Perioperative Impact of Early Limited Surgical Intervention to Treat Pilon Fractures.

BACKGROUND: The operative treatment of pilon fractures is classically treated with a staged protocol with ankle spanning external fixator, followed by definitive open reduction and internal fixation in order to decrease risk of soft tissue complications and infection. However, treatment of pilon fractures with patrial tibial fixation in addition to ankle spanning external fixation at the time of index procedure may facilitate final fixation while avoiding complications that were associated with acute definitive fixation. METHODS: Retrospective cohort series of 113 patients treated for pilon fractures from September 2012 to November 2018 at a single level 1 trauma center. Charts were reviewed to compare patients who underwent traditional management with a staged protocol and those who had a limited tibial reduction and fixation (LTRF) during the index procedure. The main outcome measurement was time to definitive fixation. RESULTS: Twenty-six percent of patients (29 of 113) had limited tibial reduction and fixation (LTRF) during index surgery. Mean time between index procedure and definitive ORIF was 4.75 days less for LTRF cohort compared to standard stage cohort (10.86 ± 7.44 vs. 15.61 ± 8.59 days, P = .009). The index procedure took on average 51 minutes longer in the LTRF cohort (P < .001), yet definitive procedure operative time was decreased by an average of 98 minutes (P < .001), and overall (index plus definitive) operative duration was shortened by an average of 50 minutes (P = .044). There was no difference in rate of infection between LTRF (3.1%) and traditional treatment (2.5%) (P = .86) or reduction quality (P = .270). There were no nonunions in either treatment group. CONCLUSION: Patients who had LTRF had quicker time to definitive ORIF and decreased operative time for definitive ORIF. There was no difference in infection rate, reduction quality, or nonunion rate between groups. LEVEL OF EVIDENCE: Level IV, Retrospective Cohort Study.

Distal Humerus Traction Radiographs: Is the Interobserver and Intraobserver Reliability Comparable With Computed Tomography?

OBJECTIVES: To compare the interobserver and intraobserver reliability of traction radiographs with 2-dimensional computed tomography (2D CT) in distal humerus fracture classification and characterization. DESIGN: Randomized controlled radiographic review of retrospectively collected data. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: Skeletally mature patients with intra-articular distal humerus fractures with both traction radiographs and CT scans were reviewed by 11 orthopaedists from different subspecialties and training levels. INTERVENTION: The intervention involved traction radiographs and 2D CT. MAIN OUTCOME MEASUREMENTS: The main outcome measurements included interobserver and intraobserver reliability of fracture classification by the OTA/AO and Jupiter-Mehne and determination of key fracture characteristics. RESULTS: For the OTA/AO and Jupiter-Mehne classifications, we found a moderate intraobserver agreement with both 2D CT and traction radiographs (κ = 0.70-0.75). When compared with traction radiographs, 2D CT improved the interobserver reliability of the OTA/AO classification from fair to moderate (κ = 0.3 to κ = 0.42) and the identification of a coronal fracture from slight to fair (κ = 0.2 to κ = 0.34), which was more pronounced in a subgroup analysis of less-experienced surgeons. When compared with 2D CT, traction radiographs improved the intraobserver reliability of detecting stable affected articular fragments from fair to substantial (κ = 0.4 to κ = 0.67). CONCLUSIONS: Traction radiographs provide similar diagnostic characteristics as 2D CT in distal humerus fractures. For less-experienced surgeons, 2D CT may improve the identification of coronal fracture lines and articular comminution.

Orthopaedic trauma during COVID-19: Is patient care compromised during a pandemic?

