H. Claude Sagi

Comparative Radiographic and Clinical Outcome of Two-Hole and Multi-Hole Symphyseal Plating

Objectives: To report on the radiographic and clinical outcome of symphyseal plating techniques, with specific attention to the incidence of implant failure, reoperation secondary to implant complication, and ability to maintain reduction of the pelvic ring. Design: Retrospective chart and radiographic review. Setting: Level 1 trauma center. Patients: A total of 229 skeletally mature patients with traumatic pelvic disruptions associated with pubic symphysis diastasis requiring open reduction internal fixation. Intervention: Symphyseal plating: (1) group THP, a two-hole plate; (2) group MHP, a multi-hole plate (minimum 2 holes/screws on either side of the symphysis). Patients were analyzed with respect to technique of anterior ring fixation and posterior ring injury pattern and fixation. Main Outcome Measurement: Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. Analysis included pelvic ring injury, type of anterior and/or posterior fixation, maintenance of postoperative reduction, rate of implant failure, and need for reoperation secondary to implant complication. Additionally, logistic regression analysis was performed to detect correlation between any other variable (posterior injury pattern, presence or absence of posterior fixation, time to surgery) and failure or malunion. Statistical analyses were performed using SPSS software. Results: A total of 92 complete data sets were available for review. There were 51 patients in group THP and 41 patients in group MHP. When comparing the results of the 2 different methods of anterior fixation (THP versus MHP), the rate of fixation failure was greater in group THP (17 of 51; 33%) than group MHP (5 of 41; 12%). This was statistically significant (P = 0.018). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (29 of 51; 57%) than in the MHP group (6 of 41; 15%). Again, this was highly statistically significant (P = 0.001). Although the reoperation rate was slightly higher in the THP group (16%) as compared to the MHP group (12%), this was not statistically significant (P = 0.67). Logistic regression analysis did not reveal any other variables to correlate as a risk factor for failure or malunion in this group of patients. Conclusions: In this group of patients, the two-hole symphyseal plating technique group had a higher implant failure rate and, more importantly, a significantly higher rate of pelvic malunion. On the basis of these findings, we recommend multi-hole plating of unstable pubic symphyseal disruptions.

A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis.

Purpose: To analyze the radiographic, clinical, and functional results of triangular osteosynthesis constructs for the treatment of vertically unstable comminuted transforaminal sacral fractures. Setting: Level I trauma center. Methods: During a 3-year period (July 1, 2003 to June 30, 2006), 58 patients with vertically unstable pelvic injuries were treated with triangular osteosynthesis fixation by a single surgeon at a single institution. Patients were followed-up prospectively as a single cohort, with institutional review board approval. Inclusion criteria for this study were skeletally mature patients with a vertically unstable pelvic ring injury associated with a comminuted transforaminal sacral fracture. Minimum follow-up, both clinically and radiographically, was 1 year. Computed tomography scan was performed on all patients at 6 months to assess healing of the fracture. If the fracture healed, the fixation was removed. Functional outcome was assessed using the Short Form 36, version 2, and short version of Musculoskeletal Functional Assessment questionnaires at 6 months (before fixation removal) and 12 months. Results: Forty of 58 patients with an average age of 39 years were available for a minimum of 1-year follow-up. Wound complications requiring surgical debridement occurred in 5 patients (13%), all of whom had severe soft tissue wounds with internal degloving. Two patients required removal of infected fixation. Iatrogenic L5 nerve injury occurred in 5 patients (13%). Ten patients (25%) had a delayed union on computed tomography scans, and 3 patients had a nonunion as a result of residual fracture gap and incomplete reduction. Six patients (15%) were found to have pronounced tilting of the L5 vertebral body (scoliosis) and distraction of the L5/S1 facet joint ipsilateral to the fixation. This did not correct with removal of the fixation. Failure of the triangular osteosynthesis construct resulting in malunion occurred in 2 patients (5%). All but 2 patients (95%) complained of painful and prominent implants. Functional outcome scoring showed that patients continued to function below the population mean at 1 year but continued to improve, particularly with function and daily activity. Ninety-seven percent of patients returned to some form of work or schooling. Conclusions: Triangular osteosynthesis fixation is a reliable form of fixation that allows early full weight-bearing at 6 weeks while preventing loss of reduction in comminuted vertical shear transforaminal sacral fractures. For this study group, operative reduction was maintained until healing in 95% of patients. However, the 1-year follow-up shows a substantial rate of potential technical problems and complications. Of primary concern were the asymmetric L5 tilting with L5-S1 facet joint distraction and the need for a second surgery in all patients to remove painful fixation. Iatrogenic nerve injury occurred in 5 patients (13%) and is thought to arise secondary to fracture manipulation and reduction. We recommend selective use of this technique for comminuted transforaminal sacral fractures in situations only where reliable iliosacral or trans-sacral screw fixation is not obtainable.

