Obstetricians are likely to elect for cesarean section in women with retained pelvic implants: a radiographic survey study.

PURPOSE: Women with a history of pelvic fracture undergo cesarean section (CS) at a higher rate than the general population. The purpose of our study is to query obstetricians on their preferences. METHODS: An electronic survey consisting of 22 radiographs of patients who underwent pelvic fixation was sent to obstetricians at 3 academic medical centers. For each radiograph, a hypothetical scenario was given, and the respondents were asked if they would elect for a vaginal delivery or CS. RESULTS: We collected 58 responses. The overall CS rate was 59%. Respondents were significantly more likely to elect for CS with trans-symphyseal fixation or sacroiliac fixation, independently (p < 0.001). DISCUSSION: Obstetricians are likely to elect for elective CS in the presence of pelvic implants especially in patients with trans-symphyseal and sacroiliac fixation. Based on there is an opportunity for collaboration between orthopedic trauma surgeons and obstetricians.

Opportunistic Use of Computed Tomography to Determine Muscle-Adipose Ratio Reliably Predicts Wound Complications After Kocher-Langenbeck Surgical Exposure of the Acetabulum.

OBJECTIVES: To determine whether muscle-to-adipose ratio (MAR) along the course of a Kocher-Langenbeck incision is more accurate at predicting postoperative wound complications after acetabular fixation than waist-to-hip ratio or body mass index (BMI). DESIGN: Retrospective case series. SETTING: Level 1 Trauma Center. PATIENT SELECTION CRITERIA: Patients who sustained an acetabular fracture and had fixation through a Kocher-Langenbeck approach from January 1 st , 2008 to December 31 st , 2018. For inclusion, patients had to have a pre-operative and a post-operative CT of the pelvis and a minimum follow up of 12 months. Patients were excluded if an antibiotic other than cefazolin was administered for prophylaxis, if they had a femur fracture treated with an antegrade intramedullary nail, if there was any associated pelvic ring injury requiring surgical treatment of any type, if there were any abdominal or pelvic procedures completed by another surgical service, if the patient underwent pelvic embolization of a vessel, if there was presence of a genitourinary injury or Morel-Lavallée lesion, or if there was a subsequent surgical procedure unrelated to the primary endpoint (e.g., revision fixation). OUTCOME MEASURES AND COMPARISONS: Presence of a surgical site infection or a wound healing complication. BMI, WHR and MAR were evaluated and compared for their ability to predict a surgical site infection or a wound healing complication. RESULTS: One-hundred ninety-three patients were included in this study, and the mean follow-up was 17.4 months. Thirty patients (15.5%) developed a wound complication. Seventeen patients (8.8%) developed a superficial infection and 13 (6.7%) developed a deep infection. The mean BMI for those who developed a wound complication was 35.9. The mean MAR was 0.67 for patients who developed a wound complication versus 0.75 for those who did not. Receiver operator characteristic analysis showed an area under curve for BMI to be 0.717 (95% confidence interval [CI] 0.577-0.857, P = 0.006) and for MAR to be 0.680 (inverted, 95% CI, 0.507-0.854, P = 0.022). The area under curve for waist-to-hip ratio was not statistically significant. CONCLUSIONS: MAR is a significant predictor of postoperative wound complication in patients undergoing treatment of posterior wall acetabular fractures. The higher rate of wound complications in patients with a low MAR should be considered in the treatment of these patients and may be used to guide discussion regarding the risks of surgery and the potential use of adjuncts to reduce wound healing complications. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Chiropractic Manipulation Causing Anterior-Posterior Compression Type Pelvic Ring Injury: A Case Report.

CASE: We present a case of an anteroposterior compression (APC) type pelvic ring injury that occurred after chiropractic manipulation in a patient with a history of quadriplegia. Emergent surgical stabilization was undertaken, and he had an excellent outcome with no complications at 3.5-year follow-up. CONCLUSION: APC type pelvic ring injuries usually occur to high-energy mechanisms. We describe a case of a patient with quadriplegia and osteopenia that suffered a pelvic ring injury because of a unique mechanism. Practitioners performing pelvic manipulation should be aware of this type of injury in at-risk patients.

Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis.

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients. Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality. Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups. Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

Positive Correlation Between Social Media Utilization by Orthopaedic Journals and Impact Factor.

