Search

Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Fracture-related infection is one of the most challenging complications in orthopaedic trauma surgery. However, the effect of infection on functional and pain-related outcomes has not been well established. The aims of this study were to evaluate functional recovery for patients with fracture and a deep surgical site infection compared with patients with fracture without infection and to evaluate whether pain severity, social support, and preinjury mental health have a moderating effect on the magnitude and direction of the relationship between deep surgical site infection and functional recovery., Methods: This is a secondary retrospective cohort study using prospectively collected data from the VANCO trial (Local Antibiotic Therapy to Reduce Infection After Operative Treatment of Fractures at High Risk of Infection) and the OXYGEN (Supplemental Perioperative Oxygen to Reduce Surgical Site Infection After High Energy Fracture Surgery) trial. In this study, 2,116 patients with tibial plateau, pilon, or calcaneal fractures at high risk for infection were included. Patients were divided into cohorts of patients who experienced a deep surgical site infection and those who did not. The primary outcome measure was the functional outcome using the Veterans RAND 12-Item Health Survey (VR-12)., Results: After controlling for covariates, deep surgical site infection was independently associated with functional outcome, with a 3.3-point reduction in the VR-12 Physical Component Score, and pain severity was independently associated with functional outcome, with a 2.5-point reduction in the VR-12 Physical Component Score. Furthermore, the Brief Pain Inventory pain severity demonstrated an important moderating effect on the relationship between infection and functional outcome. In patients with lower pain scores, infection had a large negative impact on functional outcome, whereas, in patients with higher pain scores, infection had no significant impact on functional outcome. Furthermore, the functional outcome in the entire cohort remains at only 61% of baseline., Conclusions: This study documents the negative impact of postoperative infection on functional recovery after injury, as well as the novel finding of pain severity as an important moderating factor. This study emphasizes not only the importance of developing effective interventions designed to reduce postoperative infection, but also the role that factors that moderate pain severity plays in limiting recovery of physical function., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A590)., (Copyright © 2024 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved.)

Objectives: To estimate the generalizability of treatment effects observed in the VANCO trial to a broader population of patients with tibial plateau or pilon fractures., Methods: Design and Setting: Clinical trial data from 36 United States trauma centers and Trauma Quality Programs registry data from more than 875 Level I-III trauma centers in the United States and Canada.Patient Selection Criteria: Patients enrolled in the VANCO trial treated with intrawound vancomycin powder from January 2015 to June 2017 and 31,924 VANCO-eligible TQP patients admitted in 2019 with tibial plateau and pilon fractures.Outcome Measure and Comparisons: Deep surgical site infection and gram-positive deep surgical site infection estimated in the TQP sample weighed by the inverse probability of trial participation., Results: The 980 patients in the VANCO trial were highly representative of 31,924 TQP VANCO-eligible patients (Tipton generalizability index 0.96). It was estimated that intrawound vancomycin powder reduced the odds of deep surgical infection by odds ratio (OR) = 0.46 (95% confidence interval [CI] 0.25-0.86) and gram-positive deep surgical infection by OR = 0.39 (95% CI, 0.18-0.84) within the TQP sample of VANCO-eligible patients. For reference, the trial average treatment effects for deep surgical infection and gram-positive deep surgical infection were OR = 0.60 (95% CI, 0.37-0.98) and OR = 0.44 (95% CI, 0.23-0.80), respectively., Conclusions: This generalizability analysis found that the inferences of the VANCO trial generalize and might even underestimate the effects of intrawound vancomycin powder when observed in a wider population of patients with tibial plateau and pilon fractures., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Underweight patients experience poor outcomes after elective orthopaedic procedures. The effect of underweight body mass index (BMI) on complications after acetabular fracture is not well-described. We evaluate if underweight status is associated with inpatient complications after acetabular fractures., Methods: Adult patients (≥ 18 years) presenting with acetabular fracture between 2015 and 2019 were identified from Trauma Quality Program data. Adjusted odds (aOR) of any inpatient complication or mortality were compared between patients with underweight BMI (< 18.5 kg/m 2 ) and normal BMI (18.5-25 kg/m 2 ) using multivariable logistic regression and stratifying by age ≥ 65 years., Results: The 1299 underweight patients aged ≥ 65 years compared to 11,629 normal weight patients experienced a 1.2-times and 2.7-times greater aOR of any complication (38.6% vs. 36.6%, p = 0.010) and inpatient mortality (7.9% vs. 4.2%, p < 0.001), respectively. The 1688 underweight patients aged 18-64 years compared to 24,762 normal weight patients experienced a 1.2-times and 1.5-times greater aOR of any inpatient complication (38.9% vs. 34.8%, aOR p = 0.006) and inpatient mortality (4.1% vs. 2.5%, p < 0.001), respectively., Conclusion: Underweight adult patients with acetabular fracture are at increased risk for inpatient complications and mortality, particularly those ≥ 65 years old., Level of Evidence: Prognostic Level III., (© 2023. The Author(s).)

