Placement Of External Fixator Research Articles

Early external fixation of tibial plateau fractures is associated with an increased risk of compartment syndrome

IntroductionTibial plateau fractures are often associated with high-energy trauma necessitating external fixation as a means of temporization. There is evidence that pin placement and fracture distraction may result in transient increases in compartment pressures, and the optimal timing of external fixator placement is unknown. This study sought to determine the effect of early versus late external fixator placement on the risk of compartment syndrome after a tibial plateau fracture. MethodsThe Trauma Quality Improvement Program was retrospectively queried between 2015 and 2019 for adult patients with a tibial plateau fracture who underwent external fixator placement. Patients with concomitant tibial shaft and/or distal femur fractures, requiring lower extremity fasciotomy before external fixation, or external fixation >7 days after admission were excluded. The primary study outcome was inpatient compartment syndrome. Secondary outcomes were inpatient acute respiratory failure/unplanned intubation, surgical site infection, and venous thromboembolism (VTE). A time threshold of delayed external fixation was identified at which the odds of compartment syndrome no longer significantly decreased with increasing time using a Markov Chain Monte Carlo simulation of a restricted cubic spline model. The odds of each outcome were compared between patients who underwent early versus delayed external fixation on or after the time threshold, adjusting for potential confounding by patients, injury, and hospital characteristics. Significance was defined as p < 0.05. ResultsA threshold for delayed external fixation was identified at 28.8 h from admission. Of the 3,185 eligible patients, 2,656 (83.4 %) were classified as early external fixation and 529 (16.6 %) were classified as delayed external fixation. Delayed external fixation was associated with lower adjusted odds (aOR) of compartment syndrome (aOR: 0.31, 95 % Confidence Interval (CI): 0.13–0.74, p = 0.008) and higher aOR of acute respiratory failure/unplanned intubation (aOR: 2.13, 95 % CI: 1.13–4.0.2, p = 0.019), however no significant differences in adjusted odds of surgical site infection or VTE were observed. ConclusionPatients with tibial plateau fractures who underwent closed reduction and external fixation within 28.8 h of admission were associated with greater odds of compartment syndrome than those undergoing external fixation after this time threshold.

Delayed Life-Threatening Hemorrhage Caused by Cranial Tibial Artery Pseudoaneurysm in Two Dogs.

Two adult dogs were presented at 25 and 30 days following tibial external skeletal fixator placement (case 1) and tibial plateau leveling osteotomy (case 2), respectively. Clinical signs at presentation for each of them included acute onset lethargy, non-weight-bearing lameness, and hemorrhage at the surgical site with large hematoma formation. On admission, emergency whole blood transfusion was required in case 2 with a preoperative packed cell volume of 13%. Both dogs were diagnosed with pseudoaneurysm of the cranial tibial artery based on color Doppler ultrasonography. Additionally, computed tomography angiography was performed in one dog. Surgical treatment of the dogs included ligation of the cranial tibial artery supplying the pseudoaneurysm and curettage of hematoma. The surgery was completed without complications in case 1, but case 2 experienced inadvertent rupture of pseudoaneurysm with significant blood loss, which required another whole blood transfusion during the procedure. Both dogs had excellent functional recovery with no recurrence of clinical signs. We hypothesized that pseudoaneurysms were primarily caused by trauma secondary to placement of surgical implants or osteotomy. For orthopedic surgeons, it is important to recognize clinical signs of a potential tibial arterial pseudoaneurysm, as early surgical intervention may prevent loss of limb or life.

Early surgery and number of injured ligaments are associated with postoperative stiffness following multi-ligament knee injury surgery: a systematic review and meta-analysis.

