Sacral Dysmorphism and Lumbosacral Transitional Vertebrae (LSTV) Review.

BACKGROUND: Anatomic variation in the relationship between the lumbar spine and sacrum was first described in the literature nearly a century ago and continues to play an important role in spine deformity, low back pain (LBP), and pelvic trauma. This review will focus on the clinical and surgical implications of abnormal lumbosacral anatomy in the context of sacroiliac joint (SIJ) disease, spine deformity, and pelvic trauma. METHODS: A PubMed search using the keywords "lumbosacral transitional vertebrae," "LSTV," "transitional lumbosacral vertebrae," "TLSV," and "sacral dysmorphism" was performed. The articles presented here were evaluated by the authors. CLINICAL SIGNIFICANCE: The prevalence of LSTV varies widely in the literature from 3.9-% to 35.6% in the spine literature, and sacral dysmorphism is described in upwards of 50% of the population in the trauma literature. The relationship between LSTV and LBP is well established. While there is no agreed-on etiology, the source of pain is multifactorial and may be related to abnormal biomechanics and alignment, disc degeneration, and arthritic changes. SURGICAL IMPLICATIONS: Understanding abnormal lumbosacral anatomy is crucial for preoperative planning of SIJ fusion, spine deformity, and pelvic trauma surgery. LSTV can alter spinopelvic parameters crucial in planning spine deformity correction. Traditional safe zones for sacroiliac screw placement do not apply in the first sacral segment in sacral dysmorphism and risk iatrogenic nerve injury. CONCLUSIONS: LSTV and sacral dysmorphism are common anatomic variants found in the general population. Abnormal lumbosacral anatomy plays a significant role in clinical evaluation of LBP and surgical planning in SIJ fusion, spine deformity, and pelvic trauma. Further studies evaluating the influence of abnormal lumbosacral anatomy on LBP and surgical technique would help guide treatment for these patients.

Acute total hip arthroplasty versus open reduction internal fixation for posterior wall acetabular fractures in middle-aged patients.

INTRODUCTION: Open reduction internal fixation (ORIF) is the standard of care for displaced acetabular fractures, but the inability to achieve anatomic reduction, involvement of the posterior wall, articular impaction, and femoral head cartilaginous injury are known to lead to poorer outcomes. Acute total hip arthroplasty (THA) is a reasonable treatment option for older patients with an acetabular fracture and risk factors for a poor outcome, but it is only described in case series. The purpose of this study is to compare outcomes of ORIF and acute THA in middle-aged patients with an acetabular fracture from a single center. METHODS: Retrospective case-controlled study of patients aged 45 to 65 years old with acetabular fractures involving the posterior wall treated with acute THA or ORIF at a level 1 trauma center between 1996 and 2011. Patients were matched by fracture pattern and age at a 2 (ORIF):1 (acute THA) ratio. Functional outcome, complications, and reoperation rates of acute THA and ORIF were compared. RESULTS: Sixteen acute THA patients (average age 56.4 years) and 32 ORIF patients (average age 54.3 years) were evaluated at an average follow-up of 6.2 years (range 1-15.2). The average Oxford Hip Score in the acute THA group was 44 compared to 40 in the ORIF group (P = .075). Complication rates were similar between both the groups. Twelve hips (37%) in the ORIF group had undergone THA or been referred for THA, and 2 revisions (13%) had occurred in the acute THA group. A Kaplan-Meier survival analysis showed that those undergoing acute THA had significantly better survival of their index procedure (P = .031). CONCLUSIONS: Both ORIF and acute THA for high-energy acetabular fractures involving the posterior wall in middle-aged patients can provide excellent results, with acute THA patients achieving improved survival of the index procedure and improved functional scores.

A biomechanical study comparing minimally invasive anterior pelvic ring fixation techniques to external fixation.

