Modified Lumbopelvic Technique Using S1 Pedicle Screws for Spinopelvic Dissociation U-Type and H-Type Sacral Fractures With Kyphotic Deformity.

SUMMARY: Spinopelvic dissociation injuries are complex injuries defined as discontinuity between the appendicular and axial skeleton. Fracture patterns are variable, but U-type and H-type fractures are common and often present with kyphotic deformity along with translational displacement and impaction. The ideal method of fixation has not been established for these injuries. The goals of treatment include restoration of alignment, stability, and neural decompression as needed. Traditional methods of lumbopelvic fixation have spanned the upper sacral fracture site. Our novel modified method of lumbopelvic fixation directly instruments the S1 body. This allows for direct manipulation of the fracture which we theorize improves reduction and increases stability across the fracture. This article characterizes the injury patterns, outlines the modified technique, and reports the clinical and radiographic outcomes of our modified lumbopelvic fixation technique and construct.

Sciatic Nerve Entrapment and Transection in a Combined Pelvic Ring-Acetabular Fracture: A Case Report.

CASE: A traumatic sciatic nerve entrapment and transection because of a combined pelvic ring injury and acetabular fracture has never previously been described. We report such a case of a 32-year-old man who was found intraoperatively to have entrapment and transection of the sciatic nerve within the acetabular fracture. CONCLUSION: Consideration for urgent intervention should be given to patients who present with a sciatic nerve palsy in the setting of certain acetabular fracture patterns with residual posterior column displacement. Early recognition and intervention with neurolysis may help provide the best environment for recovery.

Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails.

INTRODUCTION: Optimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology. METHODS: A retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation. RESULTS: There were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold. CONCLUSION: This is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability. LEVEL OF EVIDENCE: IV.

A Biomechanical Comparison of Trochanteric Versus Piriformis Reconstruction Nails for Femoral Neck Fracture Prophylaxis.

OBJECTIVES: To compare piriformis fossa to greater trochanteric entry cephalomedullary implants in an evaluation of femoral neck load to failure when the device is used for femoral shaft fractures with prophylaxis of an associated femoral neck fracture. METHODS: Thirty fourth-generation synthetic femur models were separated into 5 groups: intact femora, entry sites alone at the piriformis fossa or greater trochanter, and piriformis fossa and greater trochanteric entry sites after the insertion of a cephalomedullary nail. Each model was mechanically loaded with a flat plate against the superior femoral head along the mechanical axis and load to failure was recorded. RESULTS: Mean load to failure was 5487 ± 376 N in the intact femur, 3126 ± 387 N in the piriformis fossa entry site group, 3772 ± 558 N in the piriformis entry nail, 5332 ± 292 N for the greater trochanteric entry site, and 5406 ± 801 N for the greater trochanteric nail group. Both piriformis groups were significantly lower compared with the intact group. Both greater trochanteric groups were similar to the intact group and were statistically higher than the piriformis groups. CONCLUSIONS: A piriformis fossa entry site with or without an intramedullary implant weakens the femoral neck in load to failure testing. A greater trochanteric entry yields a load to failure equivalent to that of an intact femoral neck. Instrumentation with a greater trochanteric cephalomedullary nail is significantly stronger than a piriformis fossa cephalomedullary nail during axial loading in a composite femur model.

National Metrics Improved Timeliness of Antibiotic Administration for Open Extremity Fractures.

INTRODUCTION: Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons' Trauma Quality Improvement Program, based on a committee of physician leaders including orthopaedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric before trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution. METHODS: A retrospective review of all patients treated at our institution for open extremity fractures was performed over 3 periods separated by 2 quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines. RESULTS: Neither antibiotic order placement within 1 hour nor administration within 1 hour improved after our first institution-specific initiative. Both outcome measures significantly improved after the second quality initiative, as did median times from arrival to antibiotic order and administration. CONCLUSIONS: Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change.

Low Superior Pubic Ramus Screw Failure Rate With Combined Anterior and Posterior Pelvic Ring Fixation.