Tibial plateau fractures are a common injury treated by orthopaedic trauma surgeons. Depression of the articular surface of the tibial plateau is often an associated injury pattern. The methods used to address depressed tibial plateau fractures can vary, as it has yet to be determined if the type of bone void filler utilized affects the long-term functional outcomes of patients with tibial plateau fractures. A 28-question survey was created to better elucidate the current practices used by orthopaedic surgeons and the factors influencing the selection of bone void fillers for treatment of these injuries. The survey was distributed online to Orthopaedic Trauma Association (OTA) members. There were 106 orthopaedic surgeons that completed the survey with a wide range of responses. The survey determined the current practice of orthopaedic surgeons varies widely when selecting bone void fillers in the treatment of depressed tibial plateau fractures. (Journal of Surgical Orthopaedic Advances 32(3):156-159, 2023).

Background: Heterotopic ossification (HO) is a frequent and debilitating complication of traumatic musculoskeletal injuries and orthopedic procedures. Prophylactic dosing of botulinum toxin type A (BTxA) holds potential as a novel treatment option if accurately distributed throughout soft-tissue volumes where protection is clinically desired. We developed a high-resolution, microcomputed tomography (microCT)-based imaging strategy to assess drug distribution and validated this platform by quantifying distribution achieved via a prototype delivery system versus a single-bolus injection., Methods: We injected an iodine-containing contrast agent (iodixanol 320 mg I/mL) into dissected rabbit musculature followed by microCT imaging and analysis. To contrast the performance of distributed versus bolus injections, a three-dimensional (3D) 64-cm 3 -printed soft-tissue holder was developed. A centered 2-cm 3 volume of interest (VOI) was targeted with a single-bolus injection or an equal volume distributed injection delivered via a 3D-printed prototype. VOI drug coverage was quantified as a percentage of the VOI volume that was < 1.0 mm from the injected fluid., Results: The microCT-based approach enabled high-resolution quantification of injection distribution within soft tissue. The distributed dosing prototype provided significantly greater tissue coverage of the targeted VOI (72 ± 3%, mean ± standard deviation) when compared to an equal volume bolus dose (43 ± 5%, p = 0.031) while also enhancing the precision of injection targeting., Conclusions: A microCT-based imaging technique precisely quantifies drug distribution within a soft-tissue VOI, providing a path to overcome a barrier for clinical translation of prophylactic inhibition of HO by BTxA., Relevance Statement: This platform will facilitate rapid optimization of injection parameters for clinical devices used to effectively and safely inhibit the formation of heterotopic ossification., Key Points: • MicroCT provides high-resolution quantification of soft-tissue drug distribution. • Distributed dosing is required to maximize soft-tissue drug coverage. • Imaging platform will enable rapid screening of 3D-printed drug distribution prototypes., (© 2023. The Author(s).)