To perform a systematic review and meta-analysis to investigate the rate of stiffness after multi-ligament knee injury (MLKI) surgery and identify potential risk factors associated with postoperative stiffness. This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Registration was done on the PROSPERO International Prospective Register of Systematic Reviews (CRD42022321849). A literature search of PubMed, Ovid, Embase, and Cochrane Library databases was conducted in October 2022 for clinical studies reporting postoperative stiffness after MLKI surgery. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. The following variables were extracted from studies for correlation to postoperative stiffness: study characteristics, cohort demographics, Schenk classification, neurovascular injury, mechanism of injury, external fixator placement, timing of surgery, and concomitant knee injuries. Thirty-six studies comprising 4,159 patients who underwent MLKI surgery met the inclusion criteria, including two Level-II, fourteen Level-III, and twenty Level-IV studies. The average MINOR score of the studies was 14. The stiffness rate after MLKI was found to be 9.8% (95% CI 0.07-0.13; p < 0.01; I2 = 87%), and the risk of postoperative stiffness was significantly lower for patients with two ligaments injured compared to patients with ≥ 3 ligaments injured (OR = 0.45, 95% CI (0.26-0.79), p = 0.005; I2 = 0%). The results of the pooled analysis showed early surgery (< 3weeks) resulted in significantly increased odds of postoperative stiffness compared with delayed surgery (≥ 3weeks) (OR = 2.18; 95% CI 1.11-4.25; p = 0.02; I2 = 0%). However, age, gender, body mass index, energy of injury, and neurovascular injury were not associated with an increased risk of postoperative stiffness (n.s.). Performing surgery within the first 3 weeks following MLKI, or concomitant injury of ≥ 3 ligaments, are significantly associated with increased risk of postoperative stiffness. These findings can be utilized by surgeons to decide the timing of surgery for MLKI surgeries especially in which ≥ 3 ligaments are injured. Level IV.

Fracture blisters: predictors for time to definitive fixation in pilon fractures.

Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2days vs 7.9days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

Free vascularized fibula graft for staged reconstruction of infected humerus nonunions.

To evaluate the union rate and rate of post-operative complications in patients with septic nonunions of the humerus following a two-stage reconstruction using a free vascularized fibula graft. Retrospective case series. Academic, tertiary referral center. Adult patients with staged reconstruction for infected nonunion of the humerus with at least 2 years follow up after vascularized fibula graft transfer. First, infected nonunion debridement with antibiotic spacer and external fixator placement. After antimicrobial treatment, free vascularized fibula transfer with internal fixation. Time to union, pain, affected extremity range of motion and function. 10 patients with septic humerus nonunion treated with staged reconstruction using a free vascularized fibula graft, with a mean follow-up of 32.3 months were included. Following the two-stage reconstruction using a free fibula, radiographic union was achieved in 6/10 patients, with a mean time to union of 19.9 weeks. The remaining four patients required an additional procedure with graft augmentation and/or implant revision. After the revision procedure, union was noted in 3/4 patients, 21 weeks post-operatively. Mean patient visual analog scale pain scores improved from 5.8 pre-operatively to 0.9 at final follow up (p=0.02). Post-operatively mean elbow flexion was 110±20 degrees and extension 15±7.5 degrees. A two-stage reconstruction using a free fibula graft can be used in patients with septic nonunions of the humerus in the setting of multiple failed prior surgeries and compromised local biology. Additional procedures may be needed in some to achieve final union. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Secondary intramedullary nailing for open tibial shaft fractures. Comparison of a one-stage versus two-stage surgical procedure

IntroductionThe objective of this study was to compare the rates of radiological and clinical complications after sequential treatment of a tibial shaft fracture by external fixation followed by secondary nailing with an early-stage conversion (C1S) versus a two-stage late conversion (C2S). The hypothesis of this work was that treatment with C1S does not increase the risk of surgical site infections compared to C2S, and allows faster healing with a lower malunion rate. Material and methodsWe carried out a retrospective and comparative study based on the files of the traumatology department of the Édouard Herriot University Hospital in Lyon. We reviewed the records of patients who presented with a Gustilo grade 1, 2 or 3a open tibial fracture treated with external fixation with conversion by intramedullary nailing within 6 months from January 2010 to December 2020. We assessed the occurrence of Surgical Site Infections (SSI), consolidation time, time until resumption of weight bearing and the malunion rate. ResultsOf the 55 patients included, a C1S procedure was performed in 25 cases (45.5%) versus 30 cases (54.5%) for C2S. No significant difference was found concerning the occurrence of SSI after intramedullary nailing between the two groups (p=0.81). A significant difference was observed in terms of bone healing (p=0.036) and the malunion rate (0.0013) in favor of nailing in one stage. DiscussionThe strategy of converting an open leg fracture early, in one stage (C1S), after initial external fixator placement allows for faster healing and weight bearing, while ensuring a lower malunion rate compared to that of a late two-stage conversion. In the absence of a scar at the time of intramedullary nailing, C1S does not increase the risk of surgical site infections. While the choice of a late and sequential two-stage operation is likely related to the surgeon's apprehension around conversion of an open leg fracture by intramedullary nailing, this study could promote the use of C1S in a greater number of situations. Level of evidenceIV.

