Conserving alpha and beta diversity in wood-production landscapes.

International demand for wood and other forest products continues to grow rapidly, and uncertainties remain about how animal communities will respond to intensifying resource extraction associated with woody bioenergy production. We examined changes in alpha and beta diversity of bats, bees, birds, and reptiles across wood production landscapes in the southeastern United States, a biodiversity hotspot that is one of the principal sources of woody biomass globally. We sampled across a spatial gradient of paired forest land-uses (representing pre and postharvest) that allowed us to evaluate biological community changes resulting from several types of biomass harvest. Short-rotation practices and residue removal following clearcuts were associated with reduced alpha diversity (-14.1 and -13.9 species, respectively) and lower beta diversity (i.e., Jaccard dissimilarity) between land-use pairs (0.46 and 0.50, respectively), whereas midrotation thinning increased alpha (+3.5 species) and beta diversity (0.59). Over the course of a stand rotation in a single location, biomass harvesting generally led to less biodiversity. Cross-taxa responses to resource extraction were poorly predicted by alpha diversity: correlations in responses between taxonomic groups were highly variable (-0.2 to 0.4) with large uncertainties. In contrast, beta diversity patterns were highly consistent and predictable across taxa, where correlations in responses between taxonomic groups were all positive (0.05-0.4) with more narrow uncertainties. Beta diversity may, therefore, be a more reliable and information-rich indicator than alpha diversity in understanding animal community response to landscape change. Patterns in beta diversity were primarily driven by turnover instead of species loss or gain, indicating that wood extraction generates habitats that support different biological communities.

Conservación de la Diversidad Alfa y Beta en Paisajes de Producción Maderera Resumen La demanda internacional de madera y otros productos forestales sigue creciendo rápidamente mientras permanecen las incertidumbres sobre cómo responderán las comunidades animales a la intensificación de la extracción de recursos asociada con la producción de bioenergía leñosa. Examinamos los cambios en la diversidad alfa y beta de murciélagos, abejas, aves y reptiles en los paisajes de producción maderera en el sureste de los Estados Unidos, un punto caliente de biodiversidad y una de las fuentes principales de biomasa leñosa a nivel mundial. Muestreamos a lo largo de un gradiente espacial de usos de suelo forestales emparejados (representando la pre- y postcosecha) que nos permitió evaluar los cambios en las comunidades biológicas resultantes de varios tipos de recolección de biomasa. Las prácticas de corta rotación y de eliminación de residuos después de la tala estuvieron asociadas con la reducción de la diversidad alfa (−14.1 y −13.9 especies, respectivamente) y una diversidad beta más baja (es decir, diferencia de Jaccard) entre los pares de uso de suelo (0.46 y 0.50, respectivamente), mientras que el raleo de rotación media incrementó la diversidad alfa (+3.5 especies) y beta (0.59). Durante la duración de una rotación permanente en una sola ubicación, la cosecha de biomasa generalmente derivó en menos biodiversidad. La respuesta de los taxones a la extracción de recursos estuvo muy mal pronosticada por la diversidad alfa: la correlación de las respuestas entre los grupos taxonómicos fue altamente variable (−0.2 a 0.4) con muchas incertidumbres. Como contraste, los patrones de diversidad beta fueron fuertemente coherentes y predecibles en todos los taxones, mientras que la correlación de las respuestas entre los grupos taxonómicos siempre fue positiva (0.05 a 0.4) con incertidumbres más limitadas. Por lo tanto, la diversidad beta puede ser un indicador más confiable y rico en información que la diversidad alfa para entender las respuestas de la comunidad animal a los cambios en el paisaje. Los patrones de la diversidad beta estuvieron impulsados principalmente por la rotación en lugar de la pérdida o ganancia de especies, lo que indica que la extracción de madera genera hábitats que mantienen a diferentes comunidades biológicas.

Shifting landscapes of risk: Quantifying pluvial flood vulnerability beyond the regulated floodplain.