Objective: Associated both column acetabular fractures (OTA/AO 62C) with concomitant posterior wall fracture fragments (ABC + PW) have not been well-defined. The purpose of this study was to report on the incidence and morphology of ABC + PW fractures., Methods: A retrospective review of associated both column (ABC) fractures between 2014 and 2020 was performed. Computed tomography scans including 3-D surface rendered reformats for each were reviewed to determine whether a posterior wall (PW) fragment was present and its morphologic characteristics., Results: One hundred fifty-two ABC fractures were identified. Sixty-two fractures (41%) were identified as ABC + PW. 3D-computed tomographies were available on 58 fractures. Morphologic analysis was performed based on the relationship of the fracture to the gluteal pillar. Twenty PW fragments were posterior to the gluteal pillar, 19 extended into the gluteal pillar, and 19 extended anterior. Fifty-two fractures were treated with operative fixation; 32 (62%) were clamped and fixed with screws from the same anterior approach whereas 15 (29%) required a separate posterior approach; and no fixation was placed in 5 (9%). 29 of 32 PW fragments (91%) requiring fixation that extended into or anterior to the pillar were fixed from the anterior approach, and 7 of 15 posterior fractures (47%) required a separate posterior approach., Conclusions: A separate PW fragment was identified in 41% of ABC fractures. Their variation in morphology can be classified into 3 types based on the relation to the gluteal pillar that has potential implications for treatment from the anterior approach compared with requiring a separate posterior approach. We suggest these data could be used to update the 2018 OTA/AO Fracture Compendium., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Case: Closed reduction of acetabular fractures with femoral head protrusion and superolateral femoral head impaction may be challenging because the intact acetabular roof may block anatomic reduction with traditional maneuvers. We report the use of a 5-step technique for this unique pattern: medializing force to disengage the femoral head, axial traction to clear the intact ilium, lateralizing force to center the head underneath the acetabular roof, confirmation of femoral head stability, and skeletal traction placement., Conclusion: Acetabular fractures with femoral head protrusion and concomitant superolateral impaction may be reduced with an initial medializing force followed by axial and lateralizing forces., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C156)., (Copyright © 2023 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Obesity remains a global epidemic. The effect of obesity on the risk of complications after acetabular fracture is unknown. Here, we evaluate the effect of BMI on early complications and mortality after acetabular fracture. We hypothesize that the risk of inpatient complications and mortality will be greater in patients with high BMI when compared to those with normal BMI., Methods: Adult patients with acetabular fracture were identified via the Trauma Quality Improvement Program data from 2015 to 2019. The primary outcome was overall complication rate with reference to normal-weight patients (BMI = 25-30 kg/m 2 ). The secondary outcome was rates of death. The association of obesity class on the primary and secondary outcomes was assessed using Bonferroni-corrected multiple logistic regression models considering patient, injury, and treatment covariates., Results: A total of 99,721 patients with acetabular fracture were identified. Class I obesity (BMI = 30-35 kg/m 2 ) was associated with 1.2 greater adjusted relative risk (aRR; 95% confidence interval (CI) 1.1-1.3) of any adverse event, without significant increases in adjusted risk of death. Class II obesity (BMI = 35-40 kg/m 2 ) was associated with aRR = 1.2 (95% CI 1.1-1.3) of any adverse event and aRR = 1.5 (95% CI 1.2-2.0) of death. Class III obesity (BMI ≥ 40 kg/m 2 ) was associated with aRR = 1.3 (95% CI 1.2-1.4) of any adverse event and aRR = 2.3 (95% CI 1.8-2.9) of death., Conclusion: Obesity is associated greater risk of adverse events and death following acetabular fracture. Obesity severity classification scales with these risks., (© 2023. The Author(s).)

Purpose: To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries., Methods: This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up., Results: Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up)., Conclusion: The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objectives: To determine the rate of erectile dysfunction in male patients who have sustained an acetabular fracture with no previously identified urogenital injury., Design: Cross-sectional survey., Setting: Level 1 Trauma Center., Patients/participants: All male patients treated for acetabular fracture without urogenital injury., Intervention: The International Index of Erectile Function (IIEF), a validated patient-reported outcome measure for male sexual function, was administered to all patients., Main Outcome Measurements: Patients were asked to complete the International Index of Erectile Function score for both preinjury and current sexual function, and the erectile function (EF) domain was used to quantify the degree of erectile dysfunction. Fractures were classified according the OTA/AO classification schema, fracture classification, injury severity score, race, and treatment details, including surgical approach were collected from the database., Results: Ninety-two men with acetabular fractures without previously diagnosed urogenital injury responded to the survey at a minimum of 12 months and an average of 43 ± 21 months postinjury. The mean age was 53 ± 15 years. 39.8% of patients developed moderate-to-severe erectile dysfunction after injury. The mean EF domain score decreased 5.02 ± 1.73 points, which is greater than the minimum clinically important difference of 4. Increased injury severity score and associated fracture pattern were predictive of decreased EF score., Conclusion: Patients with acetabular fractures have an increased rate of erectile dysfunction at intermediate-term follow-up. The orthopaedic trauma surgeon treating these injuries should be aware of this as a potential associated injury, ask their patients about their function, and make appropriate referrals., Level of Evidence: III., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Introduction: Acetabular fractures requiring an anterior approach have historically been delayed, allowing a stable clot to form before creating large surgical exposures. The purpose of this study was to determine whether immediate fixation of acetabular fractures within 24 hours using an anterior approach demonstrates notable difference in blood loss, length of stay (LOS), complications, or mortality compared with acetabular fractures treated after 24 hours., Methods: Ninety-three patients were optimized for surgery within 24 hours of injury. Thirty-two patients underwent fixation within 24 hours using an anterior approach to the acetabulum. Demographics, hours from injury to operating room, fracture classification, embolization, surgical approach, intraoperative cell salvage use, Charlson Comorbidity Index, American Society of Anesthesiologists class, Injury Severity Score, and Abbreviated Chest Injury Score were recorded. Estimated blood loss, transfusions, intensive care unit stay, total hospital LOS, complications, and mortality rates were compared., Results: No statistically significant differences were observed in fracture classification, blood loss, or intraoperative transfusions between the immediate and delayed fixation groups. Six patients in the delayed group (9.8%) returned to the operating room for a complication compared with one patient (3.1%) in the immediate group ( P = 0.42). Three patients in the delayed group (4.9%) developed a surgical site infection compared with none (0%) in the immediate group ( P = 0.55). The immediate group had an average LOS of 7 days compared with 11 days in the delayed fixation group ( P = 0.01). No notable differences were observed in 30- or 90-day mortality rates., Discussion: Medically optimized patients with acetabular fractures who undergo immediate fixation through an anterior approach do not seem to have an associated increase in blood loss, transfusions, or mortality. Prompt surgical management may also be associated with a shorter preoperative and postoperative LOS., Level of Evidence: Therapeutic level III., (Copyright © 2023 by the American Academy of Orthopaedic Surgeons.)

