Orthopaedic emergencies demand rapid recognition and decisive action, particularly in resource-constrained or nontertiary settings where the community surgeon often serves as the first and only line of defense. It is important to provide a practical, evidence-informed guide for the management of musculoskeletal injuries, including irreducible joint dislocations, ultra-low-energy knee dislocations, open fractures with vascular compromise, compartment syndrome, and femoral neck fractures in young patients. Emphasis is placed on early diagnosis, stabilization strategies, soft-tissue management, and the integration of adjunct technologies. Technical pearls, decision-making frameworks, and contemporary research support timely intervention and optimize outcomes, especially in settings wherein access to subspecialty care may be limited.

Background:The pelvis is one of the most common areas for metastatic bone disease. We recently described the use of a minimally invasive percutaneous screw fixation of metastatic non-periacetabular pelvic lesions, with excellent results. Description:The procedure can be completed in a standard operating theater without the need for special instruments. In our video we describe the appropriate intraoperative patient positioning, surgical equipment, surgical approach, and obtainment of the necessary fluoroscopic views for placement of various pelvic percutaneous screws. Alternatives:Alternative treatments include surgical procedures such as curettage, cement packing, and modified Harrington total hip arthroplasty through extensive open approaches. Additionally, as an alternative to standard fluoroscopy, intraoperative navigation and an O-arm could be utilized for the placement of screws. In our experience, intraoperative navigation has been helpful for confirmation of final screw placement and length. Overreliance on intraoperative navigation in the setting of poor bone quality and an abandonment of tactile feedback and the various tips described in this video article can lead to inadvertent extraosseous screw placement and injury. Furthermore, as navigation involves only a virtually computed image, we have found it challenging to utilize in complex, curved bones, such as the superior pubic ramus. Rationale:Percutaneous screw fixation is safe and effective for the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and instrumentation, and the tolerance of concomitant treatments, this approach is worthy of broader consideration. Expected Outcomes:In our recent study, 22 consecutive patients with painful non-periacetabular pelvic metastatic cancer underwent percutaneous screw fixation. There were no surgical complications. Postoperatively, there was significant improvement in visual analog scale pain scores and functional Eastern Cooperative Oncology Group scores, as compared with baseline3. Important Tips:Despite the simplicity of the intraoperative set-up and instrumentation, the procedure is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging. Acronyms and Abbreviations:CT = computed tomographyASIS = anterior superior iliac spineGT = greater trochanterAP = anteroposteriorAIIS = anterior inferior iliac spineSI = sacroiliacTSTI = transsacral-transiliacVAS = visual analog scaleECOG = Eastern Cooperative Oncology GroupDVT = deep vein thrombosis.

