Patient-Reported Outcomes and Computed Tomography Review After Minimally Invasive Fusion of the Sacroiliac Joint With Aggressive Joint Decortication and Joint Compression.

The sacroiliac joint (SIJ) is a common, underrecognized source of low back pain. We evaluated outcomes in patients undergoing sacroiliac joint fusion (SIJF) using a novel, minimally invasive SIJF system emphasizing compressive forces across an aggressively debrided SIJ. We retrospectively reviewed data from a continuous set of patients presenting to a large, tertiary care hospital from September 2017 to August 2019. All patients received the novel SIJF device. Outcomes were assessed at 8 weeks, 6 months, and 12 months using the Oswestry Disability Index (ODI) score, Numerical Rating Scale (NRS) score, Single Assessment Numerical Evaluation (SANE) score, and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, plus radiographic evaluation of fusion status. Data from 75 patients were analyzed. At 8 weeks, 6 months, and 12 months, the ODI score improved by 10.5 points (P=.002), 17.4 points (P<.0001), and 23.6 points (P<.0001), respectively, while the NRS score improved by 4.6 points (P<.0001), 4.4 points (P<.0001), and 4.6 points (P<.0001), respectively. SANE scores indicated high levels of patient satisfaction (81.0%, 92.18%, and 89.2%, respectively). PROMIS physical function scores improved by 2.65 points, 3.30 points, and 3.63 points, respectively, while PROMIS mental health scores showed changes of -1.93 points, 1.57 points, and -0.47 points, respectively. A review of computed tomography scans demonstrated grade 3 fusion (complete) in 81% of cases at a mean of 371 days postoperatively. There was one revision case for a malpositioned implant. The use of a novel SIJF device emphasizing compressive forces provided early, durable improvements in patient-reported outcomes and extremely high patient satisfaction. [Orthopedics. 2024;47(2):101-107.].

Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis.

BACKGROUND: Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis. METHODS: A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment. RESULTS: Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18). CONCLUSION: Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.

Winquist View of the Femoral Neck: Ideal Visualization of Femoral Neck Fixation.

Background: Despite the increased frequency of cephalomedullary fixation for unstable intertrochanteric hip fractures, failure with screw cut-out and varus collapse remains a significant failure mode. Proper positioning of implants into the femoral neck and head directly influences the stability of fracture fixation. Visualization of the femoral neck and head can be challenging and failure to do so may lead to poor results; Obstacles include patient positioning, body habitus, and implant application tools. We present the "Winquist View," an oblique fluoroscopic projection that shows the femoral neck in profile, aligns the implant and cephalic component, and assists in implant placement. Methods: With the patient in the lateral position, the legs are scissored when possible. Following standard reduction techniques, the Winquist view is used to check reduction prior to surgical draping. Intraoperatively, we rely on a perfect image to place implants in the ideal portion of the femoral neck, with a trajectory that achieves the center-center or center-low position of the femoral neck. This is achieved by incorporating the anterior-posterior, lateral, and Winquist view. Results: We present 3 patients who underwent fixation with a cephalomedullary nail for intertrochanteric hip fractures. The Winquist view facilitated excellent visualization and positioning in all cases. All postoperative courses were uneventful, without failures or complications. Conclusion: While standard intraoperative imaging may be adequate in many cases, the Winquist view facilitates optimal implant positioning and fracture reduction. With lateral imaging, implant insertion guides may obscure visualization of the femoral neck during which Winquist view is the most helpful. Level of Evidence: V.

Patella Fracture Fixation With Novel Wagon Wheel Construct Versus Tension-Band Construct: A Technical Trick.