Introduction: Patients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures., Methods: Adults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality., Results: After propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality., Conclusion: Cirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture., Level of Evidence: Prognostic Level III., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Talar fractures and pantalar dislocations are usually the results of high-energy trauma. Dislocations and open injuries are managed urgently. Temporary stabilization with splinting, Kirschner wires, or external fixation may be performed until the soft tissues are ready for definitive fixation. A CT scan is critical to identify all injuries and is helpful in planning treatment including reduction of dislocations and definitive fixation. Lateral and posterior process fractures are often missed initially and require a high index of suspicion.

Case: We present a case report of an elderly patient with a displaced lateral compression type II pelvic ring injury and describe a novel technique for maintaining a percutaneously obtained reduction during percutaneous fixation using a supra-acetabular Schantz pin attached to a mechanical limb positioner., Conclusion: The mechanical limb positioner used allows the surgeon to hold a multidirectionally obtained reduction of the hemipelvis with ease., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B820)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: To evaluate the perceived utility and associated charges of the anteroposterior (AP) radiograph during rotational ankle fracture postoperative follow-up., Design: Survey study with charge analysis using published data at 50 orthopaedic hospitals in the United States., Setting: Not Applicable., Participants: Orthopaedic Trauma Association Members with an active email address who were invited and interested in answering a survey., Results: Ninety-four percent of respondents stated that they did routinely obtain an AP radiograph during rotational ankle fracture follow-up. However, 57% thought that the AP view should be eliminated from standard follow-up and only 51% found this view useful after initial treatment., Charge Analysis: The mean difference between a 2-view and 3-view ankle radiograph series was $102.00. Using this value and the assumption that each patient with a rotational ankle fracture gets 3 follow-up radiographs, there is the potential for a charge reduction of $306 per patient. Assuming over 134,000 rotational ankle fractures, a charge reduction of 41 million US dollars (USD) per year is possible if the AP image is routinely removed. Actual savings are likely to be less based on agreed on payer rates. Although less easy to quantify, there is also a potential reduction of radiation exposure, radiologists' interpretation time, and data storage., Conclusions: Routine AP radiographs should potentially be eliminated from routine postoperative ankle x-ray protocols based on this survey of experienced orthopaedic surgeons. If this specific radiograph is ordered on a case-by-case basis, then significant savings may occur., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction., Design: Multicenter retrospective review., Setting: Sixteen trauma centers., Patients: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures., Main Outcome Measures: Fracture-related infection (FRI) in open ankle fractures., Results: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01)., Conclusions: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To (1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons and subspecialists universally around the world and (2) delineate those injury subtypes that are most difficult to classify reliably to refine the classification before evaluating clinical outcomes., Design: Agreement study., Setting: All-level trauma centers, worldwide., Participants: One hundred seventy-two members of the AO Trauma and AO Spine community., Intervention: The AO Sacral Classification System was applied by each surgeon to 26 cases in 2 independent assessments performed 3 weeks apart., Main Outcome Measurements: Interobserver reliability and intraobserver reproducibility., Results: A total of 8097 case assessments were performed. The kappa coefficient for interobserver agreement for all cases was 0.72/0.75 (assessment 1/assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the kappa coefficient was 0.84/0.85, corresponding to excellent reliability. The kappa coefficients for interobserver reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall kappa statistic for intraobserver reliability was 0.82 (range 0.18-1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average kappa value was 0.87 (range 0.18-1.00), representing excellent reproducibility., Conclusion: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial interobserver and excellent intraobserver reliability., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To review a large, multicenter experience to identify the current salvage and amputation rates of these combined injuries and, where possible, the variables that predict amputation., Design: Retrospective., Setting: Nine trauma centers., Patients: This study involved 199 patients presenting to 9 trauma centers with orthopaedic and vascular injuries resulting in ischemic limbs for whom the orthopaedic service was involved with the decision for salvage versus amputation., Results: We reviewed 199 patients, 17-85 years of age. One hundred seventy-two of the injuries were open. Thirty-eight patients (19%) were treated with amputation upon admission as they were deemed to be unsalvageable. Of the remaining 161 patients who had attempted salvage, 36 (30%) required late amputation. Closed injuries were successfully salvaged in 25 of 27 cases (93%). The highest rate of amputation was in tibia fractures with a combined amputation rate of 62%. In those attempted to be salvaged, 21 of 48 (44%) required amputation. The ischemia time for successful salvage was significantly less, P = 0.03. One hundred twenty-four patients had their definitive vascular repair before the bony reconstruction. There were 15 vascular complications, of which 13 (86%) had the definitive vascular repair performed before the definitive osseous repair, although this was not statistically significant., Conclusions: In this series of combined orthopaedic and vascular injuries, we found a high rate of acute and late amputations. It is possible that other protocols, such as shunting and stabilizing the osseous injury, before vascular repair may benefit limb salvage, although this needs more study., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Case: There is limited literature reporting on sacral insufficiency fractures as a cause of lumbopelvic instability. We describe the presentation, treatment, and clinical outcome with a 2-year follow-up of a woman who sustained a low-energy spinopelvic dissociation diagnosed with magnetic resonance imaging. There was significant delayed displacement, and the patient was treated surgically with percutaneous iliosacral and trans-sacral screws., Conclusion: U-type sacral insufficiency fractures may be subtle on advanced imaging and must be followed closely if nonoperative treatment is chosen. These patients may require surgical intervention. Iliosacral screws and lumbopelvic fixation are treatment options, each with advantages and disadvantages., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B417)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients., Methods and Analysis: PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections., Ethics and Dissemination: The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients., Trial Registration Number: NCT02984384., Competing Interests: Competing interests: CDM has received grant funding as PI from Merck and receives consulting income from AstraZeneca, Bayer Pharmaceuticals, Janssen/J&J, Merck and Pfizer. ERH is/was the primary investigator of contracts from The Patient-Centred Outcomes Research Institute (PCORI) entitled 'Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centred Care via Health Information Technology' (CE-12-11-4489) and 'Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis' (DI-1603-34596); is the primary investigator of a grant from the Agency for Healthcare Research and Quality (AHRQ) (1R01HS024547) entitled 'Individualised Performance Feedback on Venous Thromboembolism Prevention Practice,' and is a co-investigator on a grant from the NIH/NHLBI (R21HL129028) entitled 'Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis'; receives research grant support from the DOD/Army Medical Research Acquisition Activity and has received grant support from the Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF); receives book royalties from Lippincott, Williams, Wilkins; and is a paid consultant to Vizient for their HIIN Venous Thromboembolism (VTE) Prevention Action Network., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Case: A patient with history of nonunion repair of traumatic midshaft clavicle fracture was referred to our orthopaedic trauma clinic for new-onset shoulder pain and paresthesias involving the ipsilateral arm. Computed tomography angiography revealed an axillary artery pseudoaneurysm adjacent to the instrumentation and recurrent nonunion of the fracture site. The patient underwent coil embolization of the pseudoaneurysm and nonunion repair., Conclusion: This case demonstrates that iatrogenic neurovascular injury during clavicle fracture nonunion repairs can present in a delayed fashion requiring more thorough clinical and imaging evaluation to achieve successful treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B269)., (Copyright © 2020 by The Journal of Bone and Joint Surgery, Incorporated.)