INTRODUCTION: Social media use has exploded in popularity over the past decade with over 1.5 billion users on Facebook and 320 million users on Twitter. The aim of this study was to analyze the use of social media by orthopaedic journals and determine whether a relationship exists between social media followers and journal impact factor. METHODS: The Clarivate Analytics Impact Factor tool was used to identify all orthopaedic journals with a 2022 impact factor of greater than 1.5. We then conducted a query on Instagram, Twitter, LinkedIn, and Facebook to determine which programs had pages on each platform. RESULTS: Seventeen journals were included across all orthopaedic subspecialties. Of the 17 journals, 14 (82.4%) had a Facebook page, eight (47%) had an Instagram page, 15 (88.2%) had a Twitter account, and 8 (47%) had a LinkedIn profile. When compiling the number of followers by social media platform, Twitter had the most (177,543), followed by Facebook (149,388), Instagram (81,739), and LinkedIn (77,459). We found a significant correlation between the number of social media followers and journal impact factor (Pearson correlation coefficient [PCC] = 0.67; P = 0.003). When analyzing each social media platform independently, we found a significant correlation between the number of Facebook and Twitter followers and journal impact factor (PCC = 0.54; P = 0.02 and PCC = 0.80; P < 0.001, respectively). DISCUSSION: We have shown a notable association between the number of social media followers and a journal's impact factor. With the increasing shift toward online distribution, orthopaedic journals may use our data when evaluating their social media strategy to maintain and potentially increase their exposure and potentially their impact factor.

Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons.

INTRODUCTION: Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship. METHODS: We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality. RESULTS: One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001). DISCUSSION: Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.

The Evolution of the Musculoskeletal Trauma Section of the Orthopaedic In-Training Examination.

INTRODUCTION: In 1963, the American Academy of Orthopaedic Surgeons administered the Orthopaedic In-Training Examination (OITE), the first and longest running yearly medical specialty examination. There have been no recent studies to evaluate the content of the musculoskeletal trauma section of the OITE. METHODS: We analyzed all questions that were classified by the American Academy of Orthopaedic Surgeons as musculoskeletal trauma from 2012 to 2019. We recorded the number of musculoskeletal trauma questions in each examination, the topics and imaging modalities tested, the references cited, and the taxonomy classification of each question. We extrapolated from a similar musculoskeletal trauma study published in 2011 to create the previous examination cohort for comparison. RESULTS: For the current cohort, the average number of musculoskeletal trauma questions was 43.5 questions per examination (18.4%). The most frequently tested topics were proximal tibia fractures, pediatric trauma, hip fractures, and diaphyseal femur fractures, respectively. In previous examinations, questions from T1 and 2 were tested significantly more frequently compared with the current examinations (P < 0.001 and P = 0.02, respectively). In the current cohort, T3 questions were tested significantly more frequently than previous examinations (P = 0.001). Previous examinations had significantly more questions without an image (36 questions per year versus 25 questions per year, P < 0.001). In current versions of the examination, radiographs are tested significantly more frequently than other imaging modalities (P < 0.001). DISCUSSION: The musculoskeletal trauma section of the OITE has evolved. To improve and focus study efforts, residents may use this study as a guide when preparing for the examination.

Sinus Tarsi Versus Extended Lateral Approach for Displaced Intra-Articular Calcaneal Fractures: A Single Surgeon's Experience.

BACKGROUND: The aim of the study is to investigate the differences between the extensile lateral (EL) and sinus tarsi (ST) approaches for the treatment of displaced intra-articular calcaneus fractures as treated by a single surgeon. METHODS: A retrospective cohort study performed at a Level 1 trauma center. One hundred twenty-nine consecutive intra-articular calcaneus fractures from 2011 to 2018 that were surgically treated by a single surgeon. Primary outcomes were time to surgery, operative time, postoperative restoration of the critical angle of Gissane, postoperative wound complications, and need for unplanned re-operation. RESULTS: Patient characteristics, including demographics, mechanism of injury, and fracture patterns were similar between the EL and ST approach groups. There was a significant decrease in unplanned secondary procedures (P = .008), shorter time to definitive fixation (P = .00001), and shorter average operative time in the ST group (P = .00001). Postoperative measurement of the critical angle of Gissane between the two groups was significantly different, but minute with an average difference of approximately 3 degrees (P = .025). Measurements in both groups were within the expected range of normal. CONCLUSIONS: For displaced intra-articular calcaneus fractures, a limited open ST approach is associated with a significant reduction in the time to definitive fixation and decreased operative time. The EL approach was associated with a small, but significant improvement in the restoration of the critical angle of Gissane compared with the ST approach. Therefore, an ST approach may allow for earlier surgical intervention and result in equivalent quality of reduction compared with an EL approach. LEVEL OF EVIDENCE: Level III.