SUMMARY: Internal fixation of patella fractures remains technically challenging. Cannulated screws with an anterior tension band have been associated with high rates of implant prominence, and fracture comminution can make appropriate application of a tension band impractical. We present the results of a novel technique using a transtendinous/transligamentous mini-fragment plate positioned peripherally around the patella with radially directed screws: termed the wagon-wheel (WW) construct. Compared with a cohort of fractures treated with cannulated screws with an anterior tension band, there was no difference in final range of motion and rate of nonunion. The WW construct had a significantly decreased incidence of symptomatic implants (5% vs. 32%, P = 0.02), rate of reoperation (9% vs. 38%, P = 0.018), dependency on gait aids (10% vs. 38%, P = 0.031), and a faster time to union (HR: 2.2; 95% CI, 1.28-3.95, P = 0.005). In summary, the WW was designed with the goal of obtaining peripheral plate fixation to maximize fragment-specific fixation while minimizing implant prominence. Patients treated with the WW demonstrated reduced rates of implant prominence and reoperation.

Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined With Percutaneous Reduction Techniques Is Safe and Results in a Low Rate of Cutout.

OBJECTIVES: To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. DESIGN: Retrospective cohort study. SETTING: Level-1 trauma center. PATIENTS: Two-hundred 20 consecutive patients with intertrochanteric fractures. INTERVENTION: Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. MAIN OUTCOME MEASUREMENTS: Radiographic outcome including union, cutout, and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. RESULTS: Mechanical complications (nonunion, cutout, and varus collapse) occurred in 8.8% of patients at 1 year. Eleven of 13 patients who developed these complications had either suboptimal implant placement (tip-to-apex distance >25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, P = 0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and 1 patient (0.7%) who did not have an accessory incision developed a postoperative infection. CONCLUSIONS: The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracture reduction and optimal implant placement and not hesitate to use an accessory incision to assist with fracture reduction. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient-Reported and Radiographic Outcomes After Revision Sacroiliac Joint Fusion.

BACKGROUND: Sacroiliac joint fusion (SIJF) has been established as an effective treatment for sacroiliac joint dysfunction. However, failure necessitating revision has been reported in up to 30% of cases. Little is known regarding outcomes of revision SIJF. METHODS: We retrospectively reviewed all revision SIJF at a single academic center between 2017 and 2020. Revision surgery was performed using the principles of joint decortication, bone grafting, compression, and rigid internal fixation. Outcomes were assessed at 6 months and 1 year after surgery using the Oswestry Disability Index (ODI), Numeric Pain Rating Scale (NPRS), and Single Assessment Numeric Evaluation (SANE) scale. Fusion was assessed using computed tomography at 12 months postoperatively. RESULTS: Eighteen revision SIJFs in 13 patients were included. The mean age was 55.8 years (range 35-75). Mean body mass index was 27.9 (range 21.7-36.7). Sixty-two percent of the patients were women. The indications for revision were pseudarthrosis without fixation failure in 14 cases (77.8%), hardware failure (loosening) in 3 cases (16.7%), and continued pain after partial fusion in 1 case (5.6%). ODI and NPRS scores demonstrated significant statistical and clinical improvements at all timepoints. Mean (SD) ODI scores improved from 53.8 (19.9) preoperative to 37.5 (19.8) at 6 months and 32.9 (21.7) at 12 months. Improvement in ODI was found in 15 joints (83.3%), and the minimal clinically important difference (MCID) was achieved in 12 joints (66.7%). Mean (SD) NPRS scores improved from 6.5 (1.4) preoperative to 3.2 (2.8) at 6 months and 3.4 (2.6) at 12 months. Improvement in NPRS was also identified in 17 joints (94.4%), and 10 joints (55.6%) achieved MCID for NPRS. Mean (SD) SANE score was 72.0% (30.8) at 6 months and 70.0% (33.8) at 12 months. There were no radiographic lucencies, implant subsidence, or implant fractures at final follow-up. We identified an 88.9% fusion rate with definitive bridging bone across the sacroiliac joint. CONCLUSION: Utilizing a principles-based technique of joint decortication, compression, and rigid internal fixation, revision SIJF showed an improvement in patient-reported outcomes as well as high rate of fusion at 12 months. The most common indications for revision SIJF are symptomatic pseudarthrosis and implant loosening. This is the largest series of revision SIJF to date.

