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Background: Ballistic fractures of the femoral neck, rare injuries that overwhelmingly affect younger adults, pose significant challenges to the treating surgeon. However, there is limited literature that the treating surgeon can leverage to guide their treatment decisions. The goal of this study is to describe the demographics, associated injuries, outcomes, and complications associated with ballistic femoral neck fractures., Patients and Methods: This retrospective case series, performed at a single, academic, urban, level-one trauma center, evaluated patients with a ballistic fracture of the femoral neck (AO/OTA 31B) between 2003 and 2022. International Classification of Disease codes were utilized to identify patients in the electronic medical record. Chart review was performed to assess patient demographics, associated injuries, success rate of operative and nonoperative intervention, and post-operative complication rate and types., Results: Seventeen patients were included (94 % male; median age 22.5 years). Median follow up was 12.2 months (range 1-84 months). Five patients (29 %) sustained a concomitant vascular injury. Eight patients (47 %) sustained an additional osseous injury. The median injury severity score was 9 (interquartile range 4-17). Thirteen patients were treated with operative reduction and fixation, 3 patients with incomplete fractures were treated nonoperatively, and one was treated with acute total hip arthroplasty (THA). Overall, 12 of 17 patients (71 %) healed their fracture or had an uncomplicated recovery after acute THA. Of the 13 patients treated with operative reduction and fixation, 8 (62 %) healed their fracture and 5 (38 %) developed one or more post-operative complications., Conclusions: Nearly 1 in 3 patients with ballistic femoral neck fractures sustain concomitant vascular injury and almost half sustain another osseous injury. In this series, only 62 % of patients who underwent operative reduction and fixation healed their fractures, and nearly 40 % of patients treated with operative reduction and fixation developed a post-operative complication. Given the poor outcomes and high complication rates associated with these injuries, surgeons should counsel patients with ballistic femoral neck fractures accordingly. Further research into the optimal treatment of ballistic femoral neck fractures is needed., Competing Interests: Declaration of competing interest None., (Copyright © 2025 Elsevier Ltd. All rights reserved.)

Background: Suture buttons and metal screws have been used and compared in biomechanical, radiographic, and clinical outcome studies for syndesmotic injuries, with neither implant demonstrating clear superiority. The aim of this study was to compare clinical outcomes of both implants., Methods: Patients who underwent syndesmosis fixation at 2 separate academic centers from 2010 through 2017 were compared. Thirty-one patients treated with a suture button and 21 patients treated with screws were included. Patients in each group were matched by age, sex, and Orthopaedic Trauma Association fracture classification. Tegner Activity Scale (TAS), Foot and Ankle Ability Measure (FAAM), patient satisfaction score, surgical failure, and reoperation rates were compared., Results: Patients who underwent suture button fixation had significantly higher TAS scores than those who underwent screw fixation (p < 0.001). There was no significant difference in FAAM ADL scores between cohorts (p = 0.08). Symptomatic hardware removal rates were similar (3.2% suture button cohort vs 9.0% in screw cohort). One patient (4.5%) underwent revision surgery secondary to syndesmotic malreduction after screw fixation, for a reoperation rate of 13.5%., Conclusion: Patients with unstable syndesmotic injuries treated with suture button fixation had higher mean TAS scores compared to patients treated with screws. Foot and Ankle Ability Measure and ADL scores in these cohorts were similar. Level of Evidence: Level 3 Retrospective Matched Case-Cohort., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.D.B.—Medline Unite: royalties and consultant, Marrow Access Technologies: Stock options, and board and committee member in AOFAS. C.M.M.—Afix: consultant; OsteoCentric Technologies and AO North America: honorarium and travel expenses. W.M.R.—ownership interest: Cable Fix LLC, CrookedFoot Medical LLC, McGinley Orthopaedic Innovations, LLC, Primo MC LLC, and HS2; royalties from MicroPort, Smith & Nephew, Wolters Kluwer, OsteoCentric Technologies; and consultant for Smith & Nephew and receives institutional support from AONA and COTA. He serves on the board for the OTA, JOT, and HSS. M.J.G.—conventus: IP royalties; paid consultant; stock or stock options, Genesis Innovations Group: stock or stock options, Globus Medical: IP royalties; Paid consultant, imagen technologies: stock or stock options, intelligent implants: stock or stock options, KCI: paid consultant; paid presenter or speaker, N’Site Medical: stock or stock options, OsteoCentric Technologies: paid consultant, SI-Bone: IP royalties; paid consultant, StabilizOrtho: paid consultant, Synthes: IP royalties; paid consultant, Wolters Kluwer Health—Lippincott Williams & Wilkins: publishing royalties, financial, or material support. Journal of Bone and Joint Surgery—American: Publishing royalties, financial or material support, Journal of Orthopaedic Trauma: Editorial or governing board, AAOS: Board or committee member, OTA: Board or committee member. T.O.C.—Arthrex: consultant, royalties, speaker, and research support; Stryker: consultant, royalties, speaker; SubioMed: consultant, stock options, research support; BICMD: consultant, AOFAS Board or committee member, and FAI editorial board member. The remaining authors have nothing to disclose.