A multicenter retrospective analysis of risk factors for poor outcomes after tibial pilon fractures

Background: Despite the high rate of complications associated with tibial pilon fractures, treatment often remains fairly algorithmic. This study highlights risk factors for poor outcomes to guide individualized treatment in an effort to minimize complications. Methods: One hundred and fifty-seven surgically treated pilon fractures in 151 patients over 6 yr were included. The following factors were studied: age, gender, presence of diabetes, smoking status, presence of an open fracture, Association for Osteosynthesis-Orthopaedic Trauma Association (AO/OTA) fracture classification, number of plates and incisions, time to external fixator placement, time to definitive treatment, and incisions used. The two primary outcomes were nonunion and infection/wound complications requiring re-operation. Univariate tests were used for each variable in isolation. Multiple regression models were used to control important covariates. Interactions between the number of incisions, patient history of smoking, the number of plates utilized, and patient history of diabetes were analyzed. Results: Male gender, open fracture, history of diabetes and increasing time to fixation were associated with infection/wound complications. Open fractures were strongly associated with the development of nonunion. The interaction model for diabetes and increasing number of plates showed that each additional plate used when treating patients with a history of diabetes was associated with 6.08 times higher odds of developing an infection, a marginally significant result (P=0.065). Conclusions: Increased caution may be warranted when treating tibial pilon fractures in patients with certain risk factors. In patients with a history of diabetes, the additional dissection needed to place more implants may contribute to higher rates of infection. Level of Evidence: Prognostic Level III.

Le rôle thérapeutique du fixateur externe dans le traitement des fractures pelviennes instables chez l’enfant

BackgroundUnstable pelvic fractures in children are serious and complex injuries, and the optimal method to manage these injuries is controversial. HypothesisWe hypothesized that an external fixator would be a satisfactory method of treating unstable pelvic fractures in children. Patients and methodsWe retrospectively reviewed 40 pediatric patients with unstable pelvic fractures who were treated with an external fixator in Beijing Children's Hospital from June 2006 to June 2016. Postoperative follow-up was 12 to 108months, with an average of 26months. One year after the operation, fracture healing, pelvic asymmetry, and deformity index were assessed by X-ray. Pelvic function was evaluated with the Cole evaluation standard, and daily cognitive and motor functions were evaluated by weeFIM. Patient complications were recorded. ResultsThe average age of the 40 patients was 5.9±3.1years (2.0 to 14.5years), including 25 boys and 15 girls. Among these cases, 37 (92.5%) had injuries caused by traffic accidents and 3 (7.5%) had injuries caused by falling from height. Based on the Tile classification, there were 18 cases of class B (14 class B2 and 4 class B3) and 22 cases of class C (15 class C1, 6 class C2, and 1 class C3). The X-rays showed good fracture healing at the 1-year postoperative follow-up. The pelvic asymmetry was reduced from 1.13cm before the operation to 0.88cm after (p<0.05), and the deformity index was decreased from 0.09 before to 0.05 after the operation (p<0.05). At the 1-year postoperative follow-up, 36 patients had excellent Cole scores, and 4 had good Cole scores, with a good or excellent rate of 100%. According to the weeFIM, 28 patients had complete independence, 11 had basic independence, and 1 had conditional independence. Three patients (7.5%) had complications, all of which were postoperative pin-site infections. DiscussionFor children with horizontally unstable pelvic fractures, an external fixator can be used alone. For children with horizontally and vertically unstable pelvic fractures, after external fixator placement and reduction, lower extremity traction can be performed to achieve better reduction and maintain stability, and the therapeutic effect is satisfactory. Level of evidenceIV, retrospective observational cohort study.