OBJECTIVES: To determine whether fracture pattern, implant size, fixation direction, or the amount of posterior pelvic ring fixation influences superior ramus medullary screw fixation failure. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: After exclusion criteria, 95 patients with 111 superior ramus fractures with 3 months minimum follow-up were included. INTERVENTION: All patients underwent anterior and posterior pelvic ring fixation. MAIN OUTCOME MEASUREMENTS: Comparison of immediate postoperative radiographs and/or computer tomography scan with the latest postoperative image to calculate interval fracture displacement and implant position. Postoperative fracture displacement or implant position change greater than 1 cm were considered fixation failures. RESULTS: Five screws were defined as failures (4.5%), including 3 retrograde, 3 with bicortical fixation, 4 with a 4.5-mm screw, and 1 with a 7.0-mm screw. Fracture patterns included 2 oblique and 3 comminuted fractures. Based on the Nakatani classification, there were 3 zone II, 1 zone I, and 1 zone III. Failure modes included 3 with cut-out along the screw head and 1 cut-out and 1 cut-through at the screw tip. CONCLUSIONS: Our incidence of superior pubic ramus intramedullary screw fixation failure was 4.5%. Even with anterior and posterior fixation along with precise technique, failures still occur without a common failure predictor. The percutaneous advantages and proven strength provided by an intramedullary implant make it desirable to help reestablish global pelvic ring stability. Biomechanical and clinical studies are needed to further understand intramedullary superior ramus screw fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Spontaneous pubic symphysis disruption and concomitant bladder rupture during competitive squatting: A case report.

Pubic symphysis disruption is typically secondary to external blunt force trauma. This report presents a case of concomitant bladder wall rupture and pubic symphysis diastasis during competitive squatting. This required open bladder repair, small artery embolization, and internal fixation of the pubic symphysis. Surgeons should be aware that pelvic ring instability and organ damage can result even without any external trauma.

Effects of Micronized Cartilage Matrix on Cartilage Repair in Osteochondral Lesions of the Talus.

BACKGROUND: The repair of osteochondral lesions remains a challenge due to its poor vascularity and limited healing potential. Micronized cartilage matrix (MCM) is dehydrated, decellularized, micronized allogeneic cartilage matrix that contains the components of native articular tissue and is hypothesized to serve as a scaffold for the formation of hyaline-like tissue. Our objective was to demonstrate in vitro that the use of MCM combined with mesenchymal stem cells (MSCs) can lead to the formation of hyaline-like cartilage tissue in a single-stage treatment model. DESIGN: In group 1 (no wash), 250 µL MCM was reconstituted in 150 µL Dulbecco's phosphate-buffered saline (DPBS) for 5 minutes. Group 2 (saline wash) included 250 µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated to remove all DPBS and reconstituted in 150 µL DPBS. Group 3 (serum wash): 250µL MCM washed in 20 mL DPBS for 30 minutes, then aspirated and reconstituted in 150 µL fetal bovine serum. Each group was then added to 50 µL solution of MSC suspended in DPBS at a concentration of 1.2 × 106 cells/350 µL. After 3 weeks, the defects were extracted and sectioned to perform viability and histologic analyses. RESULTS: Stem cells without rehydration of the MCM showed almost no viability whereas near complete cell viability was seen after rehydration with serum or saline solution, ultimately leading to chondrogenic differentiation and adhesion to the MCM particles. CONCLUSION: We have shown in this proof-of-concept in vitro study that MCM can serve as a scaffold for the growth of cartilage tissue for the treatment of osteochondral lesions.

External iliac vein compression secondary to osteolysis-induced hematoma in total hip arthroplasty.

A 62-year-old man with a history of right total hip arthroplasty, who was managed conservatively for moderate osteolysis, presented with acute-onset, painless, significant, and diffuse right lower extremity edema. Initial laboratory markers were negative for infection. Advanced imaging demonstrated a complex extrapelvic fluid mass along the psoas sheath causing compression of the external iliac vein. Intraoperatively, significant hematoma was removed from the iliopsoas sheath, followed by metal head and liner exchange as well as bone grafting of the osteolytic defects adjacent to the hip implant. Postoperative imaging showed adequate decompression, no deep vein thrombosis, and a patent external iliac vein. At 2 weeks, postoperative swelling completely resolved. At 3 months, the patient recovered to normal baseline level and underwent contralateral total hip arthroplasty for symptomatic osteoarthritis.