Objectives: The purpose of this study was to investigate whether residual fracture gapping and translation at time of intramedullary nail (IMN) fixation for diaphyseal femur fractures were associated with delayed healing or nonunion., Design: Retrospective cohort study SETTING: Level 1 trauma hospital, quaternary referral center PATIENTS/PARTICIPANTS/INTERVENTION: Length stable Winquist type 1 and 2 diaphyseal femur fractures treated with IMN at a single Level I trauma center were retrospectively reviewed., Main Outcome Measure: The largest fracture gap and translation were evaluated on immediate anteroposterior (AP) and lateral postoperative radiographs. Radiographic healing was assessed using Radiographic Union Score in Femur (RUSF) scores at each follow-up. Radiographic union was defined as a RUSF score ≥8 and consolidation of at least 3 cortices. ANOVA and student's t-tests were used to evaluate the influence of fracture gap parameters on time to union (TTU) and nonunion rate. Patients were stratified to measured average gap and translation distances <1mm, 1-3mm and >3mm for portions of the analysis., Results: Sixty-six patients who underwent IMN with adequate follow-up were identified. A total of 93.9% of patients achieved union at an average of 2.8 months. Fractures with average AP/lateral gaps of <1mm, 1-2.9 mm, and >3mm had an average TTU of 70.1, 91.7, and 111.9 days respectively; fractures with larger residual gap sizes had a significantly longer TTU (p=0.009). Fractures with an average gap of 1-2.9mm and >3 mm had a significantly higher nonunion rate (1.5% and 4.5% respectively) compared to 0% nonunion in the <1 mm group (p=0.003)., Conclusion: Residual gapping following intramedullary fixation of length stable diaphyseal femur fractures is associated with a significant increase in likelihood of nonunion., Summary: Residual displacement of length stable femoral shaft fractures following intramedullary nailing can have a significantly negative impact on fracture healing. An average 3 mm AP/lateral residual fracture gap or a total of 6 mm of the AP + lateral fracture gap appeared to be a critical gap size with increased rates of nonunion and time to union. Therefore, we suggest minimizing the sum of the residual AP and lateral fracture gap to less than a total of 6 mm., Competing Interests: Declaration of Competing Interest Dr. Marschall Berkes is a Smith and nephew consultant, Mediflix consultant, and Arthrex consultant. This relationship does not have any conflicts of interest in the submitted study., (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: To document the prevalence of, and the effect on outcomes, operatively treated bilateral femur fractures treated using contemporary treatments., Design: A retrospective cohort using data from the National Trauma Data Bank., Participants: In total, 119,213 patients in the National Trauma Data Bank between the years 2007 and 2015 who had operatively treated femoral shaft fractures., Main Outcome Measurements: Complication rates, hospital length of stay (LOS), days in the intensive care unit (ICU LOS), days on a ventilator, and mortality rates., Results: Patients with bilateral femur fractures had increased overall complications (0.74 vs. 0.50, P < 0.0001), a longer LOS (14.3 vs. 9.2, P < 0.0001), an increased ICU LOS (5.3 vs. 2.4, P < 0.0001), and more days on a ventilator (3.1 vs. 1.3, P < 0.0001), when compared with unilateral fractures. Bilateral femoral shaft fractures were independently associated with worse outcomes in all primary domains when adjusted by Injury Severity Score (P < 0.0001), apart from mortality rates. Age-adjusted bilateral injuries were independently associated with worse outcomes in all primary domains (P < 0.0001) except for the overall complication rate. A delay in fracture fixation beyond 24 hours was associated with increased mortality (P < 0.0001) and worse outcomes for all other primary measures (P < 0.0001 to P = 0.0278) for all patients., Conclusions: Bilateral femoral shaft fractures are an independent marker for increased hospital and ICU LOS, number of days on a ventilator, and increased complication rates, when compared with unilateral injuries and adjusted for age and Injury Severity Score. Timely definitive fixation, in a physiologically appropriate patient, is critical because a delay is associated with worse inpatient outcome measures and higher mortality rates., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: C. T. Cosgrove and M. B. Berkes report no conflict of interest. D. L. Stwalley: AbbVie, Bristol-Myers Squibb: stock or stock options in a company or supplier. A. N. Miller: AONA, Smith & Nephew, Stryker: Other financial or material support. American College of Surgeons, Association for the Advancement of Automotive Medicine, Orthopaedic Trauma Association: Board or committee member. Bone support: Research support. Journal of Bone and Joint Surgery Am, Journal of Orthopaedic Trauma: Editorial or governing board. C. M. McAndrew: Zimmer: Paid consultant. P. R. Wolinsky: AAOS, American College of Surgeons, California Orthopaedic Association, Orthopaedic Trauma Association: Board or committee member Journal of Orthopaedic Trauma: Editorial or governing board, Zimmer: Paid presenter or speaker., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank., Methods: Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator., Results: Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001)., Conclusions: Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors have no relevant conflicts of interest, (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs., Design: Retrospective case series., Setting: Urban academic Level 1 trauma center., Patients/participants: Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up., Intervention: Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure., Main Outcome Measurements: Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure., Results: The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs., Conclusions: The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection., Level of Evidence: Diagnostic Level IV. 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: Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity orthopaedic injuries. Skeletal traction has proven to be an effective initial means of stabilization in patients with these injuries. Traction may be used for both temporary and definitive treatment in a variety of orthopaedic injuries. With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications. Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons to be proficient not only in their application but also understanding of the appropriate indications for use. Here we present a case example of a patient with a right femur fracture and discuss the technique and indications for placement of proximal tibia skeletal traction., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist., Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections., Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers., Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder., Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence., Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections., Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin., Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

Objective: To report on the incidence of surgical wound complications after percutaneous posterior pelvic ring fixation in patients who have also undergone pelvic arterial embolization (PAE) and determine whether the risks outweigh the benefits., Design: Retrospective cohort study., Setting: Academic level 1 trauma center., Patients: Two hundred one consecutive patients who underwent percutaneous posterior pelvic fixation at our institution were included in this study. Of these, 27 patients underwent pelvic arterial embolization., Intervention: Percutaneous posterior pelvic fixation and pelvic arterial embolization., Main Outcome Measurements: Charts were reviewed for posterior percutaneous surgical wound complications including infection, dehiscence, seroma, tissue necrosis, and return to OR for debridement in all patients., Results: Of the 27 patients who received PAE, none developed posterior surgical wound complications. Of those who did not receive PAE, there was one posterior surgical wound complication documented. There were no cases of wound infection in either group., Conclusion: Pelvic arterial embolization can be a valuable intervention in treating hemodynamically unstable patients with pelvic ring injuries. Although even selective pelvic arterial embolization is not entirely benign, there seems to be minimal risk of wound complications when percutaneous posterior pelvic ring fixation is performed., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Adequate surgical exposure is necessary for anatomical reduction and fixation of posterior wall acetabular fractures. This video demonstrates the Kocher-Langenbeck approach to the posterior acetabulum, as well as operative indications, surgical reduction and fixation techniques, and outcomes for posterior wall acetabular fractures.

Nitrogen-containing bisphosphonates (N-BPs), such as alendronate, are the most widely prescribed medications for diseases involving bone, with nearly 200 million prescriptions written annually. Recently, widespread use of N-BPs has been challenged due to the risk of rare but traumatic side effects such as atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ). N-BPs bind to and inhibit farnesyl diphosphate synthase, resulting in defects in protein prenylation. Yet, it remains poorly understood what other cellular factors might allow N-BPs to exert their pharmacological effects. Here, we performed genome-wide studies in cells and patients to identify the poorly characterized gene, ATRAID Loss of ATRAID function results in selective resistance to N-BP-mediated loss of cell viability and the prevention of alendronate-mediated inhibition of prenylation. ATRAID is required for alendronate inhibition of osteoclast function, and ATRAID -deficient mice have impaired therapeutic responses to alendronate in both postmenopausal and senile (old age) osteoporosis models. Last, we performed exome sequencing on patients taking N-BPs that suffered ONJ or an AFF. ATRAID is one of three genes that contain rare nonsynonymous coding variants in patients with ONJ or an AFF that is also differentially expressed in poor outcome groups of patients treated with N-BPs. We functionally validated this patient variation in ATRAID as conferring cellular hypersensitivity to N-BPs. Our work adds key insight into the mechanistic action of N-BPs and the processes that might underlie differential responsiveness to N-BPs in people., (Copyright © 2020 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Objectives: To determine stability of 2-part intertrochanteric femur fractures and to determine whether secondary collapse is related to fixation method., Design: A retrospective cohort series., Setting: Single Level I Trauma Center., Patients: One hundred fourteen patients (82 female) older than 50 years (average age 75 years, range 50-100 years) with an acute low-energy standard obliquity 2-part intertrochanteric femur fracture (OTA/AO 31A) identified from an orthopaedic trauma database were studied., Intervention: Twenty-three patients were treated with a sliding hip screw (dynamic hip screw [DHS]), 53 with a dual screw trochanteric entry nail (INTERTAN), and 38 with a single-blade or screw trochanteric entry intramedullary nail (trochanteric fixation nail [TFN]) based on surgeon choice by 4 fellowship-trained orthopaedic trauma surgeons., Main Outcome Measures: Fracture collapse was measured by comparing immediate postoperative radiographs to those at final follow-up while controlling for magnification and rotation., Results: Collapse averaged 6.8 mm in the DHS group, 3.7 mm in the INTERTAN group, and 7.3 mm in the TFN group. When comparing groups, there was significantly more collapse in the DHS group compared with the INTERTAN group (P = 0.021), and significantly more collapse in the TFN group compared with the INTERTAN group (P < 0.001). Six patients (26%) in the DHS group had >10-mm collapse including 4 (17%) with greater than 20-mm collapse (max = 34.2 mm). Four patients (8%) in the INTERTAN group had >10-mm collapse and none had greater than 12.9 mm. Ten patients (26%) in the TFN group had >10-mm collapse and 3 (5%) had greater than 20-mm collapse (max = 30.7 mm)., Conclusion: Stability of 2-part intertrochanteric femur fractures is dependent on the fixation device. These fractures are not necessarily stable when treated with a sliding hip screw as 26% treated with this method collapsed greater than 10 mm and 17% more than 20 mm. Dual screw intramedullary nail fixation seems to be most effective to maintain stability for patients with this fracture pattern., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: The purpose of this study was to survey trauma and arthroplasty surgeons to investigate associations between subspecialty training and management of geriatric femoral neck fractures and to compare treatments with the American Academy of Orthopaedic Surgeons clinical practice guidelines., Methods: Five hundred fifty-six surgeons completed the online survey consisting of two sections: (1) surgeon demographics and (2) two geriatric hip fracture cases with questions regarding treatment decisions., Results: In both clinical scenarios, arthroplasty surgeons were more likely than trauma surgeons to recommend total hip arthroplasty (THA) (case 1: 96% versus 84%; case 2: 29% versus 10%; P ≤ 0.02) and spinal anesthesia (case 1: 70% versus 40%; case 2: 62% versus 38%; P < 0.01). Surgeons who have made changes based on clinical practice guidelines (n = 96; 21% of surveyed) cited more use of THA (n = 56; 58% of respondents) and cemented stems (n = 28; 29% of respondents)., Conclusion: Arthroplasty surgeons are more likely to recommend THA over hemiarthroplasty and have a higher expectation for spinal anesthesia for the management of geriatric femoral neck fractures.