Total Hip Arthroplasty for Femoral Neck Fracture: What Are the Contemporary Reasons for Failure?

BACKGROUND: Total hip arthroplasty (THA) for femoral neck fracture (FNF) appears to provide superior functional outcomes compared to hemiarthroplasty in selected active, elderly patients; however, the historical tradeoff has been higher risk of complications including dislocation. We aimed to describe implant survivorship and reasons for failure after THA for FNFs. METHODS: We identified 217 FNFs treated with THA from 2000 to 2017 from our institutional total joint registry (during the same time period 2039 FNFs were treated with hemiarthroplasty). Mean age was 70 years, and 65% were female. Cemented femoral components were utilized in 41%. Approach was anterolateral in 71%, posterior in 21%, and direct anterior in 8%. Dual-mobility constructs were utilized in 3%. A competing risk model accounting for death was used to analyze revisions and complications. Mean follow-up was 6 years. RESULTS: The 5-year cumulative incidence of any revision was 8%. Nineteen hips were revised for the following indications: postoperative periprosthetic femur fracture (6: 3 uncemented stems and 3 cemented), infection (5), aseptic loosening of the femoral component (3: 2 cemented and 1 uncemented), dislocation (3), iliopsoas impingement (1), and liner dissociation (1). The 5-year cumulative incidence of periprosthetic femur fractures was 7%, including 7 intraoperative fractures and 11 postoperative fractures. The 5-year cumulative incidence of dislocation was 1.4%. CONCLUSION: The 5-year cumulative incidence of any revision after THA for FNFs was 8%, mostly attributed to periprosthetic fracture and infection. Hip instability was not as common after FNF with contemporary patient selection, techniques, and implants compared to previous series. LEVEL OF EVIDENCE: Prognostic, level III.

How are peri-implant fractures below short versus long cephalomedullary nails different?

BACKGROUND: Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails. METHODS: This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups. RESULTS: Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2-57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2-57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250-1200 vs median 200 cc, IQR 100-300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1-135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs. CONCLUSION: Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.

High incidence of "in-out-in" posterosuperior screws after cannulated screw fixation of femoral neck fractures.

INTRODUCTION: Cadaveric models have demonstrated a high incidence of extraosseous "in-out-in" (IOI) posterosuperior screws after cannulated screw fixation of femoral neck fractures. The purpose of this study was to determine the incidence of IOI screws in vivo and to evaluate their association with osteonecrosis and revision surgery. METHODS: A total of 104 patients with 107 hips with a pelvis computed tomography (CT) scan after cannulated screw fixation of a femoral neck fractures were included. Screw position was evaluated on postoperative radiographs and CT scan to determine if screws were IOI or all-in. Osteonecrosis and revision surgeries were documented. RESULTS: IOI posterosuperior screws were identified on CT scan in 58 (54%) hips. On postoperative AP and lateral radiographs, IOI screws were a median (interquartile range) of 10 mm (7-11 mm) and 3 mm (0-4 mm) from the cortex, respectively. The sensitivity and specificity of radiographs to detect IOI screws was 39% and 92%, respectively. The incidence of osteonecrosis and revision surgeries in hips, with and without IOI screws, was 6% versus 6% [Odds ratio (OR) 1.1, 95% confidence interval (CI) 0.2-5.3] and 10% versus 10% (OR 1.0, CI 0.3-3.1), respectively; a true clinical difference cannot be excluded due to the width of the confidence intervals. CONCLUSIONS: There was a high incidence of IOI posterosuperior screws on CT scans. Postoperative radiographs had a poor sensitivity for detecting IOI screws. A larger sample size is necessary to evaluate the association of IOI screws with osteonecrosis and revision surgery. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Sequential fluoroscopic rollover images reliably identify "in-out-in" posterosuperior screws during percutaneous fixation of femoral neck fractures.

