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Introduction: Surgical repair of symptomatic, retracted rotator cuff tears unresponsive to non-operative treatments requires closure of the tear without undue tension and reattaching the torn tendon to its former insertion site. In this study, the length of the torn tendon edge was hypothesized to be longer than the length of the humeral insertion site. The objective of this study was to quantify the discrepancy in length of the torn tendon edge and the length of the avulsed humeral insertion site. Materials and methods Full thickness, rotator cuff tears that were found in twelve fresh frozen cadaver shoulders was studied. The length of the torn tendon edge, the length of the avulsed humeral insertion site and the retraction were measured using digital calipers. Results Each tear involved the supraspinatus and the infraspinatus was additionally torn in six. The size of the tear was medium in eight and large in four. The length of the torn tendon edge was always longer than the length of the avulsed humeral insertion site. Retraction was 29.9 ± 9.3 mm (range 21-48 mm). The repair ratio, defined as the ratio of length of torn tendon edge to the length of avulsed humeral insertion site, was 2.6 ± 0.4 (range 2.1-3.5). Conclusion As only the length of the torn tendon edge equal to the length of the avulsed humeral insertion site can be repaired to bone, a repair ratio more than one precludes a simple repair and an additional repair technique such as margin convergence would be necessary for the remaining unapproximated torn tendon edge in rotator cuff tears. Repair ratio may aid in selection of the surgical repair technique of these rotator cuff tears. © 2009 The Author(s).

Case: A 34-year-old man with a distal tibia bone defect was treated with an intramedullary bone transport nail (Precice Bone Transport System, NuVasive). During planned removal after successful treatment, 7 separate subcomponents of the nail became disconnected and had to be separately removed using specialized instrumentation. This occurred despite adherence to the manufacturer's recommended technique for nail removal and in the absence of clinical or radiographic evidence of implant failure., Conclusion: When planning for implant removal, surgeons should be aware of potential intraoperative disconnection of subcomponents of this magnetic bone transport nail and ensure that equipment for retrieval (e.g., very long endoscopy forceps) is available., Competing Interests: Financial Disclosure Statement: No author associated with this article has any relevant conflicts of interest to report. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C439)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation., Methods: All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate., Results: Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN., Conclusion: Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Patients with complex distal clavicle and acromioclavicular (AC) joint injuries are at risk of loss of reduction, especially when plates are removed postoperatively. The purpose is to review the authors' preferred technique for treatment of distal clavicle and AC joint injuries utilizing combined suture button and plate fixation, aiming to optimize biomechanical strength of fixation and limit loss of reduction after implant removal. Pre-contoured locking plates or hook plates were utilized atop suture buttons to maintain reduction and optimize biomechanical strength. At final follow-up over one year after plate removal and suture button retention in thirteen patients, reduction was maintained to coracoclavicular interval 1.5 ± 1.4 mm less than contralaterally. DASH scores at final follow-up averaged 5.7 ± 2.5 (range: 3.3 - 11.7). Placing suture button fixation prior to and beneath plate fixation in complex AC joint injuries and distal clavicle fractures allows for maintained fixation and prevents loss of reduction after plate removal., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment., Methods: A narrative review of the literature was performed., Results: During glenohumeral reduction, an iatrogenic humeral neck fracture may occur due to the presence of an occult neck fracture or forceful reduction attempts with inadequate muscle relaxation. Minimally displaced GT fragments after shoulder reduction can be successfully treated nonoperatively, but close follow-up is needed to monitor for secondary displacement of the fracture. Surgery is indicated for fractures with >5 mm displacement to minimize the risk of subacromial impingement and altered rotator cuff biomechanics. Multiple surgical techniques have been described and include both open and arthroscopic approaches. Strategies for repair include the use of transosseous sutures, suture anchors, tension bands, screws, and plates. Good-to-excellent radiographic and clinical outcomes can be achieved with appropriate treatment., Conclusions: GT fracture dislocations of the proximal humerus represent a separate entity from their isolated fracture counterparts in their evaluation and treatment. The decision to employ a certain strategy should depend on fracture morphology and comminution, bone quality, and displacement., (© 2023 The Author(s).)

