Surgical complications after fixation of minimally displaced lateral compression type 1 pelvic ring injuries.

PURPOSE: To review surgical complications after fixation of stress-positive minimally displaced (< 1 cm) lateral compression type 1 (LC1) pelvic ring injuries. METHODS: A retrospective study at a level one trauma center identified patients who received surgical fixation of isolated LC1 pelvic ring injuries. Surgical complications and additional procedures were reviewed. RESULTS: Sixty patients were included. The median age was 61 years (Interquartile range 40-70), 65% (n = 39) were women, and 57% (n = 34) had high-energy mechanisms. Anterior-posterior, posterior-only, and anterior-only fixation constructs were used in 77% (n = 46), 15% (n = 9), and 8% (n = 5) of patients. Anterior fixation was performed with rami screw fixation in 82% (49/60), external fixation in 2% (1/60), and open reduction and plate fixation in 2% (1/60). There were 15 surgical complications in 23% (14/60), and 12 additional procedures in 17% (10/60). Complications included loss of reduction ≥ 1 cm (8%), symptomatic hematomas (8%), symptomatic backout of unicortical retrograde rami screws (5%), deep infection of the pelvic space after a retrograde rami screw (1.6%), and iatrogenic L5 nerve injury (1.6%). All losses of reduction involved geriatric females with distal rami fractures sustained in ground-level falls. Loss of reduction was found to be more likely in patients with low energy mechanisms (proportional difference (PD) 62%, 95% confidence interval (CI) 18% to 76%; p = 0.01) and 2 versus 1 posterior pelvic screws (PD 36%; CI 0.4% to 75%; p = 0.03). CONCLUSIONS: Surgical complications and additional procedures routinely occurred after fixation of LC1 injuries. Patients should be appropriately counseled on the risks of surgical fixation of these controversial injuries. LEVEL OF EVIDENCE: Diagnostic, Level III.

Are pre- and postoperative true translational and angular displacement predictive of nonunion after intramedullary nail fixation of tibial shaft fractures?

PURPOSE: To determine if there is an association between pre-/postoperative translational and angular displacement with nonunion after intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS: Retrospective review of 120 patients with tibial shaft fractures undergoing IMN at an urban level-one trauma center was performed. Demographics, injury characteristics, and pre-/postoperative translational and angular fracture displacement in the coronal and sagittal planes were recorded. True fracture translational and angular displacement (TTD and TAD) were calculated by combining sagittal and coronal displacement utilizing the Pythagorean theorem. RESULTS: 10.8% of patients (n = 13) developed nonunion with remaining patients serving as the control. Groups were similar across age, sex, and BMI. Univariate analysis revealed no difference in pre-/postoperative TAD between nonunion and union groups and an increased preoperative TTD (median difference (MD): 6.2 mm, CI: 1.4-10.8 mm) and postoperative TTD (MD: 1.8 mm, CI: 0-3.7 mm) in the nonunion group. On multivariate analysis, however, only tobacco use and type 2 or 3 open fractures were associated with nonunion (OR: 5.1, CI: 1.2-22.8 and OR: 4.9, CI: 1.2-19.2, respectively). CONCLUSION: True translational and angular displacement of tibial shaft fractures before and after IMN fixation were not independently associated with nonunion. Tobacco use and type 2 or 3 open fracture are independent factors for nonunion.

Pelvic ring injuries after alpine ski and snowboard accidents.

PURPOSE: The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. METHODS: Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. RESULTS: Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. CONCLUSION: The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

Pelvic ring injuries after road and mountain bike accidents.