INTRODUCTION: Percutaneous screws placed into the posterosuperior femoral neck are frequently extraosseous or "in-out-in" (IOI). These IOI screws are not readily identifiable on anteroposterior (AP) and lateral fluoroscopic images. The purpose of this study was to examine the ability of surgeons to identify IOI guide pins using sequential fluoroscopic rollover images. MATERIALS AND METHODS: A 3.2-mm guide pin was placed into the posterosuperior quadrant of eleven synthetic femur models. Five samples were "all-in" (AI), and six were IOI. Sequential fluoroscopic rollover images were obtained starting with an AP image, then images at 10-degree rollover intervals ending with a direct lateral image. Images were reviewed in a blinded fashion by five attending orthopedic trauma surgeons and 20 resident surgeons to determine whether guide pins were AI or IOI. Accuracy, interobserver reliability, sensitivity, and specificity were assessed. RESULTS: The overall accuracy of responses was 86% with no difference between attending trauma surgeons and residents (p = 0.5). The sensitivity and specificity for an IOI guide pin were 98.0% and 71.2%, respectively. Interobserver reliability among surgeons was good (κ = 0.703). CONCLUSION: The use of the sequential fluoroscopic rollover images after placement of the posterosuperior guide pin into the femoral neck was highly sensitive for detecting an IOI position. The 40-degree rollover image was the best view to evaluate the proximity of the guide pin to the posterior cortex.

Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate.

BACKGROUND: Locking plate technology has increased the frequency of open reduction and internal fixation (ORIF) of proximal humerus fractures (PHF). A number of technical pearls have been recommended to lower the complication rate of ORIF. These pearls are particularly relevant for patients aged >60 years, when nonoperative treatment and arthroplasty are alternatives commonly considered. There have been few large, single-center studies on the modern application of this technology. METHODS: Between 2005 and 2015, a total of 173 PHFs in patients aged >60 years were treated at our institution with ORIF using locking plates. Failure was defined as reoperation or radiographic evidence of failure. Average follow-up was 6.1 years. RESULTS: There was an overall complication rate of 44%. The overall failure rate was 34% and correlated with fracture type: 26% failure rate in 2-part fractures (16 failures), 39% in 3-part fractures (23 failures), and 45% in 4-part fractures (11 failures). There was no difference between the failure rate with and without fibular allograft (33% vs. 34%). Most patients with radiographic or clinical failure did not undergo reoperation. The overall reoperation rate was 11% (14 patients). Seven percent of 2-part fractures (4 shoulders), 14% of 3-part fractures (8 shoulders), and 18% of 4-part fractures (2 shoulders) required reoperation. CONCLUSIONS: ORIF of PHFs with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. There was a trend toward higher complication and failure rates in older patients and more complex fractures. Refinement in fixation techniques and indications are necessary to optimize the surgical management of PHFs.

The Not-So-Simple Ankle Fracture: Avoiding Problems and Pitfalls to Improve Patient Outcome.

Ankle fractures are among the most common fractures encountered by orthopaedic surgeons and, in the setting of tibiotalar instability, are usually treated surgically. Although orthopaedic surgeons from diverse educational backgrounds often feel comfortable treating such fractures, many controversies and clinical challenges remain. A detailed understanding of the unique issues presented by each patient as well as the best available treatments are required to optimize outcome. Given the unforgiving soft-tissue envelope and the particular importance of both precise reduction and absolute stability, poorly conceived and executed surgery will predictably end in compromised patient outcomes. The purpose of this manuscript is to update practicing surgeons on the best strategies for improving patient outcome after ankle fracture. The focus will be on some of the more nuanced, controversial, and complex ankle fracture-related topics, both in terms of decision making and technical execution. These will include the optimal management of posterior malleolus fractures and syndesmosis injuries as well as the best strategies to minimizing risks in poor hosts such as diabetics, obese patients, and the frail elderly. We will also provide a framework with which surgeons can approach the salvage of patients in whom the initial management has failed.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study.