INTRODUCTION: INFIX and Pelvic Bridge are two new minimally invasive surgical techniques for unstable pelvic ring injuries, and they have demonstrated early clinical success in small, single-center case-series. The primary objective of this study is to gather evidence speaking to the biomechanical stability of internal bridging methods relative to external fixation, with the expectation of biomechanical equivalence. METHODS: Ten human cadaveric pelvic specimens were dissected free of all skin, fat, organs, and musculature and were prepared with a partially unstable pelvic ring injury (OTA/AO 61-B). The specimens were randomized to two groups and were repaired and tested with anterior pelvic external fixation (APEF) and INFIX sequentially, or APEF and Pelvic Bridge sequentially. Testing was performed with each specimen mounted onto a servo-hydraulic testing frame with axial compression applied to the superior base of the sacrum under five axial loading/unloading sinusoidal cycles between 10 N and 1000 N at 0.1 Hz. Relative translational motion and rotation across the osteotomy site was reported as our primary outcome measures. Outcome measures were further analyzed using a Wilcoxon signed-rank test to determine differences between non-parametric data sets with significance defined as a p value < 0.05. RESULTS: We found no statistical difference in translation (p = 0.237, 0.228) or rotation (p = 0.278, 0.873) at the fracture site when comparing both new constructs to external fixation. Under the imposed loading protocol, no episodes of implant failure or failure at the bone-implant interface occurred. DISCUSSION: Our study provides the biomechanical foundation necessary to support future clinical trial implementation for pelvic fracture patients. While biomechanical stability of these newer, subcutaneous techniques is equivalent to APEF, the surgeon must take into account their technical abilities and knowledge of pelvic anatomy, patient-specific factors including body habitus, and the potential complications associated with each implant and the ability to avoid them.

Intra-articular Hematoma Block Compared to Procedural Sedation for Closed Reduction of Ankle Fractures.

BACKGROUND: Initial treatment for a displaced ankle fracture is closed reduction and splinting. This is typically performed in conjunction with either an intra-articular hematoma block (IAHB) or procedural sedation (PS) to assist with pain control. The purpose of this study was to compare the safety of IAHB to PS and evaluate the efficiency and efficacy for each method. METHODS: A retrospective chart review for ankle fractures requiring manipulation was performed for patients seen in a level I trauma center from 2005 to 2016. The primary outcome was rate of successful reduction. Several secondary outcome measures were defined: reduction attempts, time until successful reduction, time spent in the emergency department (ED), rate of hospital admission, and adverse events. The analysis included 221 patients who received IAHB and 114 patients who received PS. RESULTS: The demographics between the 2 groups were similar, with the exception that more patients with a dislocation received PS, which prompted a subgroup analysis. This analysis demonstrated that patients with an ankle fracture and associated tibiotalar joint subluxation underwent closed reduction in a shorter period of time with the use of an IAHB compared with those receiving PS. In patients sustaining a tibiotalar fracture dislocation, patients receiving PS were successfully reduced with 1 reduction attempt more frequently than those receiving IAHB. Orthopedic surgeons also had higher rates of success on first attempt compared with ED providers. CONCLUSION: Both IAHB and PS were excellent options for analgesia that resulted in high rates of successful closed reduction of ankle fractures with adequate safety. IAHB can be considered a first-line agent for patients with an ankle fracture and associated joint subluxation. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Displacement of diaphyseal clavicle fractures related to patient position and progressive displacement in the peri-injury period.