BACKGROUND: The Coronavirus disease-2019 (COVID-19) placed unprecedented pressure on the healthcare system. Many institutions implemented a government-mandated restructured set of safety and administrative protocols to treat urgent orthopaedic trauma patients. The objective of this study was to compare two cohorts of patients, a COVID group and non-COVID control group, and to evaluate the effectiveness of safety measures outlined in the Rutgers Orthopaedic Trauma Patient Safety Protocol (ROTPSP). Secondary outcomes were to elucidate risk factors for complications associated with fractures and COVID-19. METHODS: Patients treated for orthopaedic traumatic injuries were retrospectively identified between March and May 2020, and compared to a series of patients from the same time period in 2018. Main outcome measures included surgical site infections (SSI), length of stay (LOS), post-operative LOS (poLOS), presentation to OR time (PORT), and length of surgery. RESULTS: After review, 349 patients (201 non-COVID, 148 COVID) undergoing 426 surgeries were included. Average LOS (11.91 days vs. 9.27 days, p = 0.04), poLOS (9.68 days vs. 7.39 days, p = 0.03), and PORT (30.56 vs. 25.59 h, p < 0.01) was significantly shorter in the COVID cohort. There were less SSI in the COVID group (5) compared to the non-COVID group (14) (p = 0.03). Overall complications were significantly lower in the COVID group. Patients receiving Cepheid tests had significantly shorter LOS and poLOS compared to patients receiving the RNA and DiaSorin tests (p < 0.01 and p < 0.01, respectively). The Cepheid test carried the best benefit-to-cost ratio, 0.10, p < 0.05. CONCLUSION: The restructuring of care protocols caused by COVID-19 did not negatively impact perioperative complication rates, PORT or LOS. Cepheid COVID test type administered upon admission plays an integral role in a patient's hospital course by reducing both length of stay and hospital costs. This information demonstrates we can continue to treat orthopaedic trauma patients safely during the COVID-19 pandemic by utilizing strict safety protocols.

External Fixator-Assisted Reduction of Distal Femur Fractures: A Technical Trick.

SUMMARY: Restoration of anatomical alignment while preserving the soft-tissue envelope around the fracture site remains a challenge during distal femur fracture fixation. Although the lateral distal femoral locking plate allows surgeons to achieve adequate bony stability, their application has been associated with malalignment leading to inferior outcomes. We propose a biologically friendly, percutaneous technique that sequentially reduces and aligns distal femur fractures with an anterior external fixator before definitive fixation with a lateral distal femoral locking plate.

Patella fracture fixation with a non-locked anterior plating technique: A biomechanical study.

OBJECTIVES: The purpose of this study was to compare the biomechanical attributes of patella fracture fixation with either anterior plating utilizing two parallel, longitudinal 2.0 mm plates technique versus a cannulated screw tension band technique. METHODS: Five matched pairs (ten specimens) of fresh frozen cadavers were utilized. A transverse patella fracture (OTA 34C1.1) was fixed using either two 4.0 mm cannulated screw anterior tension band (CATB) or with two 2.0 mm stainless steel non-locking plates along the anterior cortex secured with 2.4 mm cortical screws traversing the fracture site. Specimens underwent 1000 cycles of simulated active knee range of motion before load to failure destructive testing. RESULTS: During cyclic loading there were no failures in the plate fixation group, and 2 out of 5 specimens catastrophically failed in the CATB group (p = 0.22). Average fracture displacement at the end of fatigue testing was 0.96 mm in the plate fixation group and 2.72 mm in the CATB group (p = 0.18). The specimens that withstood cyclic testing underwent a destructive load. Mean load to failure for the plate fixation specimens was 1286 N, which was not significantly different from the CATB group mean of 1175 N (p = 0.48). The mechanism of failure in the plate fixation cohort was uniformly via a secondary vertical patella fracture around the plates in all five specimens. In the CATB group, the mechanism of failure was via wire elongation and backing out of the screws. CONCLUSIONS: Patella fixation with anterior plating technique statistically performed equivalent to cannulated screw anterior tension band in ultimate load to failure strength and fatigue endurance under cyclical loading. No failures were observed cyclic simulated active range of motion in the anterior plate group. There was a trend towards improved fatigue endurance in the plate fixation group, however this did not reach statistical significance. We believe plate fixation technique represents a low-profile implant option for treatment of transverse patella fractures, which may allow for early active range of motion, and these data support biomechanical equivalency to standard of care.

Treating the Orthopaedic Trauma Knowledge Gap: Quantification of Orthopaedic Resident Knowledge Gaps and Validation of a Multimodal Course to Address the Deficiencies.

