Jonathan Eastman

OBJECTIVES: To assess the outcomes of patients with complete articular distal femur fractures treated with open reduction and retrograde intramedullary nailing. METHODS: Design: Retrospective cohort analysis. Setting: Single-center, Level 1 Academic Trauma Center. Patient Selection Criteria: Patients treated between January 1, 2016, and January 1, 2023, with complete articular distal femur fractures (AO/OTA 33 C1-3)W who underwent independent articular reduction and retrograde intramedullary nailing were included. Patients were included who had a minimum of 3 months of follow-up or until fracture union. Outcome Measures and Comparisons: Patient data pertaining to demographics, surgical details, and radiographic outcomes were systematically collected and analyzed. Coronal and sagittal alignments were evaluated using the anatomic lateral distal femur angle and anatomic posterior distal femoral angle, respectively. Reoperations were stratified into planned and unplanned categories and further classified as major or minor. RESULTS: The study cohort comprised 127 patients (52% males) with 130 complete articular distal femur fractures (3 patients with bilateral fractures) with a mean age of 49.9 years (range: 12–95 years). The mean clinical follow-up was 254.1 days (range: 90–1882 days). Postoperative mean anatomic lateral distal femur angle was 83.4 degrees, and anatomic posterior distal femoral angle was 1.2 degrees apex posterior. Articular reductions were anatomic (0 mm residual displacement, 93.8%) or near anatomic (between 0 and 2 mm residual displacement, 6.2%) in all cases. All reductions were maintained at final follow-up. The reoperation rate was 15.4%, with 3.8% of cases classified as major unplanned operations. Most minor unplanned reoperations (8% of cases) were for implant irritation or knee arthrofibrosis. The rate of osseous union was high, with only 1 case of nonunion observed, yielding an aseptic nonunion rate of 0% and an infected nonunion rate of 0.8%. CONCLUSIONS: Independent articular reduction and retrograde intramedullary nailing of AO/OTA 33C femur fractures resulted in an overall reoperation rate of 15.4%, major unplanned reoperation rate of 3.8%, an osseous union rate of 99%, and maintained articular and metaphyseal reductions at final follow-up. The study's findings support this technique as an effective treatment option for managing these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To characterize the rate and risk factors for a posterior wall fragment becoming intra-articular following closed reduction in posterior acetabular fracture-dislocations when the fragment was positioned between the femoral head and acetabulum prior to reduction. METHODS: Design : Retrospective case series. Setting: Regional Level 1 trauma center. Patient Selection Criteria: Patients with posterior wall, posterior column–posterior wall, or transverse–posterior wall acetabular fracture-dislocations and posterior hip dislocation between January 2019 and December 2023 were reviewed. Inclusion required pre- and post-reduction CT imaging demonstrating a posterior wall fragment between the femoral head and acetabulum. Outcome Measures and Comparisons: Pre- and post-reduction CT scans were reviewed to define fragment position relative to the femoral head and determine whether fragments were intra- or extra-articular after reduction. RESULTS: Of 44 patients with a posterior wall fragment positioned between the femoral head and acetabulum prior to reduction, 21 (47.7%) had the fragment become intra-articular following closed reduction. All fragments that displaced into the joint were medial to the femoral head (100%) prior to closed reduction (mean age 37.4 years [18.0–77.0], 57.1% male) and 23 (52.3%) remained extra-articular (mean age 34.3 years [20.0–80.0], 65.2% male). Among intra-articular fragments, 21 of 21 (100.0%) were medial to the femoral head before reduction compared with 6 of 23 (26.1%) extra-articular fragments (p<0.001). Inferior fragment position was present in 20 of 21 (95.2%) intra-articular fragments and 8 of 23 (34.8%) extra-articular fragments (OR 37.5, 95% CI 4.2–333.1; p<0.001). Fragment length was 2.6 ± 1.1 cm versus 3.6 ± 1.0.98 cm (p=0.003). Medial fragment position was associated with non-concentric reduction (74.2% vs. 30.8%; OR 6.5, 95% CI 1.6–26.9; p=0.015), whereas inferior fragment position was not (p=0.172; OR 2.9, 95% CI 0.8–10.9; p=0.172). CONCLUSIONS: Medial and inferior posterior wall fragment position before reduction were each associated with post-reduction intra-articular translation, while medial position was also associated with non-concentric reduction. Recognition of this morphology may aid surgical planning and anticipation of fragment retrieval. LEVEL OF EVIDENCE: Prognostic Level IV.

Cases: We describe 2 cases of ballistic hip arthrotomies with retained intra-articular fragments lodged deep to the quadrilateral plate, where arthroscopic retrieval alone may be challenging and often requires an open approach. Both patients were treated using a strategy combining hip arthroscopy for joint debridement and fragment mobilization followed by a Pfannenstiel intrapelvic approach for definitive removal. Conclusion: This combined arthroscopic and intrapelvic surgical technique offers an alternative method for addressing difficult-to-access intra-articular ballistic fragments while minimizing additional chondral injury.