Are piriformis reconstruction implants ideal for prophylactic femoral neck fixation?

OBJECTIVES: Prophylactic femoral neck fixation may be performed in the setting of geriatric diaphyseal femur fracture, pathologic or impending atypical femur fractures. Fixation constructs often utilize cephalomedullary implants with one or two proximal interlocking screws into the femoral head/neck. Variations in proximal femoral anatomy and implant design can interfere with the placement of two screws in the femoral head and neck. Our objective was to assess the strength of piriformis entry reconstruction implants with one versus two proximal interlock screws for prophylactic femoral neck fixation. METHODS: Thirty fourth generation synthetic femur models were separated into 5 groups. The control group was an intact femur, and the second group was an intact femur with an entry hole in the piriformis fossa. The remaining groups had an intramedullary nail placed with either 0, 1, or 2 screws placed into the femoral head and neck. Each femur was mechanically loaded along the mechanical axis through the femoral head. Load to failure and failure displacement were recorded. RESULTS: Mean load to failure was 5583 ± 543 N in the intact femur. Constructs with 2 screws had a significantly higher mean load to failure (3223 ± 474 N) compared to one screw constructs (2368 ± 280 N). All of the experimental groups remained significantly lower than the intact femur model (p < 0.05). CONCLUSION: Our results demonstrate that piriformis entry reconstruction implants have a significantly lower load to failure compared to an intact femur irrespective of screw construct. Further studies are needed to investigate this potential iatrogenic weakening.

Why total knees fail-A modern perspective review.

Historically, the most common mechanism of total knee arthroplasty (TKA) failures included aseptic loosening, instability and malalignment. As polyethylene production improved, modes of failure from polyethylene wear and subsequent osteolysis became less prevalent. Newer longitudinal studies report that infection has become the primary acute cause of failure with loosening and instability remaining as the overall greatest reasons for revision. Clinical database and worldwide national registries confirm these reports. With an increasing amount of TKA operations performed in the United States, and with focus on value-based healthcare, it is imperative to understand why total knees fail.

Revision Meniscal Surgery in Children and Adolescents: Risk Factors and Mechanisms for Failure and Subsequent Management.

BACKGROUND: The mechanisms of failure and risk factors for failed meniscal surgery in children and adolescents have not been well described. PURPOSE: To investigate the risk factors, mechanisms of failure, and subsequent operative management for revision meniscal surgery in a pediatric population, as well as to identify the local incidence of failed meniscal surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All patients younger than 20 years who had arthroscopic management for meniscal injuries at a single institution between 2008 and 2012 underwent retrospective review. Demographic data and intraoperative findings at the time of the initial surgery were documented. All patients undergoing a second procedure on the same meniscus were further analyzed. Multivariate logistic regression with purposeful selection was performed to identify independent risk factors for revision meniscal surgery. RESULTS: Arthroscopic knee surgery was performed on 293 patients and 324 menisci, including 129 primary repairs, 149 primary partial meniscectomies, and 46 discoid saucerizations ± stabilization. At a mean of 40 months (range, 19-62 months) after surgery, 13% of all menisci required a revision procedure. The primary repair cohort had the highest failure rate (18%), followed by the primary discoid saucerization cohort (15%) and the partial meniscectomy cohort (7%). Multivariate analysis indicated that meniscal repair was predictive of retear (odds ratio, 2.04 [95% CI, 1.01-4.1]; P = .046), and children with an open physis and a bucket-handle tear had the highest retear rate of 46% (P = .039). Independent variables shown to have no significant relationship to revision meniscal surgery included age, sex, body mass index, extremity side, laterality (medial-lateral), time to repair, tear location, and associated ligament reconstruction. The most common indication for revision surgery was an acute reinjury during intense physical activity. Revision procedures were performed at a mean of 14 months after the index procedure, and the majority of failures (83%) were identified within 1 year. Of patients undergoing a revision surgery, 44% underwent a further debridement, whereas 56% underwent a repair. CONCLUSION: The success rate of meniscal surgery is 87% in children and adolescents. The revision rate was higher when repair was attempted in the index procedure, particularly in those children with open physes and bucket-handle tears. Most failures are the result of an acute reinjury within 1 year, and nearly half will require debridement of the retorn meniscus.