PURPOSE: The purpose of this study was to compare patients with traumatic pelvic ring injuries sustained in road and mountain bicycling accidents to evaluate for differences in injury types and hospital courses. METHODS: A retrospective review of 60 patients presenting with pelvic ring injuries after road (n = 46) and mountain (n = 14) bicycling accidents was performed to compare patient/injury characteristics and hospital course. RESULTS: LC1 injuries were the most common pelvic ring injury (n = 31, 51.7%), 38.7% (n = 12) of which were considered unstable, followed by isolated iliac wing (n = 11, 18.3%), pubic rami (n = 6, 10.0%), and sacral fractures (n = 6, 10.0%). Hospital admission was required for 41 (68.3%) patients. The median hospital LOS was 4 days (IQR 2-9) and 12 (20%) patients received operative treatment. Patients in road versus mountain bicycling accidents were more likely to be older tobacco users and were similar in sex, body mass index, and injury severity score. Road bicycling resulted in more LC1 injuries (58.7% vs 28.6%, p = 0.04), while mountain bicycling resulted in more iliac wing fractures (42.9% vs. 10.9%, p = 0.01). Road cycling injuries required more days in the hospital to clear PT (median difference 2, CI 0-4, p = 0.04) and had longer hospital stays (median difference 2, CI 0-6, p = 0.02) but had no difference in the rate of admission, operative intervention, or discharge to rehabilitation facilities. CONCLUSION: The majority of pelvic ring injuries from road and mountain bicycling accidents were LC1 injuries that were frequently unstable and often required hospital admission and operative fixation.

Open fixation of the posterior malleolus increases the morbidity of trimalleolar ankle fracture fixation.

PURPOSE: To assess the morbidity of open reduction internal fixation (ORIF) of posterior malleolus fractures (PMFs) in the setting of trimalleolar ankle fractures. METHODS: A retrospective review of 79 trimalleolar ankle fractures was performed to identify need for syndesmotic fixation, blood loss, operative/tourniquet time, complications, and reoperations. Patients with PMF ORIF (n = 38) were compared to those with no fixation (n = 41). A subanalysis of patients with small PMFs (< 25%) was performed. RESULTS: The PMF ORIF group required less syndesmosis fixation (proportional difference (PD) - 44.6%, 95% confidence interval (CI) - 61.8 to - 23.0%), had more blood loss (MD 20 ml, CI 0-40), longer operative times (MD 53.0 min, CI 35.9-70.1), longer tourniquet times (MD 26 min, CI 4-33), and had no difference in postoperative joint step-off or concentrically reduced joints. The PMF ORIF group had more postoperative complications (PD 26.9%, CI 6.3-44.8%) and a trend for more reoperations (PD 13.6%, CI -3.4 to 29.6%). Wound complications were more common in the PMF ORIF group (PD 26.5%, CI 6.9-43.6%), resulting in 5 (16.1%) irrigation and debridement procedures. On analysis of patients with small PMFs (n = 42), PMF ORIF (n = 15) resulted in longer operative/tourniquet times and had no observed difference in postoperative joint step-off, concentrically reduced joints, need for syndesmotic fixation, blood loss, or complications/reoperations. CONCLUSION: PMF ORIF in the setting of trimalleolar ankle fractures was associated with increased operative/tourniquet times, blood loss, wound complications, and did not eliminate the need for syndesmosis fixation.

The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries.

PURPOSE: The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10 mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course. METHODS: A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis. RESULTS: The median maximum dynamic displacement on LSRs was 12.2 mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0 years, 95% CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95% CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities. CONCLUSION: LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.

A standardized method of measuring screw breach on postoperative computed tomography scans following percutaneous fixation of the posterior pelvic ring.

PURPOSE: To assess the reliability of a standardized measurement of screw breach on postoperative computed tomography (CT) scans following percutaneous fixation of the posterior pelvic ring. METHODS: Three orthopedic trauma surgeons independently utilized a standardized method of measuring posterior pelvic ring screw breaches on post-operative CT scan images. Breaches were measured as a continuous variable on sagittal images reformatted to be perpendicular to the screw on axial images. The inter-rater and intra-rater reliability of screw breach distance measurements was assessed. RESULTS: Measurements were performed on 42 screws in 20 patients. Screw types included S1-iliosacral (IS) (n = 16), S1-transsacral (TS) (n = 8), S2-IS (n = 2), and S2-TS (n = 16). Patients with varying degrees of screw breaches were chosen to test measurements across breach severities, including 0 mm (n = 10), ≤ 2 mm (n = 12), > 2 to 4 mm (n = 11), and > 4 mm (n = 9). The mean difference and 95% confidence interval (CI) between screw breach measurements between the three surgeons was - 0.13 mm (CI - 0.48 to 0.20), 0.05 mm (CI - 0.6 to 0.7), and 0.18 mm (CI - 0.47 to 0.85), respectively. The inter-rater reliability of the measurements was considered excellent (intraclass correlation coefficient (ICC), 0.93). The mean intra-rater reliability for the observers was considered good (ICC 88.5, CI 82 to 95). CONCLUSIONS: This simple standardized method of measuring screw breaches had excellent inter-rater reliability and would support comparisons of screw breach severity across studies. LEVEL OF EVIDENCE: Level III.