Removal of internal fixation implants previously placed to stabilize posterior pelvic ring injuries may be technically challenging. Described techniques for extraction require specialized equipment, extensile measures, or purchase of additional implants. We describe a technique for removal of large diameter cannulated screws and washers from the posterior pelvic ring, which requires no additional equipment or implants beyond the instrumentation used for implant insertion, as well as a series of 15 cases in which the technique was applied.

Objectives: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample., Design: Consecutive retrospective cohort review., Setting: Eighteen academic orthopedic trauma centers., Patients/participants: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery., Intervention: Humeral shaft nonunion repair and assessment of postoperative radial nerve function., Main Outcome: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery., Results: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved., Conclusion: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Conventional fixation methods of posterior wall acetabular fractures feature the use of plating and lag screws. However, fixation of posterior wall fractures with buttress plating alone offers potential advantages by avoiding the hardware complications related to hardware placement through the wall fragment. The purpose of this study was to examine if buttress plating alone, without screw fixation through the wall would be a viable method of treating these fractures. Our hypothesis was that this technique would not result in loss of reduction., Methods: Consecutive series of patients with isolated posterior wall acetabular fractures treated by two independent surgeons at two Level I Trauma centers without screw fixation across the fracture (Boston Medical Center/Harborview Medical Center)., Results: All 72 fractures treated without a screw through the posterior wall fragment maintained reduction at an average of 1.6 years post-operatively. For fractures fixed with buttress plating alone, 92 % were reduced within 2 mm of being anatomic compared to 94 % of fractures that had screws cross the fracture., Conclusion: The described buttress plating technique without screw fixation in the wall is an acceptable form of fixation for posterior wall acetabular fractures without the theoretical risk of intra-wall screw fixation., (COPYRIGHT 2020 © BY THE ARCHIVES OF BONE AND JOINT SURGERY.)