Current evidence suggests at least one-third of humeral shaft fractures initially managed nonoperatively will fail closed treatment, and this review highlights surgical considerations in those circumstances. Although operative indications are well-defined, certain fracture patterns and patient cohorts are at greater risk of failure. When operative intervention is necessary, internal fixation through an anterolateral approach is a safe and sensible alternative. Determining which patients will benefit most involves shared decision-making and careful patient selection. The fracture characteristics, bone quality, and adequacy of the reduction need to be carefully evaluated for the specific operative risks for individuals with certain comorbid conditions, inevitably balancing the patient's expectations and demands against the probability of infection, nerve injury, or nonunion. As our understanding of the etiology and risk of nonunion and symptomatic malunion of the humeral diaphysis matures, adhering to the principles of diagnosis and treatment becomes increasingly important. In the event of nonunion, respect for the various contributing biological and mechanical factors enhances the likelihood that all aspects will be addressed successfully through a comprehensive solution. This review further explores specific strategies to definitively restore function of the upper extremity with the ultimate objective of an uninfected, stable union., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Purpose: Although several classifications are used to assess radiographs following radial head arthroplasty (RHA), including the Popovic classification for radiolucency, the Chanlalit classification for stress shielding (SS), the Brooker classification for heterotopic ossification (HO), and the Broberg-Morrey classification for radiocapitellar arthritis, little is known about the reliability of these classification systems. The purpose of this study was to determine the interobserver and intraobserver reliability of these classifications., Methods: Six orthopedic surgeons at various levels of training reviewed elbow radiographs of 20 patients who underwent RHA and classified them according to the Popovic, Chanlalit, Brooker, and Broberg-Morrey classifications for radiolucency, SS, HO, and RHA, respectively. Four weeks after initial review, radiographic reviews were repeated. Reliability was measured using the Fleiss kappa and the intraclass correlation coefficient. Agreement was interpreted as none (<0), slight (0.01-0.2), fair (0.21-0.4), moderate (0.41-0.6), substantial (0.61-0.8), and almost perfect (0.81-1) based on agreement among attending surgeons., Results: Among fellowship-trained attending surgeons, interobserver reliability was slight for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), fair for radiocapitellar arthritis (Broberg-Morrey) and HO (Brooker), and substantial for the ordinal interpretation of radiolucency (Popovic). Residents had a higher interobserver reliability than attending physicians when using the Brooker classification. Mean intraobserver reliability was fair for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), moderate for HO (Brooker) and radiocapitellar arthritis (Broberg-Morrey), and almost perfect for the ordinal interpretation of radiolucency (Popovic). Trainees had higher intraobserver reliability than attending surgeons using the SS (Chanlalit) classification., Conclusions: The number of Popovic zones is reliable for communication between physicians, but caution should be taken with the Brooker, Chanlalit, Broberg-Morrey, and categorical interpretation of the Popovic classifications. All the classifications had better intraobserver than interobserver reliability., Clinical Relevance: Reliability of classification systems for radiographic complications after RHA is less than substantial except the number of zones of radiolucency; therefore, caution is required when drawing conclusions based on these classifications., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Management of subtrochanteric femur fractures is challenging because of the multiple planes of fracture deformity. Specific techniques starting with patient positioning and appropriate operating room table selection can improve the efficiency of the surgery. Sequential reduction techniques starting with closed methods, percutaneous techniques, and finally open clamping can be performed to obtain anatomic reduction of the fracture. The gold standard implant for definitive fixation is a locked intramedullary nail and overall outcomes are excellent if anatomic alignment and stable fixation is achieved.

The management of femoral neck fracture in young and middle-aged adults remains challenging. Although the influence of timing on the outcome is controversial, surgical management within 12 hours is recommended. Reduction quality is the most important modifiable factor that is correlated with outcomes. The rates of osteonecrosis and nonunion remain high and the patients need to be informed of this at the beginning of treatment.

Treatment of displaced intra-articular calcaneal fractures is controversial and must be individualized by patient and fracture type. With an extensile lateral approach, all components of the deformity in displaced intra-articular calcaneal fractures can be addressed. The extensile lateral approach is indicated in more complex fracture patterns and when delay of surgery is necessary because of severe soft-tissue injury beyond 2 to 3 weeks. Careful patient selection, proper surgical timing, incision placement, and soft-tissue handling minimize the high rate of wound healing complications associated with the extensile lateral approach. The goals of surgical treatment of displaced intra-articular calcaneal fractures may also be achieved using less invasive approaches, such as the sinus tarsi approach and closed reduction with percutaneous fixation, decreasing the risk of wound complications. Multiple factors influence determination of the specific approach.

Diaphyseal femur fractures are common injuries globally and range in complexity. The most common mechanism worldwide is motor vehicle accidents. Initial evaluation should include Advanced Trauma Life Support protocol and evaluation of the soft tissues, neurovascular examination, and associated injuries. The gold standard for treatment is a closed functional reduction (restoration of length, alignment, and rotation) and fixation with a reamed, statically locked, intramedullary nail. Fracture pattern, associated injuries, and patient factors can increase the difficulty of treatment. Malrotation and limb length discrepancy are not uncommon. Awareness of the problem and knowledge of the how to obtain and verify adequate reduction is critical. Diagnosis of malrotation and/or limb length discrepancy should prompt a detailed discussion of the deformity and treatment options with the patient. Most patients recover remarkably well from diaphyseal femur fractures. They should be followed until union and return to prior functional level with a watchful eye placed on any warning signs of complications such as nonunion and infection.

Intertrochanteric hip fractures are among the most common osteoporotic fractures seen by orthopaedic surgeons. These fractures have a significant effect on a patient's mobility, independence, and mortality. In addition, they represent a substantial component of health care spending. Treatment is almost universally surgical, and surgeons must pay attention to patient optimization, fracture characteristics, and surgical planning. The goal of surgical intervention is to maximize the patient's ability to return to preinjury level of function by early postoperative mobilization. This can be achieved by obtaining and maintaining reduction to fracture healing.

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.

Glenohumeral instability causing bipolar bone loss is increasingly being recognized and treated to minimize recurrence. Large Hill-Sachs and reverse Hill-Sachs lesions of the humerus must be addressed at the time of surgery to prevent recurrent dislocations and restore the native anatomic track. For patients with epilepsy, locked dislocations may create defects that must be addressed with bony procedures, including osteochondral allograft reconstruction as soft-tissue remplissage may not adequately addresses the magnitude of the bone loss. Osteochondral allografts have been successfully used to address bony defects ranging from 20% to 30% of humeral bone loss whereas shoulder arthroplasty is indicated for larger defects where the native anatomy can no longer be restored. In this Technical Note, we present a technique to address concomitant large Hill-Sachs and reverse Hill-Sachs lesions., (© 2022 The Authors.)