The interobserver reliability of clinical relevance in orthopaedic research.

PURPOSE: A ratio of observed difference (OD) over the 95% confidence interval (CI) has been shown to be strongly associated with the perceived clinical relevance (CR) of medical research results. The purpose of this study was to evaluate the association between the OD/CI ratio and perceived CR in orthopaedic research. METHODS: Sixty-seven orthopaedic surgeons completed a survey with 15 study outcomes (mean difference and CI) and were asked if they perceived the findings as clinically relevant. The interobserver reliability of perceived CR and the association between CR and the OD/CI ratio and p-value were assessed. RESULTS: The interobserver reliability of CR between respondents was moderate (kappa = 0.46, CI 0.45 to 0.48). P-values did not differ between results with and without CR (median difference (MD) - 0.12, CI - 0.74 to 0.0009, p = 0.07). The OD/CI ratio, however, was greater for results with CR (MD 1.01, CI 0.3 to 3.9, p = 0.004). The area under the curve (AUC) for the p-value and OD/CI ratio receiver operating characteristic (ROC) curves was 0.80 (p = 0.01) and 0.97 (p = 0.0003). The cutoff p -value and OD/CI ratio that maximized the sensitivity (SN) and specificity (SP) for CR were 0.001 (SN 80%, SP 80%) and 0.84 (SN 100%, SP 90%). The SN and SP of a p-value cutoff of 0.05 was 100% and 50%. CONCLUSION: The interobserver reliability of the perceived CR of orthopaedic research findings was moderate. The OD/CI ratio, in contrast to the p-value, was strongly associated with perceived CR making it a potentially useful measure to evaluate research results.

Should a history of pelvic fracture fixation be an indication for cesarean section?

PURPOSE: To compare the success rate of a trial of labor (TOL) in a cohort of patients with pelvic fractures, with and without internal fixation, in order to better counsel patients and avoid unnecessary cesarean section (CS). METHODS: A retrospective review of 35 female patients with 28 pelvic ring, five acetabular, and two combined fractures that had subsequent pregnancy; 12 patients had operative fixation and 23 did not. Fracture classification, treatment, type of fixation, mode of deliveries, and reason for CS were documented. RESULTS: The rate of vaginal delivery, unscheduled CS, and scheduled CS across all patients was 80.0% (n = 28), 14.3% (n = 5), and 5.7% (n = 2), respectively, which was similar to institutional rates of 87.0, 12.0, and 1.0%. A TOL was attempted in 91.4% (32/35) and successful in 87.5% (28/32). Patients who failed a TOL were more likely to have Tile B/C pelvic fractures (100.0 vs. 30.4%, observed difference (OD) 69.6%, 95% confidence interval (CI) 16.4, 86.3%; p = 0.01) and more pelvic displacement (6.0 vs. 1.5 mm, OD 4.0, CI 1.0, 18.0; p = 0.01). The fixation and control groups had no observed difference in successful TOL (72.7% vs. 95.2%, OD 22.5%, - 49.7%, 5.5%; p = 0.10). CONCLUSIONS: A majority of women had successful vaginal deliveries after pelvic fractures, with or without fixation, suggesting that these patients should consider a TOL. LEVEL OF EVIDENCE: Diagnostic Level III.

The utility of air on computed tomography scans in the assessment of type 1 open fractures.