Background: The optimal treatment of acetabular fractures in the senior cohort is undetermined. Total hip arthroplasty in the setting of an acetabular fracture is increasing in popularity. However, there is concern regarding the fixation of a prosthetic cup in a fractured acetabulum. The purpose of this study is to map the area of stable articular surface and bone corridors available for cup fixation in this fracture cohort., Methods: CT scans of acetabular fractures in 131 consecutive geriatric patients older than 65 years from two level 1 academic trauma centers were analyzed. Acetabular fractures were classified using the Letournel classification, the available stable articular surface, and the bone corridors available for fixation., Results: Fractures involving the anterior column were the most common fracture type seen. The dome only pattern was the most common stable articular surface pattern. The sciatic corridor was available for fixation in all fracture types, followed by the gluteal pillar corridor. Most fractures had at least two corridors (93%) available for screw fixation., Conclusions: The findings of this study may aid in the development and evaluation of fixation strategies for acetabular cups allowing geriatric acetabular fracture patients earlier weight bearing after primary hip arthroplasty.

Lateral process fractures of the talus may occur either in isolation or in combination with a talar neck or body fracture. Screw fixation has been well described as a means of stabilization; however, many patients have multifragmentary fragments, unable to be controlled by isolated screw fixation alone. Plate fixation of the lateral process has been yet to be described in detail with presence of a clinical series. Here, we describe our technique of plate fixation for both isolated lateral process fractures and those that occur in conjunction with talar neck or body fracture.

Objectives: In patients with traumatic pelvic fracture urethral injuries (PFUI), the interaction between urethral management and orthopaedic decision making remains unknown. We aimed to survey orthopaedic and urologic surgeons to assess interdisciplinary interactions in the management of PFUI., Methods: An anonymous cross-sectional survey of members of the Orthopaedic Trauma Association (OTA) and the Society of Genitourinary Reconstructive Surgeons (GURS) was conducted between September 2017 and August 2018. Participants were queried regarding the impact of urethral injuries and their management on orthopaedic operative decision making., Results: Fifty-three GURS and 64 OTA members responded (17% response rate). For urethral injury management, 73% of OTA respondents preferred that suprapubic tubes (SPTs) were not placed for urethral injury management, whereas 43% of GURS respondents preferred SPTs (P = 0.08). Ninety-two percent of OTA respondents stated that SPTs increase hardware infection risks in patients undergoing pelvic open reduction with internal fixation (ORIF), whereas only 8% of GURS respondents agreed (P < 0.01). Although 66% of GURS respondents reported not considering the operative plans of orthopaedics when determining urethral management, 75% of OTA respondents reported that they were less inclined to proceed with ORIF, and 70% would perform external fixation in the setting of an SPT, despite 78% believing that this resulted in an inferior outcome for the patient., Conclusions: There is discordance between urologists and orthopaedists as to the optimal management of PFUI patients, with significant disagreement regarding the infectious risks of SPT in the setting of ORIF. Improved data and interdisciplinary dialogue are required to maximize patient outcomes., Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures., Design: Retrospective review., Setting: Level 1 academic trauma center., Patients/participants: Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period., Intervention: Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis., Main Outcome Measurements: Radiographic evidence of subtalar arthritis., Results: Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001)., Conclusion: Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Identify risk factors for early conversion to total hip arthroplasty (THA) in an effort to aid in counseling patients and selecting the optimal treatment for patients who sustain a fracture involving the posterior wall of the acetabulum., Design: Retrospective cohort analysis., Setting: Level I trauma center., Patients: Patients with acetabular fractures involving the posterior wall managed with open reduction internal fixation at least 4 years out from surgery., Intervention: Preoperative and postoperative computed tomography scans were reviewed for injury characteristics and reduction quality. Participants were contacted by telephone to document reoperations and functional outcomes including the SF-8 and modified Merle d'Aubigne Hip Scale., Main Outcome Measure: Conversion to THA., Results: The overall rate of conversion to THA was 5% at 2 years, 14% at 5 years, and 17% at 9 years. Presence of 5 specific radiographic features was associated with a 50% rate of conversion to THA in contrast to 11% if 4 or less features were present. Among cases with less than 1 mm of diastasis/step-off on postoperative computed tomography scan, there were no THA conversions, 10% conversion for 1-4 mm, and 54% if 4 mm or more of malreduction. There was no difference in SF-8 or modified Merle d'Aubigne scores comparing patients who underwent THA and those who did not., Conclusions: Acetabular fractures with posterior wall involvement are associated with a significantly higher rate of conversion to THA if reduction is not near-anatomic. A combination of clinical/radiographic findings is associated with poorer reductions and higher rate of conversion to THA., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Pediatric and adolescent pelvic ring injuries are frequently treated without surgery. In patients with unstable injuries to the pelvic ring, surgical stabilization aids in resuscitation, provides pain relief, and allows for mobilization. Percutaneous pelvic screw fixation is commonly performed in adult patients for unstable pelvic ring injuries, but a paucity of literature exists regarding their use in pediatric patients. The purpose of this study is to review the use, outcome, and management of percutaneous posterior pelvic screws in pediatric patients with unstable pelvic ring injuries., Methods: A retrospective review of a prospectively collected orthopaedic trauma database was performed over a 7-year period at a regional level-1 trauma center. All patients between the ages of 7 and 17 who sustained an injury to the pelvic ring and were treated with percutaneous fixation of the posterior pelvic ring were identified. We evaluated the frequency of this technique in the described patient population, incidence of nerve injury, infection, loss of fixation, and need for hardware removal., Results: A total of 238 pediatric patients who sustained a pelvic ring injury were initially identified; following application of study criteria, 67 (28.1%) patients were included in the study. Additional anterior ring fixation was performed in 33 (49.2%) patients. There were no iatrogenic nerve injuries, no infections, and surgical blood loss was <50 mL in all cases. Clinical and radiographic follow-up averaged 33 weeks. No loss of reduction was observed. Eight patients (13%) reported persistent low back pain at last follow-up. Elective hardware removal was performed in 3 patients., Conclusions: The majority of pediatric pelvic ring injuries can be treated without surgery. In the setting of instability, percutaneous pelvic screw fixation can be performed safely. A computed tomography scan is used to evaluate the available osseous pathways for screws and intraoperative fluoroscopy is used to safely perform this technique. Screw removal should be discussed in select patients., Level of Evidence: Level IV.

