Cortical fragments within the intramedullary canal can pose a challenge during intramedullary nail treatment of tibial and femoral shaft fractures. Complications including reamer entrapment, malunion, and inability to pass final implants have all been reported. To limit soft tissue injury and avoid an open approach, laparoscopic instrumentation can be a useful adjunct to manipulate or retrieve cortical fragments at distant sites. Our objective is to outline a method to remove cortical fragments during treatment of tibial and femoral shaft fracture and characterize the standard shaft lengths diameters, tip configurations and jaw opening widths for common laparoscopic instruments.

(1) Understanding the osseous and ligamentous anatomy as well as the injury pattern is paramount. (2) Because the elbow consists of three bones and three articulations, anatomic reduction is required to maximize function and outcome. (3) Stable, minimally displaced injuries benefit from initial immobilization in either a sling or a splint to reduce pain, as well as initiation of early range of motion (immediate to 7-10 days) to prevent stiffness. (4) Unstable and/or displaced injuries benefit from surgical intervention to reduce the deformity, stabilize the osseous and/or ligamentous injury, and allow for early range of motion to reduce stiffness and/or arthritis. (5) Ipsilateral proximal and/or distal upper extremity injuries are common and should not be overlooked

Although preoperative antibiotics are used routinely in ankle fracture surgery, there is considerable variability in postoperative antibiotic dosing regimens amongst surgeons. The aim of this study is to compare the rate of surgical site infection (SSI) in patients receiving one dose of preoperative antibiotics to patients who received more than one dose of antibiotics. A single-center Level I Trauma Center retrospective review of patients with isolated closed ankle fractures who underwent open reduction internal fixation over a 10- year period was performed. Demographics data and risk factors were obtained from the electronic medical record. SSI was detected using a text-mining algorithm on all postoperative clinic notes. Factors associated with the development of SSI or increased antibiotic dosing were evaluated. Eight-hundred and twenty-six patients were included in the analysis. There was no correlation between infection rate and any of the potential risk factors evaluated. Two-hundred and ninety-two patients received only one dose of antibiotics preoperatively and 534 patients received more than one antibiotic dose. The rate of SSI was not significantly different between the single-dose cohort (5.8 %) and the multi-dose cohort (3.9 %) (p=0.215). Routine use of postoperative antibiotics in open reduction internal fixation of closed ankle fractures did not decrease the rate of SSI, regardless of associated comorbidities. (c) 2024 by the American College of Foot and Ankle Surgeons. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Fractures of the tibia and femur are common. Rotation of the limb can affect the outcome of the injury, both in the immediate term and the long term. Because plain radiographs are two dimensional, rotation is hard to assess radiographically. As a result, rotational malalignment is common. It is important to provide technical tips on the assessment of rotation preoperatively, intraoperatively, and postoperatively. The goal is to better assess rotation so that deformity can be minimized. This applies to fractures of the tibia and femur. Even after careful treatment, rotational deformities can occur. When they are symptomatic, correction should be considered. Techniques for correction of malrotation of both tibial and femoral fractures are presented.

OBJECTIVES:To determine the accuracy of the intermalleolar method, an intraoperative fluoroscopic method for assessing tibial rotation in patients undergoing intramedullary nail fixation for tibial shaft fractures, by comparing it with the gold standard computed tomography (CT).METHODS:DESIGN:Prospective cohort study.SETTING:Academic Level 1 trauma center.PATIENT SELECTION CRITERIA:Consecutive patients, aged 18 years and older, with unilateral tibial shaft fractures who underwent intramedullary fixation from September 2021 to January 2023.OUTCOME MEASURES AND COMPARISONS:Intraoperatively, tibial rotation measurements were obtained using the intermalleolar method on both the uninjured and injured limbs. Postoperatively, patients underwent bilateral low-dose lower extremity rotational CT scans. CT measurements were made by 4 blinded observers. Mean absolute rotational differences and standard errors were calculated to compare the injured and uninjured limbs. Subgroup analysis was performed assessing accuracy relating to injured versus uninjured limbs, body mass index, OTA/AO fracture pattern, tibial and fibular fracture location, and distal articular fracture extension requiring fixation.RESULTS:Of the 20 tibia fractures, the mean patient age was 43.4 years. The intermalleolar method had a mean absolute rotational difference of 5.1 degrees (standard error 0.6, range 0-13.7) compared with CT. Sixty percent (24/40) of the measurements were within 5 degrees, 90% (36/40) of the measurements were within 10 degrees, and 100% (40/40) were within 15 degrees of the CT. No patients were revised for malrotation postoperatively.CONCLUSIONS:The intermalleolar method is accurate and consistently provides intraoperative tibial rotation measurements within 10 degrees of the mean CT measurement for adult patients undergoing intramedullary nail fixation for unilateral tibial shaft fractures. This method may be employed in the operating room to accurately quantify tibial rotation and assist with intraoperative rotational corrections.LEVEL OF EVIDENCE:Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Malreductions in the axial plane (ie, length and rotation) are common when managing long bone fractures. Careful attention to detail during the initial treatment can prevent these malreductions. Various fluoroscopy-based techniques exist for the prevention of malrotation and limb-length discrepancy during surgery for fracture. If malreductions do occur, a systematic clinical and radiographic evaluation can provide the necessary information to correct rotational malreduction and limb-length discrepancy.