Floods are recognized as the costliest type of natural hazard both worldwide and in the United States, with projected increases in frequency and magnitude in the absence of effective adaptation strategies. In the fall of 2018, Hurricane Florence made landfall in southeastern North Carolina, USA, bringing record rainfall and resulting in widespread inundation that impacted many areas outside of the federally designated Special Flood Hazard Area (SFHA). Much of this flooding was from inland pluvial inundation, which is an understudied component of coastal risk and vulnerability assessments primarily due to the scarcity of infrastructure data and historically lower flooding recurrence rates. This has resulted in severe damages in areas that residents and local officials considered at low risk from flooding. Using nearly-coincident high-spatial, high-temporal resolution CubeSat satellite imagery, we quantified the areal extent of post-Hurricane Florence floodwater within and beyond the 100-year floodplain (SFHA) and the proportion of residential structures exposed to flooding within an eight-county study area. We propose a novel approach to estimate flood risk resulting from this singular event (termed an actualized risk index) when compared to a published empirical model of vulnerability. We show that 24.3% of detected floodwater was outside the 100-year floodplain, 43.4% of exposed residential structures are outside the 100-year floodplain, and communities of highest vulnerability are not only along the coast but also inland along the Cape Fear, Northeast Cape Fear, Trenton, and Neuse Rivers. This suggests that the SFHA may not adequately show the spatial distribution of pluvial flood risk in riverine areas, and that misunderstanding of this risk has led to a pattern of development in which houses have a higher than expected risk of flooding. Moreover, this additional flood risk may disproportionately affect lower-income residents of these largely rural areas. These results have important implications in light of recent policy guidance in southeastern USA states that mandate that predictive coastal vulnerability assessments to sea level rise be conducted relative to 100-year SFHA zones.

Algal blooms and the nitrogen-enrichment hypothesis in Florida springs: evidence, alternatives, and adaptive management.

Contradictions between system-specific evidence and broader paradigms to explain ecosystem behavior present a challenge for natural resource management. In Florida (U.S.A.) springs, increasing nitrate (NO3-) concentrations have been implicated as the cause of algal overgrowth via alleviation of N-limitation. As such, policy and management efforts have centered heavily on reduction of nitrogen (N) loads. While the N-limitation hypothesis appears well founded on broadly supported aquatic eutrophication models, several observations from Florida springs are inconsistent with this hypothesis in its present simplified form. First, NO3- concentration is not correlated with algal abundance across the broad population of springs and is weakly negatively correlated with primary productivity. Second, within individual spring runs, algal mats are largely confined to the headwater reaches within 250 m of spring vents, while elevated NO3- concentrations persist for several kilometers or more. Third, historic observations suggest that establishment of macroalgal mats often lags behind observed increases in NO3- by more than a decade. Fourth, although microcosm experiments indicate high thresholds for N-limitation of algae, experiments in situ have demonstrated only minimal response to N enrichment. These muted responses may reflect large nutrient fluxes in springs, which were sufficient to satisfy present demand even at historic concentrations. New analyses of existing data indicate that dissolved oxygen (DO) has declined dramatically in many Florida springs over the past 30 years, and that DO and grazer abundance are better predictors of algal abundance in springs than are nutrient concentrations. Although a precautionary N-reduction strategy for Florida springs is warranted given demonstrable effects of nutrient enrichment in a broad suite of aquatic systems worldwide, the DO-grazer hypothesis and other potential mechanisms merit increased scientific scrutiny. This case study illustrates the importance of an adaptive approach that explicitly evaluates paradigms as hypotheses and actively seeks alternative explanations.

Life cycle assessment of nutrient remediation and bioenergy production potential from the harvest of hydrilla (Hydrilla verticillata).

Hydrilla (Hydrilla verticillata) is one of the world's most problematic invasive aquatic plants. Although management of hydrilla overgrowth has often been based on use of chemical herbicides, issues such as the emergence of herbicide-resistant hydrilla biotypes and the need for in situ nutrient remediation strategies have together raised interest in the use of harvester machines as an alternative management approach. Using a life cycle assessment (LCA) approach, we calculated a range of net energy and economic benefits associated with hydrilla harvests and the utilization of biomass for biogas and compost production. Base case scenarios that used moderate data assumptions showed net energy benefit ratios (NEBRs) of 1.54 for biogas production and 1.32 for compost production pathways. NEBRs for these respective pathways rose to 2.11 and 2.68 when labor was excluded as a fossil fuel input. Base case biogas and compost production scenarios respectively showed a monetary benefit cost ratio (BCR) of 1.79 and 1.83. Moreover, very high NEBRs (3.94 for biogas; 6.37 for compost) and BCRs (>11 for both biogas and compost) were found for optimistic scenarios in which waterways were assumed to have high hydrilla biomass density, high nutrient content in biomass, and high priority for nutrient remediation. Energy and economic returns were largely decoupled, with biogas and fertilizer providing the bulk of output energy, while nutrient remediation and herbicide avoidance dominated the economic output calculations. Based on these results, we conclude that hydrilla harvest is likely a suitable and cost-effective management program for many nutrient-impaired waters. Additional research is needed to determine how hydrilla harvesting programs may be most effectively implemented in conjunction with fish and wildlife enhancement objectives.