Examination under anesthetic for occult pelvic ring instability.

Objective: To describe the technique and results of stress examination with fluoroscopy under anesthesia (EUA) to determine stability and the need for operative stabilization of traumatic pelvic ring injuries. Design: Retrospective chart and radiographic review. Setting: Level I trauma center. Subjects: Skeletally mature patients with traumatic incomplete posterior pelvic ring injuries. Methods: Patients were consented for EUA if preoperative radiographs and computed tomographic scanning of the pelvis demonstrated an incomplete injury to the posterior pelvic ring (Orthopaedic Trauma Association [OTA] 61-B type injuries). Patients with nondisplaced anterior compression fractures of the sacral ala without internal rotation or a fracture line exiting the posterior cortex were excluded from this analysis. Similarly, skeletally immature patients or those with complete instability of the pelvic ring (OTA 61-C type injuries) were excluded. All patients meeting inclusion criteria were taken to the operating room, anesthetized, and placed in the supine position for stress examination (EUA) of the pelvic ring using intraoperative dynamic fluoroscopy. Examination consisted of a resting static film followed by internal rotation, external rotation, and push-pull maneuvers of both lower extremities. Each of these maneuvers was performed using the anteroposterior, inlet, and outlet projections, providing a total of 15 distinct images for each patients examination. The preoperative classification of the pelvic ring injury was then accepted or redefined based on the amount of rotational and translational instability in the axial, coronal, and sagittal planes. The decision to proceed with anterior and/or posterior operative reduction and stabilization was subsequently based on the degree of pelvic ring instability noted during the EUA. Results: A total of sixty-eight patients underwent an EUA of their pelvis by the senior author. Fifty males and 18 females with an average age of 35 years comprised the study group. In all, 37 anteroposterior compression (APC or OTA 61-B1) injuries and 31 lateral compression (LC or OTA 61-B2) injuries were evaluated. Of the 14 pelvic ring injuries initially classified as an APC-1, seven (50%) were deemed stable and treated nonsurgically, whereas seven (50%) were felt to have sufficient instability (an occult APC-2) to warrant treatment with anterior fixation based on EUA. Of the 23 injuries initially classified as an APC-2, all but one required surgical fixation: 13 (57%) were treated with anterior fixation alone (APC-2a), whereas nine (39%) were treated with anterior fixation and supplemental iliosacral screw placement (APC-2b) based on the degree of instability noted during the EUA. Of the 20 injuries initially classified as an LC-1, 13 (65%) were stable and treated nonsurgically (LC-1a), whereas seven (35%) were treated with anterior and/or posterior stabilization (LC-1b) based on the degree of instability noted during the EUA. Conclusions: The reported incidence of poor functional outcomes associated with pelvic fracture may be attributable, in part, to inadequate treatment of misdiagnosed injuries and chronic instability and/or malunion. Performing an examination under anesthesia with dynamic stress fluoroscopy as described in this series revealed occult instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. We propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. We conclude that pelvic EUA merits further analysis as an important diagnostic tool that may provide additional information regarding instability of the pelvic ring.

