Pelvic Ring Injuries: Stable or Not?

Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.

Removal of a Bent Tibial Intramedullary Nail Through Osteotomy and Partial Sectioning: A Case Report.

CASE: An 18-year-old male patient presented with a closed fracture of the left tibia and fibula and a bent intramedullary nail after a repeat motorcycle accident. The patient was 5 weeks postoperative from intramedullary nailing of a closed left tibia fracture. The site of angulation of the tibial nail was noted to be more proximal than the fracture site. Partial sectioning of the nail through an osteotomy permitted the removal of the nail and revision tibial nailing. CONCLUSION: This is the first reported use of an osteotomy and partial sectioning during the extraction of a bent tibial intramedullary nail.

The impact of COVID-19 restrictions on participant enrollment in the PREPARE trial.

Background: At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment. Methods: The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020. Results: All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7-121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment. Conclusion: A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.

Open reduction and internal fixation alone versus open reduction and internal fixation plus total hip arthroplasty for displaced acetabular fractures in patients older than 60 years: A prospective clinical trial.

INTRODUCTION: The optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively. METHODS: Inclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years. RESULTS: Forty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p < 0.01). No postoperative hip dislocation occurred in either group. CONCLUSIONS: In patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.

Fixed angle device comparison in young femoral neck fractures: Dynamic hip screw vs dynamic helical hip system.

INTRODUCTION: Femoral neck fractures in the young patient present a unique challenge. Most surgeons managing these injuries prefer a fixed angle implant, however these devices are fraught with problems. A dynamic hip screw (DHS) is one such fixed angle device that risks malreduction through rotational torque during screw insertion. To avoid this risk some surgeons utilize a dynamic helical hip system (DHHS), however little is known about the complication profile of this device. We hypothesized that the complication rate between these two devices would be similar. PATIENTS AND METHODS: All patients presenting to a single tertiary referral center with a femoral neck fracture were identified from a prospectively collected trauma database over an 11-year period. Patients were included if they were less than 60 years of age, treated with a DHS or DHHS, and had at least 6 months of follow-up. Demographic data, injury characteristics, and post-operative complications were obtained through chart review. Standard statistical comparisons were made between groups. A total of 77 patients met inclusion criteria. RESULTS: Average age of patients was 38 years (range: 18-59) and 56 (73%) were male. The DHS was used in 37 (48%) patients and the DHHS was used in 40 (52%) patients. Demographic data including average age, gender, body mass index, and smoking status did not differ between the groups. There were 29 (39%) total complications of interest (femoral neck shortening >5 mm, non-union requiring osteotomy, conversion to THA, and osteonecrosis. There were 19 (51%) complications in the DHS group and 10 (25%) in the DHHS group (p = 0.01, risk difference 25%, 95% CI 7-43). Comparisons of the individual complications about the DHS and DHHS cohort did not reach statistical significance for non-union (8% vs 3%) or THA (16% vs 13%) (p = 0.33, p = 0.64, respectively) but a difference was detected in the rate of shortening (27% vs 10%; p = 0.05). CONCLUSION: This study demonstrates a high risk of complication when managing young femoral neck fractures in line with prior literature. The major complication rate of non-union requiring osteotomy or fixation failure resulting in THA was no different between the two groups, but the rate of shortening was greater the DHS group. This data suggests the DHHS may be a suitable device to manage the young femoral neck fracture and without increased risk of complication.

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study.

OBJECTIVES: To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study. SETTING: Academic trauma center. PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation. MAIN OUTCOME MEASURES: Skin perfusion (fluorescence units) as measured by LA-ICGA. RESULTS: Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01). CONCLUSIONS: LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Implementing stakeholder engagement to explore alternative models of consent: An example from the PREP-IT trials.

INTRODUCTION: Cluster randomized crossover trials are often faced with a dilemma when selecting an optimal model of consent, as the traditional model of obtaining informed consent from participant's before initiating any trial related activities may not be suitable. We describe our experience of engaging patient advisors to identify an optimal model of consent for the PREP-IT trials. This paper also examines surrogate measures of success for the selected model of consent. METHODS: The PREP-IT program consists of two multi-center cluster randomized crossover trials that engaged patient advisors to determine an optimal model of consent. Patient advisors and stakeholders met regularly and reached consensus on decisions related to the trial design including the model for consent. Patient advisors provided valuable insight on how key decisions on trial design and conduct would be received by participants and the impact these decisions will have. RESULTS: Patient advisors, together with stakeholders, reviewed the pros and cons and the requirements for the traditional model of consent, deferred consent, and waiver of consent. Collectively, they agreed upon a deferred consent model, in which patients may be approached for consent after their fracture surgery and prior to data collection. The consent rate in PREP-IT is 80.7%, and 0.67% of participants have withdrawn consent for participation. DISCUSSION: Involvement of patient advisors in the development of an optimal model of consent has been successful. Engagement of patient advisors is recommended for other large trials where the traditional model of consent may not be optimal.