Staged Hindfoot Fusion for Osteomyelitis of the Distal Tibia and Talus

Category:Ankle; Diabetes; Hindfoot; TraumaIntroduction/Purpose:Management of hindfoot osteomyelitis involves eradication of infection, deformity correction, and bony stabilization in the setting of bone loss and poor bone quality. In this case series of 12 patients, we present a two-stage technique; debridement, deformity correction, joint surface preparation, and intramedullary reaming with placement of antibiotic rod and ring external fixation followed by a second stage of external fixator removal and exchange of antibiotic rod for definitive hindfoot rod. The purpose of this poster is to highlight techniques that can improve the success of obtaining stable fixation, remission of infection, and ultimately fusion. Techniques highlighted are ring fixator placement, preparation of the antibiotic rod, intramedullary canal preparation, rod exchange, and use of blocking screws to enhance compression and axial loading of the fusion.Methods:Twelve patients were treated with this two-stage protocol. The most common indication was post-traumatic osteomyelitis followed by neuropathic (Charcot) joint. All were treated in a staged manner with an initial debridement of nonviable tissue including osteomyelitic bone. The tibiotalar and talocalcaneal joints were resected and prepared for fusion at the initial debridement. Provisional stabilization and compression were obtained through the use of a ring external fixator. An intramedullary antibiotic impregnated cement coated rod was introduced through the calcaneus, talus, and the intramedullary space of the tibia. The patients were kept in the fixator until the skin was healed and all incisions were dry. At this point, the fixator was removed, and the antibiotic rod was exchanged for the definitive hindfoot fusion rod.Results:Cultures were positive for Staphylococcal or Streptococcal species in 58% of cases, fungal in 8%, and Gram negative organisms in 33%. On average patients spent 93 days in the fixator while wounds were healing, and they were receiving systemic antibiotics. One patient died while in the frame. There have been no amputations in the series. Of the patients that have completed the protocol, all have gone on to either bony fusion or stable fibrous union. All are able to walk unaided. And thus far, all are free of active infection. Secondary procedures are described.Conclusion:This technique of staged fusion for hindfoot osteomyelitis offers the following advantages. the first stage involves thorough debridement and deformity correction. Oftentimes there is extensive scarring and the soft tissue envelope is not conducive to internal fixation. This technique allows the soft tissues to heal before placing the definitive internal fixation. It also allows for graduated compression at the fusion site with the ring fixator. The antibiotic rod not only delivers high concentration of local antibiotics, but it prevents deformity recurrence during the compression phase. The definitive rod provides support of pathologic bone and maintains deformity correction.

Therapeutic effect of an external fixator in the treatment of unstable pelvic fractures in children

BackgroundUnstable pelvic fractures in children are serious and complex injuries, and the optimal method to manage these injuries is controversial. HypothesisWe hypothesized that an external fixator would be a satisfactory method of treating unstable pelvic fractures in children. Patients and MethodsWe retrospectively reviewed 40 pediatric patients with unstable pelvic fractures who were treated with an external fixator in Beijing Children's Hospital from June 2006 to June 2016. Postoperative follow-up was 12 to 108 months, with an average of 26 months. One year after the operation, fracture healing, pelvic asymmetry, and deformity index were assessed by X-ray. Pelvic function was evaluated with the Cole evaluation standard, and daily cognitive and motor functions were evaluated by weeFIM. Patient complications were recorded. ResultsThe average age of the 40 patients was 5.9±3.1 years (2 to 14.5), including 25 boys and 15 girls. Among these cases, 37 (92.5%) had injuries caused by traffic accidents and 3 (7.5%) had injuries caused by falling from height. Based on the Tile classification, there were 18 cases of class B (14 class B2 and 4 class B3) and 22 cases of class C (15 class C1, 6 class C2, and 1 class C3). The X-rays showed good fracture healing at the 1-year postoperative follow-up. The pelvic asymmetry was reduced from 1.13cm before the operation to 0.88cm after (p<0.05), and the deformity index was decreased from 0.09 before to 0.05 after the operation (p<0.05). At the 1-year postoperative follow-up, 36 patients had excellent Cole scores, and 4 had good Cole scores, with a good or excellent rate of 100%. According to the weeFIM, 28 patients had complete independence, 11 had basic independence, and 1 had conditional independence. Three patients (7.5%) had complications, all of which were postoperative pin-site infections. DiscussionFor children with horizontally unstable pelvic fractures, an external fixator can be used alone. For children with horizontally and vertically unstable pelvic fractures, after external fixator placement and reduction, lower extremity traction can be performed to achieve better reduction and maintain stability, and the therapeutic effect is satisfactory. Level of evidenceIV, retrospective observational cohort study.