BACKGROUND:Minimally invasive techniques such as percutaneous screw fixation have previously been shown to be mostly successful for pain relief and functional improvement in patients with pelvic metastases. In this study, we retrospectively reviewed the largest single-center cohort to date to further characterize the impact of this treatment on pain palliation, ambulation, and function; the predictors of suboptimal outcomes; and complications. METHODS:Electronic medical records were reviewed. The primary outcome measures were pain, as assessed with use of the visual analog scale (VAS) score; functional status, as assessed with use of the Eastern Cooperative Oncology Group (ECOG) score; and ambulation, as assessed with use of the Combined Pain and Ambulatory Function Score (CPAFS), including preoperatively and postoperatively. Secondary outcome measures included radiographic evidence of fracture healing and the need for narcotics. RESULTS:The study included 103 consecutive patients (42 men, 61 women) with a mean age of 64.1 years (range, 34 to 93 years) and a median follow-up of 14.4 months (range, 3 to 64 months) who underwent 107 procedures (bilateral in 4 patients). Sixty-nine had periacetabular lesions, whereas 38 had non-periacetabular lesions. VAS, ECOG, and CPAFS values improved from preoperatively at all time points (p < 0.001). Fifty-seven (85.1%) of the 67 patients presenting with a pathologic fracture demonstrated radiographic healing. A lack of radiographic healing was associated with a prolonged need for narcotics (p < 0.001). Six hips were converted to total hip arthroplasties, and 1 underwent a Girdlestone procedure. Complications were observed in 3 cases (2.8%). CONCLUSIONS:Percutaneous screw fixation provided sustained benefits of pain relief and functional improvement in the treatment of metastatic pelvic lesions, with a low rate of complications. Bone healing after fixation was common. The risk of prolonged narcotic usage was higher in patients without evidence of bone healing. LEVEL OF EVIDENCE:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:The purpose of this study was to (1) perform the first analysis of bone-derived DNA methylation, (2) compare DNA methylation clocks derived from bone with those derived from whole blood, and (3) establish a relationship between DNA methylation age and 1-year mortality within the geriatric hip fracture population. METHODS:Patients ≥65 years old who presented to a Level-I trauma center with a hip fracture were prospectively enrolled from 2020 to 2021. Preoperative whole blood and intraoperative bone samples were collected. Following DNA extraction, RRBS (reduced representation bisulfite sequencing) libraries for methylation clock analysis were prepared. Sequencing data were analyzed using computational algorithms previously described by Horvath et al. to build a regression model of methylation (biological) age for each tissue type. Student t tests were used to analyze differences (Δ) in methylation age versus chronological age. Correlation between blood and bone methylation ages was expressed using the Pearson R coefficient. RESULTS:Blood and bone samples were collected from 47 patients. DNA extraction, sequencing, and methylation analysis were performed on 24 specimens from 12 subjects. Mean age at presentation was 85.4 ± 8.65 years. There was no difference in DNA extraction yield between the blood and bone samples (p = 0.935). The mean follow-up duration was 12.4 ± 4.3 months. The mortality cohort (4 patients, 33%) showed a mean ΔAgeBone of 18.33 ± 6.47 years and mean ΔAgeBlood of 16.93 ± 4.02 years. In comparison, the survival cohort showed a significantly lower mean ΔAgeBone and ΔAgeBlood (7.86 ± 6.7 and 7.31 ± 7.71 years; p = 0.026 and 0.039, respectively). Bone-derived methylation age was strongly correlated with blood-derived methylation age (R = 0.81; p = 0.0016). CONCLUSIONS:Bone-derived DNA methylation clocks were found to be both feasible and strongly correlated with those derived from whole blood within a geriatric hip fracture population. Mortality was independently associated with the DNA methylation age, and that age was approximately 17 years greater than chronological age in the mortality cohort. The results of the present study suggest that prevention of advanced DNA methylation may play a key role in decreasing mortality following hip fracture. LEVEL OF EVIDENCE:Prognostic Level I . See Instructions for Authors for a complete description of levels of evidence.

Abstract The use of nail–plate constructs has been suggested for treatment of elderly patients with distal femur fractures to facilitate stable fixation and early ambulation. In this article, we describe a technique to link the 2 implants without the use of fluoroscopic “perfect-circle” technique. This technique can be used with implants from different manufacturers.

Posterior malleolus fractures (PMFs) (OTA 43B1.1) are frequently seen in combination with fractures of the fibula, medial malleolus, and distal tibia; they can rarely be seen in isolation. PMFs affect the alignment of the ankle mortise and the stability of syndesmosis. Techniques described for fixation of PMFs include open reduction internal fixation through a posterolateral or posteromedial approach or anterior-to-posterior screw fixation. For selected minimally displaced or nondisplaced fractures of the posterior malleolus, we developed a percutaneous technique through the Achilles tendon for the insertion of a posterior-to-anterior cannulated screw. The technique is described, and a clinical series is reviewed.