While there are multiple reports on venous thromboembolism (VTE) associated with several orthopedic procedures, the knowledge regarding incidence and risk factors of VTE in tibial plateau fractures is limited. This study aimed to investigate the incidence and risk factors of clinically important venous thromboembolism (CIVTE) in patients with tibial plateau fractures. All adult patients who underwent surgical treatment of tibia plateau fractures between 2003 and 2018 in our level 1 trauma center were included in the study. All patients suspected CIVTE were assessed by the ultrasonography and/or CT scan. Univariate and multivariate analysis were used to evaluate the association between potential risk factors and CIVTE Variables. Thirty-nine of 462 patients (8.4%) developed clinically important venous thromboembolism, in which pulmonary embolism (PE) and deep vein thrombosis (DVT) were observed in 18 (3.9%) and 21 (4.54%) patients, respectively. Male gender (OR 9.75; 95% CI 2.34-40.66), spine injury (OR 9.51; 95% CI 3.39-26.64), other extremity injury (OR 3.7; 95% CI 1.58-8.66), length of stay in ICU (OR 1.14; 95% CI 1.09-1.2) were all risk factors for CIVTE. The incidence of CIVTE in tibial plateau fracture was relatively high (8.4%); The male gender, spine injury, other extremity injury, length of stay in ICU were the independent risk factors., (© 2022. The Author(s).)

Objectives: To quantify the total hospital costs associated with the treatment of lower extremity long-bone fracture aseptic and septic unhealed fracture, to determine if insurance adequately covers these costs, and to examine whether insurance type correlates with barriers to accessing care., Design: Retrospective cohort study., Setting: Academic Level II trauma center., Patients: All patients undergoing operative treatment of OTA/AO classification 31, 32, 33, 41, 42, and 43 fractures between 2012 and 2020 at a single Level II trauma center with minimum of 1-year follow-up., Main Outcome Measures: The primary outcome was the total cost of treatment for all hospital-based episodes of care. Distance traveled from primary residence was measured as a surrogate for barriers to care., Results: One hundred seventeen patients with uncomplicated fracture healing, 82 with aseptic unhealed fracture, and 44 with septic unhealed fracture were included in the final cohort. The median cost of treatment for treatment of septic unhealed fracture was $148,318 [interquartile range(IQR) 87,241-256,928], $45,230 (IQR 31,510-68,030) for treatment of aseptic unhealed fracture, and $33,991 (IQR 25,609-54,590) for uncomplicated fracture healing. The hospital made a profit on all patients with commercial insurance, but lost money on all patients with public insurance. Among patients with unhealed fracture, those with public insurance traveled 4 times further for their care compared with patients with commercial insurance (P = 0.004)., Conclusions: Septic unhealed fracture of lower extremity long-bone fractures is an outsized burden on the health care system. Public insurance for both septic and aseptic unhealed fracture does not cover hospital costs. The increased distances traveled by our Medi-Cal and Medicare population may reflect the economic disincentive for local hospitals to care for publicly insured patients with unhealed fractures., Level of Evidence: Economic Level V. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: 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., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Interdisciplinary standardized protocols for the care of patients with hip fractures have been shown to improve outcomes. A hip fracture protocol was implemented at our institution to standardize care, focusing on emergency care, pre-operative medical management, operative timing, and geriatrics co-management. The aim of this study was to evaluate the efficacy of this protocol., Methods: We conducted a retrospective review of adult patients admitted to a single tertiary care institution who underwent operative management of a hip fracture between July 2012 and March 2020. Comparison of patient characteristics, hospitalization characteristics, and outcomes were performed between patients admitted before and after protocol implementation in 2017., Results: A total of 517 patients treated for hip fracture were identified: 313 before and 204 after protocol implementation. Average age, average Charlson Comorbidity Index, percent female gender, and distribution of hip fracture diagnosis did not vary significantly between groups. There was a significant reduction in time from admission to surgical management, from 37.0 ± 47.7 to 28.5 ± 27.1 h (p = 0.0016), and in the length of hospital stay, from 6.3 ± 6.5 to 5.4 ± 4.0 days (p = 0.0013). The percentage of patients whose surgeries were performed under spinal anesthesia increased from 12.5 to 26.5% (p = 0.016). There was no difference in 90-day readmission rate or mortality at 30 days, 90 days, or 1 year between groups., Conclusion: With the implementation of an interdisciplinary hip fracture protocol, we observed significant and sustained reductions in time to surgery and hospital length of stay, important metrics in hip fracture management, without increased readmission or mortality. This has implications to minimize health care costs and improve outcomes for our aging population., Level of Evidence: III, therapeutic., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, DE part of Springer Nature.)

Purpose: Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures. The aim of this study was to characterize the risk of RHA failure with respect to the stem angle in anatomic RHA design., Methods: A retrospective review of patients who underwent anatomic RHA for acute fractures between 2006 and 2019 at 2 academic centers was conducted. Initial postoperative elbow radiographs were reviewed to measure RSA on the anterior-posterior and lateral views. Radiolucency, stress shielding, and radiocapitellar arthritis were also evaluated. Implant failure was defined as prosthesis removal or revision., Results: Implant failure was associated with significantly larger lateral RSA than that in intact implants. Increasing stem shaft angle on a lateral radiograph was associated with decreased implant survival. Radiolucency, stress shielding, and radiocapitellar arthritis were similar between the 2 groups., Conclusions: Anatomic radial head implants are commonly used; however, the importance of prosthesis positioning, specifically that of the stem within the proximal radius, remains understudied. Higher RSA is associated with the risk of implant failure and need for revision., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2022. Published by Elsevier Inc.)

Perioperative pain management remains an important focus of both patient and provider attention in orthopaedic trauma surgery. There is a constant effort to improve pain management while decreasing opioid consumption, and peripheral nerve blocks are a safe and effective way to achieve these two goals. This is particularly relevant because more procedures are being done in outpatient surgery centers, and the need to safely provide analgesia without the systemic risk of opioid medications is paramount. The primary goal of this article was to describe the diagnosis-based approach for the utilization of preoperative peripheral nerve blocks in perioperative care for orthopaedic trauma surgery procedures based on the experience and current practice at our center., (Copyright © 2021 by the American Academy of Orthopaedic Surgeons.)

