1. Implement definitive treatment of pelvic fractures.

2. Classify acetabular types based on Letournel protocol.

3. Execute operative treatment of acetabular fractures.

4. Perform intramedullary nailing for tibial shaft fractures.

5. Manage nonunions of the tibia.

Definitive Treatment of Pelvic Fractures: Decision Making
Mark C. Reilly, MD, Associate Professor of Orthopaedics and Co-Chief of Orthopaedic Trauma Service, University of Medicine & Dentistry of New Jersey, New Jersey Medical School, Newark

Introduction: after initial treatment, patient at least semi-stable with mechanically unstable pelvic ring injury; radiologic studies obtained; fractures identified and treated; preventing deformity next goal

Classification

Based on stability: type A—stable; type B—rotationally (partially) unstable, ie, incomplete posterior ring disruption; type C—complete posterior ring disruption

Based on anatomy: proposed by Letournel; documents site of injury and magnitude of displacement; anterior ring injuries—dislocation of synthesis pubis; fractures of pubic body; fractures through pubic rami; posterior pelvic ring injuries—sacroiliac joint dislocation; sacroiliac fracture dislocation (“crescent fracture”); ilium fractures; sacral fracture

Indications for treatment

Anterior pelvic ring: type B injuries—synthesis dislocation >2.5 cm; parasymphysial (pubic body) fractures; type C injuries—pubic ramus fracture displaced >2 cm; certain open pelvic and open rami fractures; nonoperative treatment—synthesis dislocations <2.5 cm (patient may present later with sacroiliac joint pain)

Posterior pelvic ring: proposed indications—<1 cm shortening; complete loss of hip rotation; sacroiliac incongruity; severe cosmetic deformity from rotation of hemipelvis; important to remember—all unstable pelvic ring injuries require reduction and fixation; type C injuries—complete disruption; type B injuries—external rotation (open book appearance; usually through synthesis pubis); internal rotation (lateral compression injury)

Treatment

Posterior ring injury: usually mild sacroiliac opening (indirectly reduced by reduction and fixation of anterior pelvic ring); sacroiliac joint (nonoperative management); sacral fractures (treat operatively); sacral internal rotation injury (treat nonoperatively)

Conclusion

Type B injuries: external rotation (open book)—fix anterior ring (not posterior ring); internal rotation—treat nonoperatively

Type C fractures: posterior pelvic ring—anatomic reduction; internal fixation (iliosacral screws for maintaining reduction); external fixation—not recommended as sole means of definitive treatment

Surgical Indications and Decision Making for Acetabular Fractures
Joel M. Matta, MD, Clinical Professor of Orthopaedics, the Keck School of Medicine of the University of Southern California, and John C. Wilson Jr. Chair of Orthopaedics, Good Samaritan Hospital, Los Angeles

Introduction: Robert Judet and Emile Letournel developed improved treatment for acetabular fractures; speaker attended international course teaching surgeons operative care; radiology emphasized

Radiology protocol: plain films (anteroposterior [AP], oblique, caudad, and cephalad views); computed tomography (CT; fractures of quadrilateral surface; intra-articular injuries); 45° oblique views (posterior and anterior column fractures); 3-dimensional CT useful

Letournel classification: 10 fracture types

Simple fracture types: anterior wall; anterior column; posterior wall; posterior column; transverse fractures

Combined fracture types: posterior wall and posterior column; posterior wall and transverse fractures; T-shaped fracture; anterior and posterior hemitransverse fractures (anterior wall or anterior column predominating in displacement)

Radiologic interpretation: surgeon should be able to draw accurate representation of fracture on innominate bone (model or drawing) before surgery

Rationale for surgery: preservation of hip; functional treatment of hip; prevention of deformity of innominate bone; prevention of nonunion or acetabular defects

Indications for surgery: articular displacement of acetabulum; significant possibility of bad outcome with nonoperative approach; probability of good outcome