Introduction: Malicious cyberattacks are increasing in frequency and severity with healthcare institutions spending an average of over 10 million dollars to resolve the consequences of healthcare data breaches. This cost does not include the effect of a downtime event should a healthcare system electronic medical record (EMR) lose functionality. An Academic Level 1 trauma center suffered a cyberattack resulting in a total EMR downtime of 25 days. Orthopedic operative time was used as a surrogate for OR functional-ity during the event and a framework with specific examples is presented to promote rapid adaptation during downtime events. Methods: Operative time losses were identified by calculating a running average of weekday total in room operative time during a total downtime event secondary to a cyberattack. This data was compared to week-of-the-year matched data from the year prior and the year after the attack. A framework for creating adaptations to a total downtime event was created by repeatedly interviewing different provider groups and identifying how they adjusted care to the challenges faced.Results: Total weekday in room operative time during the attack decreased by 53.4% +/- 12.2% and 53.2% +/- 14.9% when comparing the matched period one year prior and one year after, respectively. Immediate challenges to patient care were identified by small groups of highly motivated individuals, with self -assigned agile teams formed. These teams sequenced system processes, identified failure points, and cre-ated real-time solutions. A frequently updated EMR backup mirror and hospital disaster insurance were crucial for mitigating the impact of the cyberattack.Conclusions: Cyberattacks are expensive and their downstream effects, including downtime events, can be crippling. Agile team formation, process sequencing, and understanding EMR backup times are tactics used to combat the challenges of a prolonged total downtime event. Level of Evidence: Level III retrospective cohort (c) 2023 Elsevier Ltd. All rights reserved.

Commentary In most cases, orthopaedic surgeons advocate for timely debridement of open fractures. However, the definition of what constitutes “timely” is controversial. It is unknown whether a surgical debridement delay is justified to better optimize patients for a surgical procedure and to await a well-rested and/or more experienced operative team. Recently, one of the largest patient cohort studies on the topic was published. The Global Open Fracture Collaborative to Investigate Available Evidence in The Literature (GOLIATH) meta-analysis included 84 different studies with 18,239 patients and found that “early” debridement was associated with a lower infection rate1. However, the arbitrary time cutoff defining early versus late was not standardized in the included studies. Most studies used a 6-hour injury-to-debridement time cutoff to define early, but other studies used 12 or 24 hours. However, the GOLIATH authors were able to perform a subgroup analysis of multiple time points. They were able to find an association between increasingly later debridement and higher infection risk in patients with a Gustilo-Anderson type-III open fracture. Unfortunately, their subgroup cohort sizes were smaller and the data quality was assessed as low. In their study, Cortez et al. add new information to the conversation regarding the timing of open fracture debridement. Not only did their study have a large sample size of >10,000 patients, but also the authors had the exact time from injury to debridement. This allowed the authors to analyze the time to operative debridement more like a continuous variable, making their study unique in this regard. Their results are not surprising: earlier open fracture debridement was associated with a lower infection rate in all patients with open fracture regardless of the severity or lower-extremity location. Most importantly, the authors reported the absolute increased infection risk with incremental operative debridement delay. This information is critical to understanding the effect of delay on infection risk. Cortez et al. found that, for all open fractures, the probability of infection increased 0.17% for every 6-hour delay in treatment. Additionally, the increased infection probability per 6-hour delay ranged from as low as 0.13% for Gustilo-Anderson type-I or II fractures to as high as 0.23% for type-III fractures. There was also no obvious time point at which the infection rate exponentially increased. Instead, it had a relatively linear increase with time and no “golden hour” time cutoff was found. There are obvious limitations to the study and multiple potential confounding factors. The authors appropriately point out that antibiotic data were incompletely recorded, including the timing of antibiotic administration or whether it was given at all. Other potentially confounding factors such as patient medical comorbidities, tobacco use, severity of infection, and definitive fracture and wound management were not controlled for. There was also a large loss to follow-up of 72.7%. It is unknown if open fracture treatment in a high-income country with early antibiotic administration and advanced soft-tissue coverage techniques would result in a similar association between incremental operative delay and increased infection rate. Therefore, the study’s generalizability to a high-income-country environment is unknown. I think the study’s results support the current state of open fracture care at most high-income-country institutions and will not drastically change my practice. Early debridement is best, but, given the relatively low absolute increase in infection rate with delay, one can still justify waiting until the patient and operative teams are optimized, especially for open fractures of lower severity. Thanks to this study, I can now approximate the increased infection risk with surgical debridement delay and use that data when discussing optimal open fracture care with patients, anesthesia staff, and network hospital administrators.