OBJECTIVE: To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail. DESIGN: Prospective, randomized. SETTING: Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN. PATIENTS/PARTICIPANTS: Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts. MAIN OUTCOME MEASURES: The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation. RESULTS: SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures. CONCLUSIONS: Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

In Vitro Biomechanical Evaluation of a Novel, Minimally Invasive, Sacroiliac Joint Fixation Device.

BACKGROUND: Sacroiliac (SI) joint pathology may result in low-back pain, which causes substantial disability. Treatment failure with operative management of SI pain may be related to incomplete fusion of the joint and to fixation failure. The objective of this study was to evaluate the initial biomechanical stability of SI joint fixation with a novel implantable device in an in vitro human cadaveric model. METHODS: The right and left sides of 3 cadaveric L4-pelvis specimens were tested (1) intact, (2) destabilized, and (3) instrumented with an implantable SI joint fixation device using a simulated single-stance load condition. Right-leg and left-leg stance data were grouped together for a sample size of 6, and angular range of motion (ROM) was determined during application of flexion-extension, lateral bending, and axial rotation bending moments to a limit of 7.5 Nm. RESULTS: Following intact testing, destabilization by severing the posterior SI joint capsule and ligaments and the pubic symphysis reliably produced a significantly destabilized joint with the mean angular ROM more than doubling in flexion-extension and lateral bending and more than tripling in axial rotation (P ≤ .003) compared to the intact condition. Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition in all 3 anatomic planes tested (P < .001). When compared to the intact condition, the SI-instrumented condition significantly reduced lateral bending (P = .01) and had a similar ROM in flexion-extension (P = .14) and axial rotation (P = .85). CONCLUSIONS: Instrumentation with the SI screw fixation device significantly reduced mean joint ROM compared to the destabilized condition, with similar ROM in flexion-extension and axial rotation, and it significantly reduced ROM in lateral bending compared to that for the intact joint. The ROM values observed with the instrumented condition were comparable to levels of mobility considered favorable for spinal fusion.

Bone Autograft Coupled with Locking Plates Repairs Symptomatic Rib Fracture Nonunions.

Symptomatic rib nonunions are a rare complication after rib fractures. Methods used to address these nonunions range from pain management, rib resection, and rib fixation with plates and occasional autologous bone grafting. Given potential complications associated with rib resections such as pulmonary hernia, we hypothesized that plate fixation and autologous bone grafting would yield satisfactory long-term outcomes and a high union rate. Patients (aged ≥18 years) at a single institution with a symptomatic rib nonunion who underwent surgical rib stabilization of the nonunion coupled with bone autograft were evaluated (2010-2014). Pertinent clinical, operative, radiologic, and follow-up data were abstracted. Univariate analyses to assess the relationship of clinical outcomes were performed. Six patients underwent nonunion repair with autograft and plating. The mean time from injury to surgical repair of nonunion was 15 (±6.1) months. A median of 3 [1-3] ribs were repaired with surgery. Postoperative radiographic union was demonstrated on cross-sectional imaging at three months in four patients (57%) and in all patients at five months postoperatively. No patients developed postoperative pulmonary hernia during follow-up. All patients had a significant reduction in median patient-reported pain at follow-up. Surgical rib fixation and bone autograft can provide acceptable outcomes for patients with rib fracture nonunion. This method provides pain relief and promotes healing of the nonunion gap without pulmonary hernia development. Operative fixation and bone autograft should be considered as a viable technical alternative to resection alone for rib nonunion.

Minimally Invasive Sacroiliac Joint Fusion: 2-Year Radiographic and Clinical Outcomes with a Principles-Based SIJ Fusion System.