The Effect of Suture Pattern and Tension on Cutaneous Blood Flow as Assessed by Laser Doppler Flowmetry in a Pig Model

Objective: To determine the effects of various suture patterns on cutaneous blood flow (CBF) at the wound edge as increasing tension is applied through the suture. Methods: Four different suture patterns commonly used for wound closure (simple, vertical mattress, horizontal mattress, and Allgower-Donati) were placed individually after a full-thickness incision was made in an anesthetized pig. A laser Doppler flowmeter (LDF) was placed on the skin edge after the suture was passed. Baseline CBF was recorded. Increasing tension was applied to the wound edge via the suture through a tensionometer in 0.5-lb (0.23-kg) increments from 0 to 2.5 lb (1.13 kg). CBF was then recorded as a function of tension for each suture pattern. Results: The Allgower-Donati suture pattern affected CBF significantly less than the other three suture patterns did for all tensions from 0.5 to 2.0 lb (0-0.9 kg; P < 0.05). There were no significant differences between vertical mattress, horizontal mattress, and simple suture patterns. Conclusions: The Allgower-Donati suture pattern had the least effect on CBF with increasing tension in this model. Further study is warranted on the benefits of this suture pattern because it may decrease wound complications in traumatized tissues.

Indomethacin prophylaxis for heterotopic ossification after acetabular fracture surgery increases the risk for nonunion of the posterior wall.

Objectives: To determine if indomethacin has a positive clinical effect for the prophylaxis of heterotopic ossification (HO) after acetabular fracture surgery. To determine whether indomethacin affects the union rate of acetabular fractures. Design: Prospective randomized double-blinded trial. Setting: Level 1 regional trauma center. Patients: Skeletally mature patients treated operatively for an acute acetabular fracture through a Kocher–Langenbeck approach. Intervention: Patients were randomly allocated to 1 of 4 groups comparing placebo (group 1) to 3 days (group 2), 1 week (group 3), and 6 weeks (group 4) of indomethacin treatment. Main Outcome Measurements: Factors analyzed included the overall incidence, Brooker class and volume of HO, radiographic union of the acetabular fracture, and pain. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year. Serum levels of indomethacin were drawn at 1 month to assess compliance. Computed tomographic scans were performed at 6 months to assess healing and volume of HO. Results: Ninety-eight patients were enrolled into this study, 68 completed the follow-up and had the 6-month computed tomographic scan, and there was a 63% compliance rate with the treatment regimen. Overall incidence of HO was 67% for group 1, 29% for group 2 (P = 0.04), 29% for group 3 (P = 0.019), and 67% for group 4. The volume of HO formation was 17,900 mm3 for group 1, 33,800 mm3 for group 2, 6300 mm3 for group 3 (P = 0.005), and 11,100 mm3 for group 4. The incidence of radiographic nonunion was 19% for group 1, 35% for group 2, 24% for group 3, and 62% for group 4 (P = 0.012). Seventy-seven percent of the nonunions involved the posterior wall segment. Pain visual analog scores (VASs) were significantly higher for patients with radiographic nonunion (VAS 4 vs. VAS 1, P = 0.002). Conclusions: Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Technical Aspects and Recommended Treatment Algorithms in Triangular Osteosynthesis and Spinopelvic Fixation for Vertical Shear Transforaminal Sacral Fractures

Vertically unstable pelvic ring injuries associated with comminuted transforaminal sacral fractures present a special problem to the treating surgeon in applying stable fixation for maintaining reduction. Triangular osteosynthesis and spinal-pelvic constructs are relatively new techniques used to avoid loss of reduction for treating these difficult fractures, and the last decade has seen a marked increase in the use of these techniques. This article aims to describe the indications and technical aspects in the use of spinal-pelvic constructs for vertical shear sacral fractures such that they can be applied to better help the patients with these injuries.

Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint ankylosis or anatomic reduction contribute to functional outcome?

Objective: To prospectively analyze a homogenous group of trauma patients with pure sacroiliac (SI) joint dislocations treated with iliosacral screws (ISS), with specific attention to functional outcome and its correlation with the presence or absence of SI joint ankylosis and quality of reduction. Design: Retrospective chart and radiographic review of initial injury and treatment, with prospective long-term evaluation of radiographs, computed tomography (CT) scans, and functional assessments. Setting: Level One Regional Trauma Center. Patients: Twenty-three patients who were skeletally mature with traumatic vertical shear pelvic injuries associated with a pure SI joint dislocation. Intervention: Treatment consisted of closed or open reduction in the supine or prone position and insertion of a single ISS placed percutaneously for the fixation of the posterior ring injury. Main Outcome Measurement: Each patient was evaluated for functional outcome using version 2 of the Short-Form 36 (SF-36v2), the short version of the Musculoskeletal Functional Assessment (sMFA), the Iowa Pelvic Scoring System, and the Majeed Pelvic Scoring System. Additionally, at the follow-up visit, each patient received plain radiographs of the pelvis and CT scanning of the pelvis. Results: Minimum follow-up was 1 year postindex procedure (13-120 months). In this subset of patients with pure SI dislocations treated with ISS alone, anatomic reduction was the only predictor of a more favorable functional outcome (P = 0.04). Specifically, SI joint ankylosis did not affect functional outcome in these patients. Conclusions: Based on the results of this study, in the treatment of vertically displaced, pure SI joint dislocations, an anatomic reduction (whether closed or open), followed by ISS fixation should be the goal because this appears to be the only predictor of a more favorable functional outcome in patients with this injury. Complete SI joint ankylosis appears to have no effect, either positive or negative, on functional outcome in these patients.

