Systematic Review of Combined Pelvic Ring and Acetabular Injuries: What Do We Know From the Literature?

The purpose of this review is to examine the literature on combined pelvic ring and acetabular fractures. We hope to further define the classifications, severities (ISS & Mortality), healing, radiographic parameters, and functional outcomes of such injuries to report all potential recommendations based on findings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a systematic search on PubMed and Google Scholar was performed. Articles included were in the English Language or through English translation, between the years 1996 and 2022. Articles that had met the inclusion criteria were systematically assessed for the relevance of their content. Eleven articles were identified with a total of 985 patients. All eleven were retrospective case series and the presence of both an injury within the pelvic ring and another injury within the acetabulum, either ipsilateral or contralateral, was the indication of a combination injury. The overall mortality rate averaged over all studies was 7.9% and the Injury Severity Score (ISS) of 22.98. When considering the higher mortality rate seen in pelvic ring injuries compared to the isolated acetabulum, there appears to be survivability beyond reductive means as a reason for reducing and fixing the pelvic ring first. However, accurate reduction of the acetabulum has a greater weight in overall patient recovery compared to the reduction of the pelvic ring and thus surgical emphasis on the anatomic reduction of the acetabulum may be paramount. Despite this good to excellent outcomes can be achieved with careful preoperative planning and surgical execution in patients with fractures of the pelvic ring and acetabulum. Further research as well as uniform radiographic scoring system and outcomes scores should be required to better evaluate and treat these injuries.

Periprosthetic Supracondylar Femoral Fractures Above a Total Knee Replacement: An Updated Compatibility and Technique Guide for Fixation With a Retrograde Intramedullary Nail.

BACKGROUND: Multiple studies have described retrograde nailing as a treatment of periprosthetic supracondylar femoral fractures (OTA/AO type 33A-C) above total knee replacements (TKRs). It is often difficult to discern which TKRs will be compatible with intramedullary nailing because the femoral component design and intercondylar distance is highly variable among total knee designs. The goal of our study is 3-fold: (1) Review and update previous work of intercondylar distances of all currently available prostheses in the United States. (2) Review retrograde nails currently on the market and associated driving end to nail shaft diameter mismatch and opening reamer sizing. (3) Review technical tricks for executing a retrograde femoral nail for the treatment of periprosthetic supracondylar femur fractures. METHODS: Data for the intercondylar distance of the femoral components, diameter of retrograde nails and reamers, and notch compatibility were gathered. RESULTS: The results were compiled and recorded. A "technical tricks" section was included that highlights reduction and fixation techniques. CONCLUSIONS: This update further empowers surgeons to use all the tools available when treating periprosthetic femur fractures and allows efficient identification of the compatibility of different TKR designs with various intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Patient-Reported Outcomes After Lateral Process Talus Fracture.

OBJECTIVES: To evaluate functional outcome after lateral process talus fracture using patient-reported instruments and identify injury characteristics that portend a worse prognosis. DESIGN: Retrospective case series. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Fifty-three patients with isolated lateral process talus fracture and 12 months of minimum follow-up. MAIN OUTCOME MEASUREMENTS: Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and Foot and Ankle Ability Measure (FAAM). RESULTS: Mean patient age was 33 years (range, 17-62 years), and mean follow-up was 6.5 years (range, 1-12 years). Twenty-one patients were initially treated nonoperatively and 14 of these patients (67%) failed nonoperative management. Patients who failed nonoperative treatment more commonly had a displaced fracture (12 patients) (P = 0.009). Thirty-two patients had displaced fracture and were treated with early operative fixation. For the entire cohort, final PROMIS PF was 55 (SD -8.3), FAAM Activities of Daily Living (ADL) was 89 (SD -14), and FAAM sport was 77 (SD -20). The patients treated with operative fixation had significantly larger fracture fragments (2050 vs. 1066 mm3, P = 0.017). There was no difference in final outcome between operative and nonoperative patients for PROMIS PF (P = 0.84), FAAM ADL (P = 0.95), or FAAM sport (P = 0.94). There were significantly more subtalar fusions in the nonoperative group (4 patients) as compared to the operative group (one patient) (P = 0.05). CONCLUSIONS: Most patients with lateral process talus fracture achieve excellent outcome as measured by the PROMIS PF and FAAM at medium-term follow-up. Displaced fractures are likely best managed with early surgical treatment. Patients treated with early surgery have significantly fewer subtalar fusions as compared to patients with nonoperative treatment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transvenous lead extraction on uninterrupted anticoagulation: A safe approach?