Case: A 29-year-old man previously treated with closed reduction and intramedullary nail (IMN) fixation for a right tibial shaft fracture presented with complaint of the foot pointing outward compared with uninjured side. He was diagnosed with tibial malrotation, and a novel intraoperative imaging technique was used for correction., Conclusion: Literature suggests that the prevalence of tibial malrotation after IMN fixation is greater than previously thought. This case highlights the need for a simple and reliable intraoperative approach to guide and confirm correction of tibial malrotation after IMN fixation, and it demonstrates a technique that can be implemented with immediate results., 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/B602)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Aims: While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty., Methods: In 2017, our institution introduced a standardized interdisciplinary hip fracture protocol. We retrospectively reviewed adult patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fracture between July 2012 and March 2020, and compared patient characteristics and outcomes between those treated before and after the introduction of the protocol., Results: A total of 157 patients were treated before the introduction of the protocol (35 (22.3%) with a THA), and 114 patients were treated after its introduction (37 (32.5%) with a THA). The demographic details and medical comorbidities were similar in the two groups. Patients treated after the introduction of the protocol had a significantly reduced median time between admission and surgery (22.8 hours (interquartile range (IQR) 18.8 to 27.7) compared with 24.8 hours (IQR 18.4 to 43.3) (p = 0.042), and a trend towards a reduced mean time to surgery (24.1 hours (SD 10.7) compared with 46.5 hours (SD 165.0); p = 0.150), indicating reduction in outliers. Patients treated after the introduction of the protocol had a significantly decreased rate of major complications (4.4% vs 17.2%; p = 0.005), decreased median hospital length of stay in hospital (4.0 days vs 4.8 days; p = 0.008), increased rate of discharge home (26.3% vs 14.7%; p = 0.030), and decreased one-year mortality (14.7% vs 26.3%; p = 0.049). The 90-day readmission rate (18.2% vs 21.7%; p = 0.528) and 30-day mortality (3.7% vs 5.1%; p = 0.767) did not significantly differ. Patients who underwent HA were significantly older than those who underwent THA (82.1 years (SD 10.4) vs 71.1 years (SD 9.5); p < 0.001), more medically complex (mean Charlson Comorbidity Index 6.4 (SD 2.6) vs 4.1 (SD 2.2); p < 0.001), and more likely to develop delirium (8.5% vs 0%; p = 0.024)., Conclusion: The introduction of an interdisciplinary protocol for the management of elderly patients with a femoral neck fracture was associated with reduced time to surgery, length of stay, complications, and one-year mortality. Such interventions are critical in improving outcomes and reducing costs for an ageing population. Cite this article: Bone Joint J  2021;103-B(7 Supple B):3-8.

Objective: This study aimed to compare the efficacy and safety of the new method including 3D printing-based preoperative planning, surgical workshop, and contouring of the plate versus conventional method in the surgical treatment of complex acetabular fractures., Methods: We retrospectively analyzed the data in a cohort of 88 patients of complex acetabular fracture with mean 29.95 ± 4.84 months (24-41 months) follow-up. Patients were divided into two groups. Group 1 consisting of 41 patients were performed previewed surgery with a 3D printing-based pre-contoured plate on a 3D printing model. Group 2, comprised of 47 patients, were treated by the traditional contoured plate technique. The quality of reduction was assessed using criteria described by Matta. Functional outcome was evaluated using Modified Postel Merle D'Aubigne score. A custom-made quiz was used to evaluate the chief assistant., Results: The study showed no significant differences in measured preoperative variables except for the age between the Group 1 and Group 2 (p > 0.05). Compared with the Group 2, the intraoperative blood loss, operative time was significantly decreased in Group 1 (p < 0.05). There were no significant statistical differences in the quality of reduction and Modified Postel Merle D'Aubigne score (p > 0.05). The result of evaluation of assistant in Group 1 was significantly high than in Group 2 (p < 0.05)., Conclusion: 3D printing-based pre-contoured plate is a more effective and reliable method than traditional contoured plate technique for treating the complex acetabular fractures. Meanwhile, the 3D printing is a useful orthopedic surgical education tool which can improve the understanding of the complex acetabular fracture for a young surgeon.

Tibial plafond fractures include a wide spectrum of injuries that show their complexity. Soft-tissue injury in tibial plafond fractures is much more important than bony injury. Commonly, a staged treatment, that is, temporary external fixation followed by definitive surgery when the soft tissue is ready, is performed. Knowledge of multiple surgical approaches is a prerequisite for open reduction and internal fixation of tibial plafond fractures because of the large variation of fracture patterns.