Periprosthetic distal femur fractures treated by retrograde intramedullary nails with a 10-degree distal bend achieve significantly better post-operative radiographic alignment when compared to conventional retrograde nails.

INTRODUCTION: Periprosthetic distal femur fractures (PPDFFs) are a common complication after total knee arthroplasty (TKA). In the setting of well-fixed TKA components, treatment options include retrograde intramedullary nailing (rIMN) or lateral locked plating. Treatment with rIMN has historically been associated with potential for extension deformity when using conventional nails. We hypothesized that the PPDFFs treated with an intramedullary nail with a specifically designed 10-degree distal bend for periprosthetic fractures would result in improved post-operative sagittal alignment compared to conventional intramedullary nails. MATERIALS AND METHODS: The study was conducted at a level-1 trauma center over a 12-year period (2010 - 2022). Patients over the age of 18 who sustained a PPDFF treated with rIMN were identified. The primary outcomes of the study were post-operative coronal and sagittal alignment determined by reviewing post-operative radiographs. RESULTS: A total of 50 patients were included. Twenty-three patients were treated with a rIMN with a 10° distal bend. Twenty-seven patients were treated with a rIMN with distal bend of 5° The mean aPDFA for the 10° distal bend group was 81.7° compared to 92.8° in the 5° distal bend group (p<0.001). There were 3/23 (13%) significant sagittal plane deformities the 10° distal bend group compared to 11/27 (41%) in the 5° distal bend group (p = 0.03). There was one patient with a post-operative extension deformity in the 10° distal bend group compared to 11 patients in the 5° distal bend group (p = 0.02). CONCLUSION: Retrograde intramedullary nailing of PPDFF with a 10° distal bend results in significantly better alignment in the sagittal plane when compared to a conventional 5° nail. The use of a 5° nail resulted in an extension deformity significantly more frequently. We therefore recommend the utilization of a rIMN with a 10° distal bend when treating PPDFFs. SUMMARY: Periprosthetic distal femur fractures are a common complication following total knee arthroplasty. While several studies report on the use of retrograde intramedullary nails in the treatment of periprosthetic distal femur fractures, there are limited reports of the use of a novel retrograde intramedullary nail with a 10° distal bend in the treatment of these injuries. Herein we present a radiographic study comparing coronal and sagittal postoperative alignment following treatment with retrograde intramedullary nails with a 10° distal bend versus conventional retrograde nails with a 5° distal bend.

Clinical outcomes in prone positioning for percutaneous fixation of posterior column acetabular fractures.

PURPOSE: Percutaneous retrograde fixation of posterior column acetabular fractures is becoming a commonly practiced technique. Prone positioning provides reliably reproducible intraoperative fluoroscopic images necessary for precise preparation of the osseous fixation corridor necessary for accurate and safe implant placement. Additionally, the prone position facilitates an open posterior approach if an open reduction is necessary. The purpose of this study was to analyze the radiographic and clinical outcomes of retrograde posterior column fixation utilizing the prone position. METHODS: From 2017 to 2020, 41 patients were included in the retrospective study. Clinical outcomes were collected for a minimum of 6 months. Implant placement was assessed on post-operative pelvic computed tomography (CT) scans and fracture union was assessed on routine follow-up radiographs. RESULTS: All (100%) cases achieved union by 4 months, with an average time to union of 3.2 months. Every post-operative CT scan demonstrated screw placement contained throughout the posterior column with no intrusion into the hip joint or sciatic notch. Clinically, one patient reported pain with sitting. No patients required additional surgical intervention. CONCLUSION: Prone positioning is a versatile and effective approach for retrograde percutaneous fixation of posterior column acetabular fractures. This study is the first to report clinical outcomes utilizing this technique and contributes to a growing body of the literature supporting the value and safety of percutaneous fixation of acetabular fractures appropriate for this fixation strategy.

A New Algorithm for Classifying Acetabular Fracture Patterns on Three-dimensional Computed Tomography Reconstructions Markedly Improves Residents' Ability to Correctly Classify Fractures.