148. Sacroiliac joint fusion navigation: how accurate is pin placement?

BACKGROUND CONTEXT Percutaneous pin placement is used in a variety of orthopedic surgery settings. These include, but are not limited to, external fixator placement, fracture fixation, and reference frame application for navigation. Although pin placement typically is uncomplicated, it can become more difficult with the need for obliquely angled pins and the potential for the pin to slip off the bone. For spine and pelvic cases with intraoperative navigation, often a standard reference frame is placed using a percutaneous pin. The goal is for this pin to be placed into the posterior ilium, which is an oblique surface. Proper placement of this pin helps to ensure the correct placement of the sacroiliac joint (SIJ) fusion implants. To date, there is no literature specifically examining the accuracy of pin placement. PURPOSE The purpose of our study was to evaluate the occurrence of ideal percutaneous pin placement into the iliac wing during navigated SIJ fusion surgery. STUDY DESIGN/SETTING IRB approved retrospective chart review study completed at an academic medical institution. PATIENT SAMPLE Patients who underwent navigated SIJ fusion by the senior author between 10/2013 and 1/2020. OUTCOME MEASURES Pin placement accuracy graded in concordance with a scheme developed and tested by the authors. METHODS Following IRB approval, we reviewed the charts and intraoperative CT imaging of patients who underwent navigated SIJ fusion by the senior author between 10/2013 and 1/2020. A pin placement grading scheme was developed initially and tested. The definition of ‘ideal’ placement was a concept developed by the authors. A modification was made and found to be acceptable to attending surgeons. This was then used for two rounds of grading. Six attending surgeons completed two rounds of pin placement grading. RESULTS Of the 95 eligible patients, 54.7% had ‘ideal’ pin placement. There were no observed complications from pin placement. There was no relationship between BMI and ideal placement. Male patients were 3.6 times more likely to have ideal placement than females. Additionally, patients undergoing right-sided fusion were 2.9 times more likely to have ideal placement than those with left-sided fusion. Interobserver reliability was rated as 0.48 and 0.47 in the first and second rounds defined as ‘moderate agreement.’ The measured intraobserver reliability ranged from 0.62 to 0.74 defined as ‘substantial agreement.’ Conclusions This study shows that even in the hands of an experienced surgeon, nonideal pin placement occurs 45.3% of the time. However, engagement of the lateral or medial cortex may make the pin more rigid. Though pin placement does not meet our preconceived ‘ideal’, it is only rarely a true ‘miss’ where it is placed into the sacrum. Male patients and patients undergoing right-sided fusion were more likely to have ‘ideal’ pin placement. When placing percutaneous pins, regardless of the location, it is important to be aware of factors that can decrease the accuracy of pin placement. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Prevalence of Vitamin D Deficiency in Adult Limb Lengthening and Deformity Correction Patients

Introduction: Limb lengthening and deformity correction surgery (LLDC) requires adequate bone metabolism for distraction osteogenesis. Low Vitamin D is a common nutritional deficit that places bone health at risk and has been associated with fracture. It is currently unknown what the Vitamin D levels are among patients undergoing elective osteotomy. The goal of this research is to determine the prevalence of Vitamin D deficiency in adult patients undergoing lower extremity osteotomies for LLDC. Materials and Methods: A retrospective review was performed for adult patients (≥18 years old) who underwent an osteotomy surgery at a single institution between 2014 and 2018. The primary outcome measure was perioperative 25(OH)D serum level. Of 139 subjects identified as undergoing a lower extremity osteotomy surgery, 96 (69%) underwent perioperative Vitamin D testing. Deficiency and insufficiency were defined as a 25(OH)D value of &lt;20 ng/mL and between 20 and 30 ng/mL, respectively. Results: Patients undergoing external fixator placement for length and/or deformity correction were most likely to have this laboratory assessed (88%) versus acute correction patients (65%) and intramedullary lengthening patients (62%), (P = 0.033). The mean Vitamin D level was 29.5 ± 17.8 ng/mL (range: 5.7–95.9 ng/mL). A total of 63% of patients had low perioperative Vitamin D: 33.3% deficient, 30.2% insufficient. Conclusion: The majority of adult LLDC patients have deficient or insufficient Vitamin D levels perioperatively. Vitamin D “prehabilitation” whereby testing and repleting before limb lengthening surgery should be highly considered as standard practice.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4min; 95% CI, - 32 to 22; p = 0.68). In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