The insertion of intramedullary nail locking screws without fluoroscopy: a faster and safer technique.

Objective: This study was designed to compare the accuracy, time, and radiation exposure during the insertion of intramedullary nail locking screws using either standard fluoroscopic assistance or an electromagnetic (EM)-based navigational system without fluoroscopy. Design: Prospective. Setting: Level I academic trauma center. Methods: Patients were divided into 2 groups: group 1 (fluoroscopic assistance), consisted of standard freehand fluoroscopically assisted insertion of locking screws (OEC 9900; G.E. HealthCare, Waukesha, WI), whereas group 2 (EM), consisted of EM navigationally assisted insertion without fluoroscopy (SureShot; Smith & Nephew, Memphis, TN). Technician arrival time, setup (SU) time, screw insertion (SI) time (seconds), fluoroscopy time (seconds), radiation exposure (mrads), and accuracy (hit or miss) were recorded for each screw. For group 1, the SU time was recorded as the time and radiation required to obtain “perfect circles” before insertion, and for group 2, the SU time was recorded as the time required to set up the navigational EM unit. Data collected regarding SI were then compared using standard analysis of variance. Results: Forty-one locking screws were inserted in group 1, whereas 60 screws were inserted in group 2. Accuracy was 100% for both groups. For group 1, mean technician wait time was 77 seconds plus a mean perfect circle SU time of 105 seconds (9.2 mrads and 10 seconds of fluoroscopy). Mean SU time for group 2 was 94 seconds (no fluoroscopy). Mean insertion time was 342 seconds per screw for group 1 (32.9 mrads and 18 seconds of fluoroscopy) compared with 234 seconds per screw for group 2 (no fluoroscopy). These differences were statistically significant (P = 0.006). Conclusions: The use of EM navigation (SureShot; Smith & Nephew) for the insertion of intramedullary nail locking screws demonstrated accuracy similar to conventional fluoroscopic-guided insertion. However, EM-guided locking SI resulted in a significantly shorter total procedural time and completely eliminated radiation exposure. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Use of temporary partial intrailiac balloon occlusion for decreasing blood loss during open reduction and internal fixation of acetabular and pelvis fractures

Summary: Patients with pelvic and/or acetabular fractures can sustain significant blood loss at the time of their injury and during surgery. We report on the technique, effect on blood loss, and complications with the use of temporary partial intrailiac balloon occlusion during open reduction and internal fixation of pelvic and acetabular fractures in a series of patients refusing allogeneic blood products for philosophical or religious reasons. An intra-arterial balloon is positioned in the common iliac artery immediately preoperatively, ipsilateral to the fracture in the interventional radiography suite. This balloon is then periodically inflated and deflated throughout the case by the anesthesiologist to mitigate operative blood loss. For anterior approaches, average blood loss was significantly less for those patients operated with temporary partial intrailiac balloon occlusion compared with those without. For posterior approaches, blood loss was not significantly different. One complication occurred in a patient who developed an arterial thrombus requiring surgical removal by the vascular surgery service at the conclusion of the orthopaedic surgery. He had no further sequelae. Although not recommended for routine use in all pelvic and acetabular fractures, we feel the use of temporary partial intrailiac balloon occlusion merits further study and may be beneficial in reducing blood loss during anterior pelvic or acetabular procedures in those patients who are opposed to allogeneic blood products and cell saver or those who cannot tolerate an anticipated massive blood loss.