Background: Periprosthetic fractures (PPFx) are a severe complication of total hip and hemiarthroplasty. Surgical treatment is typically performed but can result in major morbidity. Nonoperative PPFx management may provide a successful treatment alternative in select patients. Methods: Vancouver B1 PPFx patients treated over a 10-year period were identified. Patient demographic data were retrospectively recorded. Injury and postoperative radiographs were reviewed. There were 48 patients who met the study criteria. Patients were divided into operative and nonoperative comparative cohorts. Outcome comparisons between the 2 cohorts included 1-year mortality, unplanned surgery within 24 months of injury, fracture union rate, and return to preinjury ambulation status. Results: There was no difference in 1-year mortality between the nonoperative and operative cohorts (17 versus 8%; P =.32). We found no significant difference in unplanned surgery between the nonoperative and operative groups (8.7 versus 12%; P =.71), fracture union (100 versus 96%, P =.34), or return to ambulation status (86 versus 91%; P =.86). Nonoperative fractures were minimally displaced and within the metaphyseal region of the proximal femur without stem subsidence. Nonoperative fractures with subsequent treatment failure had initial fracture extension closer to the tip of the stem compared to successfully treated nonoperative fractures (5.5 versus 10.2 centimeters; P =.02). Conclusion: Select nonoperatively treated patients had infrequent need for unplanned surgery, high union rate, and return to their preinjury ambulation status. Nonoperative management is not appropriate for all Vancouver B1 PPFx, but those patients who have minimally displaced meta-diaphyseal fractures and partial remaining distal fixation can be successfully treated. Published by Elsevier Inc.

Objectives: Evaluate how total knee arthroplasty (TKA) implant design, femoral component size, and preoperative knee range of motion affect retrograde femoral nailing. Methods: Cadaveric specimens were prepared for TKA with a single radius (SR) or medial pivot (MP) design and tested with cruciate retaining (CR), cruciate substituting (CS), and posterior stabilizing (PS) 9-mm liners. Knee extension identified the minimum flexion required to pass an opening reamer without impinging on TKA components. The angle between the reamer path and the femoral shaft was calculated from lateral fluoroscopic images. Results: In SR TKA, the average flexion required was 70, 71, and 82 degrees for CR, CS, and PS, respectively. The required flexion in PS was significantly greater (P = 0.03). In MP TKA, the average flexion required was 74, 84, and 123 degrees for CR, CS, and PS, respectively. The required flexion was significantly greater in CS and PS designs (P < 0.0001). Femoral component size did not affect the minimum flexion required. The entry reamer resulted in 9.2 (SR) and 12.5 (MP) degrees of apex anterior deviation. Conclusions: When performing retrograde nailing through either of these TKA designs with a 12-mm opening reamer, at least 70 degrees of knee flexion is required to avoid damage to the polyethylene liner or femoral component. PS implants require significantly more flexion with both TKA designs. Femoral component size did not affect the flexion requirement. Approximately a 10-degree deviation exists between the reamer path and femoral shaft.