Indications for nonoperative treatment: appropriate for 15% to 20% of displaced fractures (very distal anterior column or posterior wall fractures); sometimes used for both-column fractures (ie, secondary congruence and small displacement); medical contraindication to surgery

Surgery in older patients: appropriate for majority of displaced acetabular fractures; avoid extensile approaches; primary total hip arthroplasty (doubtful outcome with open reduction and internal fixation [ORIF] alone; solid fixation of innominate bone precondition)

Operative protocol: single surgical approach; orthopedic table (speaker uses PROfx table); specialized reduction forceps screw and plate fixation

Approaches: Kocher-Langenbeck (KL); ilioinguinal; extended iliofemoral; in minority of cases, combined KL and ilioinguinal successively; in combined anterior column and posterior column fractures any one of these 3 approaches, depending on fracture configuration; “understand the x-rays perfectly”

Implants: 3.5-mm screw most common; plates (various curvatures; flexible; somewhat stiffer; avoid overuse of flexible plates; most fractures require ≥1 plate)

Instrumentation: instruments for pushing bone in pelvis; specialized clamps (go around innominate bone and span both sides of transverse fracture; placed inside pelvis)

Minimize trauma: by utilizing KL or ilioinguinal approach alone, whenever possible; however, anatomic reduction remains key

Orthopedic table: designed to maximize capabilities of each surgical approach; positioning—extended approach (lateral); KL (prone); ilioinguinal (supine); without table—second approach more likely to be required

Goals of surgery: anatomic reduction of innominate bone and acetabulum; minimal surgical trauma by limiting surgical approach; avoidance of complications

Results: in ≈80% of cases, results excellent or good across fracture types; anatomic reduction main determinant of good outcome; injury to femoral head and age of patient additional determinants

Tibial Shaft Fractures: Current Concepts
Bradley R. Merk, MD, Associate Professor of Orthopaedic Surgery, and Director of Orthopaedic Traumatology, Northwestern University Feinberg School of Medicine, Chicago, IL

Patient assessment issues: soft tissue envelope key; compartment syndrome; possible vascular injury

Indications for nonoperative treatment: low-energy fractures—<5° of angulation; minimal shortening; treatment (casting; functional brace); early weight-bearing

Indications for operative treatment: open fractures; neurovascular issues; compartment syndromes; high-energy injuries; segmental fractures; fractures in or near joints

Intramedullary (IM) nailing: most fractures

ORIF: fractures near joints; metaphyseal or metadiaphyseal fractures

Plating: small intramedullary canal

External fixation: temporizing measure—vascular injury; unstable patient; severe soft tissue injury; definitive treatment—significant infection; segmental bone loss

IM nailing: minimally invasive; stable implant (early weight-bearing); helps diaphyseal fracture reduction; early total care possible (definitive closure in 5-7 days); technique—exacting for injuries at ends of bone

Reduction during procedure: for metaphyseal fractures; incision—through, medially, or laterally to tendon; above patella

Useful adjuncts: distractors; external fixators; percutaneous clamps; blocking screws (fractures at ends of bone); plates (provisional fixation for open injuries)

Results from Harbor View: using adjuncts above; 37 fractures; acceptable alignment in 92%; union in 100; low infection rate

Reaming: advantages in healing; fewer secondary procedures; safe to ream open fractures

Large trial: Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT); multicenter trial (>29 centers in North America); enrolled >1300 patients with diaphyseal fractures of tibia; focus on reamed vs unreamed nailing; no difference in outcome at 1-yr follow-up ; unexpected finding (even in best case [isolated closed fracture with successful union], only 54% of patients able to return to sports; ≈20% of patients did not return to work)

Treatment of open tibial fractures: plating—higher incidence of infection; external fixation—fewer reoperations than with plating, but more reoperations than with nailing; nailing—safer; fewer infections; bone morphogenic protein (BMP)-2—best results with standard 1.5 mg/mL of BMP-2 in grade 3 open injuries (big decrease in bone grafting, secondary procedures, and infection rates)

Segmental defects after nailing: results similar, whether using autograft, iliac crest bone graft, or BMP-2 and allograft