Supplemental Digital Content is Available in the Text. Objective:Acute compartment syndrome (ACS) is a true emergency. Even with urgent fasciotomy, there is often muscle damage and need for further surgery. Although ACS is not uncommon, no validated classification system exists to aid in efficient and clear communication. The aim of this study was to establish and validate a classification system for the consequences of ACS treated with fasciotomy.Methods:Using a modified Delphi method, an international panel of ACS experts was assembled to establish a grading scheme for the disease and then validate the classification system. The goal was to articulate discrete grades of ACS related to fasciotomy findings and associated costs. A pilot analysis was used to determine questions that were clear to the respondents. Discussion of this analysis resulted in another round of cases used for 24 other raters. The 24 individuals implemented the classification system 2 separate times to compare outcomes for 32 clinical cases. The accuracy and reproducibility of the classification system were subsequently calculated based on the providers' responses.Results:The Fleiss Kappa of all raters was at 0.711, showing a strong agreement between the 24 raters. Secondary validation was performed for paired 276 raters and correlation was tested using the Kendall coefficient. The median correlation coefficient was 0.855. All 276 pairs had statistically significant correlation. Correlation coefficient between the first and second rating sessions was strong with the median pair scoring at 0.867. All surgeons had statistically significant internal consistency.Conclusion:This new ACS classification system may be applied to better understand the impact of ACS on patient outcomes and economic costs for leg ACS.

Abstract. Treatment of fractures around the foot and ankle can be challenging in patients who are unable to remain non weight bearing on their lower extremity. Traditional implants are not sufficient to resist loads incurred during weight bearing and can also lead to complications related to wound healing and infection. We describe a technique for fracture fixation of the foot and ankle that uses low profile implants to minimize soft tissue insult combined with multiplanar external fixation to allow for immediate weight bearing.

Bicortical fixation of medial malleolus fractures provides increased interfragmentary compression and resistance to pull out. Achieving bicortical fixation with two 3.5 mm screws can be challenging especially with smaller fractures. We present a simple technique where two 2.7 mm screws are utilized for fixation of medial malleolus fractures. Level of Evidence: Level V—expert opinion.

Abstract. Purpose:. During the coronavirus disease (COVID) pandemic elective surgeries were cancelled and operative indications curtailed to counteract shortages in resources. We aimed to review each orthopedic operative indication at an urban Level 1 Trauma Center inundated with COVID. We aimed to classify the appropriateness of each operative intervention and determine if exposure to COVID impacted morbidity or mortality. Methods:. All orthopedic procedures between March 16, 2020 and May 16, 2020 were reviewed. The most urgent surgical indication for each procedure was classified by 2 fellowship trained orthopedic trauma surgeons and 2 senior residents. The appropriateness of the operative intervention was determined. The American Academy of Orthopedic Surgery (AAOS) and American College of Surgeons (ACS) guidelines for surgery during the pandemic were considered. Results:. Seventy-six surgical encounters were performed on 71 inpatients including 99 total procedures. No outpatient procedures were performed. Fifty-four of 71 patients were male. There was a mean age of 51.6 years. Of 71 patients, 41 presented to the emergency department without trauma activation with a mean time to presentation of 2.7 days post injury. The most urgent surgical indications included 18 hip fractures, 18 periarticular fractures, 17 open fractures, 7 severe infections, 5 pelvic fractures, 5 femoral shaft fractures, 3 spinal injuries, 1 tibial fracture, 1 tendon injury, and 1 clavicle fracture. Four procedures could have been delayed for conservative management without causing significant harm. Upon discharge 13/71 patients had tested positive for COVID, 41/71 had remained negative throughout their hospital stay, and 17/71 patients never were tested. Four patients contracted COVID in the hospital. There were 4 in hospital deaths, 2 attributed to hypoxemic respiratory failure secondary to COVID pneumonia. Conclusion:. It was determined that 72/76 cases were considered appropriate in following guidelines of the AAOS and ACS. This highlights the value of halting outpatient procedures and limiting patient exposure to COVID. Comprehensive patient/provider discussions addressing the risks, benefits, alternatives to surgery, and the risk of exposure to respiratory illness are vital. It behooves the surgical team to follow established guidelines such as those of the AAOS and ACS when triaging orthopedic patients for a surgical admission.

