Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring?

PURPOSE: Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging. METHODS: All adult patients (≥ 18 years) presenting with either a Young-Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared. RESULTS: Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001). CONCLUSIONS: Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

Incidence of Suboptimal Fluoroscopic Outlet Imaging of the Sacrum and Pelvic Retroversion Necessary for Optimal Views.

OBJECTIVES: To estimate the prevalence of suboptimal fluoroscopy of sacral outlet images due to anatomic and equipment dimensions. Pelvic retroversion is hypothesized to mitigate this issue. DESIGN: In silico simulations using retrospectively collected computed tomography (CT) data from human patients. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: Adults with OTA/AO 61 pelvic ring disruptions treated with posterior pelvic fixation between July and December 2021. OUTCOME MEASURES AND COMPARISONS: C-arm tilt angles required to obtain 3 optimal fluoroscopic sacral outlet images, defined as vectors from pubic symphysis to S2 and parallel to the first and second sacral neural foramina, were calculated from sagittal CT images. A suboptimal view was defined as collision of the C-arm radiation source or image intensifier with the patient/operating table at the required tilt angle simulated using the dimensions of 5 commercial C-arm models and trigonometric calculations. Incidence of suboptimal outlet views and pelvic retroversion necessary to obtain optimal views without collision, which may be obtained by placement of a sacral bump, was determined for each view for all patients and C-arm models. RESULTS: CT data from 72 adults were used. Collision between patient and C-arm would occur at the optimal tilt angle for 17% of simulations and at least 1 view in 68% of patients. Greater body mass index was associated with greater odds of suboptimal imaging (standard outlet: odds ratio [OR] 0.84, confidence interval [CI] 0.79-0.89, P < 0.001; S1: OR 0.91, CI 0.87-0.97, P = 0.002; S2: OR 0.85, CI 0.80-0.91, P < 0.001). S1 anterior sacral slope was associated with suboptimal S1 outlet views (OR 1.12, Cl 1.07-1.17, P < 0.001). S2 anterior sacral slope was associated with suboptimal standard outlet (OR 1.07, Cl 1.02-1.13, P = 0.004) and S2 outlet (OR 1.16, Cl 1.09-1.23, P < 0.001) views. Retroversion of the pelvis 15-20 degrees made optimal outlet views possible without collision in 95%-99% of all simulations, respectively. CONCLUSIONS: Suboptimal outlet imaging of the sacrum is associated with greater body mass index and sacral slope at S1 and S2. Retroversion of the pelvis by 15-20 degrees with a bump under the distal sacrum may offer a low-tech solution to ensure optimal fluoroscopic imaging for percutaneous fixation of the posterior pelvic ring. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures.

OBJECTIVES: Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel. METHODS: A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column. RESULTS: Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries. CONCLUSIONS: PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.

What's New in Geriatric Acetabular Fractures.

The incidence of acetabular fractures in the geriatric population is growing, yet the optimal treatment algorithm remains a controversial topic among orthopaedic surgeons. This review highlights key studies published over the past 5 years on the outcomes of various treatment options for geriatric acetabular fractures. Topics include surgical timing, mortality and risk factors, nonoperative treatment, open reduction internal fixation, and acute total hip arthroplasty.

Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis.