BACKGROUND: Sacroiliac joint (SIJ) degeneration is a common source of low back pain (LBP). Minimally invasive (MI) SIJ fusion procedures have demonstrated meaningful clinical improvement. A recently developed MI SIJ fusion system incorporates decortication, placement of bone graft and fixation with threaded implants (DC/BG/TF). PATIENTS AND METHODS: Nineteen patients who had MI SIJ fusion with DC/BG/TF were enrolled at three centers. Fusion was assessed in CT images obtained 12 and 24 months postoperatively by an independent radiographic core laboratory. LBP was assessed using a 0-10 numerical pain scale (NPS) preoperatively and at 12 and 24 months postoperatively. RESULTS: At 12 months, 15/19 patients (79%) had bridging bone across the SIJ, and at 24 months 17/18 patients (94%) available for follow-up had SIJ fusion. Of the patients with bridging bone 88% had fusion within the decorticated area, with solid fusion in 83%. A significant reduction in NPS scores was demonstrated, representing a 73% reduction in average low back pain. CONCLUSION: The patients in this series demonstrated significant improvement in LBP. Fusion rates at 24 months demonstrate promise for this system, which utilizes the established orthopedic principles of DC/BG/TF to achieve arthrodesis. Further study is warranted to demonstrate comparative fusion rates for different implant systems.

Hip Arthroplasty After Surgical Treatment of Intertrochanteric Hip Fractures.

BACKGROUND: Although use of intramedullary hip screws (IMHS) for intertrochanteric (IT) hip fractures has become more common, limited data have suggested difficulties in conversion to hip arthroplasty. The present study investigates whether conversion of failed IT fracture fixation with an intramedullary vs extramedullary device leads to different rates or types of complications or decreased arthroplasty survivorship. METHODS: One hundred eleven patients were converted to hip arthroplasty after previous surgical treatment of an IT fracture from 2000 to 2010. Seventy hips had been treated with an extramedullary fixation device (EFD) and 41 with an IMHS. RESULTS: Length of hospital stay and operative times were similar (6 days and 206 minutes for EFD vs 6 days and 208 minutes for IMHS; P > .7). The presence of a Trendelenburg gait at last clinical follow-up was similar between groups (37% in EFD group and 38% in IMHS group). Five-year survivorship free of revision was 95% in the EFD group and 94% in the IMHS group (P = 1.0). The overall complication rate was similar (21% for EFD vs 27% for IMHS; P = .51) between groups. The most common complication was late periprosthetic fracture in the EFD patients (6% vs 0% in IMHS; P = .29) and intraoperative femoral fracture in the IMHS patients (12% vs 1% in EFD; P = .02). CONCLUSION: The short-term survivorship of conversion hip arthroplasty after surgical treatment of an IT fracture is excellent regardless of original fracture fixation method. If early complications, particularly periprosthetic fractures, can be minimized, the likelihood of a successful outcome is high. The risk of intraoperative femoral fracture was greater during conversion from an IMHS compared to an EFD.

Tranexamic Acid Safely Reduced Blood Loss in Hemi- and Total Hip Arthroplasty for Acute Femoral Neck Fracture: A Randomized Clinical Trial.

OBJECTIVES: We aimed to determine whether (1) tranexamic acid (TXA) reduces the incidence of transfusion (2) TXA reduces the calculated blood loss, and (3) there are any observable differences in 30- and 90-day complications with TXA administration during arthroplasty for femoral neck fracture (FNF). DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred thirty-eight patients who presented with a low-energy, isolated, FNF (AO 31B) treated with either hemi- or total hip arthroplasty within 72 hours of injury were randomized to either the TXA group (69 patients) or placebo group (69 patients). INTERVENTION: In the TXA group, patients received 2 doses of 15 mg/kg intravenous TXA dissolved in 100 mL of saline, each administered over 10 minutes; 1 dose just before incision, and the second at wound closure. In the placebo group, 100 mL of saline solution was administered in a similar fashion. Perioperative care was otherwise standardized including conservative transfusion criteria. MAIN OUTCOME MEASUREMENTS: Our primary outcome was to determine the proportion of patients who underwent blood transfusion during hospitalization. Secondary outcomes were calculated blood loss, number of units transfused during hospitalization, and incidence of adverse events at 30 and 90 days including thromboembolic event, wound complications, reoperation, hospital readmission, and all-cause mortality. RESULTS: TXA reduced mean incidence of transfusion by 305 mL (P = 0.0005). There was a trend toward decreased transfusion rate in the TXA group (17% vs. 26%, P = 0.22). TXA was safe with no differences in adverse events at 30 and 90 days. CONCLUSIONS: This randomized clinical trial found that TXA administration safely reduced blood loss with a tendency for decreased transfusion rate and total blood product consumption for patients undergoing hip arthroplasty for acute FNF. More studies are needed to further ascertain the role of TXA in the management of patients with FNF. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Acetabular Fractures in the Senior Population- Epidemiology, Mortality and Treatments.