Background: The pelvis is one of the most common locations for metastatic bone disease. While many of the publications that describe surgical treatments focus on periacetabular lesions (Enneking zone II), there is a lack of investigation into lesions in the non-periacetabular areas (zones I, III, and IV). We recently described a minimally invasive percutaneous screw application for metastatic zone-II lesions with excellent results. In the present study, we aimed to extend this approach to the other pelvic areas. Methods: Twenty-two consecutive patients with painful non-periacetabular pelvic metastatic cancer were included based on retrospective chart review. There were 16 women and 6 men with an average age of 60 years (range, 36 to 81 years). The most common primary cancers were multiple myeloma (7 cases) and breast (5 cases). The most common locations were the sacrum and the ilium. A pathologic fracture was identified in 15 patients. Most of the lesions were treated with multiple large-diameter screws, except for the isolated zone-III lesions. All of the procedures were completed in a standard operating room without the need for special instruments. Radiation therapy was given to 19 patients; the average dose was 15 Gy. The studied outcomes were pain and functionality as assessed by a visual analog scale (VAS) score and the Eastern Cooperative Oncology Group score (ECOG), respectively. Results: There were no surgical complications and no need for blood transfusion. The average follow-up time was 7 months (range, 0.3 to 34.0 months). Two patients died within 4 weeks of surgery due to COVID-19 infection. There was significant improvement in the postoperative VAS pain score (p < 0.0001) and the ECOG score (p < 0.05) when compared with the preoperative scores. There was no implant failure or revision surgery. Local bone-healing was observed in 12 of 14 patients (86%) who survived for >3 months after surgery. Conclusions: Percutaneous screw application is safe and effective in the treatment of metastatic non-periacetabular pelvic lesions. Given the simplicity of the technique and the instrumentation and the tolerance for concomitant treatments, this approach is worthy of broader consideration. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Summary: Periprosthetic fractures about the hip and knee are challenging injuries to treat for the orthopaedic surgeon. The pre-existing femoral implant and poor bone quality provide for difficulties in achieving stable fixation. We present a surgical technique and clinical series of 5 patients describing the use and outcomes of a 3.5 screw with a “double washer” technique to achieve bicortical fixation around a femoral prosthesis.

Introduction: There is a paucity of research addressing the morbidity and mortality associated with poly-trauma in elderly patients. This study aimed to compare the outcomes of elderly trauma patients with an isolated lower extremity fracture, to patients lower extremity fractures and associated musculoskeletal injuries. Methods: This study is a retrospective review from the National Trauma Database (NTDB) between 2008 and 2014. ICD 9 codes were used to identify patients 65 years and older with lower extremity fractures. Patients were categorize patients into three sub groups: patients with isolated lower extremity fractures (ILE), patients with two or more (multiple) lower extremity fractures (MLE) and, patients with at least one upper and at least one lower extremity fracture (ULE). Groups were stratified into patients age 65-80 and patients >80 years of age. Results: A total 420,066 patients were included in analysis with 356,120 ILE fracture patients, 27,958 MLE fracture patients, and 35,988 ULE fracture patients. The MLE group reported the highest dispatch to ACS level 1 trauma centers at 31.8% followed by the ULE group at 28.5% and the ILE group at 24.7% of patients (p<0.001). The overall rate of complications was highest in the MLE group followed by the ULE and then the ILE group (41.4%, 40.3%, 36.1%, respectively p<0.001). Motility rates in patients >80 years old in the MLE group and ULE group were similar (1.483 vs 1.4432). However, in the 65-80 year group the odds of mortality was 1.260 in the MLE group and 1.450 in the ULE group (p<0.001), such that the odds of mortality after sustaining a MLE fracture increases with age, whereas this effect was not seen in the ULE group. Conclusion: Patients who sustained MLE and ULE fractures, had increased mortality, complications and in hospital care requirements as compared to patients with isolated lower extremity injuries. These outcomes are comparable between ULE and MLE fracture patients over the age of 80 however patients 65-80 with ULE fractures had increased mortality as compared patients 65-80 with MLE fractures. Understanding the unique considerations and requirements of elderly trauma patients is vital to providing successful outcomes. (C) 2020 Elsevier Ltd. All rights reserved.

