Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes? Objective: To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo–Anderson type IIIB open tibial diaphyseal fractures. Design: Retrospective comparative cohort study over a 2-year period. Setting: Level 1 trauma center. Patients/Participants: A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. Intervention: Time to initial debridement and definitive management. Main Outcome Measurement: Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. Results: Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. Conclusions: Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Commentary on: “Two-Stage Combined Ortho-plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?” No abstract available

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Preperitoneal Pelvic Packing Is Not Associated With an Increased Risk of Surgical Site Infections After Internal Anterior Pelvic Ring Fixation Objective: To investigate the risk of postoperative surgical site infections after plate fixation of the anterior pelvic ring subsequent to preperitoneal pelvic packing (PPP). Design: Retrospective observational cohort study. Setting: Level I academic trauma center. Patients: Adult trauma patients with unstable pelvic ring injuries requiring surgical fixation of the anterior pelvic ring. Intervention: Pelvic plate fixation was performed as a staged procedure after external fixation and PPP/depacking (PPP group; n = 25) or as a single-stage primary internal fixation (control group; n = 87). Main Outcome Measure: Incidence of postoperative surgical site infections of the pelvic space. Results: Anterior pelvic plate fixation was performed in 112 patients during a 5-year study period. The PPP group had higher injury severity scores and transfused packed red blood cells than the control group (injury severity score: 46 ± 12.2 vs. 29 ± 1.5; packed red blood cells: 13 ± 10 vs. 5 ± 2; P < 0.05). The mean time until pelvic depacking was 1.7 ± 0.6 days (range: 1–3 days) and 3.4 ± 3.7 days (range: 0–15 days) from depacking until pelvic fracture fixation. Two patients in the PPP group and 8 patients in the control group developed a postoperative infection requiring a surgical revision (8.0% vs. 9.2%; n.s.). Both PPP patients with a pelvic space infection had undergone anterior plate fixation for associated acetabular fractures. Conclusions: These data support the safety of the PPP protocol for bleeding pelvic ring injuries due to the lack of increased infection rates after fracture fixation. Caution should be applied when considering PPP in patients with associated acetabular fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries Objectives: Describe the trajectory of functional recovery for patients with surgically treated unstable pelvic ring injuries from baseline to 5 years. Design: Prospective cohort study. Setting: Level I Trauma Center. Patients/Participants: One hundred eight adult patients with surgically treated pelvic fractures (72% OTA/AO 61 B1-B3 and 28% OTA/AO 61 C1-C3) were enrolled into the institutions orthopaedic trauma database between 2004 and 2015. The cohort was 78% men with a mean age of 44.9 years and injury severity score of 16.9. Intervention: Surgical pelvic stabilization. Main Outcome Measurements: Function was measured at baseline and prospectively at 6 months, 1, and 5 years postoperatively using the Short Form–36 Physical Component Score (SF-36 PCS). The trajectory was mapped, and the proportion of patients achieving a minimal clinically important difference (MCID) between time points was determined. Results: The mean SF-36 PCS improved for the entire group between 6 and 12 months (P = 0.001) and between 1 and 5 years (P = 0.02), but did not return to baseline at 5 years (P < 0.0001). The proportion of patients achieving a MCID between 6 and 12 months and 1 and 5 years was 75% and 60%, respectively. The functional level was similar between type B and C groups at baseline (P = 0.5) and 6 months (P = 0.2); however, the type B cohort reported higher scores at 1 year (P = 0.01) and 5 years (P = 0.01). Neither group regained their baseline function (P < 0.0001). Conclusions: Functional recovery for patients with surgically treated pelvic fractures is characterized by an initial decline in function, followed by sharp improvement between 6 and 12 months, and continued steady improvement between 1 and 5 years. Type B injuries show better early recovery than type C and reach a higher level of function at the final follow-up. Despite the proportion of patients achieving MCID, patients do not regain the preinjury level of function. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Operative Intervention Provide Early Pain Relief for Patients With Unilateral Sacral Fractures and Minimal or No Displacement? Objectives: To compare pain after operative versus nonoperative pelvic ring injuries with unilateral sacral fractures. Design: Prospective, multicenter, observational. Setting: Sixteen trauma centers. Patients/Participants: Skeletally mature patients with pelvic ring injury and minimally displaced unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. Main Outcome Measurements: Pelvic displacement was documented on injury plain radiographs and computed tomography scans; a 10 point Visual Analog Scale (VAS) was used to evaluate pain was obtained in the anterior and posterior pelvic ring during the time of union (12 weeks). Results: One hundred ninety-four patients with unilateral sacral fractures displaced less than 5 mm, mean age of 38.7, and mean Injury Severity Score of 14.5 were included. Ninety-nine percent had lateral compression injuries, and 62% were in zone 1. Seventy-four percent were treated nonoperatively. Nonoperative patients had more zone 1 fractures (71%, P = 0.004). Nonoperative patients reported mean VAS 2.7 points higher in the posterior pelvis (P = 0.01) and 1.9 points higher anteriorly (P = 0.11) 24 hours after injury compared with patients treated operatively. After 3 months, nonoperative patients reported higher VAS scores than operative patients: 4.0 versus 2.9 posteriorly (P = 0.019) and 3.2 versus 2.3 anteriorly (P = 0.035). Conclusions: For sacrum fractures with minimal or no displacement, slight differences in the VAS were noted within 24 hours after injury or surgery, but limited differences were seen at 3 months for either operatively treated minimally or undisplaced sacrum fractures. It is unknown whether this represents clinical relevance. These differences were below the minimally important clinical difference for VAS scores for other orthopaedic conditions. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Surgery for Unilateral Sacral Fractures: Are the Indications Clear? Objectives: To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery. Design: Prospective, multicenter, observational study. Setting: Sixteen trauma centers. Patients/Participants: Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. Main Outcome Measurements: Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement. Results: Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively. Conclusions: Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Commentary on: “Surgery for Unilateral Sacral Fractures: Are the Indications Clear?” No abstract available

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Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery Objectives: To determine factors associated with nerve injury after acetabulum fracture and to evaluate recovery and outcomes. Design: Retrospective cohort study. Setting: Level 1 trauma center. Patients and Participants: Nine hundred seventy-five skeletally mature patients with acetabulum fracture. Intervention: Operative and nonoperative management. Main Outcome Measurements: Nerve injuries, categorized as traumatic or iatrogenic, recovery (none, partial, or complete), and patient-reported functional outcomes with the Musculoskeletal Function Assessment (n = 353, 36.2%). Results: Thirty-two patients (3.3%) experienced nerve injury with 24 (78%) resulting from trauma and 23 with an associated posterior hip dislocation. Eight injuries (25%) were iatrogenic. Thirty-one (97%) occurred in patients with operative fractures (n = 738). The most common fracture pattern associated with nerve injury was transverse posterior wall (31% of injuries). Obesity was more common in patients with nerve injuries (59% vs. 30% in those without nerve injury (P = 0.001), but was not related to age or sex. Sixty-five percent of sciatic nerve injuries were to the common peroneal division only, while none were isolated to the tibial division. All iatrogenic injuries occurred after the ilioinguinal approach (P < 0.001). Overall, 50% experienced partial nerve recovery and 22% had complete recovery. However, 24% of patients with sciatic or common peroneal injuries had no recovery. Thirty-three percent of tobacco smokers experienced no recovery (vs. 26% of nonsmokers). Average Musculoskeletal Function Assessment scores for patients with nerve injuries was 32, similar to those without (33). Conclusions: Posterior acetabulum fracture dislocations are associated with traumatic nerve injury, although 25% of nerve injuries were iatrogenic. Nerve injuries are more common in obese patients. More than one-quarter of patients had no recorded nerve recovery. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.