BACKGROUND: The purposes of this study were (1) to determine how supine versus upright patient position affects the measurement of diaphyseal clavicle fracture displacement, (2) to describe the incidence of progressive displacement in the peri-injury period, and (3) to investigate variables associated with the progressive displacement. METHODS: Between 2013 and 2015, patients aged 14 years or older presenting with a diaphyseal clavicle fracture within 7 days of injury were included (N = 50). A well-defined radiographic protocol was established. Nine patients underwent surgery after the second follow-up, and the remaining 41 patients, who did not undergo surgery, received the full complement of measures at the first, second, and third follow-up time points. The second follow-up (8-21 days after injury) and third follow-up (22-60 days after injury) had the same defined radiographic protocol as the first visit. The amount of displacement and angulation was measured in both the supine and upright positions on the initial injury radiographs and subsequent follow-up radiographs. RESULTS: Vertical translation was 2.4 mm (95% confidence interval, 1.8-3.0 mm) greater and angulation was 3.9° (95% confidence interval, 3.3°-4.6°) greater in the upright position. Progressive displacement occurred in 16 patients (32%). Older age (P = .015) and ipsilateral shoulder girdle or chest wall injury (P = .007) were significantly associated with progressive displacement. CONCLUSIONS: Upright radiographs evaluate maximal displacement in diaphyseal clavicle fractures. Close follow-up of nonoperatively treated clavicle fractures is warranted. Progressive displacement was more likely in older patients and/or those who had ipsilateral shoulder girdle or chest wall injury.

Minimally invasive anterior pelvic internal fixation: An anatomic study comparing Pelvic Bridge to INFIX.

OBJECTIVES: Anterior external fixation for pelvic ring fractures has shown to effectively improve stability and reduce mortality. However, these fixators can be associated with substantial morbidity such as pin tract infection, premature loss of fixation, and decreased quality of life in patients. Recently, two new methods of subcutaneous anterior pelvic internal fixation have been developed; the INFIX and the Pelvic Bridge. These methods have the purported advantages of lower wound complications, less surgical site pain, and improved quality of life. We sought to investigate the measured distances to critical anatomic structures, as well as the qualitative and topographic differences notable during implantation of both devices in the same cadaveric specimen. MATERIALS AND METHODS: The Pelvic Bridge and INFIX were implanted in eleven fresh cadavers. Distances were then measured to: the superficial inguinal ring, round ligament, spermatic cord, lateral femoral cutaneous nerve (LFCN), femoral nerve, femoral artery, and femoral vein. Observations regarding implantation and topography were also recorded. RESULTS: The INFIX had greater measured distances from all structures except for the LFCN, in which its proximity placed this structure at risk. Neither device appears to put other critical structures at risk in the supine position. Significant implantation and topographic differences exist between the devices. The INFIX application lacked "safety margins" concerning the LFCN in 10/11 (90.9%) specimens, while Pelvic Bridge placement lacked "safety margins" with regard to the right superficial ring (1/11, 9%) and the right spermatic cord (1/11, 9%). CONCLUSIONS: Both the Pelvic Bridge and INFIX lie at safe distances from most critical pelvic structures in the supine position, though INFIX application places the LFCN at risk.

Publication of Podium Presentations at the Orthopaedic Trauma Association Annual Meetings: 2008-2012.

OBJECTIVE: To determine journal publication rates of podium presentations from the OTA Annual Meetings between 2008 and 2012. METHODS: Podium presentations from the 2008 to 2012 OTA annual meeting were compiled from the Annual Meeting archives. During December 2016, and Google Scholar were performed using individual keywords in the abstract title and content. The results were reviewed for matches to the meeting abstracts with regard to the title, authors, and abstract content. Yearly publication rates were calculated, along with time to publication and common journals for publication. RESULTS: The publication rate for the 357 podium abstracts presented at the OTA between 2008 and 2012 was 72.8%. Eighty-one percent of abstracts were from the US institutions. The mean time to publication from podium presentation was 23.4 months, and the most common journals of publication were Journal of Orthopaedic Trauma (45.4%) and The Journal of Bone & Joint Surgery (15.3%). CONCLUSIONS: The publication rate of the podium presentations at the OTA Annual Meeting from 2008 to 2012 has increased since previous years. Compared with other orthopaedic subspecialty and nonorthopaedic specialty meetings, the OTA publication rate is among the highest in the medical field. OTA annual meetings are an opportunity for early access to high-quality research in the area of orthopaedic trauma.