PURPOSE: The presence of air on computed tomography (CT) scans has been demonstrated to accurately diagnose occult traumatic arthrotomies. The purpose of this study was to determine if the presence of air on CT scans also has diagnostic utility for type 1 open fractures. METHODS: A retrospective review at a level 1 trauma center identified twenty-eight patients with Gustilo-Anderson Type 1 open fractures and preoperative CT scans. These patients were matched 2:1 with 56 closed fractures who also had CT scans. CT scans were reviewed to determine the presence of suprafascial and subfascial air. RESULTS: Air near the fracture site on CT scan was more common in open fractures then closed fractures (21 (75%) vs. 9 (16%) patients, proportional difference: 59% (37-75%), p < 0.0001). In the open fracture group, 18 (64.2%) patients had both supra- and subfascial air, 2 (7.1%) patients had isolated subfascial air, and 1 (3.5%) patient had isolated suprafascial air. In the closed fracture group, 3 (5.3%) patients had supra- and subfascial air, 4 (7.1%) had isolated subfascial air, and 2 (3.5%) had isolated suprafascial air. The sensitivity and specificity of air on CT for identifying a type 1 open fracture was 75 and 84%, respectively. CONCLUSIONS: This study found that the presence of air on CT scan was more likely in type 1 open versus closed fractures; however, the sensitivity or specificity was too low to be used reliably to identify occult open fractures in isolation. LEVEL OF EVIDENCE: Diagnostic Level III.

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement.

PURPOSE: Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. METHODS: Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm. RESULTS: As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively). CONCLUSION: Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively. LEVEL OF EVIDENCE: Level III, prognostic retrospective cohort study.

The effect of pelvic ring rotation and tilt on the radiographic teardrop distance: an important consideration in the assessment of dynamic displacement on stress radiographs.

PURPOSE: The purpose of this study was to determine the effect of rotation and tilt on the radiographic teardrop distance (TD) on anteroposterior (AP) pelvis radiographs. METHODS: Radiographic examination of a pelvis models was conducted utilizing increasing degrees of beam rotation and tilt on portable C-arm fluoroscopy. The TD, x-plane rotation (symphyseal-mid-sacrum distance (SMS)), and y-plane tilt (sacroiliac joint-symphysis distance (SIS)) were measured by four independent observers. Interobserver reliability was assessed using intraclass correlations. RESULTS: TD was altered by less than 2 mm with up to 7.5° fluoroscopic rotation (SMS: 3 cm) and up to 30° of inlet and 15° of outlet (SIS: ± 3.3 cm). SMS distance effectively corresponded to the degree of rotation present (r = 1.00, CI: 0.97 to 1.00, p < 0.0001) and was strongly correlated to TD (r = -0.95, CI: -0.99 to -0.67, p = 0.001). SIS distance effectively corresponded to the degree of tilt present (r = -0.97, CI: -0.99 to -0.88, p < 0.0001) and was correlated to TD (r = 0.94, CI: 0.75 to 0.99, p = 0.0001). Linear regression models determined that, with every degree of rotation and tilt, TD was altered by 0.4 mm and 0.09 mm, respectively (p = 0.0004, r2 = 0.93 and p < 0.0001, r2 = 0.94, respectively). Interobserver reliability among observers was excellent (0.92). CONCLUSION: The TD has excellent interobserver reliability and is minimally impacted by up to 7.5° of rotation, 30° inlet tilt, and 15° of outlet tilt. Utilization of these thresholds may ensure reliability of TD measurements when assessing pelvis stress radiographs.

Percutaneous pelvic fixation model: an affordable and realistic simulator for pelvic trauma training.

PURPOSE: To describe the construction and use of a percutaneous pelvic fixation model, evaluate its translational validity among fellowship-trained orthopedic trauma surgeons, and investigate the importance of specific criteria for effective competency-based assessment of pelvic fixation techniques. METHODS: Five orthopedic trauma surgeons were asked to place percutaneous wires on a pelvic fixation model, including anterior column (antegrade/retrograde), posterior column (antegrade/retrograde), supra-acetabular, transsacral, and iliosacral. Evaluation criteria included successful wire placement, redirections, cortical breaches, procedure duration, radiation exposure, and quality of fluoroscopic views. Following completion, participants were provided a survey to rate the model. RESULTS: There were no differences between approaches on successful screw placement, wire redirections, or fluoroscopic quality. Antegrade approaches to the anterior and posterior columns took longer (p = 0.008) and used more radiation (p = 0.02). There was also a trend toward more cortical breaches with the antegrade anterior column approach (p = 0.07). Median ratings among surgeons were 4 out of 5 for their overall impression and its accuracy in tactile response, positioning constraints, and fluoroscopic projections. Learning parameters considered most important to the progression of trainees (most to least important) were successful screw placement, corridor breaches, wire redirections, quality of fluoroscopic views, radiation exposure, and procedure duration. CONCLUSION: In being affordable, accessible, and realistic, this percutaneous pelvic fixation model represents an opportunity to advance orthopedic surgery education globally. Future research is needed to validate the findings of this pilot study and to expand upon how trainees should be evaluated within simulations and the operating room to optimize skill progression.

Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures.

PURPOSE: To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS: Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit. RESULTS: Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004). CONCLUSION: Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.

Bilateral subtrochanteric stress riser fractures following percutaneous screw fixation of femoral neck stress fractures: a literature review and case report.

Hip and groin pain in patients at-risk for femoral neck stress fracture demand a careful workup including advanced imaging in the setting of normal radiographs. A delay in diagnosis can lead to fracture displacement, which negatively impacts outcomes. Non-displaced tension-sided fractures and displaced fractures warrant operative fixation, while non-displaced compression-side fractures can be managed conservatively. Fixation with a sliding hip screw or cephalomedullary nail is recommended over cannulated screws. In addition, all patients should undergo a metabolic workup to identify correctable parameters. We present a rare case of bilateral compression-sided basicervical femoral neck stress fractures in a non-compliant osteoporotic patient who was treated with cannulated screws. The postoperative course was complicated by bilateral subtrochanteric stress riser fractures requiring revision fixation, which could have been prevented with use of a different implant.

The effect of the orthopaedic trauma association's (OTA) pain management guidelines on opioid prescriptions, pain control, and refills in outpatient orthopaedic trauma surgery.

PURPOSE: To determine the effect of the Orthopaedic Trauma Association (OTA) pain management guidelines for acute musculoskeletal injuries on opioid prescription sizes, pain control, and refills. METHODS: A prospective cohort study was performed at an academic urban level 1 trauma center. 90 patients undergoing outpatient orthopaedic trauma surgery were enrolled before and after the implementation of the OTA pain management guidelines. Adherence to guidelines, pain visual analog scale, and refills were recorded postoperatively and at the 2- and 6-week follow-up visit. RESULTS: After implementation of the guidelines, the number of patients receiving oxycodone decreased from 100 to 27%, with these patients receiving the less potent hydrocodone, instead. The discharge morphine equivalent dose (MED) decreased from a median (interquartile range) of 225 (169-300) to 140 mg (140-210) (p < 0.001). More patients required refills in the guidelines group (42% vs. 20%), resulting in no difference in total MED prescribed (210 (140-280) vs. 225 (169-307)). Adherence to the guidelines occurred in 66% of patients. As-treated analysis of patients with adherent and non-adherent prescriptions found no detectable difference in pain control, number of opioid pills used, or refills at the 2-week and 6-week follow-up. CONCLUSIONS: In the midst of a national opioid crisis, adoption of the OTA's pain management guidelines for orthopaedic trauma surgery warrants further research to determine if it's implementation can reduce the size, variability, and duration of opioid prescriptions. LEVEL OF EVIDENCE: Level II, prospective cohort.

The utilization of intraoperative contralateral ankle images for syndesmotic reduction.

PURPOSE: To evaluate the variability in ankle syndesmotic morphology on contralateral ankle fluoroscopic images and the reductions obtained utilizing these images. METHODS: A retrospective cohort study was performed at a level one trauma center including 46 adult patients undergoing operative fixation of malleolar ankle fractures that also had anteroposterior (AP) and lateral fluoroscopic images of the uninjured contralateral ankle intraoperatively. Contralateral and post-fixation fluoroscopic images were used to measure the tibiofibular clear space (TFCS) as a proportion of the superior clear space (SCS) on mortise images and the posterior tibiofibular distance (PTFD) as a proportion of the lateral superior clear space (LSCS) on lateral images. Differences between contralateral and post-fixation ankle measurements were compared between those patients with syndesmotic injuries and those without (control group). RESULTS: The mean TFCS/SCS and PTFD/LSCS ratios measured on contralateral ankle images were 1.2 (95% confidence interval (CI) 1.1 to 1.3; range 0.7 to 1.8) and 1.8 (95% CI 1.5 to 2; range 0.5 to 3.4). The mean difference between the contralateral and post-fixation TFCS/SCS and PTFD/LSCS in patients with and without syndesmotic fixation was 0.07 vs. 0.13 (F-ratio 0.3, p = 0.5) and -0.2 vs 0.5 (F ratio 5.2, p= 0.02). CONCLUSIONS: Contralateral syndesmotic measurements varied widely and the utilization of these images allowed for syndesmotic reductions with similar measurements. Intraoperative contralateral ankle images should be considered to assess syndesmotic reduction.