Failure of fracture plate fixation.

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

Investigation of the influence of transport from oil and natural gas regions on elevated ozone levels in the northern Colorado front range.

The Northern Colorado Front Range (NCFR) has been in exceedance of the ozone National Ambient Air Quality Standard (NAAQS) since 2004, which has led to much debate over the sources of ozone precursors to the region, as this area is home to both the Denver, CO, metropolitan area and the Denver-Julesburg Basin, which has experienced rapid growth of oil and natural gas (O&NG) operations and associated emissions. Several recent studies have reported elevated levels of atmospheric volatile organic compounds (VOCs) as a result of O&NG emissions and the potential for significant ozone production from these emissions, despite implementation of stricter O&NG VOC emissions regulations in 2008. Approximately 88% of 1-hr elevated ozone events (>75 ppbv) occur during June-August, indicating that elevated ozone levels are driven by regional photochemistry. Analyses of surface ozone and wind observations from two sites, namely, South Boulder and the Boulder Atmospheric Observatory, both near Boulder, CO, show a preponderance of elevated ozone events associated with east-to-west airflow from regions with O&NG operations in the N-ESE, and a relatively minor contribution of transport from the Denver Metropolitan area to the SE-S. Transport from upwind areas associated with abundant O&NG operations accounts for on the order of 65% (mean for both sites) of 1-hr averaged elevated ozone levels, while the Denver urban corridor accounts for 9%. These correlations contribute to mounting evidence that air transport from areas with O&NG operation has a significant impact on ozone and air quality in the NCFR. IMPLICATIONS: This article builds on several previous pieces of research that implied significant contributions from oil and natural gas emissions on ozone production in the Northern Colorado Front Range. By correlating increased ozone events with transport analyses we show that there is a high abundance of transport events with elevated ozone originating from the Denver-Julesburg oil and natural gas basin. These findings will help air quality regulators to better assess contributing sources to ozone production and in directing policies to curb ozone pollution in this region.

The Role of Elevated Lactate as a Risk Factor for Pulmonary Morbidity After Early Fixation of Femoral Shaft Fractures.

OBJECTIVES: To evaluate lactate levels before reamed intramedullary nailing (IMN) of femur fractures treated with early fixation. DESIGN: Retrospective study. SETTING: Three academic, tertiary care trauma centers. PATIENTS: Age ≥18 years, injury severity score ≥17, admission lactate ≥ 2.5 mmol/L, elevated preoperative lactate = preoperative lactate ≥ 2.5 mmol/L. INTERVENTION: Reamed IMN of femur fracture within 24 hours. MAIN OUTCOME MEASURE: Total duration of mechanical ventilation, pulmonary complications (PC) = duration of mechanical ventilation ≥5 days. RESULTS: Four hundred and fourteen patients identified; 294/414 (71.0%) with admission lactate ≥ 2.5 mmol/L. No difference in PC among the groups (86/294, 29.3% vs. 28/120, 23.3%; P = 0.22). Median admission lactate: 3.7 (interquartile range: 3.0-4.6); median preoperative lactate: 2.8 (interquartile range: 1.9-3.5). 184/294 (62.6%) demonstrated an elevated preoperative lactate (≥ 2.5 mmol/L) before fracture fixation. No difference in elevated preoperative lactate and vent days (4.8 ± 9.9 vs. 3.9 ± 6.0, P = 0.41) or PC (50/86, 58.1% vs. 134/208, 64.4%; P = 0.31). There was no difference in PC when preoperative lactate was considered separately for a lactate ≥3.0 (34/123, 27.6% vs. 52/171, 30.4%; P = 0.61), ≥3.5 (21/79, 26.6% vs. 65/215, 30.2%; P = 0.54), or ≥4.0 (14/50, 28.0% vs. 72/244, 29.5%; P = 0.83). Multivariable linear regression modeling demonstrated that admission lactate [coefficient of variation: 0.84, standard error: 0.33, 95% confidence interval (CI): 0.20-1.49] was correlated with duration of mechanical ventilation, after adjusting for emergency department Glasgow Coma Scale, age, chest Abbreviated Injury Scale (AIS) score, abdominal AIS, and admission glucose. Logistic regression demonstrated admission lactate was also significantly associated with PC (odds ratio: 1.26, 95% CI: 1.03-1.53) after controlling for age, admission Glasgow Coma Scale, chest AIS, abdominal AIS, admission pulse and admission glucose; preoperative lactate was not a risk factor (odds ratio: 0.84, 95% CI: 0.65-1.09) for PC. CONCLUSION: Median admission lactate of 3.7 mmol/L was associated with duration of mechanical ventilation ≥5 days, whereas median preoperative lactate of 2.8 mmol/L was not, when multisystem trauma patients with a femoral shaft fracture were treated with reamed IMN within 24 hours after admission. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Course of treatment and rate of successful salvage following the diagnosis of deep infection in patients treated for pilon fractures (AO/OTA: 43).