OBJECTIVES: To determine whether knowledge-based deficiencies are adequately addressed at the AO North America Basic Principles of Fracture Management course. DESIGN: Pretest, posttest. SETTING: Eighteen national trauma courses. PARTICIPANTS: Two thousand one hundred forty-nine learners. INTERVENTION: Pre- and postcourse 20-item tests of basic fracture knowledge, including 14 trauma topics. MAIN OUTCOME MEASURES: Deficiencies were defined as <60% correct answers on the precourse test. Postcourse knowledge gaps were defined as <75% correct responses. RESULTS: Deficiencies were noted in 7 of the 14 topics on the precourse test. All topics with deficiencies on the precourse test were shown to have statistically significant improvement in postcourse test scores. All topics without deficiencies were shown to have statistically significant improvement in postcourse test scores. The average overall precourse test score was 63% (95% confidence interval, 61%-65%), and the average overall postcourse test score was 81% (95% confidence interval, 79%-83%). The pretest to posttest difference was statistically significant (P < 0.05). The control questions, covering material that was not discussed in the course, did not have statistically significant improvement in scores. CONCLUSIONS: Residents are entering residency programs with limited knowledge of fracture care, and significant gaps remain at the junior level at the time of course participation, suggesting that supplemental fracture courses play an important role in resident education. Validation of short-term learning is possible through a pretest and posttest technique, and it can guide design changes, as opposed to relying on satisfaction surveys alone.

Operative Versus Nonoperative Outcomes of Middle-Third Clavicle Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: Middle third clavicle fractures have long been managed conservatively with immobilization. Some patients, especially those with completely displaced or shortened clavicle fractures are now thought to have increased risk of nonunion or symptomatic malunion. The authors performed a meta-analysis to study the incidence of nonunion and symptomatic malunion and test the hypothesis that surgical fixation of these fractures significantly lowers the risk of these complications. METHODS: A search was performed in the PubMed, Embase, and Cochrane Library databases for randomized clinical trials and quasi-experimental trials that compare outcomes of operative and nonoperative management for clavicle fractures that are fully (100%) displaced or have greater than 2 cm of shortening. Pooled patient data were used to construct forest plots for the meta-analysis. RESULTS: Eleven studies including 497 patients who were treated and 457 patients treated conservatively were analyzed. Patients managed operatively had significantly lower relative risk of developing nonunion [0.17 (95% confidence interval 0.08-0.33)] and symptomatic malunion [0.13 (95% confidence interval 0.05-0.37)]. Plate fixation significantly reduced the risk of nonunion, but intramedullary nail fixation did not. There was no difference in Constant-Murley or DASH scores between the 2 treatment groups or in the rate of secondary operative procedures. CONCLUSIONS: Patients who undergo operative fixation of displaced middle-third clavicle fractures have a lower incidence of nonunion and symptomatic malunion. The clinical significance of this effect is uncertain, as functional scores were similar in both groups. Further research into the risk factors for nonunion and symptomatic malunion will be necessary to determine which patients benefit from operative fixation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Physiologic widening of the medial clear space: What's normal?

BACKGROUND: Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS: A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS: Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS: Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

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.

The Incidence of Posterior Malleolar Involvement in Distal Spiral Tibia Fractures: Is it Higher than We Think?

OBJECTIVES: To investigate the incidence of concomitant posterior malleolar fractures (PMFs) in operative, distal-third, spiral tibia fractures. DESIGN: Prospective protocol with retrospective review of data. SETTING: Single, Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred ninety-three consecutive, skeletally mature patients with operatively treated fractures of the distal-third, tibial shaft and metaphysis. Pilon fractures were excluded. INTERVENTION: Computed tomography (CT) scans were obtained in all distal-third, spiral fractures of the tibia to determine fracture morphology and presence of a PMF. MAIN OUTCOME MEASUREMENTS: The incidence of concurrent PMFs in operative spiral fractures of the distal tibia. RESULTS: Twenty-six distal-third, spiral fractures were identified with an ipsilateral PMF diagnosed in 92.3% of cases (24 cases). PMFs were over 25 times more likely to occur in distal-third, spiral fractures when compared with other distal-third fracture patterns (relative risk = 25.7, 95% confidence interval, 11.6-56.8). PMFs were treated with supplemental fixation in 23/24 (95.8%) cases. CONCLUSIONS: There is a high incidence of concomitant, ipsilateral fractures of the posterior malleolus in patients presenting with operative distal-third, spiral fractures of the tibia. A preoperative ankle computed tomography should be strongly considered in all cases with this specific fracture morphology. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management and Outcome of Transepiphyseal Femoral Neck Fracture-Dislocation with a Transverse Posterior Wall Acetabular Fracture: A Case Report.

