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Between June 1989 and May 1995, the authors surgically treated 64 patients with unstable posterior pelvic in juries. Fracture types included Tile Type C1 (75%), C2 (8%), and C3 (17%). There were 19 sacroiliac dislocations, 12 sacral fractures, 4 transiliac fractures, and 29 sacroiliac fracture dislocations. Average patient age was 32 years and Injury Severity Score was 27 points. Posterior fixation was accomplished by percutaneous iliosacral screw insertion in 53 patients (83%). Only pure transiliac fractures were treated without iliosacral screws. There were no iatrogenic nerve palsies. During the study, there was increased reliance on internal fixation of the anterior pelvic ring that aided in anatomic alignment of the pelvis for posterior fixation and resulted in decreased chronic pubic tenderness. The use of external fixation for definitive treatment was abandoned. Patients were observed for an average of 36 months (range, 5-74 months). Fifty-two patients were available for recent complete followup. Fifty-one patients (98%) healed their pelvic disruptions; there was 1 sacral nonunion. A 40-point pelvic outcome grading scale was developed based on physical examination, pain, radiographic analysis, and activity/work status. Scores obtained by this scale correlated closely with the Short Form-36 Health Survey scores. Patient functional outcome after posterior pelvic fracture was not associated with Injury Severity Score or fracture location.

Fifty consecutive open fractures of the tibia, including 22 Grade IIIB and 4 Grade IIIC, were treated using a protocol of debridement, immediate wound coverage, and intramedullary nailing. Fasciocutaneous flaps were used extensively to cover areas of exposed bone. The severity of the soft tissue injury dictated the timing of definitive fixation. Fracture location determined implant selection and nailing technique. Patients were observed for an average of 21 months. Ninety-eight percent of the fractures united < 6 months postoperatively. There was 1 infection (2%), 2 malunions (4%), and 1 case of partial flap necrosis. Locking screws broke in 1 patient (2%); the fracture united with < 5 mm of shortening. Immediate postdebridement wound coverage, and intramedullary nailing after reconstruction of the soft tissue envelope facilitate fracture healing in these complex open injuries. Intramedullary nailing can be performed safely to include all grades of open tibial fractures from the proximal to distal metaphysis.

The clinical mechanical failures of small diameter intramedullary interlocking nails were evaluated to determine the relationship of failure modes to the type or location of tibial fractures. Methods were developed to duplicate failure modes in vitro in standardized tests to simulate the clinical situations. Where standard test methods were inadequate, new methods were developed to provide quantifiable, reliable methods of evaluating potential clinical performance. The modes and rates of mechanical failure in the clinical series were consistent among participating centers: (1) In diaphyseal fractures with secondary trauma, the intramedullary nail bent at the fracture site where the working length was unsupported; (2) failures that occurred several weeks after nailing were the result of fatigue fractures of the locking screws, usually at the distal end; and (3) nail and screw failures occurred most commonly in proximal and distal tibial fractures. The strength of the 8- and 9-mm sizes of Synthes and Russell-Taylor nails were comparable.

Between March 1991 and December 1992 the authors surgically treated 55 acetabular fractures using a modified Stoppa anterior intrapelvic extensile approach. Indications for utilization of this approach included displaced anterior column or wall fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemitransverse component. The approach involves a transverse skin incision 2 cm above the pubic symphysis followed by a midline split of the rectus abdominis. Access to the intrapelvic aspect of the pelvis and acetabulum is gained by retraction of the muscular, neurovascular and urological structures. This modified Stoppa approach affords excellent visualization of the pelvic ring, facilitating the development and utilization of improved reduction and plating options. Patients were followed for an average of 17.7 months. All fractures united 6-12 weeks postoperatively. Radiographic grades were excellent (64%), good (25%), fair (7%) and poor (4%). Fixation and subsequent reduction were lost in 1 patient. Two transient obturator nerve palsies were diagnosed. There was 1 infection and 1 inguinal hernia. Posttraumatic arthritic changes were noted in 6 patients within the first postoperative year. There was no significant heterotopic ossification, major vascular injury iatrogenic palsy or intraarticular hardware placement. Clinical results were excellent (47%), good (42%), fair (9%) and poor (2%). The modified Stoppa incision offers the experienced trauma surgeon a new approach for fixation of displaced acetabular fractures. The approach offers improved reduction and fixation possibilities and may decrease the rate of complications associated with extrapelvic or extensile approaches.

The callotasis technique of De Bastiani was used to perform 11 lower extremity lengthenings in ten pediatric and adolescent patients (aged 8.1-18 years). Average gain in length was 5.0 cm per segment (15% of original bone length). All lengthened segments healed without bone grafting or internal fixation. Healing index was 32 days per centimeter gained. The device was well tolerated and easily removed in the clinic setting. There were 13 minor complications, managed without hospitalization. Three angular deformities required manipulation under anesthesia. One angular deformity remains uncorrected, and one patient lacked 1.1 cm of achieving the desired length. All other patients gained the desired length. There were no refractures, deep infections, or other complications. Limb lengthening by the De Bastiani method is a satisfactory procedure for the pediatric and adolescent patient with moderate limb-length discrepancy.