BACKGROUND/AIMS: The purpose of this study is to report the rate of successful salvage and describe typical treatment course for patients with infected pilon fractures. METHODS: This investigation was performed after gathering a Six-year retrospective database from a single academic trauma center including patients with pilon fractures diagnosed with post-operative deep infection. RESULTS: These include a rate of successful salvage in patients diagnosed with deep infection of 88.5% (46/52). Patients who were successfully salvaged required an average of 3.5 (±2.3) procedures following diagnosis of infection, 2.5 (±1.5) debridements and 1.1 (±1.2) reconstructive procedures. CONCLUSIONS: Considerable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures.

Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43).

BACKGROUND/AIMS: The purpose of this study is to evaluate risk factors of deep infection following pilon fractures. METHODS: This investigation was performed after gathering a six-year retrospective database from a single academic trauma center. RESULTS: These include an overall incidence of deep infection of 16.1% (57/355). Deep infection was diagnosed at an average of 88 days (±64 days) from initial injury with a range of 10-281 days. Development of deep infection occurred in 23.2% (33/142) of open fractures, vs 11.3% (24/213) of closed fractures. CONCLUSION: Open fractures, hypertension and male gender were associated with an increased risk of developing deep infection. In addition, even optimal surgical management may not significantly modify rates of deep surgical site infection.

Quantification of bony pelvic exposure through the modified Stoppa approach.

OBJECTIVES: Authors previously have described anatomic structures commonly seen through the modified Stoppa approach; however, no study has formally quantified the areas and amount of visual bony exposure that is obtained. This information is important for proper preoperative planning of acetabulum fractures with regard to fracture reduction and fixation. The aim of this study was to quantify and describe the extent of bony pelvis exposed while identifying the limits of exposure from osseous landmarks within the dissection of the modified Stoppa approach. METHODS: Ten modified Stoppa approaches were performed on cadavers. Specific anatomic landmarks were identified, and the far boundaries of the exposed osseous structures from the surgeon's perspective were marked on each cadaver. All soft tissues were then stripped, and calibrated digital images of the demarcated area of exposure were taken and total viewable osseous surface area was calculated. Additionally, the boundaries of exposure based on various anatomic landmarks were determined. RESULTS: All neurovascular structures at potential risk (external iliac, obturator, corona mortis, and superior gluteal) were identified in each exposure. The entire pelvic brim from the pubic symphysis to beyond the sacroiliac joint was visualized in all exposures, with an average ± SD of 10 ± 5 mm of anterior sacrum exposed. On average, visualization above the pelvic brim was possible 15 ± 5 mm anteriorly over the acetabular roof and 19 ± 5 mm posteriorly above the greater sciatic notch. The viewable area included 51 ± 5 mm below the pelvic brim along the quadrilateral surface, with 41 ± 5 mm of the obturator foramen depth and 29 ± 9 mm of the greater sciatic notch seen on average. Approximately 32% ± 4% of the total surface area of the inner pelvis was able to be visualized, which included 79% ± 5% of the inner true pelvis below the brim and 80% ± 6% of the quadrilateral surface. CONCLUSIONS: The modified Stoppa approach allows for exposure of most (79%) of the inner true bony pelvis including the entire pelvic brim and 80% of the quadrilateral surface. On average, visualization is possible 2 cm above the pelvic brim and 5 cm below the pelvic brim along the quadrilateral surface, providing adequate anterior exposure for clamp and implant placement.