Objectives: The purpose of this study was to compare bone marrow aspirate concentrate (BMAC) with cancellous allograft to iliac crest bone graft (ICBG) in the treatment of long bone nonunions., Design: Retrospective cohort study., Setting: A single level I trauma center., Patients: 26 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and BMAC, compared to 25 patients with long bone diaphyseal or metaphyseal nonunions with defects >2 mm and treated with open repair and ICBG., Intervention: Open repair of long bone nonunion using either autologous ICBG or BMAC with cancellous allograft., Main Outcome Measure: Nonunion healing, radiographically measured by the modified Radiographic Union Score for Tibia (mRUST) score. Secondary outcomes included risk factors associated with failed repair., Results: The union rates for the BMAC and ICBG cohorts were 75% and 78%, respectively ( P =  .8). Infection was the only risk factor of statistical significance for failure., Conclusion: In this study, we found no significant difference in union rate for long bone nonunions treated with ICBG or BMAC with allograft. BMAC and allograft led to 75% successful healing in this series. Given the heterogeneity of the control group and loss to follow-up, further prospective investigation should be conducted to more rigorously compare BMAC to ICBG for nonunion treatment., Level of Evidence: III, retrospective cohort., Competing Interests: Conflicts of Interest and Source of Funding: CMM: Grants: Department of Defense, OREF, COTA, AONA, DePuy Synthes, and NIH. Speakers’ bureau: AONA and AOTNA., (Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Objectives: To describe the inferior retinacular artery (IRA) as encountered from an anterior approach, to define its intraarticular position, and to define a safe zone for buttress plate fixation of femoral neck fractures., Methods: Thirty hips (15 fresh cadavers) were dissected through an anterior (Modified Smith-Petersen) approach after common femoral artery injection (India ink, blue latex). The origin of the IRA from the medial femoral circumflex artery and the course to its terminus were dissected. The IRA position relative to the femoral neck was described using a clock-face system: 12:00 cephalad, 3:00 anterior, 6:00 caudad, and 9:00 posterior., Results: The IRA originated from the medial femoral circumflex artery and traveled within the Weitbrecht ligament in all hips. The IRA positions were 7:00 (n = 13), 7:30 (n = 15), and 8:00 (n = 2). The IRA was 0:30 anterior to (n = 24) or at the same clock-face position (n = 6) as the lesser trochanter. The mean intraarticular length was 20.4 mm (range 11-65, SD 9.1), and the mean extraarticular length was 20.5 mm (range 12-31, SD 5.1)., Conclusions: The intraarticular course of the IRA lies within the Weitbrecht ligament between the femoral neck clock-face positions of 7:00 and 8:00. A medial buttress plate positioned at 6:00 along the femoral neck is anterior to the location of the IRA and does not endanger the blood supply of the femoral head. The improved understanding of the IRA course will facilitate preservation during intraarticular approaches to the femoral neck and head.

Background: Delayed diagnoses of unstable thoracolumbar spine (TL-spine) fractures can result in neurologic deficits and avoidable pain, so it is important for clinicians to reach prompt diagnostic decisions. There are no validated decision aids for determining which trauma patients warrant TL-spine imaging., Objective: Our aim was to quantify the diagnostic accuracy of the injury mechanism, physical examination, associated injuries, clinical decision aids, and imaging for evaluating blunt TL-spine trauma patients., Methods: A search strategy for studies including adult blunt TL-spine trauma using PubMed, Embase, Scopus, CENTRAL, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov was performed. Excluded studies lacked data to construct 2 × 2 tables, were duplicates, were not primary research, did not focus on blunt trauma, examined associated injuries without any utility in identifying TL-spine injuries, only studied cervical-spine fractures, were non-English, had a pediatric setting, or were cadaver/autopsy reports. Risk of bias was assessed using the Quality Assessment Tool for Diagnostic Accuracy Studies. Diagnostic predictors were analyzed with a meta-analysis of sensitivity, specificity, and likelihood ratios., Results: In blunt trauma patients in the emergency department, the weighted pretest probability of a TL-spine fracture was 15%. The estimates for detection of TL-spine fractures with plain film were: positive likelihood ratio (+LR) = 25.0 (95% confidence interval [CI] 4.1-152.2; I 2  = 94%; p < 0.001) and negative likelihood ratio (-LR) = 0.43 (95% CI 0.32-0.59; I 2  = 84%; p < 0.001), and for computed tomography (CT) were: +LR = 81.1 (95% CI 14.1-467.9; I 2  = 87%; p < 0.001) and -LR = 0.04 (95% CI 0.02-0.08; I 2  = 23%; p = 0.26)., Conclusions: CT is more accurate than plain films for detecting TL-spine fractures. Injury mechanism, physical examination, and associated injuries alone are not accurate to rule-in or rule-out TL-spine fractures., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Semiextended positioning can improve the surgeon's ability to obtain, maintain, and fluoroscopically evaluate a fracture reduction when performing fixation with an intramedullary nail, especially in fractures at the proximal and distal ends. Furthermore, this position allows for evaluation of instrument placement, including the start point, without moving the fluoroscopic unit into extremes of angulation or compromising the quality of the beam orientation. The intraarticular suprapatellar approach has been described as a soft tissue approach to maintain the leg in a position that would not complicate management of these fractures, especially those in the proximal third of the tibia. A semiextended extraarticular soft tissue approach to the start point was described by Kubiak et al, and the lateral parapatellar version has become commonly used on the Orthopaedic Trauma Service at Washington University in Saint Louis. This video demonstrates advantages of semiextended positioning while performing reduction and intramedullary nail fixation for distal tibia fractures. This lateral parapatellar approach can be performed without specialized instrumentation, results in precise establishment of the start point and completion of the fixation without injury to the knee.