Metadiaphyseal proximal radius fractures blur the distinction between the radial neck and radial shaft fractures. Operative management presents unique technical challenges both in terms of surgical approach and fixation method. We discuss relevant anatomy, safe surgical approach, and options and techniques for fracture fixation. We describe 6 patients who achieved satisfactory functional outcomes, even in cases of severe bone loss secondary to ballistic trauma. An extensile dorsal approach with exposure of the posterior interosseous nerve is recommended when normal soft tissue intervals have not already been extensively disrupted. Robust fixation can be achieved by contouring and repurposing a variety of plates such as a variety of mini fragment plates (2.4 mm T or Y-plates), flexible nails, or even distal radius plates., Competing Interests: Conflict of Interest and Source of Funding: J.T.P. reports research support from AOTrauma North America. I.I. reports stock or stock options in ROM3, payment for presenting or speaking for Skeletal Dynamics, and is a board or committee member American Society for Surgery of the Hand. N.H.L. is a board or committee member American Society for Surgery of the Hand. For the remaining authors none were declared., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: Antibiotic administration, severity of injury, and debridement are associated with surgical site infection (SSI) after internal fixation of open fractures. We sought to validate a time-dependent treatment effect of antibiotic administration., Patients: Consecutive open fracture patients at a level 1 trauma center with minimum 30-day follow-up were identified from an orthopaedic registry from 2013-2017., Methods: The primary endpoint was SSI within 90 days. A threshold time to antibiotic administration associated with SSI was ascertained by receiver-operator analysis. A Cox proportional hazards model adjusted for age, smoking, and drug use determined the treatment effect of antibiotic administration within the threshold period., Results: Ten percent of 230 patients developed a SSI. There was a trend for patients who did not develop an SSI to receive antibiotics earlier than those who did develop an SSI (61 minutes, IQR 33-107 vs 83 minutes, IQR 40-186), p=0.053). Intravenous antibiotic administration after 120 minutes of presentation of an open fracture to emergency department was significantly associated with a 2.4 increased hazard of surgical site infection (p=0.036) within 90 days., Conclusion: Antibiotic administration greater than 120 minutes after ED presentation of an open fracture was associated with an increased risk of SSI., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Trauma remains one of the largest problems that the global healthcare system faces today. In the United States it remains the leading cause of death for young and middle-aged patients, and its economic burden in direct cost and loss of productivity is tremendous. Additionally, the challenge of acute pain control in orthopaedic trauma remains substantial, and the over-reliance on opioid medications has resulted in unintended acute and chronic complications and problems. Alternative pain control strategies, such as peripheral nerve block (PNB), have the potential to decrease healthcare cost, opioid consumption, and other opioid-related complications. The purpose of this review is to summarize the current state of pain control and opioid use in acute orthopaedic injury and provide an understanding of the role of PNB to improve pain management. Finally, this review provides a specific diagnosis-based treatment guideline for the use of PNB in acute orthopaedic injury., Competing Interests: Declaration Competing of Interest No authors have any relevant disclosures, (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Case: Ciprofloxacin is increasingly used as oral suppressive therapy for musculoskeletal infections. Delirium and acute hypoglycemia are little-known, severe potential adverse drug reactions. We report here on a patient who experienced both complications. The patient is a 56-year-old woman with no psychiatric history who was managed for left lower extremity chronic osteomyelitis after fracture fixation. She developed significant, prolonged delirium and intermittent hypoglycemia within 24 hours of starting ciprofloxacin; both symptoms remitted within 24 hours of drug discontinuation., Conclusions: The neuropsychiatric complications of ciprofloxacin are under-discussed, given its frequency of use, and merit greater awareness for the prevention of postoperative delirium.

Hypothesis: This study aimed to evaluate the safety and efficacy of the fixation of Dubberley type B capitellar and trochlear fractures using dorsolateral anatomic plates with support of the distal humerus (DAPSDHs)., Methods: Fifteen patients with Dubberley type B capitellar and trochlear fractures (two type 1B, five type 2B, and eight type 3B) were treated through the extended lateral approach, and fixation was achieved with DAPSDHs. Radiographic evaluation was performed, and range of motion of the elbow and forearm was recorded. Functional outcomes were assessed using the Mayo Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand score., Results: The mean follow-up period was 32.5 months (range, 24-54 months). Fracture union was achieved in all cases. At the final follow-up, range of motion was as follows: flexion, 123.7° ± 8.1° (range, 110°-135°); lack of extension, 11.0° ± 7.1° (range, 5°-30°); pronation, 81.7° ± 5.6° (range, 70°-90°); and supination, 78.7° ± 5.2° (range, 70°-85°). At the final follow-up, the mean Disabilities of the Arm, Shoulder and Hand score was 11.9 ± 4.0 (range, 4.2-20.8) and the mean Mayo Elbow Performance Score was 89.0 ± 7.1 (range, 70-95). The outcome was rated as excellent in 12 patients (80.0%), good in 2 (13.3%), and fair in 1 (6.7%). Avascular necrosis of the capitellum developed in 1 patient. One patient had implant irritation. Heterotopic ossification developed in 1 patient. Ten patients returned to their previous activity levels., Conclusion: Capitellar and trochlear fractures with posterior comminution are safely and effectively treated through the extended lateral approach using DAPSDHs, resulting in good radiographic and functional outcomes., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: Mini-fragment plates (MFPs) are increasingly used in fracture surgery to provide provisional fixation. After definitive fixation, the surgeon decides whether to remove the plates or leave them in place as additional fixation, based on the perceived biomechanical influence of the MFP. However, there are no current biomechanical studies to guide this decision. Therefore, the purpose of this study was to evaluate the influence of MFPs on the four-point bending and torsional stiffness of long bone transverse and simple wedge fracture fixation constructs., Methods: Fourth-generation composite bone cylinders were cut to produce transverse (AO-OTA classification 12-A3) and simple wedge (AO-OTA classification 12-B2) fracture models. The specimens were fixed using a low-contact dynamic compression plate (LC-DCP) and MFPs. Specimens were tested in four-point bending and torsion utilizing 3 different MFP orientations., Results: No statistically significant differences in bending stiffness were found between control and MFP groups for transverse fracture constructs. MFPs significantly increased the bending stiffness for wedge fracture constructs under certain loading conditions. This increase was observed when MFPs were positioned both orthogonal (85.1% increase, P =  .034) and opposite (848.2% increase, P <  .001) to the LC-DCP. MFPs significantly increased the torsional stiffness for both transverse and wedge fracture constructs when MFPs were positioned both orthogonal (transverse: 27.7% increase, wedge: 16.7% increase) and opposite (transverse: 28.4%, wedge: 24.2% increase) to the LC-DCP., Conclusions: Our results indicate that including MFPs in definitive fixation can increase the bending and torsional stiffness of a long-bone fracture fixation construct. This suggests that the biomechanical influence of MFPs should be considered. However, clinical studies will be required to test the applicability of these findings to the clinical setting., Competing Interests: Conflicts of Interest: Implants and materials for this study were provided by Synthes Corporation through a research grant., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