CASE: We present the case of a 10-year-old girl who sustained a transepiphyseal femoral neck fracture with posterior dislocation of the femoral epiphysis and an associated transverse posterior wall acetabular fracture, leading to complete separation of the capital femoral epiphysis. She underwent urgent operative intervention; she was followed for 13 years and achieved an excellent outcome. CONCLUSION: Pediatric hip fracture-dislocations are complex injuries that should be managed by a competent pelvic reconstructive surgeon in a well-resuscitated patient. If a quality reduction is obtained in a timely manner, the patient has the best chance of achieving a favorable long-term outcome.

Concomitant Proximal and Distal Tibiofibular Joint Dislocation Associated With a Tibial Shaft Fracture.

An association exists between tibial shaft fractures and ankle injuries. In addition, although uncommon, an association between tibial shaft fractures and proximal tibiofibular dislocations has also been established. A review of the previous literature resulted in one case report of a complete proximal and distal tibiofibular joint dislocation without fracture of the tibia or fibula. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. To the best of our knowledge, this is the first report of this injury pattern associated with a tibial shaft fracture.

Evaluation of the Content and Accessibility of Web Sites for Accredited Orthopaedic Trauma Surgery Fellowships.

BACKGROUND: Orthopaedic trauma fellowship applicants use online-based resources when researching information on potential U.S. fellowship programs. The 2 primary sources for identifying programs are the Orthopaedic Trauma Association (OTA) database and the San Francisco Match (SF Match) database. Previous studies in other orthopaedic subspecialty areas have demonstrated considerable discrepancies among fellowship programs. The purpose of this study was to analyze content and availability of information on orthopaedic trauma surgery fellowship web sites. METHODS: The online databases of the OTA and SF Match were reviewed to determine the availability of embedded program links or external links for the included programs. Thereafter, a Google search was performed for each program individually by typing the program's name, followed by the term "orthopaedic trauma fellowship." All identified fellowship web sites were analyzed for accessibility and content. Web sites were evaluated for comprehensiveness in mentioning key components of the orthopaedic trauma surgery curriculum. By consensus, we refined the final list of variables utilizing the methodology of previous studies on the topic. RESULTS: We identified 54 OTA-accredited fellowship programs, offering 87 positions. The majority (94%) of programs had web sites accessible through a Google search. Of the 51 web sites found, all (100%) described their program. Most commonly, hospital affiliation (88%), operative experiences (76%), and rotation overview (65%) were listed, and, least commonly, interview dates (6%), selection criteria (16%), on-call requirements (20%), and fellow evaluation criteria (20%) were listed. Programs with ≥2 fellows provided more information with regard to education content (p = 0.0001) and recruitment content (p = 0.013). Programs with Accreditation Council for Graduate Medical Education (ACGME) accreditation status also provided greater information with regard to education content (odds ratio, 4.0; p = 0.0001). Otherwise, no differences were seen by region, residency affiliation, medical school affiliation, or hospital affiliation. CONCLUSIONS: The SF Match and OTA databases provide few direct links to fellowship web sites. Individual program web sites do not effectively and completely convey information about the programs. The Internet is an underused resource for fellow recruitment. The lack of information on these sites allows for future opportunity to optimize this resource.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra.

OBJECTIVE: To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation. DESIGN: Retrospective chart review of a trauma database. SETTING: University Level 1 Trauma Center. PATIENTS: Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism. MAIN OUTCOME MEASUREMENTS: The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment. RESULTS: In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm. CONCLUSIONS: The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

The Correlation Between the OTA/AO Classification System and Compartment Syndrome in Both Bone Forearm Fractures.