Unstable pelvic ring injuries represent a challenge due to the complex anatomy. Further, surgical access to the pelvic ring is altered by patient positioning in the supine versus prone position. Certain injury patterns present with the posterior pelvis in a fixed displaced position. These injuries can be exceedingly challenging to reduce from a supine position. In the prone position, these injuries can be reduced more directly with an open approach, but this is associated with wound healing complications. The technical trick herein demonstrated a successful technique utilizing a large Jungbluth clamp percutaneously applied to the posterior superior iliac spines with 4.5-mm cortical screws. This allowed for more direct manipulation of the posterior pelvic ring than supine techniques, while minimizing biologic cost. Described in this report it is particularly efficacious for reducing associated fixed dislocation of the L5/S1 facet when associated with pelvic ring injury. Care must be taken to appreciate the limitations of this technique in reducing certain vectors of displacement, particularly flexion and extension deformities.

OBJECTIVE: To investigate nonunion rates and risk factors in patients with ipsilateral femoral neck and shaft fractures. METHODS: Design: Retrospective review. Setting: Two Level I trauma centers. Patient Selection Criteria: Two hundred seven patients treated for ipsilateral femoral neck (AO/OTA 31-B) and shaft (AO/OTA 32A-C) fractures from 2013 to 2022. Patients with less than 6 months of follow-up were excluded. Outcome Measures and Comparisons: The primary outcome of this study was femoral shaft nonunion. Risk factors for nonunion were evaluated, including smoking, open fracture, delay to full weight-bearing, blood transfusions, and AO/OTA classification. RESULTS: Two hundred twenty-seven patients were initially identified, but only 154 patients had sufficient follow-up and were included in final analysis. The mean age was 38.9 years (SD = 15.3), and injury severity score was 19.5 (9.7). One hundred ten patients (71%) were male and 69 (45%) required intensive care unit care. Thirty-eight patients (25%) experienced an open fracture, and 44 fractures (29%) were AO/OTA Type C. Thirty patients (20%) underwent initial external fixation, and 88 patients (57%) received a perioperative transfusion. Thirty-four patients (22%) developed a femoral shaft nonunion, and 5 (3%) experienced a surgical site infection. Nonunion was associated with perioperative blood transfusion, AO/OTA Type C fracture, postoperative non-weight-bearing, and delay to full weight-bearing ≥12 weeks. Multivariable regression identified perioperative blood transfusion ≥3 (risk ratio [RR] = 1.91; CI, 1.12–2.72; P = 0.02) and AO/OTA Type C fracture (RR = 2.45; CI, 1.50–3.34; P = 0.001) as independent risk factors. CONCLUSIONS: Ipsilateral femoral neck and shaft fractures remain difficult injuries to treat. Much attention is given to diagnosis and treatment of the femoral neck component. These results suggest that successful treatment of the femoral shaft component presents its own challenges with high nonunion rates. LEVEL OF EVIDENCE: Prognostic Level III.

OBJECTIVES: The purpose of this study was to evaluate the biomechanical stability of a modified triangular osteosynthesis construct with S1 pedicle screws compared with other described lumbopelvic fixation constructs in a U-type sacral fracture model. METHODS: U-type sacral fractures were created in validated fourth-generation spinopelvic models. Four different constructs were cyclically loaded with displacement measured in all planes: (1) bilateral L5 pedicle screws with rods attached to iliac bolts, (2) bilateral L5 and S1 pedicle screws with rods attached to iliac bolts, (3) bilateral L5 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw, and (4) bilateral L5 and S1 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw. RESULTS: The bilateral L5 and S1 pedicle screws with rods attached to iliac bolts with a transsacral–transiliac screw construct had significantly decreased horizontal, vertical, and angular displacement compared with all other constructs. CONCLUSIONS: From a biomechanical perspective, a modified triangular osteosynthesis construct with S1 pedicle screws improves stability in fixation of U-type sacral fractures.

Summary: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.

Purpose: To describe U-type sacral fracture characteristics amenable to percutaneous sacral screw fixation. Methods: U-type sacral fractures were identified from a trauma registry at a level 1 trauma center from 2014 to 2020. Patient demographics, injury mechanism, fracture characteristics, and fixation construct were retrospectively retrieved. Associations between fracture pattern and surgical fixation were identified. Results: 82 U-type sacral fractures were reviewed. Six treated with lumbopelvic fixation (LPF) and 76 were treated with percutaneous sacral screws (PSS) alone. Patients receiving LBF had greater sacral fracture displacement in coronal, sagittal, and axial planes compared to patients receiving PSS alone (P < 0.05), negating osseous fixation pathways. All patients went onto sacral union and there were no implant failures or unplanned reoperations for either group. Conclusion: If osseous fixation pathways are present, U-type sacral fractures can be successfully treated with percutaneous sacral screws. LPF may be indicated in more displaced fractures with loss of spinopelvic alignment. Both techniques for U-type sacral fractures result in reliable fixation and healing without reoperations.

Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities.

Pelvic ring injuries and acetabular fractures are complex injuries and are often challenging to treat for a number of reasons. Orthopaedic trauma surgeons critically evaluate pelvic radiographs and CT images to generate an appropriate detailed injury and patient-specific preoperative plan. There are numerous crucial osseous details that surgeons should be aware of. Often, some of the most important factors that affect patients in treatment timing decisions, assessing reduction strategies, and deciding and inserting fixation constructs may be subtle on preoperative imaging. The radiographic and CT imaging findings covered subsequently should be sought out and appreciated preoperatively. Combining all the available osseous information helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Ensuring a methodical and meticulous imaging review allows for the development of a detailed preoperative plan and helps avoid intraoperative missteps. This process will inherently streamline the surgical procedure and optimize the patient’s surgical care. Maximizing the accuracy of the preoperative planning process can streamline the treatment algorithm and ultimately contribute to the best possible clinical outcome.