This study aimed to investigate the incidence and risk factors for deep vein thrombosis (DVT) in patients with pelvic and acetabular fractures. Patients with pelvic or acetabular fractures were included. Demographic data, fracture classification, time to surgery, and d-dimer levels at admission and one day after surgical intervention were recorded. Duplex ultrasonography was performed in the lower extremities for DVT evaluation. All patients received mechanical and chemical thromboprophylaxis. One hundred ten patients with a mean age of 44.2 ± 13.8 years were included. There were 48 patients with pelvic fractures and 62 patients with acetabular fractures. Thirty-two (29.09%) patients sustained DVT; 21 (19.09%) patients exhibited proximal thrombosis, and 3 patients suffered pulmonary embolism. The incidence of DVT in patients with acetabular fractures was significantly higher than that of patients with pelvic fractures (χ 2 = 4.42, P = .04). The incidence of proximal DVT was significantly higher in patients with complex acetabular fractures than in patients with simple acetabular fractures (χ 2 = 6.65, P = .01). Multivariate analysis showed that age older than 60 years, associated injuries, and the time to surgery longer than 2 weeks were independent risk factors ( P < .05). Despite mechanical and chemical thromboprophylaxis, the risk of DVT in patients with pelvic and acetabular fractures is still very high, and most of the thromboses were localized proximally. The risk of DVT is higher in patients older than 60 years, in those with associated injuries, and when the time from injury to operation is more than 2 weeks.

Purpose: To determine perioperative incidence and locations of deep vein thrombosis (DVT) in injured and uninjured lower extremities following isolated lower extremity fractures (ILEFs)., Methods: Retrospective analysis of a prospectively collected data of a consecutive patient series with ILEFs who underwent surgical treatment between September 2014 and September 2017 was performed. Patients' bilateral lower extremities were screened for DVT with duplex ultrasonography (DUS) before and after surgery. DVT occurrence was analyzed by location of DVT and fracture site. All patients received pharmacologic thromboprophylaxis while hospitalized. Data on demographics, time to surgery, time of DUS examinations, length of hospital stay and symptomatic pulmonary embolism (PE) was collected., Results: 1825 patients were included in the study. The incidence of symptomatic PE was 1.6%. All patients were screened with DUS of the bilateral lower extremities in a mean of 3.5 days (range: 0-18 days) after injury, and a mean of 3.6 days (range: 1-11 days) after surgery. Preoperative DUS detected DVT in 547 patients (30.0%), including 3.7% of patients with proximal DVT. 792 patients (43.4%) were found to have a DVT postoperatively, but only 6.2% of patients with proximal DVT. Proximal DVT was detected postoperatively of the represented fractures: 6.5% of the hip, 14.5% of the femoral shaft, 4.5% of the tibial plateau, 4.6% of the tibial shaft, 1.7% of the patellar, and 2.0% of the peri-ankle. Interestingly, the rate of DVT in an uninjured lower limb was significantly higher postoperatively compared to preoperatively (16.4% vs. 4.9%), however, only 0.2% of patients had proximal DVT., Conclusions: While the perioperative incidence of overall DVT is high following ILEFs, the majority were distal DVT, and the rate of symptomatic PE was low. Femoral shaft fractures were associated with the highest incidence for proximal DVT. The incidence was lower in more distal fractures. The majority of patients diagnosed with DVT postoperatively had already shown symptoms of DVT prior to surgery. DVT can occur in both the injured and uninjured leg, with an obviously higher incidence in the injured leg. The incidence of proximal DVT in an uninjured leg is rare., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

With advances in osteosynthesis technology providing improved stability of fixation and better outcomes, surgical treatment has become the standard of care for distal femur fractures. Pre-contoured distal femoral locking plates are the most commonly used implants for fixation. However, healing problems such as delayed union, failure of fixation, and /or nonunion are not uncommon. The fixation construct being "too stiff" is a commonly quoted reason when nonunion/failure of fixation occurs on distal femur fractures fixed with a plate. A flexible fixation construct allowing controlled axial micromotion could help stimulate the bone healing. In order to achieve this goal, plating construct stiffness can be modified by several methods., (© 2018 Elsevier Ltd. All rights reserved.)

Objectives: To investigate whether (1) the type of fixation at the shaft (hybrid vs. locking), (2) the position of the plate (offset vs. contact) and (3) the implant material has a significant effect on (a) construct stiffness and (b) fatigue life in a distal femur extraarticular comminuted fracture model using the same design of distal femur periarticular locking plate., Methods: An extraarticular severely comminuted distal femoral fracture pattern (OTA/AO 33-A3) was simulated using artificial bone substitutes. Ten-hole distal lateral femur locking plates were used for fixation per the recommended surgical technique. At the distal metaphyseal fragment, all possible locking screws were placed. For the proximal diaphyseal fragment, different types of screws were used to create 4 different fixation constructs: (1) stainless steel hybrid (SSH), (2) stainless steel locked (SSL), (3) titanium locked (TiL), and (4) stainless steel locked with 5-mm offset at the diaphysis (SSLO). Six specimens of each construct configuration were tested. First, each specimen was nondestructively loaded axially to determine the stiffness. Then, each specimen was cyclically loaded with increasing load levels until failure., Results: Construct Stiffness: The fixation construct with a stainless steel plate and hybrid fixation (SSH) had the highest stiffness followed by the construct with a stainless steel plate and locking screws (SSL) and were not statistically different from each other. Offset placement (SSLO) and using a titanium implant (TiL) significantly reduced construct stiffness. Fatigue Failure: The stainless steel with hybrid fixation group (SSH) withstood the most number of cycles to failure and higher loads, followed by the stainless steel plate and locking screw group (SSL), stainless steel plate with locking screws and offset group (SSLO), and the titanium plate and locking screws group (TiL) consecutively. Offset placement (SSLO) as well as using a titanium implant (TiL) reduced cycles to failure., Conclusions: Using the same plate design, the study showed that implant material, screw type, and position of the plate affect the construct stiffness and fatigue life of the fixation construct. With this knowledge, the surgeon can decide the optimal construct based on a given fracture pattern, bone strength, and reduction quality.