INTRODUCTION: CT and three-dimensional (3D) CT reconstructions have been shown to improve the understanding of acetabular fractures. With the increased availability of 3D pelvic CT reconstructions, our goal for this study was to develop an algorithm to aid residents in the classification of acetabular fractures. We hypothesized that the use of a stepwise algorithm will markedly enhance the trainees' ability to correctly identify acetabular fracture patterns. METHODS: This was a multicenter study that included 33 residents. Residents reviewed 15 sets of 3D reconstructions of the 10 acetabular fracture patterns. Residents completed the first round, and the results were collected electronically. Three weeks later, they were asked to classify the fractures a second time with the use of the algorithm. The number of correct responses from the two sessions was analyzed to determine if the algorithm improved residents' ability to correctly classify fracture patterns. RESULTS: Thirty-three residents classified 15 fractures which yielded 495 unique responses. Residents correctly classified 52.5% (260/495) of fractures without the algorithm, which significantly increased to 77.5% (384/495) (P = 0.001) with the algorithm. When stratified by year in residency, all residents were able to correctly classify markedly more fractures with the algorithm. DISCUSSION: Overall, we believe this method is a reproducible diagnostic tool that will assist residents in classifying acetabular fractures. We were able to demonstrate that with the use of this algorithm, residents' ability to correctly classify acetabular fractures is markedly enhanced, regardless of year in training. This algorithm will be a useful adjunct to assist and advance trainees' education and understanding of a complex topic.

Clamp Assisted Reduction of the Transverse Acetabular Fracture With Anterior Column Screw Fixation and Posterior Plating: A Technical Trick and Case Series.

SUMMARY: Displaced transverse acetabular fractures are unstable injuries that frequently require repair. Although multiple approaches, techniques, and fixation constructs have been described to treat this pattern, achieving an anatomical reduction and applying fixation to maintain this until union remains the goal of treatment. We present a surgical technique for transverse or transverse/posterior wall acetabular fractures repaired using a clamp-assisted reduction through the sciatic notch, followed by anterior column screw fixation and subsequent posterior column plating through a Kocher-Langenbeck exposure. We review a case series of 55 patients treated with this technique and evaluate reduction quality using postoperative computed tomogram scans to assess for any residual step-off.

Theme Park Water Slides: A New Mechanism of Causing 61B2.3 Pelvic Ring Injuries: A Case Series.

CASE: We present a series of 3 pelvic ring injuries that occurred on 1 high-speed water slide at a theme park in Orlando, FL. This is the first time this injury has been reported at a water park in the United States. All patients underwent surgical management and had an excellent outcome. CONCLUSION: Pelvic ring injuries usually occur because of high-energy mechanisms, but unique mechanisms of injuries are possible. We aim to draw attention to this unique mechanism of injury because serious injury may occur to riders. Water parks should use the information presented in this study to develop and refine safety requirements for patrons.

The Competitive Orthopaedic Trauma Fellowship Applicant: A Program Director's Perspective.

INTRODUCTION: In 2018, orthopaedic trauma had the lowest match rate among orthopaedic subspecialties. The purpose of this study was to determine the importance of factors evaluated by orthopaedic trauma fellowship directors when ranking applicants after the interview. METHODS: An electronic survey was submitted to fellowship directors and consisted of 16 factors included in a fellowship application. Respondents were asked to rate the importance of these factors for applicants they interviewed on a 1 to 5 Likert scale, with 1 being not at all important and 5 being critical. RESULTS: Thirty-seven fellowship directors responded (63.8%). The highest-rated factor was the applicant interview (mean score 4.82), followed by the quality of letters of recommendation (4.69), personal connections made to the applicant (3.89), and potential to be leader (3.86). Fellowship directors at academic programs rated interest in an academic career (P = 0.003), research experience (P = 0.023), and exposure to well-known orthopaedic traumatologists (P = 0.003) higher than their counterparts at private institutions. Programs with more than one fellow rated potential to be a leader higher than programs with one fellow (P = 0.02). DISCUSSION: Trainees may use this study when compiling an application to optimize their chances of matching at the program of their choice.

Outcomes of periprosthetic distal femur fractures following total knee arthroplasty: Intramedullary nailing versus plating.