Tibial pilon fractures are complex injuries of soft tissue and bone that challenge patients and surgeons. Outcomes following this injury are guarded, and complications are frequently reported. Soft-tissue compromise at the time of injury is potentially amplified with surgical trauma, necessitating thorough evaluation, preoperative planning, and expertise to minimize complications and maximize outcomes. Understanding angiosome anatomy and typical fracture patterns (and their variations) allows for design of surgical tactics that accomplish these goals.

Pipkin described femoral head fractures in the 1950s, but controversy still exists regarding indications for surgery and approaches for operative treatment of femoral head fractures. Clear indications for operative intervention include inability to reduce the hip with closed methods, a nonconcentric reduction, fracture fragments within the articulating surface of the hip, and associated injuries (acetabulum and femoral neck fractures) with their own indications for surgery. The anterior approach described by Smith-Petersen has been modified (using only the distal portion) and used to visualize, clean, reduce, and fix these fractures with and without anterior dislocation of the hip.

A 2-stage approach to treatment of tibia pilon fractures was reported in the 1990s and popularized over the ensuing decade to help avoid catastrophic soft-tissue complications experienced with one-stage open reduction and internal fixation. This approach can be expanded to the treatment of other high-energy injuries of the hind foot, with variation in external fixator application as needed. Key factors to maximize the utility and decrease complications of the external fixation stage include the following: (1) anatomic reduction of the talus under the long axis of the tibia in the coronal and sagittal planes, (2) strategic application of Schantz pins to resist deforming forces resulting from the injury, and (3) external fixation outside the zone of injury and definitive surgical treatment. This video demonstrates concepts and tactics to obtain and maintain fracture reduction with an external fixator with examples of a complex combined plafond and talus injury, as well as a more typical Orthopaedic Trauma Association/Arbeitsgemeinschaft fur Osteosynthesefragen C-type pilon fracture.

Background: The purpose of this study was to design and validate a novel stiffness-measuring device using locked plating of distal femur fractures as a model., Methods: All patients underwent a laterally-based approach, with a bridging locked construct after indirect reduction. A custom and calibrated intraoperative stiffness device was applied and the stiffness of the construct was blindly recorded. Fourteen of twenty-seven patients enrolled with distal femur fractures (AO/OTA 33A and 33C) completed the study. Correlations between stiffness and callus formation, working length, working length/plate length ratio, number of distal locking screws, and fracture pattern were explored., Findings: Callus and modified radiographic union scale in tibias scores as a linear function of stiffness did not correlate (R2 = 0.06 and 0.07, respectively). Construct working length and working length to plate length ratio did not correlate to stiffness (R2 = 0.18 and 0.16 respectively). A combined delayed and nonunion rate was 14%. Lower extremity measure scores were not statistically different when comparing delayed and nonunion with healed fractures., Interpretation: The lack of correlation may have been due to the mechanical properties of the plate itself and its large contribution to the overall stiffness of the construct. To our knowledge, clinically relevant stiffness has not been described and this study may provide some estimates. This methodology and these preliminary findings may lay the groundwork for further investigations into this prevalent clinical problem. Other parameters not investigated may play a key role such as body mass index and bone mineral density., Level of Evidence: Diagnostic/Prognostic Level II., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To describe a novel technique using preoperative computed tomography (CT) to plan clamp tine placement along the trans-syndesmotic axis (TSA). We hypothesized that preoperative CT imaging provides a reliable template on which to plan optimal clamp tine positioning along the TSA, reducing malreduction rates compared with other described techniques., Methods: CT images of 48 cadaveric through-knee specimens were obtained, and the TSA was measured as well as the optimal position of the medial clamp tine. The syndesmosis was then fully destabilized. Indirect clamp reductions were performed with the medial clamp tine placed at positions 10 degrees anterior to the TSA, along the TSA, and at both 10 and 20 degrees posterior to the TSA. The specimens were then separately reduced using manual digital pressure and palpation alone. CT was performed after each clamp and manual reduction., Results: On average, reduction clamp tines were within 3 ± 2 degrees of the desired angle and within 5% ± 4% of the templated location along the tibial line for all clamp reduction attempts. Palpation and direct visualization produced the overall lowest malreduction rates in all measurements: 4.9% and 3.0%, respectively. Off-axis clamping 10 degrees anterior or 20 degrees posterior to the patient-specific TSA demonstrated an increased overall malreduction rate: 15.8% and 11.3%, respectively. Significantly more over-compression occurred when a reduction clamp was used versus manual digital reduction alone (8.6% vs. 0%)., Conclusions: Reduction clamp placement directly along an optimal clamping vector can be facilitated by preoperative CT measurements of the uninjured ankle. However, even in this setting, the use of reduction clamps increases the risk for syndesmotic malreduction and over-compression compared with manual digital reduction or direct visualization.