Objectives: The goal of this study is to compare the fatigue strength of a locking intramedullary nail (LN) construct with a double locking plate (DLP) construct in comminuted proximal extra-articular tibia fractures., Methods: Eight pairs of fresh frozen cadaveric tibias with low bone mineral density [age: 80 ± 7 (SD) years, T-score: -2.3 ± 1.2] were used. One tibia from each pair was fixed with LN, whereas the contralateral side was fixed with DLP for complex extra-articular multifragmentary metaphyseal fractures (simulating OTA 41-A3.3). Specimens were cyclically loaded under compression simulating single-leg stance by staircase method out to 260,000 cycles. Every 2500 cycles, localized gap displacements were measured with a 3D motion tracking system, and x-ray images of the proximal tibia were acquired. To allow for mechanical settling, initial metrics were calculated at 2500 cycles. The 2 groups were compared regarding initial construct stiffness, initial medial and lateral gap displacements, stiffness at 30,000 cycles, medial and lateral gap displacements at 30,000 cycles, failure load, number of cycles to failure, and failure mode. Failure metrics were reported for initial and catastrophic failures., Results: DLP constructs exhibited higher initial stiffness and stiffness at 30,000 cycles compared with LN constructs (P < 0.03). There were no significant differences between groups for loads at failure or cycles to failure., Conclusions: For the fixation of extra-articular proximal tibia fractures, a LN provides a similar fatigue performance to double locked plates. The locked nail could be safely used for fixation of proximal tibia fractures with the advantage of limited extramedullary soft tissue damage.

Purpose: The goal of this study was to evaluate the safety and efficacy of a new technique for posterior column fixation through the standard ilioinguinal approach., Methods: We conducted a retrospective review involving 33 consecutive patients with complex acetabular fractures treated using a short buttress plate fixation of posterior column through single ilioinguinal approach. Radiographic evaluation was performed using criteria described by Matta. Functional outcome was assessed using modified Postel Merle D'Aubigné score., Results: Between 2008 and 2013, 33 adult patients with mean age of 46 years and mean follow up of 37.5 months were enrolled. Anatomic reduction was obtained in 61 % of cases, imperfect reduction in 24 % of cases and poor reduction in 15 % of cases. The average modified Merle d'Aubigné score was 15: categorized as excellent in seven, good in 18, fair in three, and poor in four. One patient died at 15 days because of pulmonary embolism. Four patients sustained temporary lateral femoral cutaneous palsy. At final follow up, two patients had severe post-traumatic arthritis; one of them underwent a total hip arthroplasty at 93 months. None of the patients had loss of reduction., Conclusions: A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures is a safe and effective method.

Objective: The aim of this study was to investigate the utility of direct measurement of tissue oxygenation during compartment syndrome (CS) and tourniquet-induced ischemia in a large animal model. We hypothesize that as compartment pressure (CP) rises, circulation within the compartment will decrease resulting in a decreased level of oxygen in the muscle., Methods: This study used a dog model of both CS- and tourniquet-based ischemia. In 15 animals, CS was induced in 1 hind limb with varying degrees of severity using an infusion model. Tourniquet ischemia was induced in the contralateral hind limb for varying durations. The partial pressure of oxygen (PmO2) was continuously monitored using a polarographic oxygen probe in the muscle of both hind limbs. CP was monitored in the CS limb. PmO2 and CP were analyzed after fasciotomy, performed after approximately 7 hours of warm ischemia, or release of tourniquet., Results: With the application of tourniquet ischemia, PmO2 fell from 38.40 to 1.30 mm Hg (P < 0.001) and subsequently rose after release of the tourniquet to 39.81 mm Hg (P < 0.001). Elevated CP induced by infusion was relieved by fasciotomy (52.04-11.37 mm Hg postfasciotomy, P < 0.001). PmO2 readings in the infusion model were significantly higher in pre-CS than during CS (31.77 mm Hg vs. 3.88 mm Hg, P < 0.001) and rebounded after fasciotomy (50.24 mm Hg, P < 0.001), consistent with hyperemic response., Conclusions: Increased CP caused an observable decrease in PmO2 that was reversed by fasciotomy. PmO2 can be directly measured in real time with a polarographic tissue pO2 probe. This study is the first step of evaluating an alternative method for diagnosing acute CS.