INTRODUCTION: Current guidelines advocate reviewing peri-procedural anticoagulation on individual case basis for transvenous lead extraction (TLE). We investigated the safety of TLE on uninterrupted warfarin with therapeutic INR. METHODS: Retrospective registry of consecutive patients undergoing TLE on uninterrupted warfarin (Warfarin Group) across two centres. Age and sex matched controls not on anticoagulation (No-Warfarin Group) and undergoing TLE over the same time-period were included. Both groups were compared over one-year. RESULTS: 121 TLEs over 18-months. 22 patients on uninterrupted anticoagulation were compared to 22 controls. Groups were well matched for baseline demographics other than INR. Warfarin group had mean INR of 2.2 ± 0.6 (range 2-3.5). Primary end point was procedural safety and efficacy. Amongst cases, 43/45 (96%) leads were removed in their entirety compared to 37/40 (93%) in controls (p = 0.66). In the cases, these included 44% defibrillator, 47% pace-sense and 9% CS leads of average duration 7yrs. There was no reported tamponade, haemothorax or procedural mortality in either group. One patient amongst cases required inotropic support while two patients amongst controls had device-site haematomas. No significant difference reported in Hb drop post-procedure or overall complication rate between the groups (p = 0.11,0.32). Cox regression showed a significant association between procedural success and device infection, number of leads extracted, serum creatinine (p = 0.03, 0.04, 0.02). Over a 1-year follow-up, there was lead displacement in one case and one control had infection of the re-implanted device. CONCLUSION: TLE can be carried out safely in anticoagulated patients with therapeutic INRs. Larger multicentre studies are required to confirm these findings.

Plafond Malreduction and Talar Dome Impaction Accelerates Arthrosis After Supination-Adduction Ankle Fracture.

BACKGROUND: Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis. METHODS: A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented. RESULTS: A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series. CONCLUSION: Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Fewer Hip Dislocations With Anterior Total Hip Arthroplasty for Displaced Femoral Neck Fracture.

The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12-125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P=.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P=.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P=.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [Orthopedics. 2021;44(2):e248-e252.].

Single loop allograft reconstruction for sternoclavicular joint instability.

BACKGROUND: Various surgical strategies have been used for the treatment of sternoclavicular joint instability with variable results. The purpose of this study was to report the clinical results of patients who underwent single-loop allograft reconstruction for sternoclavicular joint instability. METHODS: A total of 10 patients underwent single-loop allograft reconstruction for sternoclavicular joint instability from June 2012 to August 2014 by a single surgeon. All patients had a history of instability of the sternoclavicular joint with persistent chronic subluxation of the joint, magnetic resonance imaging disruption of the sternoclavicular ligaments, and persistent symptoms of pain and instability. Regarding the surgical technique, a single 5.5 mm drill hole was placed in the sternum and a second was placed in the medial aspect of the clavicle. A semitendinosus hamstring allograft was looped between the 2 holes and then tied in a square knot anteriorly. A #5 high-strength suture was used as cerclage as well. Nine of 10 patients (90% follow-up) were available at an average of 3.3 ± 0.84 years postoperatively. The average age of patients at the time of surgery was 42 years (range, 20-73 years). Patients were evaluated postoperatively with outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test), a question regarding tenderness at the sternoclavicular joint, and a question regarding residual instability and overall patient satisfaction (yes/no). RESULTS: The average functional outcome scores for the Simple Shoulder Test, visual analog scale pain, and American Shoulder and Elbow Surgeons score were 11.8, 0.9, and 94.8, respectively. Three of 9 patients reported some residual tenderness located to the sternoclavicular joint. No patients reported any residual instability of the sternoclavicular joint. Eight of 9 patients reported that they were satisfied with the procedure. No patients required reoperation, and there were no complications. CONCLUSION: Single-loop allograft reconstruction of the sternoclavicular joint provides reliable pain relief, functional improvement, and joint stability for patients with chronic sternoclavicular joint instability. The simplicity of the procedure eliminates the need for small, multiple drill holes that may lead to fracture between tunnels or the use of a small, thin graft.

Supination adduction ankle fractures: Ankle fracture or pilon variant?