Fractura de pelvis inestable. Estudio de cohorte longitudinal

BackgroundThere is no consensus about treatment for patients with an unstable pelvic fracture and even less when hemodynamic instability is associated with. Study was conducted to determine the outcome in the management of patients with an unstable fracture of the pelvis, with or without hemodynamic instability, in a trauma referral center in Medellín, Colombia. MethodsA retrospective, longitudinal cohort study was conducted including patients with pelvic fracture due to trauma. Demographic data, vital signs on admission, presence of hemodynamic shock on admission (according to the ATLS scale), method of bleeding control, transfusion requirement and overall mortality rate were collected. An analysis was performed on a subgroup of patients who presented with signs of associated severe hemodynamic shock, defined as ATLS III-IV upon admission and a requirement for blood products of more than 8IU in the first 48hours. ResultsA total of 567 patients with any type of pelvic fracture, between January 2011 and December 2018, identified in the institution's databases, of which 149 patients presented an unstable pelvic fracture pattern (FIP). 68.1% of the patients were male, with a mean age of 34 IQR; 30 years and an Injury Severity Score (ISS) of 34 IQR: 20. Hospital mortality was 13.3%. Angioembolization and external fixator placement were the most used method of bleeding control. A total of 37 patients (27%) underwent intervention to control bleeding in the first 48hours. There were 37 patients with pelvic fracture admitted in a state of severe shock or requiring more than 8U of blood products, 17 patients required intervention in the pelvis, using single or combined ways. The mortality calculated for these patients was 32%. DiscussionPatients with unstable pelvis fractures admitted to our institution have a high mortality rate and it is even higher in patients who present with severe shock. Various methods were used to control bleeding similar to those indicated in the current literature. We require a sustained institutional effort to treat pelvic fractures and reduce the mortality of our patients, and knowing our population characteristcs allows us to guide management strategies.Evidence Level: III

Factors associated with perioperative opioid demand in lower extremity fractures: Does consumption vary by anatomic location?

Perioperative opioid pain management protocols should reflect anticipated patient need. Fracture location and external fixation may be related to post-operative pain. The purpose of this study is to evaluate the impact of fracture location, articular injury, and pre-operative external fixation, and articular injury on perioperative opioid demand following definitive fixation. 1-month pre-operative to 1-year post-discharge opioid demand in oxycodone 5-mg equivalents in 23,441 patients undergoing fracture fixation of the femoral shaft through ankle between 2007 and 2017 was evaluated using a national database. Opioid demand was compiled over several timeframes: 1-month pre-op to 90-days post-discharge, 3 months post-discharge to 1-year post-discharge, and 1-month pre-op to 1-year post-discharge. Multivariable main effects linear and logistic regression models were constructed to evaluate the increased opioids filled, increased opioid prescriptions, and odds of refills in these timeframes with adjustment for fracture location, external fixator placement, and baseline patient and injury characteristics. Lower extremity anatomic location and pre-operative external fixation were significantly associated with increased 1-month pre-op to 1-year post-discharge opioid filling (17.6-54.7 additional oxycodone 5-mg equivalents, all p<0.05) and number of filled prescriptions (0.28-0.54 additional prescriptions, all p<0.05). Pilon fractures and pre-operative external fixation, specifically, were associated with increased odds of two or more opioid prescriptions within the 1-month pre-op to 1-year post-discharge time frame (1.25-1.32 odds ratio, all p<0.05). Fracture location and pre-operative external fixator placement predicted perioperative opioid demand. Articular zone (pilon, plateau, and distal femur) fracture fixation was associated with the largest increases in opioid demand after lower extremity fracture fixation. Patients with these injuries may be at highest risk of extensive opioid consumption.