OBJECTIVE: To evaluate the efficacy of using the Orthopaedic Trauma Association (OTA/AO) classification for both bone forearm fractures in predicting compartment syndrome. DESIGN: Retrospective cohort. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred fifty-one patients 18 years of age and older, with both bone forearm fractures diagnosed from 2001 to 2016 were categorized based on the OTA/AO classification. Patients with both bone fractures caused by gunshot wounds were excluded. MAIN OUTCOME MEASUREMENTS: The endpoint for our study was whether forearm fasciotomies were performed based on the presence of compartment syndrome. RESULTS: Of a total of 151 both bone forearm fractures, 15% underwent fasciotomy. Six of 80 (7.5%) grouped 22-A3, 8 of 44 (18%) grouped 22-B3, and 9 of 27 (33%) grouped 22-C underwent fasciotomies for compartment syndrome (P = 0.004). The relative risks of developing compartment syndrome for group 22-B3 versus 22-A3 was 2.42 (P = 0.08), 22-C versus 22-B3 was 1.83 (P = 0.15), and 22-C versus 22-A3 was 4.44 (P = 0.002). CONCLUSIONS: There is a significant correlation between the OTA/AO classification and the need for fasciotomies, with group C fractures representing the highest risk. Clinicians can use this information to have a higher index of suspicion for compartment syndrome based on OTA/AO classification to help minimize the risk of a missed diagnosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: A survey of orthopaedic traumatologists.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone. METHODS: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan. RESULTS: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT. CONCLUSION: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft.

Acetabular Fractures: A Problem-Oriented Approach.

The main goals of acetabular fracture management are to restore the congruity and stability of the hip joint. These goals are the same for all patients who have an acetabular fracture, regardless of the morphology or etiology of the fracture. Nevertheless, certain acetabular fracture types and several patient factors pose management challenges for surgeons. Therefore, surgeons who manage acetabular fractures must understand the distinctive features of acetabular fractures as well as the soft-tissue and patient-related factors that play a critical role in patient outcomes. Particular challenges in the management of acetabular fractures include acetabular fracture types that involve the posterior wall, acetabular fractures with soft-tissue concerns, acetabular fractures in patients with multiple injuries, and acetabular fractures in the geriatric population. Although the well-known protocols that were established by Judet and Letournel continue to be important guidelines for the management of acetabular fractures, the injury characteristics of acetabular fractures, the demographics of the patients in whom acetabular fractures occur, and the treatment options for acetabular fractures have evolved. Therefore, surgeons must be aware of new and more recently published information on acetabular fractures.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial.

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857.

Evaluation of Intra-articular Fracture Extension After Gunshot Wounds to the Lower Extremity: Plain Radiographs Versus Computer Tomography.

OBJECTIVE: This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION: Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES: Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS: There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS: Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Computed Tomography in Surgical Planning for Trimalleolar Fracture. A Survey of OTA Members.

OBJECTIVE: Does the additional information provided by computed tomography (CT) alter surgeons' treatment plans for trimalleolar ankle fracture? DESIGN: Prospective. SETTING: Electronic survey. PATIENTS/PARTICIPANTS: Members of the OTA. INTERVENTION: Compare management of trimalleolar ankle fracture before and after CT. MAIN OUTCOME MEASUREMENTS: Compare types of fixation used, indication for fixation, and approach need for fixation before and after CT. RESULTS: Overall, OTA members' operative technique changed in 430 of the 1710 (25.1%) cases after review of the CT images. Of the 430 observations in which the operative technique was altered, the surgeon had initially stated that they would not have requested a CT in 51.2% incidences. When analyzing if CT affected whether or not operative fixation was indicated, a total of 16.3% responses changed. Surgeons were significantly more likely to change from no fixation to fixation (11.5%) than vice versa (4.8%) after reviewing CT imaging. A total of 17.8% of responses changed operative approach after reviewing the CT; 11.7% changed to open reduction internal fixation, whereas 6.1% changed away from open reduction internal fixation. CONCLUSION: A consensus on the ideal treatment of trimalleolar fractures remains elusive, evidenced by a high variation in treatment preference, both before and after CT review. Our results demonstrate with the additional information delineated on CT, a surgeons' operative plan, technique, and approach often change. With greater than 25% of respondents changing their treatment strategy after seeing CT imaging, radiographs alone limited surgeon understanding of fracture pattern. Because of difficulty understanding the posterior fracture fragment, we recommend preoperative CT on all trimalleolar fractures. LEVEL OF EVIDENCE: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.