Need for syndesmotic fixation and assessment of reduction during ankle fracture fixation, with and without contralateral fluoroscopic images, has poor interobserver reliability.

PURPOSE: To determine the interobserver reliability of syndesmosis assessment using intraoperative ankle mortise fluoroscopic images, with and without contralateral images. METHODS: A survey of 19 operative ankle fracture cases was administered to 17 orthopedic surgeons. Respondents were presented with fluoroscopic mortise and stress images of the ankle after fracture fixation and asked if they would fix the syndesmosis. Final fluoroscopic mortise images were then shown, and respondents were asked to assess the reduction of the syndesmosis. Six weeks later, the survey was administered again with the addition of contralateral fluoroscopic ankle mortise images. Responses were compared to a standard response agreed upon by fellowship-trained orthopedic trauma surgeons. RESULTS: Interobserver reliability for syndesmosis fixation and reduction, with and without contralateral images, was considered weak (kappa 0.48 and 0.43; mean difference 0.05, 95% confidence interval (CI) 0.01 to 0.1) and minimal (kappa 0.25 and 0.22; mean difference 0.02, CI - 0.02 to 0.08). With the addition of contralateral mortise images, the number of surgeons who changed their response for syndesmosis fixation and reduction quality ranged from 0% to 41% and 0% to 88%; with the number of responses matching the standard increasing for both fixation (proportional difference (PD) 7%, CI 1% to 14%) and reduction (PD 14%, CI 7% to 21%); CONCLUSIONS: Interobserver reliability of syndesmosis fixation and reduction remained weak to minimal between surgeons, with and without contralateral images. Future studies are necessary to understand the variability in surgeon responses in order to improve the intraoperative assessment and fixation of syndesmotic injuries.

Mobilization versus displacement on lateral stress radiographs for determining operative fixation of minimally displaced lateral compression type I (LC1) pelvic ring injuries.

PURPOSE: Operative fixation of minimally displaced lateral compression type I (LC1) pelvic ring injuries is considered by some if the patient is unable to mobilize or displacement is seen on stress radiographs. The purpose of this study was to compare these methods of determining operative fixation. METHODS: A retrospective study of a prospectively gathered registry of LC1 injuries was performed before and after the adoption of a mobilization protocol. Fixation was considered if the patient was unable to mobilize 15 feet on the second day of admission. Prior to this protocol, all patients with displacement of ≥ 10 mm on stress radiographs were offered fixation. All patients received lateral stress radiographs (LSR), an anteroposterior pelvis radiograph in the lateral decubitus positions without sedation, to assess stability. RESULTS: There were 21 and 18 patients treated under the stress radiograph and mobilization protocols. Displacement ≥ 10 mm was present in 12 (57%) and six (33%) patients in the LSR and mobilization groups. Under the mobilization protocol, patients with ≥ 10 mm of displacement on LSR all had incomplete sacral fractures and were less likely to mobilize (2 (33%) vs. 11 (92%); 95% confidence interval of the difference (CID) - 86 to - 9%). The mobilization protocol did not identify all cases of occult instability and resulted in an increased time to surgery compared to the LSR protocol (5 vs. 2 days, 95% CID 1 to 5). CONCLUSION: Under the mobilization protocol, unstable LC1 injuries were less likely to mobilize and the time to surgery was increased.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

PURPOSE: External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. METHODS: This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. RESULTS: Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85 cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5 cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4 min; 95% CI, - 32 to 22; p = 0.68). CONCLUSIONS: In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.