BACKGROUND: Periprosthetic distal femur fractures (PPDFFs) present a challenge in terms of optimizing fixation in patients with poor bone quality and limited bone stock. The main treatment options include laterally based plating and intramedullary nailing. We hypothesized that treatment of PPDFFs with intramedullary nails would result in improved union rate, fewer complications, and an equivalent rate of malalignment compared to plating. MATERIALS AND METHODS: Cases of PPDFFs were identified through a query of our institutional trauma database between 2011-2018. Adult patients (>18 years) were included if they sustained a fracture of the distal femur around a total knee arthroplasty (TKA) that was not initially treated at another institution. The anatomic lateral distal femoral angle (aLDFA) and the anatomic posterior distal femoral angle (aPDFA) were measured on the follow-up radiographs. RESULTS: Ninety-seven PPDFFs in 97 patients, with a mean age of 76 years and 74% female were identified. Plating was used in 74 patients (76%) and 23 patients (24%) were treated with intramedullary nailing. Extension deformity in the sagittal plane was more common following intramedullary nailing compared to plating (10/23 nailing versus 10/74 plating) (p=0.002). There were 12 reoperations (12/75, 16%), and the method of fixation was not associated with rate of reoperation (p=0.9). CONCLUSION: Intramedullary nailing was associated with an increased risk of malalignment, most commonly an extension deformity, in this series. However, malalignment was not associated with worse outcomes.

Transverse and transverse-variant acetabular fractures with ipsilateral sacroiliac joint injuries: A technical note for reduction and stabilization.

Transverse and T-type acetabular fractures are high energy fractures that may be associated with a disruption of the pelvic ring. While several studies report upon clinical findings and outcomes associated with combination injuries of the pelvic ring and acetabulum, there are limited reports discussing surgical treatment strategies for reduction and stabilization. Herein we focus on describing reduction and stabilization techniques of transverse or transverse-variant acetabular fractures with an associated ipsilateral partial disruption of the sacroiliac joint.

Morbid obesity and short-term complications following acetabular fracture surgery: A comparative cohort study.

INTRODUCTION: Obesity is an epidemic facing the United States affecting nearly 40% of the population (93.3 million adults). The objective of this study was to compare early perioperative complications in patients with a normal BMI to patients who are pre-obese, obese, and morbidly obese. MATERIALS AND METHODS: The study was conducted at a Level-I trauma center. Patients were separated into 4 groups based on their BMI. Group 1 had a BMI < 25 (normal), Group 2 had a BMI between 25-29.9 (pre-obesity), Group 3 had a BMI between 30-39.9 (obese), and Group 4 had a BMI ≥40 (morbidly obese). Outcome variables included total operative time (OT), estimated blood loss (EBL), length of stay (LOS), and early medical and surgical complications. A comparison between groups was performed for each outcome variable and surgical complication. RESULTS: We identified 333 patients and the number of patients in Groups 1-4 were 86, 96, 121, and 30, respectively. The average BMI for Groups 1-4 was 22.3, 27.3, 35.9, and 44.9, respectively (p < 0.001). OT, EBL, and LOS did not differ between groups or between the surgical approach utilized. There were no significant relationships when comparing complication rates between groups. Patients in Group 4 experienced significantly more PE compared to patients in Group 2 (p=0.01). Additionally, patients in Group 4 experienced a significantly more PE than patients in Groups 1 and 2 combined (p<.01). The relative risk of having a PE if BMI is ≥40, compared to a BMI <30 is 18.40 (95% CI = 1.98 - 171.13). The PEs were not fatal in all cases. CONCLUSIONS: In the treatment of the obese and morbidly obese with acetabular fractures, we find that these cohorts are not at a greater risk of wound complications or infection. The higher rate of pulmonary embolism seen in the morbidly obese should be considered when evaluating these patients for appropriate thromboembolic prophylaxis.

Increasing Fellow Recruitment: How Can Fellowship Program Websites Be Optimized?

BACKGROUND: The purpose of this study was to determine the importance of factors considered by orthopaedic trauma fellowship applicants when evaluating programs. We hypothesized that applicants will prioritize consistent factors when applying to programs. In addition, we assessed how the applicants use the Internet to research potential fellowships. Our goal is to provide fellowships with information to optimize both their fellowship and online contents. METHODS: At the 2018 and 2019 Orthopaedic Trauma Association meetings, a paper survey was given to each attendee of multiple fellowships' informational sessions. The survey consisted of 25 factors that applicants may consider when evaluating fellowships ranked on a 1-to-5 Likert scale. Additional questions were asked to determine how applicants use the Internet and social media when researching fellowships. RESULTS: We received 111 surveys (roughly a 56% response rate). Ninety-eight applicants (88%) indicated that they use fellowship websites to research fellowships. The utilization of fellowship websites was markedly greater than the use of other online resources. The highest rated factors surveyed were surgical experience (mean 4.95; SD 0.26), pelvic and acetabular experience (4.80; 0.52), lower extremity fracture experience (4.75; 0.58), and current faculty at the fellowship (4.55; 0.78). The lowest rated factors were the ability to moonlight (2.04; 1.08), salary (1.88; 1.12), and spine trauma experience (1.45; 0.87). Surgical experience and pelvic/acetabular experience were rated markedly higher than every other factor surveyed. DISCUSSION: To our knowledge, this is the first study to demonstrate that most orthopaedic trauma fellowship applicants use fellowship websites when researching programs. Programs may use this study to optimize their fellowship experience to reflect what the applicants value. In addition, programs may use this study as a guide when updating their websites. Fellowships with informative websites that meaningfully highlight their fellowship experience may have a competitive edge in attracting applicants to their programs.