Background: Successful fracture fixation depends critically on the stability of the screw-bone interface. Maximum achievable screw torque reflects the competence of this interface, but it cannot be quantified prior to screw stripping. Typically, the surgeon relies on the patients' bone mineral density and radiographs, along with experience and tactile feedback to assess whether sufficient compression can be generated by the screw and bone. However, the local bone quality would also critically influence the strength of the bone-screw interface. We investigated whether Reference Point Indentation can provide quantitative local bone quality measures that can inform subsequent screw-bone competence., Methods: We examined the associations between the maximum screw torque that can be achieved using 3.5 mm, 4.5 mm, and 6.5 mm diameter stainless steel screws at the distal femoral metaphysis and mid-diaphysis from 20 cadavers, with the femoral neck bone mineral density and the local measures of bone quality using Reference Point Indentation., Findings: Indentation Distance Increase, a measure of bone's resistance to microfracture, correlated with the maximum screw stripping torque for the 3.5 mm (p < 0.01; R = 0.56) and 4.5 mm diameter stainless steel screws (p < 0.01; R = 0.57) at the femoral diaphysis. At the femoral metaphysis, femoral neck bone mineral density significantly correlated with the maximum screw stripping torque achieved by the 3.5 mm (p < 0.01; R = 0.61), 4.5 mm (p < 0.01; R = 0.51), and 6.5 mm diameter stainless steel screws (p < 0.01; R = 0.56)., Interpretation: Reference Point Indentation can provide localized measurements of bone quality that may better inform surgeons of the competence of the bone-implant interface and improve effectiveness of fixation strategies particularly in patients with compromised bone quality., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: To evaluate whether objective syndesmosis reduction predicts functional outcomes and pain scores in patients with operatively treated syndesmotic injuries at a minimum 1-year follow-up., Design: Prospective Cohort., Setting: Urban Level I Trauma Center., Patients: Sixty-nine patients with operatively treated syndesmotic injuries were initially identified and consented for inclusion in the study. Nine patients were excluded perioperatively. Twelve patients were lost to follow-up. Forty-eight patients with operatively treated unilateral syndesmotic injuries were available and participated at the final follow-up., Intervention: Trans-syndesmotic stabilization with either 1 or 2 quadricortical position screws. Postoperatively, bilateral ankle computed tomography scans were obtained to objectively assess syndesmosis reduction accuracy., Main Outcome Measurements: Olerud-Molander Ankle Score, Short Musculoskeletal Function Assessment Dysfunction Index and Bother Index, and Numeric Pain Rating Scales at a minimum 1-year postoperative follow-up., Results: At 1-year follow-up, there was no significant difference in functional outcomes between reduced and malreduced groups at the 1.5-, 2-, and 3-mm thresholds for linear measurements. Similarly, there was no functional difference between the reduced and malreduced groups for rotational malreductions at a 10 or 15 degrees threshold. Patients with state-sponsored insurance (Medicaid) had significantly worse functional scores and pain scores when compared with the groups with private insurance, Medicare, or no insurance., Conclusions: At 1-year follow-up, functional outcomes were not related to objective measures of syndesmosis reduction., Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine whether the position of the medial clamp tine during syndesmotic reduction affected reduction accuracy., Design: Prospective cohort., Setting: Urban Level 1 trauma center., Patients: Seventy-two patients with operatively treated syndesmotic injuries., Intervention: Patients underwent operative fixation of their ankle syndesmotic injuries using reduction forceps. The position of the medial clamp tine was then recorded with intraoperative fluoroscopy. Malreduction rates were then assessed with bilateral ankle computerized tomography., Main Outcome Measurement: Fibular position within the incisura was measured with respect to the uninjured side to determine whether a malreduction had occurred. Malreductions were then analyzed for associations with injury pattern, patient demographics, and the location of the medial clamp tine., Results: A statistically significant association was found between medial clamp position and sagittal plane syndesmosis malreduction. In reference to anterior fibular translation, there was a 0% malreduction rate in the 18 patients where the clamp tine was placed in the anterior third, a 19.4% malreduction rate in the middle third, and 60% malreduction rate in the posterior third (P = 0.006). In reference to posterior fibular translation, there was a 11.1% malreduction when clamp placement was in the anterior third, a 16.1% malreduction rate in the middle third, and 60% malreduction rate in the posterior third (P = 0.062). There were no significant associations between medial clamp position and coronal plane malreductions (overcompression or undercompression) (P = 1)., Conclusions: When using reduction forceps for syndesmotic reduction, the position of the medial clamp tine can be highly variable. The angle created with off-axis syndesmotic clamping is likely a major culprit in iatrogenic malreduction. Sagittal plane malreduction appears to be highly sensitive to clamp obliquity, which is directly related to the medial clamp tine placement. Based on these data, we recommend placing the medial clamp tine in the anterior third of the tibial line on the lateral view to minimize malreduction risk., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To compare the timing of soft-tissue (flap) coverage and occurrence of complications before and after the establishment of an integrated orthopaedic trauma/microsurgical team., Design: Retrospective cohort study., Setting: A single level 1 trauma center., Patients: Twenty-eight subjects (13 pre- and 15 post-integration) with open tibia shaft fractures (OTA/AO 42A, 42B, and 42C) treated with flap coverage between January 2009 and March 2015., Intervention: Flap coverage for open tibia shaft fractures treated before ("preintegration") and after ("postintegration") implementation of an integrated orthopaedic trauma/microsurgical team., Main Outcome Measure: Time from index injury to flap coverage., Results: The unadjusted median time to coverage was 7 days (95% confidence interval, 5.9-8.1) preintegration, and 6 days (95% confidence interval, 4.6-7.4) postintegration (P = 0.48). For preintegration, 9 (69%) of the patients experienced complications, compared with 7 (47%) postintegration (P = 0.23)., Conclusions: After formation of an integrated orthopaedic trauma/microsurgery team, we observed a 1-day decrease in median days to coverage from index injury. Complications overall were lowered in the postintegration group, although statistically insignificant., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Ankle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required., Questions/purposes: The purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle., Methods: Computed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph., Results: The average TSA measured 21±5° anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 23±7% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 53±17% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range., Conclusions: Reduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA., Level of Evidence: 2 (Retrospective diagnostic)., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Patellar tendon ruptures commonly are repaired using transosseous patellar drill tunnels with modified-Krackow sutures in the patellar tendon. This simple suture technique has been associated with failure rates and poor clinical outcomes in a modest proportion of patients. Failure of this repair technique can result from gap formation during loading or a single catastrophic event. Several augmentation techniques have been described to improve the integrity of the repair, but standardized biomechanical evaluation of repair strength among different techniques is lacking., Questions/purposes: The purpose of this study was to describe a novel figure-of-eight suture technique to augment traditional fixation and evaluate its biomechanical performance. We hypothesized that the augmentation technique would (1) reduce gap formation during cyclic loading and (2) increase the maximum load to failure., Methods: Ten pairs (two male, eight female) of fresh-frozen cadaveric knees free of overt disorders or patellar tendon damage were used (average donor age, 76 years; range, 65-87 years). For each pair, one specimen underwent the standard transosseous tunnel suture repair with a modified-Krackow suture technique and the second underwent the standard repair with our experimental augmentation method. Nine pairs were suitable for testing. Each specimen underwent cyclic loading while continuously measuring gap formation across the repair. At the completion of cyclic loading, load to failure testing was performed., Results: A difference in gap formation and mean load to failure was seen in favor of the augmentation technique. At 250 cycles, a 68% increase in gap formation was seen for the control group (control: 5.96 ± 0.86 mm [95% CI, 5.30-6.62 mm]; augmentation: 3.55 ± 0.56 mm [95% CI, 3.12-3.98 mm]; p = 0.02). The mean load to failure was 13% greater in the augmentation group (control: 899.57 ± 96.94 N [95% CI, 825.06-974.09 N]; augmentation: 1030.70 ± 122.41 N [95% CI, 936.61-1124.79 N]; p = 0.01)., Conclusions: This biomechanical study showed improved performance of a novel augmentation technique compared with the standard repair, in terms of reduced gap formation during cyclic loading and increased maximum load to failure., Clinical Relevance: Decreased gap formation and higher load to failure may improve healing potential and minimize failure risk. This study shows a potential biomechanical advantage of the augmentation technique, providing support for future clinical investigations comparing this technique with other repair methods that are in common use such as transosseous suture repair.

Objective: To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation., Design: Retrospective comparative study., Setting: Three academic level 1 trauma centers., Patients/participants: From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated., Intervention: Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon., Main Outcome Measurement: Majeed Pelvic Score., Results: There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84)., Conclusions: Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: The goal of this study was to objectively assess if rotational or translational syndesmotic malreduction is associated with certain syndesmotic morphologies. Prior studies based on subjective assessment of syndesmotic morphology and reduction have not shown any difference between groups., Methods: Thirty-five prospectively recruited patients with operatively treated syndesmotic injuries were recruited at an Urban Level I Trauma Center. Patients underwent postoperative bilateral computed tomographic (CT) scans of the ankle to assess incisura depth and syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences of syndesmotic reduction were measured at several anatomic points and compared to the incisura depth., Results: There was a significant correlation between more shallow syndesmoses and increased anterior translation of the fibula in the incisura (r = -0.63, P ≤ .001). Six of 8 patients with "shallow" (≤2.5 mm) incisura were anteriorly malreduced greater than or equal to 1.5 mm compared to the contralateral ankle. The anterior malreduction rate in those with a shallow incisura was significantly greater than in the "non-shallow" patients (P < .001). There were 9 patients with incisurae greater than or equal to 4.5 mm deep. Five of the "deep" patients had posterior malreductions greater than or equal to 1.5 mm. The posterior malreduction rate in the "deep" group was significantly greater than the "non-deep" patients (P = .02). There was a significant correlation between increasing syndesmotic depth and increased malrotation (r = .46, P = .01)., Conclusion: Syndesmotic morphology was found to be associated with specific malreduction patterns. Shallow syndesmoses were correlated with anterior fibular malreduction, and were less likely to be malrotated. Conversely, deep syndesmoses predisposed to posterior sagittal plane and rotational malalignment. Preoperative CT scans that assess the syndesmosis morphology may allow surgeons to alter reduction strategies to avoid syndesmotic malreduction., Level of Evidence: Level III, retrospective cohort study., (© The Author(s) 2016.)