Tibial Nonunions
Dr. Reilly

Factors in nonunions

Patient: comorbid conditions (eg, autoimmune disease); activities (eg, smoking); use of nonsteroidal anti-inflammatory drugs (NSAIDs; increase risk for nonunion in long-bone fractures); compliance; nutritional status; activities and functional level

Injury: energy involved; comminution; dysvascular fragments; soft tissue stripping; initial bone loss; neuropathy; bacterial contamination

Surgeon: excessive soft tissue stripping; inadequate fixation; leaving tibia in distracted position

Definition of nonunion: injury with no progress toward healing on multiple radiographs (6-8 mo for tibia)

Classification: based on radiographic appearance; infected nonunions; sterile nonunions (hypertrophic; oligotrophic; atrophic; synovial pseudoarthrosis)

Treatment considerations: presence of infection; status of soft tissues; host healing factors; presence of hardware (whether stable); biology

Infection present: determine extent (how much bone involved and how much resection needed); treat locally and systemically; followed by definitive reconstruction

Infection uncertain: work-up; serologies; nuclear medicine studies; CT or magnetic resonance imaging (MRI) for diagnosis and to determine extent of infection

Surgical biopsy: before or at time of definitive reconstruction

Types of nonunions

Hypertrophic: results from inadequate mechanical stability in face of good biology (ie, adequate vascularity present for bone to heal but bone insufficiently stable); abundant callus formation; thin layer of fibrous tissue; “elephant’s foot or horse’s hoof” appearance

Atrophic: poor vascularity; inadequate biology; no callus formation; bone ends resorb over time

Synovial pseudoarthrosis: slightly widened bone end capped off by significant sclerosis blocking intramedullary canal; synovial-like lining of cavity of nonunion site

Examination of patient: evaluate soft tissues; determine—presence of gross mobility in nonunion site; degree of warmth; position of bone (angular deformity; short; rotated); neurovascular status of foot

Treatment goals: correction of deformity; stabilization of bone; early range of motion of knee and ankle; early weight-bearing; ultimate healing

Stabilization options: surgeon should be knowledgable about all

IM nailing: advantages—less dissection; less soft tissue irritation; early weight-bearing; reaming promotes healing; disadvantages—obliteration of canal impedes nail passage; stability difficult with metadiaphyseal union; deformity correction less precise; stability variable; indications—hypertrophic nonunion well aligned or capable of being well aligned; previous nailing with minimal deformity; mid-diaphyseal nonunion; soft tissue compromise preventing plate reconstruction; results—success rate 89% to 96%

Dynamization alone: shown to have little effect

Bone grafting alone: useful in stable fixation with no deformity; best for “impending nonunion”

Plate fixation: advantages—helpful in correcting deformity; better initial stability; versatile; disadvantages— more surgical dissection; increased implant irritation and potential removal; delayed full weight-bearing; indications—canal difficult to reestablish; complex angular and rotational deformities; proximal and distal metadiaphyseal nonunion (soft tissue reconstructable); results (combined with bone grafting)—≤100% success rate

External fixation: advantages—restoration of length; treatment of bone defects (minimizing bone grafting); treatment of poor soft tissues; improved vascularity; versatilily; early weight-bearing; disadvantages—requires compliant patient; high maintenance; painful for patient and surgeon; pin tract sepsis; lengthy treatment; technically demanding; indications—infected segmental bone defects; soft tissues prohibiting standard technique; short segment periarticular nonunions; complex deformities with shortened limb

Investigational: bone marrow aspiration; osteobiologics; electrical stimulation; ultrasonography; minimally invasive plating techniques (speaker recommends against)

Summary: well-aligned hypertrophic nonunion—reamed exchange intramedullary nailing; malaligned hypertrophic nonunion—osteotomy followed by plate fixation or nailing; well-aligned atrophic nonunion—plate and bone grafting; malaligned atrophic nonunion—length acceptable (plate and bone grafting); lengthening required (external fixation [distraction osteogenesis; gradual correction])