A Prospective Clinical Trial Comparing Surgical Fixation Versus Nonoperative Management of Minimally Displaced Complete Lateral Compression Pelvis Fractures.

OBJECTIVE: To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN: Prospective clinical trial. SETTING: Two academic trauma centers. PATIENTS: Forty-eight adult patients with LC pelvic ring injuries with <10 mm of displacement were treated nonoperatively and 47 with surgical fixation. Sixty percent of participants were randomized. Seventy-three percent of the fractures were displaced <5 mm, and 71% were LC-1 patterns. INTERVENTION: Operative fixation versus nonoperative management. MAIN OUTCOME MEASUREMENTS: The primary outcome was patient-reported pain using the 10-point Brief Pain Inventory. Functional outcome was measured using the Majeed pelvic score. Outcomes were analyzed using hierarchical Bayesian models to compare the average treatment effect from injury to 12 and 52 weeks postinjury. The probability of the mean treatment benefit exceeding a clinically important difference was determined. RESULTS: The 3-month average treatment effect of surgery compared with nonoperative management was a 1.2-point reduction in pain [95% credible interval (CrI): 0.4-1.9] and an 8% absolute improvement in the Majeed score (95% CrI: 3%-14%). Similar results persisted to 1 year. Patients with initial fracture displacement ≥5 mm experienced a larger reduction in pain (2.2, 95% CrI: 0.9-3.5) compared with those patients with less initial displacement (0.9, 95% CrI: 0.1-1.8). CONCLUSION: On average, surgical fixation likely provides a small improvement in pain and functional outcome for up to 12 months. Patients with ≥5 mm of posterior pelvic ring displacement are more likely to experience clinically important improvements in pain. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Analysis of Computed Tomography-Based Technique for Measuring Femoral Anteversion: Implications for Measuring Rotation After Femoral Intramedullary Nail Insertion.

OBJECTIVES: To assess the reliability of the current computed tomography (CT)-based technique for determining femoral anteversion and quantify the prevalence and magnitude of side-to-side differences. DESIGN: Cross-sectional cohort study. SETTING: Academic trauma center. PATIENTS: We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICCs) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. RESULTS: Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12%-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, whereas 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference of ≥15 degrees. CONCLUSIONS: CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more.

Quantitative Lesser Trochanter Profile Versus Cortical Step Sign in Assessing Femoral Malrotation After Femoral Nailing.

We describe the novel quantitative lesser trochanter profile (QLTP) technique to determine the magnitude and direction of femoral malrotation and to compare its performance with the cortical step sign technique. For this assessment, 9 orthopaedic surgeons estimated the magnitude and direction of femoral malrotation with each technique in 198 anteroposterior view images of the proximal cadaveric femur and osteotomy sites. Based on the results, the main benefit of the QLTP technique over the cortical step sign technique is the ability to determine the direction of femoral malrotation. The QLTP technique was also more accurate in measuring malrotation and had less error. However, the QLTP technique requires additional imaging, and the mean difference in error between the 2 techniques might not be clinically meaningful.

The Orthopaedic Trauma Service and COVID-19: Practice Considerations to Optimize Outcomes and Limit Exposure.

The COVID-19 pandemic has presented challenges to healthcare systems, including the cancellation and then staged resumption of elective procedures. The orthopaedic trauma community has continued to provide care to patients with acute musculoskeletal injuries that cannot be delayed in all scenarios. This article summarizes and provides relevant information (orthopaedic trauma service, outpatient fracture clinic, inpatient surgery) to the practicing orthopaedic traumatologist on maximizing outcomes while limiting exposure during the pandemic. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Surgeons Cannot Predict Pilon Fracture Outcomes Based on Initial Radiographs.