Background: The distal tibiofibular syndesmosis is disrupted in up to 45% of operatively treated ankle fractures, and syndesmotic malreduction has historically been correlated with poor outcome. The purpose of this study was to quantify the clamp force used during syndesmotic reduction and to evaluate the effect of clamp force on fibular overmedialization (overcompression) at the level of the distal tibiofibular syndesmosis., Methods: A prospectively recruited cohort of 21 patients underwent operative syndesmotic reduction and fixation. A ball point periarticular reduction forceps that was modified to include a load cell in one tine was used for the reduction, and the clamp force required for reduction was measured. Patients underwent postoperative bilateral computed tomographic scans of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control. Side-to-side differences in fibular medialization, translation, and rotation within the tibial incisura were measured. These findings were correlated with the reduction clamp force utilized to obtain the reduction., Results: Syndesmotic overcompression (fibular medialization greater than 1.0 mm when compared with noninjured ankle) was seen in 11 of 21 patients (52%). Increased clamp force significantly correlated with syndesmotic overcompression. The mean reduction clamp forces were 88 N for the undercompressed group, 130 N for the adequately compressed group, and 163 N for the overcompressed group., Conclusion: This study demonstrated a significant correlation between increased clamp forces and syndesmotic overcompression, and determined objective forces that lead to overcompression. Our results indicate that surgeons should be cognizant of the clamp force used for syndesmotic reduction., Level of Evidence: Level III, case-control series, in accordance with STROBE guidelines., (© The Author(s) 2016.)

Introduction: Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches., Methods: A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05., Results: Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45)., Conclusion: In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: To determine current practice standards among Orthopaedic Trauma Association surgeons for postoperative fracture follow-up and to investigate the implications of these standards on clinical research., Design: Survey., Setting: Web-based survey., Participants: One hundred eighty-four orthopaedic trauma surgeons., Methods: A web-based questionnaire was distributed to Orthopaedic Trauma Association members to identify standard postoperative radiographic and clinical follow-up duration. Assuming uneventful, complete fracture healing at 3 months, data were collected for 3 generic fracture types (diaphyseal, extra-articular metaphyseal, and intra-articular) and 3 specific fractures (femoral shaft, intertrochanteric, and tibial plateau). Suggested follow-up for clinical research was also investigated., Results: For extra-articular fractures, standard radiographic and clinical follow-up were considered to be 6 months or less by greater than 70% of respondents. For intra-articular fractures, standard radiographic and clinical follow-up was considered to be 6 months or less by greater than 39% of respondents. The most common responses for radiographic follow-up were 3 months for extra-articular fractures (33%) and 12 months for intra-articular fractures (34%). The most common responses for clinical follow-up were 6 months for extra-articular fractures (37%) and 12 months for intra-articular fractures (35%). The majority (55%) indicated that follow-up to clinical and radiographic healing or the establishment of a nonunion should be the minimum follow-up for clinical fracture studies and 66% recommended follow-up to at least 1 year for functional outcome studies., Conclusions: Most surgeons follow-up patients with lower extremity extra-articular fractures (with uneventful healing) radiographically for 3-6 months and clinically for 6 months and slightly longer for intra-articular fractures. Many surgeons cease radiographic and clinical follow-up by 6 months. Therefore, retrospective fracture healing studies can only reasonably expect follow-up for 6 months. Publication requirements for longer follow-up of fracture-related studies would likely eliminated retrospective studies from consideration. Most surgeons support obtaining at least 1-year follow-up for clinical studies that include functional outcome., Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Nonunion after locked bridge plating of comminuted distal femur fractures is not uncommon. "Dynamic" locked plating may create an improved mechanical environment, thereby achieving higher union rates than standard locked plating constructs., Setting: Academic Level 1 Trauma Center., Patients/participants: Twenty-eight patients with comminuted supracondylar femur fractures treated with either dynamic or standard locked plating., Intervention: Dynamic plating was achieved using an overdrilling technique of the near cortex to allow for a 0.5-mm "halo" around the screw shaft at the near cortex. Standard locked plating was done based on manufacturer's suggested technique. The patients treated with dynamic plating were matched 1:1 with those treated with standard locked plating based on OTA classification and working length., Main Outcome Measurements: Three blinded observers made callus measurements on 6-week radiographs using a 4-point ordinal scale. The results were analyzed using a 2-tailed t test and 2-way intraclass correlations., Results: The dynamic plating group had significantly greater callus (2.0; SD, 0.7) compared with the control group (1.3: SD, 0.8, P = 0.048) with substantial agreement amongst observers in both consistency (0.724) and absolute score (0.734). With dynamic plating group, 1 patient failed to unite, versus three in the control group (P = 0.59). The dynamic group had a mean change in coronal plane alignment of 0.5 degrees (SD, 2.6) compared with 0.6 (SD, 3.0) for the control group (P = 0.9) without fixation failure in either group., Conclusions: Overdrilling the near cortex in metaphyseal bridge plating can be adapted to standard implants to create a dynamic construct and increase axial motion. This technique seems to be safe and leads to increased callus formation, which may decrease nonunion rates seen with standard locked plating., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The goals of this study were to assess syndesmotic reductions using computerized tomography and to determine whether malreductions are associated with certain injury types or reduction forceps., Design: Prospective cohort., Setting: Urban level 1 trauma center., Patients: Twenty-seven patients with operatively treated syndesmotic injuries were recruited prospectively., Intervention: Patients underwent postoperative bilateral computerized tomography of the ankle and hindfoot to assess syndesmotic reduction. The uninjured extremity was used as a control., Main Outcome Measurement: Side-to-side differences of the fibular position within the tibial incisura were measured at several anatomic points and analyzed based on injury type, the presence of posterior malleolar injury, level of fracture, and type of reduction forceps used., Results: On average, operatively treated syndesmotic injuries were overcompressed (fibular medialization) by 1 mm (P < 0.001) and externally rotated by 5° (P = 0.002) when compared with the uninjured extremity. The absence of a posterior malleolar injury and Weber B (OTA 44-B) fractures seemed to have a protective effect against malrotation, but not against overcompression. There was no difference in malreduction based on the type of the clamp used., Conclusions: It is possible, and highly likely based on these data, to overcompress the syndesmosis when using reduction forceps. Care should be taken to avoid overcompression, as this may affect the ankle motion and functional outcomes. To our knowledge, this is the first in vivo series of syndesmotic overcompression., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine if distal femoral traction pins result in knee dysfunction in patients with femoral or pelvic fracture, and to determine if skeletal traction relieves pain more effectively than splinting for femoral shaft fractures., Design: Prospective cohort trial., Setting: Level I urban trauma center., Patients/participants: One hundred twenty adult patients with femoral shaft, acetabular, and unstable pelvic fractures., Intervention: Patients with femoral shaft fractures were placed into distal femoral skeletal traction or a long-leg splint, based on an attending-specific protocol. Patients with pelvic or acetabular fractures with instability or intraarticular bone fragments were placed into skeletal traction., Main Outcome Measurements: An initial Lysholm knee survey was administered to assess preinjury knee pain and function; the survey was repeated at 3- and 6-month follow-up visits. Also, a 10-point visual analog scale was used to document pain immediately before, during, and immediately after fracture immobilization with traction or splinting., Results: Thirty-five patients (29%) were immobilized with a long-leg splint, and 85 (71%) were immobilized with a distal femoral traction pin. Eighty-four patients (70%) completed a 6-month follow-up. Lysholm scores decreased by a mean 9.3 points from preinjury baseline to 6 months postinjury in the entire cohort (P < 0.01); no significant differences were found between the splint and traction pin groups. During application of immobilization, visual analog scale pain scores were significantly lower in traction patients as compared with splinted patients (mean, 1.9 points less, P < 0.01). Traction pins caused no infections, neurovascular injuries, or iatrogenic fractures., Conclusions: Distal femoral skeletal traction does not result in detectable knee dysfunction at 6 months after insertion, and results in less pain during and after immobilization than long-leg splinting., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The null hypothesis of this study states that routine axial computed tomography (CT) images are obtained at a consistent and reproducible orientation relative to the sacrum. The secondary null hypothesis states that there is no difference in the measurement of the safe zone for placement of iliosacral screws when using routine axial CT images and standardized reconstructions in defined planes perpendicular and parallel to the sacrum., Design: Retrospective review., Setting: University Level 1 Trauma Center., Patients: Sixty-eight consecutive trauma patients evaluated with routine pelvic CT, without pelvic ring injury., Intervention: Retrospective radiographic review and measurement., Methods: Sixty-eight consecutive adult patients with routine axial pelvic CT scans, without injury to the pelvic ring, and obtained as part of a trauma evaluation were retrospectively identified. The orientation of the axial slices relative to the sacrum was measured for each patient and compared. The maximal cross-sectional distance at the smallest section of the sacral ala (safe zone) was measured using the routine axial CT images, and these measurements were compared with similar measurements taken on standardized images perpendicular (CT inlet) and parallel (CT outlet) to the body of the sacrum. Additional data referencing the orientation of multiple sacral radiographic landmarks were also collected., Results: The orientation of routine axial CT image planes relative to the sacrum spanned a wide range. The angle between the routine axial CT plane and the sacrum varied from 43.5 to 82.0 degrees (SD = 9 degrees). Significant differences were found in measured safe zones of routine axial CT images compared with standardized CT inlet and CT outlet images. Compared with CT inlet images, routine axial CT images underestimated safe zones for transverse sacral screws at both S1 (P < 0.01) and S2 (P < 0.01). When compared with CT outlet images, routine axial CT images overestimated safe zones for oblique sacroiliac screws (P < 0.01) and underestimated the safe zone for S2 transverse sacral style screws (P < 0.01). No significant differences in measured variables were found between genders and sacral morphology., Conclusions: Our null hypotheses were rejected: routine axial CT images were found to be at widely ranging orientations relative to the sacrum, and standardized CT images (CT inlet and CT outlet) demonstrated statistically significant differences in measurements of safe zones compared with routine axial CT images. Furthermore, the CT inlet and CT outlet views provide additional information regarding sacral landmarks that could be useful for preoperative planning.