External fixator of the elbow

The placement of an external elbow fixator can be statically carried out as temporary stabilization or as a hinged movement fixator. As a hinged movement fixator a functional follow-up treatment is possible due to control of the joint guidance and reduction of the compromising forces on the osteoligamentous structures. As atemporary stabilization of the elbow, the external fixator is used as adamage control method. As a movement fixator it is used as an additional protection and movement control after complex osteoligamentous interventions and persisting tendency to dislocation of the joint and also as a standalone procedure. In some cases, the procedure is also used in distraction arthrolysis of stiff elbows and as asalvage procedure in patients with relevant comorbidities as part of fracture treatment. Inexperience in relation to the procedure as well as alocal acute infection at the level of the intended pin locations should specifically be mentioned as contraindications. In addition, compliance and patient understanding of the procedure are essential for the success of treatment. Soft tissue preparation for pin placement should be preferred over percutaneous incisions to enable asafe bone exposure. Knowledge of the course of neurovascular structures (particularly the radial nerve) is essential. When placing ahinge, knowledge of the position and detection of the idealized center of rotation is of fundamental importance. The type of postoperative management required essentially depends on the underlying injury. When placing ahinged fixator, the aim is to enable movement as early as possible. Nevertheless, blocking of the hinged fixator may be useful for ashort period of time. Adequate pin care over the duration of the treatment is essential in order to prevent complications. Good functional results have been reported for the treatment of unstable elbows after primary and secondary placement of ahinged external fixator. Good functional scores and improvement in the range of motion were also recorded in the context of an arthrolysis (additive for open arthrolysis or distraction arthrolysis); however, in contrast asignificant number of complications associated with this surgery are likely to emerge. As adefinitive salvage procedure, satisfactory results were obtained in asmall case series of aselected older patient group with relevant comorbidities.

Military experience in the management of pelvic fractures from OIF/OEF

IntroductionPelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF),...

The use of external fixation in the emergency department: applications, common errors, complications and their treatment.

The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.Patients with multiple trauma should be stabilized quickly with EF.The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).Planning the type of framework to be used is crucial.Avoid mistakes in the placement of EF.Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029

Submental Artery Island Flap for Soft Tissue Coverage of a Mandibular Reconstruction Plate in a High-Risk Patient With Medication-Related Osteonecrosis of the Jaw

We present a case of a 69-year-old woman with multiple complicating comorbidities who developed medication-related osteonecrosis of the jaw secondary to extraction of multiple teeth with a history of intravenous bisphosphonate therapy for metastatic breast cancer requiring staged management with segmental mandibulectomy with placement of external pin fixator with subsequent exchange of this device for a titanium reconstruction plate and a submental island pedicled flap for soft tissue coverage of the bridging reconstruction plate. Once the surgical sites were well-healed that patient would immediately return to a satisfactory functional outcome with ability to tolerate a soft diet. Furthermore, the patient did not have complications (ie, cardiac, pulmonary, venous thromboembolism, sepsis, surgical site infection, reoperation) during her hospitalization and has done well with her long-term recovery.

Biomechanical evaluation of pin placement of external fixator in treating tranverse tibia fracture: Analysis on first and second cortex of cortical bone

Biomechanical perspective of external fixator is one of the greatest factor to consider in successfully treating bone fracture. This is due to the fact that mechanical behavior of the structure can be analyzed and optimized in order to avoid mechanical failure, increase bone fracture healing rate and prevent pre-term screw loosening. There are three significant factors that affect the stability of external fixator which are the placement of pin at the bone, configuration and components of external fixator. These factors lead to one question: what is the optimum pin placement in which exerts optimum stability? To date, literature on above mentioned factors is limited. Therefore, we conducted a study to evaluate the uniplanar-unilateral external fixator for two different pin placement techniques in treating transverse tibia fracture via finite element method. The study was started off with the development of transverse tibia fracture using Mimics software. Computed tomography (CT) data image was utilized to develop three dimensional tibia bone followed by crafting fracture on the bone. Meanwhile, the external fixator was developed using SolidWork software. Both tibia bone and external fixator were meshed in 3-matic software with triangular mesh element. Simulation of this configuration was took place in a finite element software, Marc.Mentat software. A load of 400 N was applied to the proximal tibia bone in order to simulate stance phase of a gait cycle. From the findings, the pin placement at the second cortex of bone provided optimum stability in terms of stress distribution and displacement, which should be considered for better treatment for transverse tibia fracture. On the other hand, the pin placement at first cortex should be avoided to prevent many complications.