and 1 additional procedures, respectively. CONCLUSIONS: Operative treatment was associated with early benefits over nonoperative management, including shorter time using assistive devices, less SAR use, and less fracture displacement at follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Surgical approach of T-type acetabular fractures does not affect quality of reduction on postoperative CT or the likelihood of postoperative complications.

INTRODUCTION: T-type acetabular fractures are rare but challenging injuries. The purpose of this study was to evaluate for associations between chosen surgical approach for T-type acetabular fracture fixation, reduction quality, and complications. METHODS: Retrospective, single institution study of T-type acetabular fractures who underwent surgical fixation. Surgical interventions included open reduction and internal fixation (ORIF) through an anterior intrapelvic approach (AIP) (modified Rives-Stoppa) and/or posterior (Kocher-Langenbeck [KL]), or percutaneous screw fixation. The primary outcome was reduction quality on routine postoperative computed tomography (CT) scan and postoperative complications. RESULTS: During the study period (March 2016 - October 2022), 22 patients presented with T-type acetabular fractures. Surgical approaches included AIP [31.8% (7/22)], percutaneous [27.3% (6/22)], AIP+KL [22.7% (5/22)], and KL [18.2% (4/22)]. On CT scans, 9.0% (2/22) had anatomic reductions, 27.2% (6/22) had fair reductions, and 63.6% (14/22) had poor reductions based on Matta Reduction Criteria. There was no observed difference in reduction quality between surgical approaches. Poor reductions (> 3 mm) were not associated with surgical approach, fracture classification, unstable pelvic ring injuries, posterior wall fractures, T-stem component, transverse component, preoperative articular displacement, preoperative femoral head protrusion, or surgeon experience. Complications occurred in 50.0% (11/22) of patients. No observed difference in complication rates was noted between the surgical approaches. CONCLUSION: T-type acetabular fractures are challenging injuries with few patients achieving anatomic reduction on postoperative CT scans and half of patients developing complications.

Operative Management of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries: Analysis of Outcomes Before and After Implementation of a Departmental Stress Protocol.

OBJECTIVES: To compare the hospital course of patients with minimally displaced (<1 cm) lateral compression type 1 injuries treated before and after implementation of lateral stress radiographs (LSRs) to determine management. DESIGN: Retrospective comparative cohort. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: Isolated lateral compression type 1 injuries managed before (n = 33) and after implementation of LSRs (n = 40) to determine management. INTERVENTION: Patients in a prestress cohort managed nonoperatively versus patients in an LSR cohort managed operatively if stress positive (≥1 cm displacement on LSRs). MAIN OUTCOME MEASUREMENTS: Physical therapy clearance before discharge, discharge location, hospital length of stay, and inpatient opioid morphine milligram equivalents were measured. RESULTS: The prestress and LSR protocol groups were similar in demographic/injury characteristics (age, sex, mechanism, American Society of Anesthesiologists score, Nakatani classification, bilateral/unilateral injury, Denis zone, sacral fracture completeness, and sacral comminution). Forty-five percent of LSR protocol patients were stress-positive (n = 18) and managed operatively. The LSR protocol group was more likely to clear physical therapy by discharge (97.5% vs. 75.8%, PD: 21.7%, 95% CI: 5.1%-36.8%, P = 0.009), less likely to discharge to a rehabilitation facility (2.5% vs. 18.2%, PD: -15.7%, CI: -30.0% to -0.5%, P = 0.04), and had no difference in length of stay (MD: 0.0, CI:-1.0 to 1.0, P = 0.57) or inpatient opioid morphine milligram equivalents (MD: 9.0, CI: -60.0 to 101.0, P = 0.71). CONCLUSION: Implementation of an LSR protocol to determine management of minimally displaced stress-positive lateral compression type 1 injuries was associated with increased rates of operative management, physical therapy clearance by discharge, and a reduction in the number of patients discharging to rehabilitation facilities. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Geriatric Patients Presenting With Isolated Pubic Rami Fractures and Inability to Mobilize May Have Occult Lateral Compression Pelvic Ring Injuries With Dynamic Instability.

OBJECTIVES: To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries. DESIGN: Retrospective comparison study. SETTING: Urban level 1 trauma center. PATIENTS/PARTICIPANTS: This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain. INTERVENTION: Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability. MAIN OUTCOME MEASUREMENTS: Physical therapy clearance, hospital length of stay, and discharge location. RESULTS: A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19). CONCLUSIONS: Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open fixation of the posterior malleolus increases the morbidity of trimalleolar ankle fracture fixation.

PURPOSE: To assess the morbidity of open reduction internal fixation (ORIF) of posterior malleolus fractures (PMFs) in the setting of trimalleolar ankle fractures. METHODS: A retrospective review of 79 trimalleolar ankle fractures was performed to identify need for syndesmotic fixation, blood loss, operative/tourniquet time, complications, and reoperations. Patients with PMF ORIF (n = 38) were compared to those with no fixation (n = 41). A subanalysis of patients with small PMFs (< 25%) was performed. RESULTS: The PMF ORIF group required less syndesmosis fixation (proportional difference (PD) - 44.6%, 95% confidence interval (CI) - 61.8 to - 23.0%), had more blood loss (MD 20 ml, CI 0-40), longer operative times (MD 53.0 min, CI 35.9-70.1), longer tourniquet times (MD 26 min, CI 4-33), and had no difference in postoperative joint step-off or concentrically reduced joints. The PMF ORIF group had more postoperative complications (PD 26.9%, CI 6.3-44.8%) and a trend for more reoperations (PD 13.6%, CI -3.4 to 29.6%). Wound complications were more common in the PMF ORIF group (PD 26.5%, CI 6.9-43.6%), resulting in 5 (16.1%) irrigation and debridement procedures. On analysis of patients with small PMFs (n = 42), PMF ORIF (n = 15) resulted in longer operative/tourniquet times and had no observed difference in postoperative joint step-off, concentrically reduced joints, need for syndesmotic fixation, blood loss, or complications/reoperations. CONCLUSION: PMF ORIF in the setting of trimalleolar ankle fractures was associated with increased operative/tourniquet times, blood loss, wound complications, and did not eliminate the need for syndesmosis fixation.

Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries.

OBJECTIVES: To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation. DESIGN: Retrospective comparative cohort. SETTING: Urban level-one trauma center. PATIENTS/PARTICIPANTS: LC1 injuries managed operatively. INTERVENTION: Anterior-posterior versus posterior-only fixation. MAIN OUTCOME MEASUREMENTS: Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up. RESULTS: Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups. CONCLUSION: Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. LEVEL OF EVIDENCE: Therapeutic 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.