This study sought to determine (1) whether surgeons can accurately predict functional outcomes of operative fixation of pilon fractures based on injury and initial postoperative radiographs, (2) whether the surgeon's level of experience is associated with the ability to successfully predict outcome, and (3) the association between patients' demographic and clinical characteristics and surgeons' prediction scores. A blinded, randomized provider survey was conducted at a level I trauma center. Seven fellowship-trained orthopedic traumatologists and 4 orthopedic trauma fellows who were blinded to outcome reviewed data regarding 95 pilon fractures in random order. Injury ankle radiographs, initial postoperative fixation radiographs, and brief patient histories were assessed. Midterm follow-up functional outcome scores obtained a mean 4.9 years after surgery were available for all patients. Main outcome measures were Pearson correlation coefficient-assessed functional outcomes and surgeon-predicted outcomes. A mixed-effect model determined the association between patients' characteristics and surgeons' prediction scores. Minimal positive correlation was observed between functional outcomes and prediction scores. No difference was noted between the attending and fellow groups in prediction ability. When surgeons' prediction confidence level was greater than 1 SD above the mean confidence level, correlation between functional outcome and prediction improved, although poor correlation was still observed. AO/OTA type 43C fractures, high-energy mechanisms, and older patient age were characteristics associated with lower prediction scores. Surgeons had poor ability to predict functional outcomes of patients with pilon fractures based on injury and initial postoperative radiographs, and level of experience was not associated with ability to predict outcome. [Orthopedics. 2020; 43(1): e43-e46.].

Does an Implant Usage Report Card Impact Orthopaedic Trauma Implant Stewardship?

OBJECTIVES: As hospitals seek to control variable expenses, orthopaedic surgeons have come under scrutiny because of relatively high implant costs. We aimed to determine whether feedback to surgeons regarding implant costs results in changes in implant selection. METHODS: This study was undertaken at a statewide trauma referral center and included 6 fellowship-trained orthopaedic trauma surgeons. A previously implemented implant stewardship program at our institution using a "red-yellow-green" (RYG) implant selection tool classifies 7 commonly used trauma implant constructs based on cost and categorizes each implant as red (used for patient-specific requirements, most expensive), yellow (midrange), and green (preferred vendor, least expensive). The constructs included were femoral intramedullary nail, tibial intramedullary nail, long and short cephalomedullary nails, distal femoral plate, proximal tibial plate, and lower-limb external fixator. Baseline implant usage from the previous year was obtained and provided to each surgeon. Each surgeon received a monthly feedback report containing individual implant utilization and overall ranking. RESULTS: The overall RYG score increased from 68.7 to 79.1 of 100 (P < 0.001). Three of the 7 implants (tibial and femoral nails and lower-limb external fixation) had significant increases in their RYG scores; implant selections for the other 4 implants were not significantly altered. A decrease of 1.8% (95% confidence interval, 0.4-3.2, P = 0.01) was noted in overall implant costs over the study period. CONCLUSION: Our intervention resulted in changes in surgeons' implant selections and cost savings. However, surgeons were unwilling to change certain implants despite their being more expensive.

Incidence of Knee Pain Beyond 1 Year: Suprapatellar Versus Infrapatellar Approach for Intramedullary Nailing of the Tibia.

OBJECTIVE: To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury. DESIGN: Retrospective cohort study. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours. INTERVENTION: Intramedullary nailing of a tibia fracture with either the SP or IP approach. MAIN OUTCOME MEASUREMENTS: Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful. RESULTS: The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45). CONCLUSIONS: In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prediction of tibial nonunion at the 6-week time point.

INTRODUCTION: Intramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST). METHODS: A retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study. RESULTS: Infection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratio > or < 1.0; p < 0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6-9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST <6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion. CONCLUSION: Three variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients.

The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows.

BACKGROUND: Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. METHODS: The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than 'important'. The content validity index was 0.91. Ninety-five percent of positive-point items were easy-medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46-51], κ = 0.68 (95% CI 0.59-0.77), Cronbach's α = 0.84. RESULTS: We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43-45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful. CONCLUSIONS: The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress.

Incidence of Vacuum Phenomenon Related Intra-articular or Subfascial Gas Found on Computer-Assisted Tomography (CT) Scans of Closed Lower Extremity Fractures.

OBJECTIVES: To determine the incidence of vacuum phenomenon related intra-articular or subfascial gas found on computer-assisted tomography (CT) scans of closed lower extremity fractures. DESIGN: Retrospective Review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 153 patients with closed lower extremity fractures. INTERVENTION: CT scans of identified individuals were reviewed for the presence or absence of gaseous accumulations. MAIN OUTCOME MEASUREMENTS: The presence or absence of gas on CT. RESULTS: Twenty seven (17.6%) of the 153 fractures were found to have intra-articular or subfascial gas on CT despite clear documentation, indicating a closed injury with no significant skin compromise. Of the intra-articular fractures (OTA/AO 33B/C, 41B/C and 43B/C), 20% (23 of 113) were found to have gas on CT. All cases were associated with fracture of the tibia (P = 0.002). CONCLUSIONS: Computed tomography demonstrated the presence of intra-articular or subfascial gas in 17.6% (27/153) of closed lower extremity fractures and in 20% (23/113) of closed intra-articular fractures. The possibility of vacuum phenomenon must be considered when using this imaging modality as the confirmatory test for open intra-articular fracture or traumatic arthrotomy. LEVEL OF EVIDENCE: Level IV.