High-energy transsyndesmotic ankle fracture dislocation--the "Logsplitter" injury.

OBJECTIVES: To describe and investigate the injury pattern and outcomes of high-energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries, in which the talus is axially wedged into the tibiofibular joint. DESIGN: Prospective Cohort Study. SETTING: Level 1 trauma center. PATIENTS: Prospective evaluation of 23 high-energy transsyndesmotic ankle fracture dislocations (OTA 44-B). INTERVENTION: Operative fixation. MAIN OUTCOME MEASUREMENTS: Radiographs, clinical examination, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale, Short Musculoskeletal Function Assessment. RESULTS: Fracture characteristics included 52% open fractures (all medial) and syndesmotic widening of 30.7 ± 11.9 mm. The tibial plafond was involved in 11 (48%) of 23 injuries, with 5 (22%) Chaput, 5 (22%) posterior malleolar fragments, and 6 (26%) with articular impaction. A fibula fracture occurred in all but 1 patient, on average 64.2 ± 40.0 mm above the distal tip. All patients had fixation of their fibular and medial malleolar fractures, 21 of 23 patients had syndesmotic screws, and 8 of 23 had tibial plafond fixation. Anatomic alignment (within <= 2 mm) was obtained in 21 (87%) of 23 injuries. Mean follow-up was 20.6 ± 6.2 months. Sixteen (70%) of 23 patients had radiographic evidence of posttraumatic ankle arthritis. Dorsiflexion and plantarflexion at final follow-up were 6.9 ± 9.6 and 35.6 ± 12.1 degrees, respectively. Complications included a 17% infection and 17% nonunion rate. Average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score was 67.0 ± 26.8, whereas Short Musculoskeletal Function Assessment Dysfunction index was 32.9 ± 28.6 and Bother index 34.5 ± 29.5. CONCLUSIONS: Transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries, represent an exceptional pattern of high-energy fractures with significant syndesmotic disruption, potential soft tissue compromise, and possible associated plafond injuries. Careful attention to radiographic findings can identify unique fracture characteristics relative to operative decision-making. Outcomes are comparable to those of high-energy pilon fractures, thereby providing the treating surgeon with prognostic information.

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries.

BACKGROUND: Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries. METHODS: We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case. RESULTS: We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations. CONCLUSION: Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population. LEVEL OF EVIDENCE: Therapeutic study, level III.

Quantification of anterior cortical bone removal and intermeniscal ligament damage at the tibial nail entry zone using parapatellar and retropatellar approaches.

OBJECTIVES: Anterior cortical bone removal at the tibial nail entry zone has been shown to alter biomechanical properties of the proximal tibia. However, no study has quantified the amount of bone removed. The purpose of this study was to quantify the amount of anterior bone removed at the nail entry zone and assess damage to adjacent intra-articular structures using both parapatellar and retropatellar techniques. METHODS: The study was performed using 36 cadaveric knees (18 medial parapatellar and 18 retropatellar approaches). A guide pin was placed in the anatomic safe zone using fluoroscopic guidance and a 12.5-mm entry reamer used to open medullary canal. Soft tissues were removed, damage to intra-articular structures recorded, and size of osseous defect created in proximal tibia measured. RESULTS: The surface area of bone removed with portal creation was not significantly larger with retropatellar (228.4 ± 38.1 mm) versus parapatellar technique (207.9 ± 33.4 mm(2); P = 0.108). This was substantially different than if the entry hole was perfectly round (122.7 mm(2)). No knee went without some damage to intra-articular structures using the parapatellar technique, as opposed to 33% knees with retropatellar technique (P = 0.019). Intermeniscal (IM) ligament was damaged in 83% parapatellar and 56% retropatellar knees (P = 0.146). CONCLUSIONS: A substantial amount of anterior bone is removed during nail entry portal creation using both parapatellar and retropatellar techniques. Intra-articular structure damage, most commonly IM ligament disruption, was also found to occur at a lower rate with retropatellar technique. Avoidance of both anterior bone removal and IM ligament damage may not be possible because of size and geometrical constraints.