Objectives: The use of fluoroscopy for indirect guidance in orthopaedic trauma surgery has increased. The purpose of this investigation was to assess how real-time visualization of radiation exposure impacts dose levels during orthopaedic trauma operations., Design: Observational comparative study., Setting: Level 1 trauma center orthopaedic trauma surgery operating room., Patients/participants: The participants in this study were 83 patients with fractures of the ankle, tibia, femur, or acetabulum receiving definitive surgical fixation of their fracture; children under 18 years of age were excluded from the study. Fellowship trained orthopaedic trauma surgeons, resident orthopaedic surgeons, radiology technicians, and scrub nurses involved in the operations on included fracture patients were also participants., Intervention: Real-time radiation exposure feedback from the Philips DoseAware device., Main Outcome Measurements: Radiation exposure from fluoroscopy compared between phase 1, during which participants were blinded to exposure levels, and phase 2, during which participants were able to see exposure levels in real time., Results: Overall mean radiation exposure was decreased by 60% in phase 2 compared with phase 1 (P = 0.023). Mean surgeon (MS; average of primary and assistant surgeon) and mean nonsurgeon personnel (average of x-ray technician, scrub nurse, and patient) radiation exposures were decreased from phase 1 to phase 2, by 58% and 80%, respectively (MS, P = 0.034; mean nonsurgeon personnel, P = 0.043). From phase 1 to phase 2, MS radiation for femoral shaft fractures decreased by 80% or 162.0 μSv (P = 0.02) and by 81% or 128.9 μSv (P = 0.014) for acetabular fractures., Discussion: Our data demonstrate that real-time visualization of radiation exposure during orthopaedic trauma operations can decrease radiation exposure in the highest exposure cases. Further research is necessary to determine whether the reduction in radiation exposure is sustained over time and to understand how real-time radiation exposure data mitigates exposure., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Proximal humerus fractures are commonly treated with open reduction and internal fixation with periarticular locking plates. This study compared the geometry of proximal humerus locking plate's screw distribution, amount of bone-screw interface, and the volume the screws occupy within the humeral head, as well as how leaving the screws short of the articular surface affects these measures., Methods: Locking plates from 7 manufacturers were applied to foam humerus models. The entry and exit hole of each screw trajectory was digitized using a 3-dimensional motion tracking system. A trajectory for each screw was modeled, as well as the volume enclosed by the screw trajectories. The following outcome metrics were calculated: the bone-screw interface, the volume enclosed by the screws, and the effect of leaving the screws short of the articular surface., Results: Biomet had the most bone-screw interface (7259 mm), whereas Zimmer had the least (3982 mm). The original Synthes plate had the largest screw volume, occupying 31.5% of the humeral head, whereas Smith & Nephew and Zimmer had the lowest volumes, occupying 21.2% and 12.6%, respectively. Leaving the screws 15 mm short of the articular surface resulted in the most reduction in volume for the Depuy plate (50%) and the least reduction for the new version of the Synthes plate (29%)., Conclusions: Many different manufactured periarticular locking plates exist to stabilize a proximal humeral fracture. Clinicians need to be familiar with the different plate configurations, screw lengths, and trajectories, which affect potential biomechanical performance and can optimize fracture site maintenance.

Outcomes after operative treatment of displaced femoral neck fractures in young adults are fraught with high complications rates including non-union and avascular necrosis. Among the therapeutic controversies that persist is the role of open reduction, which would allow surgeons a direct means to improve the quality of reduction, a predictor of successful treatment. We performed a systematic review of the literature to compare the outcomes (nonunion, avascular necrosis, and deep infection) after open reduction with internal fixation (ORIF) to closed reduction with internal fixation (CRIF) of acute (surgery performed less than 6 weeks from injury) femoral neck fractures in young adults (average age of 50 or younger) followed for at least one year. Despite the large literature investigating outcomes after operative treatment of femoral neck fracture, relatively few studies aimed to determine the relative risk of complications associated with method of reduction. Therefore, both observational and randomised studies as well as case series with clear descriptions of surgical approach and outcomes were included. We identified 21 studies that matched our inclusion criteria. The incidence of nonunion was 11.6% in closed reduction and 14.9% in the open reduction group (P=0.25). The incidence of avascular necrosis for CRIF and ORIF were 17.2% and 17.7% respectively (P=0.91). The incidence of deep wound infection was 0.49% in the closed reduction group and 3.9% in the open reduction group (P=0.0019). Meta-analysis of risk ratios estimated from six of the studies with comparative data revealed no significant difference in the incidence of nonunion, avascular necrosis or total complications between the two reduction techniques. In summary, systematic review of the literature reveals a lack of evidence in support of ORIF versus CRIF as a means of treating displaced femoral neck fractures in young patients with respect to union and avascular necrosis; however, the incidence of surgical site infections may be lower with CRIF. Firm conclusions cannot be drawn given the lack of high quality prospective studies and patient reported outcomes. In the future, randomised controlled trials will be required to test the effect of reduction method., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: The correct usage of preoperative and intraoperative imaging allows fixation of posterior pelvic ring injuries with safely positioned iliosacral screws in the setting of sacral dysmorphism., Step 1 Preoperative Planning: Obtain CT reformats along the longitudinal axis of the sacrum to determine the orientation and diameter of the osseous corridor for selection of the ideal screw size, length, and trajectory., Step 2 Patient Positioning: Proper positioning enables reduction and accurate iliosacral screw placement., Step 3 Fracture Reduction: Reduction of the posterior pelvic ring confers stability; if closed reduction is unsuccessful, proceed with open reduction., Step 4 Identification of the Entry Point: The entry point for an iliosacral screw into the upper sacral segment of a dysmorphic pelvis lies more posterior and caudal on the outer table of the posterior ilium than does a transsacral screw; adjust the entry point on the basis of inlet and outlet fluoroscopic views., Step 5 Drilling Technique: Insert a stout cannulated drill bit of 4.5 to 5 mm (depending on the core diameter of the intended iliosacral screw) over the Kirschner wire and drill it into the sacral body under fluoroscopic guidance, in accordance with the preoperative plan., Step 6 Screw Insertion: With the guidewire in the ideal position, measure the screw length off the inserted guidewire and advance a tap into the pathway; insert the screw and verify its position on the inlet, outlet, and lateral sacral views., Results: Understanding the three-dimensional anatomy of the posterior pelvic ring is essential to successful reduction and fixation of unstable pelvic injuries with use of percutaneous iliosacral screws.IndicationsContraindicationsPitfalls & Challenges.