Surgical site infections lead to increased morbidity and health care costs. The use of local antibiotics in the form of powder applied to the surgical wound has significantly increased in orthopaedics. We have developed a technique to introduce local antibiotics in the form of a "putty," to be directly applied to surgical implants. This technique can potentially concentrate the antibiotics around the implant, where it is most needed to prevent bacterial colonization.

Background: The time dedicated to the study of human anatomy within medical school curriculums has been substantially reduced. The effect of this on the knowledge of incoming orthopaedic trainees is unknown. The current study aimed to evaluate both the subjective perceptions and objective anatomic knowledge of fourth-year medical students applying for orthopaedic residency., Methods: A multicenter prospective study was performed that assessed 224 students during the course of their interview day for an orthopaedic residency. Participants provided demographic data and a subjective assessment of the quality of their anatomic education, and completed either an upper or lower extremity anatomic examination. Mean total scores and subscores for various anatomic regions and concepts were calculated., Results: Students on average rated the adequacy of their anatomic education as 6.5 on a 10-point scale. Similarly, they rated the level of importance their medical school placed on anatomic education as 6.2 on a 10-point scale. Almost 90% rated the time dedicated to anatomy as good or fair. Of six possible methods for learning anatomy, dissection was rated the highest.On objective examinations, the mean score for correct answers was 44.2%. This improved to 56.4% when correct and acceptable answers were considered. Regardless of anatomic regions or concepts evaluated, percent correct scores did not reach 50%. There were no significant correlations between performance on the anatomic examinations and either prior academic performance measures or the student's subjective assessment of their anatomic education., Conclusions: Current students applying into orthopaedic residency do not appear to be adequately prepared with the prerequisite anatomic knowledge. These deficits must be explicitly addressed during residency training to produce competent, safe orthopaedic surgeons., Competing Interests: None of the authors has conflicts of interest to disclose. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, and patent/licensing arrangements) that might pose a conflict of interest in connection with the submitted article. Dr. Dawson or an immediate family member has stock or stock options held in Lineage Medical—Orthobullets. Dr. Firoozabadi or an immediate family member serves as a paid consultant for Smith & Nephew. Dr. Lee or an immediate family member serves as a board member, owner, officer, or committee member of the American Society for Surgery of the Hand. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Toogood, Dr. Shaw, Dr. Nussenbaum, Dr. Acosta, and Dr. Perkins.

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.