Tibia-based referencing for standard proximal tibial radiographs during intramedullary nailing.

Limited information exists to define standard tibial radiographs. The purpose of this study was to define new landmarks on the proximal tibia for standard anteroposterior and lateral radiographs. In 10 cadaveric knees, fibular head bisection was considered the anteroposterior image, and femoral condyle overlap the lateral image. In another 10 knees, a "twin peaks" anteroposterior view, showing the sharpest profile of the tibial spines, was used. The "flat plateau" lateral image was obtained by aligning the femoral condyles then applying a varus adjustment with overlap of the tibial plateaus. Medial peritendinous approaches were performed, and an entry reamer used to open the medullary canal. A priori analysis showed good to excellent intra-/inter-observer reliability with the new technique (intra-class correlation coefficient ICC 0.61-0.90). The "twin peaks" anteroposterior radiograph was externally rotated 2.7±2.1° compared to the standard radiograph with fibular head bisection. Portal position and incidence of damage to intra-articular structures did not significantly differ between groups (P>.05). The "twin peaks" anteroposterior view and "flat plateau" lateral view can safely be used for nail entry portal creation in the anatomic safe zone. Tibia-based radiographic referencing is useful for intramedullary nailing cases in which knee or proximal tibiofibular joint anatomy is altered.

Intramedullary fixation of fibular fractures associated with pilon fractures.

OBJECTIVES: The purpose of this study was to determine the ability of intramedullary fibular fixation to maintain reduction until healing and to determine the overall complication rate in high-energy pilon fractures associated with fibular fractures. DESIGN: Retrospective study. SETTING: Level I university trauma center. PATIENTS/PARTICIPANTS: From 2000 to 2007, 972 pilon fractures were treated at our institution, 38 of which were treated with an intramedullary device for the associated fibular fracture. Two patients had acute amputations and two died; 1-year follow-up was obtained in 27 of the remaining patients. Average length of follow-up was 21 months. INTERVENTION: A retrospective chart and radiograph review was conducted of all patients for data extraction. MAIN OUTCOME MEASUREMENTS: Fibular fixation type and length, fibular healing, and complications. RESULTS: Average patient age was 36 years (range, 18-59 years). Four of the fibular fractures were segmental. All fractures had at least 50% of the cortex intact to prevent shortening. The average height of the fibular fractures from the distal tip was 6.9 cm (range, 1.3-22.2 cm). In 20 patients, a 3.5-mm fully threaded cortical screw was used for stabilization, and in the remaining seven, a 2.5-mm wire was used. The intramedullary implant extended 8.5 cm above the most proximal fracture line on average (range, 1.6-29.8 cm). Fibular alignment was within 3 degrees of anatomic in all cases after initial fixation. At final follow-up, fibular alignment had not changed more than 1 degrees in any case. No complications related to the fibular incision occurred, and all fibula fractures healed within 3 months. CONCLUSIONS: In axially and rotationally stable fibular fracture patterns associated with pilon fractures, intramedullary fibular stabilization was effective in maintaining fibular alignment. This technique led to reliable fracture healing in appropriately selected fractures and may be particularly advantageous in patients with compromised lateral and posterolateral soft tissues.

Long-term vaginal sequelae secondary to pediatric pelvic fracture.

BACKGROUND: Pediatric pelvic fractures often appear radiographically benign despite significant injury to viscera. Vaginal injuries are rare, and therefore require a high index of suspicion. CASE: A 26-year-old female patient who sustained a pelvic fracture in a motorcycle accident at the age of 10 presented with vaginal stenosis precluding sexual intercourse. Patient menstruated through a fistula in the distal vaginal vault. Radiographic and dye studies showed almost complete vaginal obstruction with heterotopic ossification. An extensive 30-year review of the literature was conducted looking for documented cases of vaginal injuries secondary to pelvic injury. SUMMARY AND CONCLUSION: This is the only recorded case of a long-term vaginal complication with subsequent heterotopic ossification secondary to pelvic fracture. Preventing debilitating long-term sequelae from vaginal injuries requires close patient follow-up and age-appropriate assessments.