Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus.

OBJECTIVE: To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD). DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables. MAIN OUTCOME MEASUREMENTS: Fetal or maternal death. RESULTS: Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD. CONCLUSIONS: The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of early operative pelvic fixation on long-term self-reported outcome following severe pelvic fracture.

BACKGROUND: Traumatic disruption of the pelvic ring is a significant cause of life-threatening hemorrhage. For those patients who survive the initial injury, these fractures are associated with long periods of immobilization and intense rehabilitation. There is little published information available regarding long-term functional outcomes in these patients. This study evaluated the impact of severe pelvic fractures on those long-term outcomes. METHODS: All patients with severe pelvic fractures over an 18-year period were identified. Severe pelvic fractures were defined as those with vascular disruption, open-book component with symphysis diastasis, or sacroiliac disruption with vertical shear. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care to assess mobility (normal, >84) and daily activity (normal, >84). Multiple linear regression analysis was used to identify predictors of functional outcome after severe pelvic fracture. RESULTS: From January 1996 to September 2014, 401 patients were identified: 240 (60%) men and 161 (40%) women. Overall mortality was 29%. Of the 285 survivors, follow-up was obtained in 145 patients (51%). Mean follow-up was 8.3 years, with a maximum of 20 years. Mean age and Injury Severity Score were 53 years and 27, respectively. Mean Activity Measure for Post-Acute Care scores for mobility and daily activity were 55 and 63, respectively; both signifying significant impairment when compared with normal. Multiple linear regression analysis using age, traumatic brain injury, transfusions, Injury Severity Score, ventilator days, presence of associated lower-extremity fractures, and time to operative pelvic fixation identified time to pelvic fixation as the only predictor of decreased mobility (ß = -0.74, p = 0.04) and activity (ß = -0.21, p = 0.03) following severe pelvic fracture. CONCLUSIONS: Prolonged time to operative pelvic fixation led to worse long-term functional outcomes in patients with severe pelvic ring disruption. Early fixation of the pelvic ring is the only potentially modifiable risk factor for decreased functional outcomes in patients with severe pelvic fractures. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Suprapatellar Intramedullary Nail Technique Lowers Rate of Malalignment of Distal Tibia Fractures.

OBJECTIVES: To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views. DESIGN: Retrospective cohort study. SETTING: Two urban level I trauma centers. PATIENTS: A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique. INTERVENTION: Intramedullary nail placement. MAIN OUTCOME MEASURES: Alignment. RESULTS: The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P < 0.0001). CONCLUSIONS: This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is there a gluteus medius tendon injury during reaming through a modified medial trochanteric portal? A cadaver study.

OBJECTIVES: The purpose of this cadaveric study was to evaluate whether there is any damage to the gluteus medius tendon when reaming through a modified medial trochanteric portal for antegrade intramedullary femoral nailing. METHODS: Ten cadaver hips were used in this study. A guidewire was placed in the modified medial trochanteric portal using the assistance of C-arm fluoroscopy and a 14-mm reamer was advanced over the wire. After the reaming was complete, each hip was dissected and the gluteus medius muscle and tendon were inspected to evaluate the amount of intrasubstance and medial tendon damage. RESULTS: Precise localization of the modified medial trochanteric portal was achieved in 9 of 10 cadaver hips. Of those nine hips, the use of the modified medial trochanteric portal did not result in any visible damage to the tendinous insertion of the gluteus medius or the medial aspect of the tendon in any of the specimens. CONCLUSIONS: There is no damage to the gluteus medius tendon with the use of the modified medial trochanteric portal. Although the clinical implications of this finding are not known with certainty, the use of the modified medial trochanteric entry portal for antegrade femoral nailing could possibly result in less postoperative morbidity because it does not damage the gluteus medius tendon as compared to the traditional more lateral trochanteric portal.