BACKGROUND: Supination adduction (SAD) fractures are rotational ankle fractures with a characteristic vertical medial malleolus fracture and tension failure fibula fracture. While these fractures are considered rotational injuries, they can have joint impaction that could lead to early joint degeneration. The purpose of this study was to characterize SAD ankle fractures and compare these injuries with partial articular pilon fractures. METHODS: Following IRB approval, we retrospectively reviewed ankle and pilon fractures (OTA 43 & 44) treated at two academic level-1 trauma centers from 2008-2016. Our primary outcome was failure defined as either ankle arthrodesis or arthroplasty. Infection and significant arthrosis were also compared. We performed multivariate Cox regression to compare failure between SAD ankles and pilon fractures. RESULTS: Seventy-nine SAD ankle and 91 pilon fractures met inclusion criteria. Patient demographics including age and open injury did not differ between groups. For SAD ankle fractures, impaction occurred in 66% (44/79) of injuries. Impaction failed to be significant risk factor for arthrosis after adjustment for malreduction (p = 0.13). Failure was significantly more common in pilon fractures (11/91, 12%) than SAD fractures (5/79, 6%) (HR=0.25, 95% CI:[0.07,0.92], p = 0.036). Infection and arthrosis rates failed to show a difference between the groups (p = 0.19, 0.63, respectively). Malreduction was significantly associated with joint arthrosis (OR=7.05, 95% CI: [1.63,36.12], p = 0.01). CONCLUSION: Rotational ankle fractures have low rates (<2%) of ankle arthrodesis or arthroplasty. The present study demonstrates that SAD ankles have failure (6%) that remains somewhere between rotational ankle fractures and pilon fractures (12%) on the ankle injury spectrum. LEVEL OF EVIDENCE: Level 3, Prognostic.

Preoperative Factors Associated With Subsequent Distal Clavicle Resection After Rotator Cuff Repair.

BACKGROUND: Acromioclavicular osteoarthritis and rotator cuff tears are commonly coincident. PURPOSE: To determine the rate of subsequent distal clavicle excision (DCE) when rotator cuff repair (RCR) is performed without DCE and the risk factors for subsequent DCE after RCR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The operative logs of 2 surgeons from 2007 to 2016 were retrospectively reviewed for all patients who underwent RCR with or without DCE. Preoperative demographic data, symptoms, physical examination, and standardized outcomes (visual analog scale for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) were noted. Acromioclavicular (AC) arthritis was classified on preoperative radiographs. The rate of subsequent surgery on the AC joint was determined via chart review, and univariate and multivariate analyses were conducted to determine risk factors for revision. RESULTS: In total, 894 patients underwent isolated RCR, and 46 underwent concomitant RCR and DCE. On retrospective chart review, of those who underwent isolated RCR, the revision rate for any reason was 7.5% (67 patients), and the rate of subsequent AC surgery was 1.1% (10 patients). Preoperatively, 88% of the total cohort was considered to have a radiographically normal AC joint. On multivariate analysis of patients who underwent isolated RCR, the risk factors for subsequent AC surgery included preoperative tenderness to palpation at the AC joint (10% vs 63%, P < .001), female sex (35% vs 80%, P < .001), and surgery on the dominant side (60% vs 100%, P = .002). On multivariate analysis, these 3 factors explained 50% of the variance in revision AC surgery. When these 3 factors were present in combination, there was a 40% rate of revision AC surgery. CONCLUSION: This records review found that 10 of 894 (1.1%) rotator cuff repairs underwent subsequent distal clavicle resection. Risk factors for subsequent DCE included tenderness to palpation at the AC joint, female sex, and surgery on the dominant side, with subsequent DCE performed in 40% of cases with a combination of these 3 factors. Because the duration of follow-up was short and the number of reoperations small, some caution is recommended in interpreting these results, as the analyses may be underpowered.

An analysis of costs associated with shoulder arthroplasty.

BACKGROUND: The purpose of this study was to identify factors associated with variation in direct costs with shoulder arthroplasty. METHODS: This was a retrospective study of all shoulder arthroplasties performed at a single facility between July 1, 2011, and November 30, 2016. We collected patient factors, indications, procedure (including implant details), implant brand (A, B, and other), and complications. We collected direct costs over a 90-day period using a validated internal tool. We identified patient and procedure characteristics associated with costs using multivariable generalized linear models. RESULTS: A total of 361 patients were included, 19% with revision arthroplasty procedures, 32% with anatomic total shoulder arthroplasties, and 66% with reverse total shoulder arthroplasties (RTSAs). Of total costs, 13% were operative facility utilization costs and 58% were operative supply costs. Factors associated with increased total cost included younger age (P = .002) and an indication for surgery of other, that is, not osteoarthritis, a failed arthroplasty, or the sequelae of a rotator cuff tear (P = .030). Factors associated with increased operative costs included younger age (P = .002), use of an RTSA (P < .001), use of a bone graft (P < .001), implant brand B (P = .098), implant brands other than A and B (P = .04), the sequelae of a rotator cuff tear as an indication for surgery (P = .041), or an indication for surgery of other (P = .007). CONCLUSION: Most short-term (90-day) costs with shoulder arthroplasty are operative costs. Nonmodified factors associated with increased cost included younger age and less common indications for surgery, whereas potentially modifiable factors included the intraoperative use of a bone graft, implant brand, and RTSA use.

The Effect of Rotator Cuff Repair on Natural History: A Systematic Review of Intermediate to Long-Term Outcomes.