Background: There has been an increasing amount of interest and research examining best practices for the treatment of proximal humerus fractures (PHF). Recent, high-level randomized control trials and many retrospective cohort studies have failed to demonstrate clear benefit of surgical management for these injuries especially in the elderly (generally defined as ≥65 years old). There is a paucity of research available on outcomes after surgical and nonsurgical treatment of proximal humerus fractures in adults younger than 65 years, and comparative data are almost nonexistent. The purpose of our study was to perform a systematic review and meta-analysis on the available data to determine if the literature supports surgical management over conservative treatment for PHFs in adults younger than 65 years. Materials and methods: Adhering to PRISMA guidelines, a systematic review of proximal humerus fractures was performed using MEDLINE and Google Scholar databases. Studies were included if they reported useable data such as outcome measures for adult patients younger than 65 years. Quality of nonrandomized studies was assessed utilizing the MINORs criteria. Extracted data were analyzed using statistical software with P-value set at 0.05. Results: Six studies were included in the study for data extraction and statistical analysis. When comparing Constant Scores (CS) and Oxford Shoulder Scores (OSS) of operatively and nonoperatively treated adult patients aged less than 65 years, no statistical differences were found. Furthermore, no statistical differences in CS or OSS were found comparing elderly patients (defined as ≥65 years) and adult patients (defined as 18 to <65 years). Analysis of DASH outcome data did show statistical differences of the three cohorts (nonoperative <65, operative <65, and operative ≥65). Thus, only the limb-specific (not joint specific) outcome score (DASH) was found to be significantly different upon data analysis. Differences in shoulder-specific outcome scores (OSS and CS) failed to meet significance. Conclusion: The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. These results challenge the widely accepted practice of choosing surgical treatment in adult patients younger than 65 years with PHFs.

Current Trends in the Evaluation and Management of Nondisplaced Femoral Neck Fractures in the Elderly.

Nondisplaced (Garden I and II) femoral neck (FN) fractures are commonly encountered by the practicing orthopaedic surgeon. Although these fractures are primarily classified based on the AP radiograph, the lateral radiograph should be closely scrutinized as well because posterior tilt has emerged as a consistent predictor of fixation failure. Internal fixation has for many years been the standard of care, with both cannulated screws and the sliding hip screw representing acceptable options. However, the outcomes after fixation of Garden I and II FN fractures have not been uniformly positive, with the rates of revision surgery ranging from 8% to 27%. Complications after fixation of nondisplaced FN fractures include nonunion, fixation failure, osteonecrosis, and femoral shortening causing inferior hip function. For these reasons, arthroplasty is increasingly considered a viable option in the treatment of these fractures, especially in the presence of factors that predispose to failure after fixation. Novel devices for FN fixation have recently been developed, although clinical data supporting their use are sparse at the present time.

Closed Incision Negative Pressure Wound Therapy in the Management of a Complex Fasciotomy Wound in a Pediatric Patient.

Acute compartment syndrome (ACS) is a known entity that most often occurs in the setting of trauma in both adult and pediatric patients. Fasciotomy remains the gold standard treatment for relieving intracompartmental pressures but is associated with significant complications. Significant variability exists regarding fasciotomy wound management and closure. We present the only known case report on use of circumferentially applied negative pressure wound therapy instill and dwell (NPWTi-d) followed by circumferentially applied closed incision negative pressure wound therapy (ciNPWT) for the soft tissue management of delayed ACS in a pediatric patient.

Hip Offset and Leg Length Equalization in Direct Anterior Approach Total Hip Arthroplasty without Preoperative Templating.

The standard practice of preoperative templating may be less important for direct anterior approach (DAA) total hip arthroplasty (THA) with intraoperative fluoroscopy (IF). However, this has yet to be tested. The purpose of this retrospective review was to report the hip offset (HO) and leg length (LL) equalization accuracy following 304 consecutively performed DAA THA with IF and no preoperative templating. A supplemental fluoroscopic gridding tool was used to assess hip symmetry. Operative and fluoroscopic times were also documented to assess for surgical efficiency. The mean HO and LL difference was 3.5 ± 2.6 mm (range: 0.0-9.3) and 2.9 ± 2.2 mm (range: 0.0-9.9), respectively. Hip offset and LL equalization within 10 mm was achieved in all patients. The mean operative time for unilateral THA was 72.2 ± 12.0 minutes, and the mean fluoroscopy time per hip was 10.5 ± 4.5 seconds. These results suggest that for surgeons with adequate experience performing DAA THA with IF, preoperative templating may not be necessary to reliably and efficiently achieve clinically acceptable HO and LL.