Clinical Results of Acetabular Fracture Fixation Using a Focal Kocher-Langenbeck Approach Without a Specialty Traction Table.

OBJECTIVES: To report the clinical result of a series of patients who underwent acetabular fracture fixation using a Kocher-Langenbeck approach without a specialty traction table. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients who sustained posterior wall or posterior wall associated acetabular fractures that were treated operatively with a Kocher-Langenbeck approach over a 5-year period. INTERVENTION: Surgical fixation of acetabular fractures using a flat, radiolucent table. MAIN OUTCOME MEASUREMENTS: Outcomes included reduction quality and complications such as infection, heterotopic ossification, loss of reduction or fixation, medical complications, and neurologic injury. RESULTS: We identified 172 patients. No articular malreductions of greater than 2 mm were noted on postoperative CT scans. There were 13 surgical complications observed (8.1%). There was 1 death in our cohort (0.6%), and 3 patients had nonfatal pulmonary emboli (1.9%). There were no nerve injuries observed. There were 6 acute infections (3.1%) requiring surgical intervention. Three patients had symptomatic heterotopic bone that required excision (1.9%). Four patients (2.5%) required eventual total hip arthroplasty. CONCLUSION: Overall, we report on the largest cohort in the literature undergoing a prone Kocher-Langenbeck without a specialty table for acetabular fracture fixation. We found that limited extremity prepping and draping for a prone Kocher-Langenbeck on a flat, radiolucent table did not result in an increased rate of postoperative neurological complications or malreductions of acetabular fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Role of the Computed Tomographic Scan in the Diagnosis of Acetabular Fracture in the Immature Pelvis.

OBJECTIVES: We present a series of skeletally immature patients sustaining acetabular fractures. We hypothesized that if the secondary ossification centers of the acetabulum are not completely ossified, fractures often will not be identified on plain radiography. Our objective was to determine the efficacy of diagnostic plain radiography in these patients. DESIGN: Retrospective case series. SETTING: Urban, level-I trauma center. PATIENTS/PARTICIPANTS: Skeletally immature patients with acetabular fractures following blunt force trauma. INTERVENTION: We obtained a dedicated axial computed tomographic (CT) scan of the pelvis with sequential sections of 2.5-mm thickness. MAIN OUTCOME MEASURES: The accuracy of plain radiography as compared with CT in diagnosing acetabular fractures in skeletally immature patients. RESULTS: Fourteen patients with 16 fractures of the acetabulum were identified by CT scan; however, 69% (11 of 16) were not visible on plain radiography. Radiographs were less likely to identify acetabular fractures compared with pelvic ring fractures [31% (5/16) vs. 92% (11/12); odds ratio, 0.04; 95% confidence interval, 0.01-0.37; P = 0.001]. Patients younger than 12 years were less likely to have acetabular fractures identified on plain radiography [9% (1/11) vs. 80% (4/5); odds ratio, 0.03; 95% confidence interval 0.01-0.59; P = 0.013]. The mean age of patients whose acetabular fractures were not identified on plain radiography was less than those whose fractures were identified on plain radiography (7.6 ± 2.9 vs. 12.8 ± 1.6; P = 0.004). Acetabular fractures visible on plain radiography were more likely to require operative stabilization [60% (3/5) vs. 0% (0/11); P = 0.004]. CONCLUSIONS: In skeletally immature patients with suspected injury to the pelvis, particularly in patients younger than 12 years, diagnostic evaluation using plain radiographs alone may lead to missed injuries. If an acetabular fracture is identified, patients should be followed closely both clinically and radiographically to ensure early identification of any developing posttraumatic deformity. LEVEL OF EVIDENCE: Level IV; Diagnostic-Investigating a diagnostic test.