BACKGROUND: Rotator cuff disease can have a progressive natural history of increasing tear size and worsening function. It remains unknown whether rotator cuff repair alters this natural history. METHODS: A systematic review of the intermediate to long-term (minimum 5-year) results of operative rotator cuff repair and no repair of rotator cuff injuries was performed to compare (1) patient-based outcomes, (2) future surgical intervention, (3) future tear progression or recurrence, and (4) tear size. The no-repair group included both conservative treatment and surgical treatment without repair. After the application of selection criteria, 29 studies with 1,583 patients remained. Meta-regression was conducted to adjust for baseline age, sex, tear size, and duration of follow-up. RESULTS: Comparison of the repair and no-repair groups revealed no significant differences in terms of age (p = 0.36), sex (p = 0.88), study level of evidence (p = 0.86), or Coleman methodology score (p = 0.8). The duration of follow-up was significantly longer for the no-repair group (p = 0.004), whereas baseline tear size was significantly larger in the repair group (p = 0.014). The percentage of patients requiring additional surgery was significantly higher in the no-repair group after adjustment for age, sex, duration of follow-up, and tear size (9.5% higher in estimated means between groups [95% confidence interval, 2.1% to 17%]; p = 0.012). The likelihood of a recurrent defect (repair group) or extension of the prior tear (no-repair group) was not different between groups after adjustment for age, sex, duration of follow-up, and tear size (p = 0.4). There were no differences between the repair and no-repair groups in terms of the Constant score after adjustment for age, sex, duration of follow-up, and tear size (p = 0.31). The final tear size was significantly larger in the no-repair group than the repair group (967 mm2 higher in estimated means between groups [95% confidence interval, 771 to 1,164 mm2]; p < 0.001). CONCLUSIONS: At intermediate to long-term follow-up, rotator cuff repair was associated with decreased final tear size and decreased need for future surgery after adjusting for age, sex, duration of follow-up, and tear size. The likelihood of a recurrent defect after rotator cuff repair did not differ from that of tear extension after nonoperative treatment. Thus, rotator cuff repair may not alter natural history. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Implementation of an Antibiotic Therapy Protocol for Open Fractures in the Emergency Department.

CONTEXT: Well established in the Emergency Department (ED) literature is that the most important factor in decreasing subsequent infection rate in open fractures is the time to first administration of antibiotics. As such, the authors developed a new ED open fracture antibiotic protocol to facilitate more expeditious antibiotic administration and appropriate choice of antibiotics. METHODS: During Phase 1 of this project, the authors identified the 2012 - 2016 historical length of time from presentation of an open fracture to the possible initiation of antibiotic therapy at their institution. Results demonstrated critical areas for improvement in both timing and types of antibiotics administered. Phase 2 of the study evaluated the effect of the new open fracture antibiotic protocol. Sample cases from both phases were then further identified based on type of open fracture, time to initiation of antibiotics from ED presentation, type of antibiotics, and time to definitive treatment. Analyses were performed using GraphPad proprietary software. RESULTS: A random sample of 110 patients were included from Phase 1 and 27 patients from Phase 2. A total of 43 Phase 1 patients were administered cefazolin (Kefzol, Ancef); the remainder of the patients received a number of different antibiotics. During Phase 2, all 27 patients received cefazolin and Gentamycin if necessary per the new protocol. The average time to initiation of antibiotics was 0.907 hours during Phase 1 compared to 0.568 hours in Phase 2. The new protocol also significantly decreased the average time to antibiotics in ED from 2.17 hours to 1.82 hours when including EMS transfer time. Average time to definitive treatment in the operating room was 6.63 hours during Phase 1 and was significantly lowered to 3.97 hours during Phase 2. CONCLUSIONS: Timing to initiation of antibiotics after open fractures is the most important aspect to decrease infection rates. In order to decrease these times, the authors implemented a new ED protocol that specifically stated the type of antibiotic to be given based on the open fracture without orthopedics needing to be notified before administration. Ideally, the use of such protocols in ED settings will serve to greatly decrease infection risks after open fracture.

Barbed versus standard sutures for closure in total knee arthroplasty: a multicenter prospective randomized trial.

Barbed suture has been associated with improved closure efficiency and safety in TKA in prior studies. We performed a multicenter randomized controlled trial to determine the efficiency and safety of this technology in TKA. We prospectively randomized 411 patients undergoing primary TKA to either barbed running (n=191) or knotted interrupted suture closure (n=203). Closure time was measured intra-operatively. Cost analysis was based on suture and OR time costs. Closure time was shorter with barbed suture (9.8 vs. 14.5 min, p<0.001). Total closure cost was less with barbed suture ($324 vs. $419, p<0.001). Early complications and outcomes were similar between groups. The use of barbed suture in TKA is associated with shorter closure time, lower cost and similar outcomes and complications when compared with standard sutures.