Objectives: To determine whether clavicle fracture displacement and shortening are different between upright and supine radiographic examinations., Design: Combined retrospective and prospective comparative study., Setting: Level I Trauma Center., Patients: Forty-six patients (mean age, 49 years; range, 24-89 years) with an acute clavicle fracture were evaluated., Intervention: Standardized clavicle radiographs were obtained in both supine and upright positions for each patient. Displacement and shortening were measured and compared between the 2 positions., Main Outcomes Measurements: One resident and 3 traumatologists classified the fractures and measured displacement and shortening. Data were aggregated and compared to ensure reliability with a 2-way mixed intraclass correlation., Results: Fracture displacement was significantly greater when measured from upright radiographs (15.9 ± 8.9 mm) than from supine radiographs (8.4 ± 6.6 mm, P < 0.001), representing an 89% increase in displacement with upright positioning. Forty-one percent of patients had greater than 100% displacement on upright but not on supine radiographs. Compared with the uninjured side, 3.0 ± 10.7 mm of shortening was noted on upright radiographs and 1.3 ± 9.5 mm of lengthening on supine radiographs (P < 0.001). The intraclass correlation was 0.82 [95% confidence interval (CI), 0.73-0.89] for OTA fracture classification, 0.81 (95% CI, 0.75-0.87) for vertical displacement, and 0.92 (95% CI, 0.88-0.95) for injured clavicle length, demonstrating very high agreement among evaluators., Conclusions: Increased fracture displacement and shortening was observed on upright compared with supine radiographs. This suggests that upright radiographs may better demonstrate clavicle displacement and predict the position at healing if nonoperative treatment is selected.

Objectives: Total elbow arthroplasty (TEA) is a viable treatment for elderly patients with distal humerus fracture who frequently present with low-grade open fractures. This purpose of this study was to evaluate the results of a protocol of serial irrigations and debridements (I&Ds) followed by primary TEA for the treatment of open intra-articular distal humerus fractures., Methods: Seven patients (mean 74 years; range 56-86 years) with open (two Grade I and five Grade 2) distal humerus fractures (OTA 13C) who were treated between 2001 and 2007 with a standard staged protocol that included TEA were studied. Baseline Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained during the initial hospitalization, and the 6- and 12-month follow-up visits. Elbow range of motion (ROM) measurements were obtained at each follow-up visit., Results: Follow-up averaged 43 (range 4-138) months. There were no wound complications and no deep infections. Complications included one case of heterotopic ossification with joint contracture, one olecranon fracture unrelated to the TEA, and two loose humeral stems. The average final ROM was from 21° (range 5-30°) to 113° flexion (range 90-130°). DASH scores averaged 25 at pre-injury baseline and 48 at the most recent follow-up visits., Conclusions: TEA has become a mainstream option for the treatment of distal humerus fractures which are on occasion open. There is hesitation in using arthroplasty in an open fracture setting due to a potential increased infection risk. The absence of any infectious complications and satisfactory functional outcomes observed in the current series indicates that TEA is a viable treatment modality for complex open fractures of the distal humerus., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this study was to compare the infection risk when internal fixation plates either overlap or did not overlap previous external fixator pin sites in patients with bicondylar tibial plateau fractures and pilon fractures treated with a 2-staged protocol of acute spanning external fixation and later definitive internal fixation., Design: Retrospective comparison study., Setting: Two level I trauma centers., Patients/participants: A total of 85 OTA 41C bicondylar tibial plateau fractures and 97 OTA 43C pilon fractures treated between 2005 and 2010. Radiographs were evaluated to determine the positions of definitive plates in relation to external fixator pin sites and patients were grouped into an "overlapping" group and a "nonoverlapping" group., Intervention: Fifty patients had overlapping pin sites and 132 did not., Main Outcome Measure: Presence of a deep wound infection., Results: Overall, 25 patients developed a deep wound infection. Of the 50 patients in the "overlapping" group, 12 (24%) developed a deep infection compared with 13 (10%) of the 132 patients in the "nonoverlapping" group (P = 0.033)., Conclusions: Placement of definitive plate fixation overlapping previous external fixator pin sites significantly increases the risk of deep infection in the 2-staged treatment of bicondylar tibial plateau and pilon fractures. Surgeons must make a conscious effort to place external fixator pins outside of future definitive fixation sites to reduce the overall incidence of deep wound infections. Additionally, consideration must be given to the relative benefit of a spanning external fixator in light of the potential for infection associated with their use., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The incidence of venous thromboembolism after major trauma has been estimated to be as high as 60%, despite appropriate prophylaxis. Pulmonary embolism is associated with deep venous thrombosis and also with significant rates of morbidity and mortality. This study examined risk factors for pulmonary embolism among patients with pelvic and lower-extremity fractures in the National Trauma Data Bank. Univariate analysis and multiple logistic regression were used to assess potential risk factors for pulmonary embolism during the index hospitalization period. A total of 199,952 patients with pelvic and lower-extremity fracture were identified. Of these patients, 918 (0.46%) had a pulmonary embolism and 117 (12%) of them died during hospitalization. The risk of pulmonary embolism was significantly increased in patients with multiple fractures (odds ratio, 1.89; P<.001) only. No significant relationship was found with fracture location (pelvis, femur, tibia). Other factors that were associated with increased rates of pulmonary embolism were obesity (body mass index >40 odds ratio, 3.38; P<.001), history of warfarin use (P=.009), hospital disposition (surgery odds ratio, 1.68; P<.001; intensive care unit odds ratio, 2.4; P<.001), and hospital setting (university odds ratio, 1.36; P<.001). Multiple pelvic or lower-extremity fractures, but not their anatomic locations, were associated with pulmonary embolism in the National Trauma Data Bank. As expected, obese patients and those with a history of warfarin therapy have higher rates of pulmonary embolism. This study offers guidance in identifying patients with musculoskeletal trauma who are at elevated risk for pulmonary embolism., (Copyright 2014, SLACK Incorporated.)

Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures' costs. Physicians have been encouraged to consider cost in the selection of devices, but several factors make acquiring cost information difficult. To assess physicians' levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs "below average" or "poor." However, more than 80 percent of all respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost containment efforts.

Objectives: This study compared results of aggressive and nonaggressive debridement protocols for the treatment of high-energy, open supracondylar femur fractures after the primary procedure, with respect to the requirement for secondary bone grafting procedures, and deep infection., Design: Retrospective review., Setting: Level I and level II trauma centers., Patients/participants: Twenty-nine consecutive patients with high-grade, open (Gustilo types II and III) supracondylar femur fractures (OTA/AO 33A and C) treated with debridement and locked plating., Intervention: Surgeons at 2 different level I trauma centers had different debridement protocols for open supracondylar femur fractures. One center used a more aggressive (MA) protocol in their patients (n = 17) that included removal of all devitalized bone and placement of antibiotic cement spacers to fill large segmental defects. The other center used a less aggressive (LA) protocol in their patients (n = 12) that included debridement of grossly contaminated bone with retention of other bone fragments and no use of antibiotic cement spacers. All other aspects of the treatment protocol at the 2 centers were similar: definitive fixation with locked plates in all cases, IV antibiotics were used until definitive wound closure, and weight bearing was advanced upon clinical and radiographic evidence of fracture healing., Main Outcome Measurements: Healing after the primary procedure, requirement for secondary bone grafting procedures, and the presence of deep infection., Results: Demographics were similar between included patients at each center with regard to age, gender, rate of open fractures, open fracture classification, mechanism, and smoking (P > 0.05). Patients at the MA center were more often diabetic (P < 0.05). Cement spacers to fill segmental defects were used more often after MA debridement (35% vs. 0%, P < 0.006), and more patients had a plan for staged bone grafting after MA debridement (71% vs. 8%, P < 0.006). Healing after the index fixation procedure occurred more often after LA debridement (92% vs. 35%, P < 0.003). There was no difference in infection rate between the 2 protocols: 25% with the LA protocol and 18% with the MA protocol (P = 0.63). All patients in both groups eventually healed and were without evidence of infection at an average of 1.8 years of follow-up., Conclusions: The degree to which bone should be debrided after a high-energy, high-grade, open supracondylar femur fracture is a matter of surgeon judgment and falls along a continuous spectrum. Based on the results of the current study, the theoretic trade-off between infection risk and osseous healing potential seems to favor an LA approach toward bone debridement in the initial treatment., Level of Evidence: Therapeutic level III.

Objective: The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months., Design: Blinded randomized questionnaire based on a retrospective cohort., Setting: University level 1 trauma center., Patients/participants: Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months., Methods: A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion., Main Outcome Measurements: Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months., Results: The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%., Conclusions: Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort., Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Spinal hardware has been adapted for fixation in the setting of anterior pelvic injury. This anterior subcutaneous pelvic fixator consists of pedicle screws placed in the supraacetabular region connected by a contoured connecting rod placed subcutaneously and above the abdominal muscle fascia., Questions/purposes: We examined the placement of the components for anterior subcutaneous pelvic fixator relative to key vascular, urologic, bony, and surface structures., Methods: We measured the CT scans of 13 patients after placement of the pelvic fixator to determine the shortest distances between the fixator components and important anatomic structures: the femoral vascular bundle, the urinary bladder, the cranial margin of the hip, the screw insertion point on the bony pelvis, the relationship between the pedicle screw and the corridor of bone in which it resided, and the position relative to the skin., Results: The average distance from the vascular bundle to the pedicle screw was 4.1 cm and 2.2 cm to the connecting rod. The average distance from the connecting rod to the anterior edge of the bladder was 2.6 cm. The average distance from the screw insertion point to the hip was 2.4 cm; none penetrated the hip. The average screw was in bone for 5.9 cm. The pedicle screws were on average 2.1 cm under the skin. The average distance from the anterior skin to the connecting rod was 2.7 cm., Conclusions: Components of this anterior pelvic fixator are close to important anatomic structures. Careful adherence to the surgical technique should minimize potential risk., Level of Evidence: Level IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.

Background: Postthrombotic syndrome (PTS) is a chronic condition in the lower extremity that develops after deep vein thrombosis (DVT). The incidence of PTS after total hip arthroplasty (THA) is not well established., Questions/purposes: We (1) determined the incidence of PTS after DVT in patients undergoing primary THA for osteoarthritis; and (2) determined whether the incidence of PTS was greater in patients with DVT than without., Methods: We retrospectively reviewed records of all 1037 patients who underwent primary THA for osteoarthritis during a 4-year period. All patients underwent postoperative screening ultrasound. We identified 21 (2%) patients with a DVT by ultrasound of whom 14 had a minimum 1-year followup (mean, 3.4 years; range, 1.0-6.0 years). PTS was diagnosed if any two of the six clinical signs were documented., Results: Three of 14 patients with DVT had at least two signs consistent with PTS; two of these had a DVT proximal to the soleal arch. Three of 91 randomly matched patients undergoing THA without DVT had at least two signs of PTS. The incidence of developing PTS after THA appeared higher in patients with DVT than in patients without DVT., Conclusions: While we observed a difference between the incidence of PTS after THA in patients with and without DVT, that incidence was based on only three of 1037 patients with DVT after THA. PTS does not appear to be a major complication after DVT in patients undergoing THA., Level of Evidence: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.