Open humeral shaft fractures comprise approximately 2% of all fractures of the humerus. Nearly 20% of open humeral shaft fractures will develop deep infection, increasing the risk of nonunion regardless of treatment method. Recalcitrant septic nonunion of the humeral shaft is a complex and challenging problem. Operative treatment should aim to eradicate infection, address bony defects, and establish a stable construct that affords early motion. We describe the case of a 38-year-old male with a recalcitrant humeral shaft septic nonunion following fixation of an open humeral shaft fracture. Management of the infection consisted of periodic surgical debridement and IV antibiotics, resulting in a 10 cm segmental defect. Definitive fixation was achieved using the combination of an antegrade intramedullary nail, intercalary femoral shaft allograft, compression plating, and autologous bone graft. In addition to achieving bony union, the patient regained his pre-injury ROM and function, which was clinically sustained at 2-year follow-up.

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

Background:Metastatic lesions in the periacetabular region can cause pain and immobility. Symptomatic patients are often treated surgically with a total hip replacement using various modified Harrington methods. These open surgical procedures confer inherent risks. Prolonged recovery and potential complications may delay adjuvant radiation and systemic therapy.Methods:We describe a novel technique for acetabular reconstruction. Three large-bore cannulated screws are placed percutaneously under fluoroscopy in a tripod configuration to reinforce the mechanical axes of the acetabulum. Increased stability improves pain control and permits weight-bearing.Results:Twenty consecutive patients with periacetabular metastases were treated using the tripod technique. Eighteen patients (90%) had Harrington class-III lesions, and 2 patients had Harrington class-II lesions. The mean surgical time was 2.3 hours. Sixteen patients (80%) were able to get out of bed on postoperative day 1. At 3 months postoperatively, there was significant improvement in pain as documented on their visual analog scale (p < 0.01) and in functionality as measured by the Eastern Cooperative Oncology Group score (p < 0.01). The mean follow-up time was 7 months (range, 0.6 to 20 months). At the most recent follow-up, only 3 among the 16 surviving patients were using opioids chronically for pain. Total hip arthroplasty was performed in 4 patients (20%) in a staged fashion using the previously placed screws as support for a cemented cup and obviating the need for a cage device. Of the 16 patients, 15 could walk either independently (6 patients) or using an ambulatory aid (9 patients). Eight patients with the primary tripod reconstruction survived >6 months postoperatively. They were found to have either new bone formation filling the defects or healing of the pathological fractures. There has been no implant loosening or failure.Conclusions:The tripod technique is a novel application to provide safe and effective pain relief in the context of periacetabular metastatic disease. It can be easily converted to support a cemented acetabular cup for a total hip replacement should disease progression occur. This technique provides an alternative to open surgery as currently practiced in these patients.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Conflicting evidence exists regarding the role of inferior vena cava filters (IVCFs) in the prevention of pulmonary embolism. The aim of this study was to review an institutional policy of prophylactic IVCF placement in all operative pelvic and acetabular fractures as a means of preventing PE by comparing it to a historical prepolicy period of significantly less aggressive IVCF placement. The trauma registry of a single level 1 trauma center was retrospectively queried for all pelvic or acetabular fractures for the prepolicy and intervention periods as defined as January 2003–December 2008 and January 2009–December 2014, respectively—yielding 231 patients for analysis. The primary and secondary outcomes measured were the incidence of PE and deep vein thrombosis. The rate of prophylactic IVCF insertion significantly increased during the study period (p < 0.001). The incidence of pulmonary embolism (1.8% vs. 5.1%, p = 0.351) and DVT (19.3% vs. 10.3%, p = 0.231) were not significantly different when comparing the prepolicy and intervention cohorts. In patients with operative fractures, a nonsignificant trend of increasing incidence of DVTs was appreciated in patients with a prophylactic IVCF versus those without prophylactic IVCF (13 vs. 2, p = 0.222). A policy of increased use of prophylactic IVCFs in patients with operative pelvic and acetabular fractures failed to reduce the incidence of PE or DVT. In contrast, several case reports and institutional series have published several risks associated with IVCF placement including failure to retrieve temporary IVCF. The benefit of prophylactic IVCF in this patient population is unclear.