Ankle arthrodesis remains an important treatment option for patients with ankle arthritis. Many methods have been described; however, no consensus has been reached regarding the best technique to achieve both successful fusion and a good position for optimal foot mechanics. Furthermore, as arthroplasty has become more popular, preservation of the fibula to allow for future arthroplasty has become critical. The present report describes an innovative technique in which temporary external fixation at operative fixation is used, along with internal fixation, to achieve both an optimal foot position and high fusion rates, while maintaining the integrity of the fibula. Seventeen patients were identified who met the criteria for inclusion. Their medical records, including pre- and postoperative radiographs, were reviewed retrospectively. Preoperative and postoperative coronal and sagittal alignment was determined. All patients achieved successful fusion, although 1 (5.9%) patient experienced delayed union. The average tibial/talar ratio preoperatively was 21% (range 8% to 33%), demonstrating anterior subluxation. Postoperatively, this ratio improved to 33% (range 26% to 40%), approximating the normal anatomic ratio. Of the 17 patients, 5 (29.4%) had preoperative varus or valgus alignment of the talas >5°. All 5 cases were successfully corrected to within 2° of normal anatomic alignment. This technique allows the surgeon to achieve good visualization of the joint for preparation and to obtain the optimal position of the foot at arthrodesis without compromising the lateral column significance of the fibula. All patients obtained fusion, and minimal complications were associated with the use of this technique., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Talar fractures are some of the most challenging injuries that orthopaedic traumatologists manage. The current knowledge of functional alterations with regard to malreduction of talar fractures is well established. Decision making with regard to timing, approach, and implant selection as well as strategies to help achieve accurate restoration of talar anatomy substantially affect outcomes and must be carefully considered. Perfect anatomic talar reconstruction should always be attempted, and orthopaedic surgeons should have a strong working knowledge of the vascular, three-dimensional, and radiographic anatomy of the talus before performing talar surgery. Almost the entire talus is surgically accessible via several approaches, all of which surgeons should be clinically familiar with to optimize reduction and fixation and safely preserve the soft-tissue envelope. Furthermore, surgeons must appreciate the plantarmedial vascular area of the talus, which must be avoided during dissection. The complication rates in patients who have talar fractures are high, particularly in those who have talar neck and talar body fractures; therefore, patients should be counseled on their expected outcome, with a specific discussion on the risk of osteonecrosis and subtalar arthritis.

Background: Anterior pelvic ring surgery includes a variety of plating techniques and insertion of retrograde superior pubic ramus screws. Anterior acetabular surgery also includes fixation through an ilioinguinal or Stoppa approach. These exposures risk injury to the spermatic cord and accompanying genital branch of the genitofemoral nerve. The primary aim of this study was to identify the distance between the midline and the spermatic cords in adult male cadaveric specimens. The secondary aim was to determine spermatic cord diameters and measure the distance between the spermatic cord and implant during instrumentation of a retrograde superior pubic ramus medullary screw., Methods: Extended Pfannenstiel and Stoppa approaches were performed on 18 embalmed male cadavers bilaterally. Spermatic cord characteristics were recorded and a number of measurements were performed to determine the distance of implants and the midline from the spermatic cord., Results: The average distance between the midline and spermatic cords was 34.2 mm. The average distance between the spermatic cord and implant was 18.2 mm. Eleven of the thirty-six dissections had abnormalities including cord lipomas and inguinal hernias. The average cord diameter was 18.6 mm. The average cord diameter in those with abnormalities was 24.9 mm and 16 mm in those without abnormalities, this difference was statistically significant., Discussion: Due to the proximity of the spermatic cord, the surgeon should either formally expose the cord or limit lateral dissection from the midline during Pfannenstiel and Stoppa exposures. Similarly, the surgeon should use soft-tissue sleeves and oscillating drills to avoid injury to the contralateral spermatic cord during the insertion of retrograde superior pubic ramus medullary screws.

Background: Surgeons performing an ilioinguinal exposure for acetabular fracture surgery need to be aware of aberrant findings such as inguinal hernias and spermatic cord lesions. The purpose of this study is to report these occurrences in a clinical series of adult males undergoing acetabular fracture fixation and a series of adult male cadavers. The secondary aim is to characterize these abnormalities to aid surgeons in detecting these abnormalities preoperatively and coordinating a surgical plan with a general surgeon., Methods: Clinical study- Retrospective review of treated acetabular fractures through an ilioinguinal approach. Incidence of inguinal canal and spermatic cord abnormalities requiring general surgery consultation were identified. Corresponding CT scans were reviewed and radiographic characteristics of the spermatic cord abnormalities and/or hernias were noted. Cadaveric study- 18 male cadavers dissected bilaterally using an ilioinguinal exposure. The inguinal canal and the contents of the spermatic cord were identified and characterized., Results: Clinical Study- 5.7% (5/87) of patients had spermatic cord lesion and/or inguinal hernia requiring general surgical intervention. Preoperative pelvic CT scan review identified abnormalities noted intraoperatively in four of the five patients. Cord lipomas visualized as enlargements of the spermatic cord with homogeneous density. Hernias visualized as enlarged spermatic cords with heterogeneous density. Cadaver Study- 31% (11/36) of cadavers studied had spermatic cord and/or inguinal canal abnormalities. Average cord diameter in those with abnormalities was 24.9 mm (15-28) compared to 16 mm (11-22) in normal cords, which was statistically significant., Discussion: The clinical and cadaveric findings emphasize the importance of understanding inguinal abnormalities and the value of detecting them preoperatively. The preoperative pelvic CT scans were highly sensitive in detecting inguinal abnormalities.