Circumferential Negative Pressure Wound Therapy with Instillation and Dwell Prior to Delayed Flap Coverage for a Type IIIB Open Tibia Fracture.

Gustilo and Anderson type IIIB open tibia fractures are associated with high rates of surgical site infection, wound complications, and flap failure. Controversy surrounds the optimal timing and method of wound management prior to flap coverage. No studies to date have investigated the use of negative pressure wound therapy with instillation and dwell for open type IIIB tibia fractures. We present a single case of an open type IIIB tibia fracture that was managed with 21 days of circumferentially applied negative pressure wound therapy with instillation and dwell prior to flap coverage. Our results suggest that negative pressure wound therapy with instillation and dwell may minimize infection risk, decrease wound size, and allow for delayed soft tissue coverage.

Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones.

BACKGROUND: Tibial osseous defects can present a serious challenge in primary total knee arthroplasty. We describe a technique of using porous tantalum cones along with primary arthroplasty implants to address large tibial osseous defects in primary total knee arthroplasty and present the short-term results. METHODS: We present 17 cases (15 patients) in which primary total knee implants and porous tantalum cones were used to address large tibial bony defects. Clinical results were evaluated using Knee Society Scores, pre- and postoperative knee range of motion, and serial radiographs. RESULTS: At an average of 3.5 years of follow-up, all 17 knees had functioning implants with stable metaphyseal cones demonstrating radiographic evidence of osteointegration. At a minimum follow-up of two years, no patient had signs of osteolysis, instability, infection, or systemic complications. All 15 patients had excellent results with an average post-operative Knee Society Score of 94.6. Knee flexion improved by an average of 12.0° and knee extension improved to neutral in all patients. CONCLUSION: Primary total knee arthroplasty with porous tantalum cone augmentation produced excellent short-term results and should be considered an effective method for addressing large tibial osseous defects in primary total knee arthroplasty.

Utilizing Negative Pressure Wound Therapy with Instillation and Dwell Time for Extensive Necrotizing Fasciitis of the Lower Extremity: A Case Report.

Necrotizing fasciitis is a rapidly spreading infection of the soft tissue, which carries significant morbidity and mortality. This condition is treated with broad-spectrum antibiotics, irrigation and surgical debridement of the affected area, and hemodynamic support. Negative pressure wound therapy (NPWT) has been utilized after surgical debridement to promote wound healing, especially when significant debridement has occurred. Newer forms of NPWT such as negative pressure wound therapy with instillation and dwell time (NPWTi-d) have shown even greater promise by reducing the time to clear infections and promoting greater debridement with fewer procedures. This case report demonstrates the successful use of NPWTi-d on a 56-year-old man with a severe case of necrotizing fasciitis of the right lower extremity after extensive debridement. Despite the significant loss of soft tissue and the circumferential devitalization of the lower leg, this patient was able to accept a skin graft in approximately four weeks after admission to the hospital. Three months after initial presentation, his wounds were completely epithelialized and healing well. The advantages of using NPWTi-d include decreased dressing changes, increased wound granulation, and faster infection clearance. The disadvantages of such systems include increased cost, additional technical requirements, and required inpatient monitoring of the system. Despite these disadvantages, the authors believe that NPWTi-d is a reasonable choice for patients similar to the one presented in this case report.

A Novel Method for Fracture Blister Management Using Circumferential Negative Pressure Wound Therapy with Instillation and Dwell.

High- and low-energy fractures can result in nearby skin blistering. These so-called "fracture blisters" can be troublesome in the face of surgery and currently no uniform consensus regarding their management exists. Preoperatively, we used circumferential negative pressure wound therapy with sterile saline instillation (NPWT-id) to treat two patients with closed fractures who had developed significant skin blistering. This technique resulted in near complete re-epithelialization of the decompressed blister beds within one week. Furthermore, no excessive surgical delay or alteration in surgical approach was necessary, and both patients healed successfully without post-operative wound complications. Thus, circumferential NPWT-id may be a worthwhile treatment option for fracture blisters.