Functional Outcomes of Elderly Patients With Nonoperatively Treated Acetabular Fractures That Meet Operative Criteria.

OBJECTIVES: To report functional outcomes of displaced acetabular fractures treated nonoperatively in the geriatric patient population. DESIGN: Retrospective case series. SETTING: Two Level I trauma centers. PATIENTS: Twenty-seven patients 60 years of age or older who sustained displaced acetabular fractures during an 11-year period. INTERVENTION: Nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Primary outcome measurements were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and Short Form 8 (SF-8) scores. Secondary outcome measurements were conversion to open reduction and internal fixation or total hip arthroplasty and 1-year mortality. RESULTS: Twenty-six patients completed the WOMAC and SF-8 surveys. The overall WOMAC score was 12.9 ± 15.6 (range, 0-59.4). The average physical SF-8 was 51.1 ± 8.7 (range, 30.4-58.6), and the average mental SF-8 was 55 ± 6.2 (range, 30.4-58.6). The 1-year mortality rate was 24%. Conversion of treatment occurred in 15% of patients. CONCLUSIONS: Elderly patients with fracture patterns that would qualify for operative treatment in younger healthy patients had surprisingly good outcome scores when treated nonoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What Is New in Trauma-Related Amputations.

Traumatic and trauma-related amputations represent unfortunate sequelae of severe injury, but should not be viewed as a treatment failure and may represent the best reconstructive option for some patients. Lessons from recent military conflicts have guided the evolution of modern surgical techniques and rehabilitation management of this challenging patient population, and treatment at a specialty center may improve patient outcomes. Despite appropriate management, however, surgical complications remain common and revision surgery is often necessary. Bridge synostosis procedures remain controversial, and clinical equipoise remains regarding their functional benefits. Based on European experience over the last 3 decades, osseointegration has evolved into a viable clinical alternative for patients unable to achieve acceptable function using conventional sockets, and several devices are being developed or tested in the United States. Targeted muscle reinnervation and advanced pattern recognition may dramatically improve the functional potential of many upper extremity amputees, and the procedure may also relieve neuroma-related pain. Furthermore, exciting new research may eventually facilitate haptic feedback and restore useful sensation for amputees. Natural disasters and global terrorism events, in addition to conventional trauma resulting in limb loss, make a working knowledge of current amputation surgical techniques essential to the practicing orthopaedic trauma surgeon.

Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome?

BACKGROUND: Intracompartmental pressure measurements are frequently used in the diagnosis of compartment syndrome, particularly in patients with equivocal or limited physical examination findings. Little clinical work has been done to validate the clinical use of intracompartmental pressures or identify associated false-positive rates. We hypothesized that diagnosis of compartment syndrome based on one-time pressure measurements alone is associated with a high false-positive rate. METHODS: Forty-eight consecutive patients with tibial shaft fractures who were not suspected of having compartment syndrome based on physical examinations were prospectively enrolled. Pressure measurements were obtained in all four compartments at a single point in time immediately after induction of anesthesia using a pressure-monitoring device. Preoperative and intraoperative blood pressure measurements were recorded. The same standardized examination was performed by the attending surgeon preoperatively, postoperatively, and during clinical follow-up for 6 months to assess clinical evidence of acute or late compartment syndrome. RESULTS: No clinical evidence of compartment syndrome was observed postoperatively or during follow-up until 6 months after injury. Using the accepted criteria of delta P of 30 mm Hg from preoperative diastolic blood pressure, 35% of cases (n = 16; 95% confidence interval, 21.5-48.5%) met criteria for compartment syndrome. Raising the threshold to delta P of 20 mm Hg reduced the false-positive rate to 24% (n = 11; 95% confidence interval, 11.1-34.9%). Twenty-two percent (n = 10; 95% confidence interval, 9.5-32.5%) exceeded absolute pressure of 45 mm Hg. CONCLUSION: A 35% false-positive rate was found for the diagnosis of compartment syndrome in patients with tibial shaft fractures who were not thought to have compartment syndrome by using currently accepted criteria for diagnosis based solely on one-time compartment pressure measurements. Our data suggest that reliance on one-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies. LEVEL OF EVIDENCE: Diagnostic study, level II.