BACKGROUND: Management of acetabular fractures in the senior population can be one of the most challenging injuries to manage. Furthermore, treating surgeons have a paucity of information to guide the treatment in this patient population. THE PURPOSE OF THIS STUDY WAS TO DETERMINE: (1) demographic and epidemiologic data, (2) mortality rates for nonoperative compared to operative management at different time points, (3) common fracture configurations, and (4) fracture fixation strategies in senior patients treated with acetabular fractures. METHODS: Retrospective review of prospectively gathered data at a Level I trauma center over a five-year period. 1123 acetabular fractures were identified. 156 of them were for patients over the age of 65 (average age of 78). RESULTS: Falls and motor vehicle accidents accounted for the two most common mechanisms of injury. 82% of patients had significant medical comorbidities. 51 patients (33%) died within one year, in which 75% of them died within 90 days of their acetabular fracture. 84% of the deceased patients, i.e. from the group of 51 patients, had non-operative treatment. For patients treated with traction alone, there was a 79% one-year mortality and 50% mortality rate within 90 days. Within the entire cohort, 70% had either an associated both-column (ABC) or anterior column/posterior hemitransverse (AC/PHT) fracture pattern. Fifty-seven patients (36.5%) underwent open reduction and internal fixation using standard reduction techniques and surgical implants via two main surgical exposures of ilioinguinal (69%) and Kocher-Langenbeck (29%). CONCLUSION: Geriatric patients with acetabular fractures are uncommon accounting for only 14% of all acetabular fractures. Patients who undergo surgery show lower mortality rates. ABC and AC/PHT fracture patterns are the two most common fracture patterns. Routine fixation constructs and implants can be used to manage these challenging fractures. Most patients are unable to return to their homes and instead require skilled nursing facility during their convalescence.

Allgöwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography.

OBJECTIVE: The purpose of this study was to evaluate which primary wound closure technique for ankle fractures affords the most robust perfusion as measured by laser-assisted indocyanine green angiography: Allgöwer-Donati or vertical mattress. DESIGN: Prospective, randomized. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: Thirty patients undergoing open reduction internal fixation for ankle fractures were prospectively randomized to Allgöwer-Donati (n = 15) or vertical mattress (n = 15) closure. Demographics were similar for both cohorts with respect to age, sex, body mass index, surgical timing, and OTA/AO fracture classification. MAIN OUTCOME MEASUREMENTS: Skin perfusion (mean incision perfusion and mean perfusion impairment) was quantified in fluorescence units with laser-assisted indocyanine green angiography along the lateral incision as well as anterior and posterior to the incision at 30 separate locations. Minimum follow-up was 3 months with a mean follow-up 4.7 months. RESULTS: Allgöwer-Donati enabled superior perfusion compared with the vertical mattress suture technique. Mean incision perfusion for Allgöwer-Donati was 51 (SD = 13) and for vertical mattress was 28 (SD = 10, P < 0.0001). Mean perfusion impairment was less in the Allgöwer-Donati cohort (12.8, SD = 9) compared with that in the vertical mattress cohort (23.4, SD = 14; P = 0.03). One patient in each cohort experienced a wound complication. CONCLUSIONS: The Allgöwer-Donati suture technique offers improved incision perfusion compared with vertical mattress closure after open reduction internal fixation of ankle fractures. Theoretically, this may enhance soft tissue healing and decrease the risk of wound complications. Surgeons may take this into consideration when deciding closure techniques for ankle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.