Insertion of iliac wing implants requires understanding of the curvilinear shape of the ilium. This study serves to quantitatively identify the area of iliac inner–outer table convergence (IOTC), characterize the iliac wing osseous corridor, and define the gluteal pillar osseous corridor. Computed tomography scans of 100 male and 100 female hemipelves were evaluated. The iliac wing was studied using manual best-fit analysis of the bounds of the inner and outer cortices. The IOTC was defined as the location of the iliac wing with an intercortical width less than 5 mm. The shortest distance from the apex of the iliac crest to the superior border of the IOTC was defined as the iliac wing osseous corridor. Finally, the width of the gluteal pillar corridor from the gluteus medius tubercle to the ischial tuberosity was measured. The IOTC is an elliptical area measuring 22.3 cm2. All ilia had an area where the inner and outer cortices converged to an intercortical width of less than 5 mm; 48% converged to a single cortex. The shortest mean distance from the superior edge of the iliac crest to the beginning of the IOTC was 20.3 mm in men and 13.8 mm in women (p < 0.001). The gluteal pillar diameter averaged 5.3 mm in men and 4.3 mm in women (p < 0.001). All ilia converge to a thin and frequently unicortical central region. A 4.5 mm iliac wing lag screw will not breach the cortex if it remains within 20 mm or 14 mm distal to the cranial aspect of the iliac crest in males and females, respectively. Not only is the gluteal pillar smaller than previously thought, in 41% of males and 73% of females, it is not be large enough for 5 mm implants. This study quantitatively assesses the dimensions of the IOTC, the iliac crest osseous corridor, and the gluteal pillar. Overall, our findings provide improved understanding of the limits for implant use in the iliac wing as well as better appreciation of the complex osteology of the ilium. This will help surgeons to identify safe areas for implant placement and avoid inadvertent cortical penetration.

Objective: To evaluate the accuracy and reliability of a novel fluoroscopic technique for assessing tibial rotation and compare it with a previously described fluoroscopic method. Methods: A multiplanar circular ring external fixator was secured to the tibial diaphysis of 5 cadaveric lower extremity specimens. Using deformity correction software, the frame and tibia were programed to randomly rotate 5, 10, 15, 20, 25, and 30 degrees of internal and external rotation. After each rotation, 2 blinded, independent observers measured the degree of tibial rotation using 2 different fluoroscopic methods: the previously described "mortise" method and the novel "intermalleolar" method. A total of 65 measurements were made by each observer. Accuracy and interobserver reliability were calculated. Results: Both intermalleolar and mortise methods had a mean absolute rotational difference from the true torsion of 3 degrees (standard error 1; range, 0-10 degrees intermalleolar vs. 0-18 degrees mortise). We found that 98.5% (128/130) of measurements using the intermalleolar method were less than 10 degrees from the true rotation compared with 93.8% (122/130) using the mortise method. Both the intermalleolar and the mortise methods had excellent interobserver reliability (intraclass correlation coefficient 0.99 and 0.96, respectively). Conclusion: Measuring tibial rotation fluoroscopically using the intermalleolar method is both accurate and reliable. Compared with the previously described mortise method, it has similar accuracy and provides a value that approximates the true tibial rotation. Also, it can be used reliably and effectively intraoperatively to identify tibial malrotation and assist in intraoperative rotational corrections.

Introduction Insertion of iliac wing implants requires understanding of the curvilinear shape of the ilium. This study serves to quantitatively identify the area of iliac inner-outer table convergence (IOTC), characterize the iliac wing osseous corridor, and define the gluteal pillar osseous corridor. Methods Computed tomography scans of 100 male and 100 female hemipelves were evaluated. The iliac wing was studied using manual best-fit analysis of the bounds of the inner and outer cortices. The IOTC was defined as the location of the iliac wing with an intercortical width less than 5 mm. The shortest distance from the apex of the iliac crest to the superior border of the IOTC was defined as the iliac wing osseous corridor. Finally, the width of the gluteal pillar corridor from the gluteus medius tubercle to the ischial tuberosity was measured. Results The IOTC is an elliptical area measuring 22.3 cm(2). All ilia had an area where the inner and outer cortices converged to an intercortical width of less than 5 mm; 48% converged to a single cortex. The shortest mean distance from the superior edge of the iliac crest to the beginning of the IOTC was 20.3 mm in men and 13.8 mm in women (p < 0.001). The gluteal pillar diameter averaged 5.3 mm in men and 4.3 mm in women (p < 0.001). Discussion All ilia converge to a thin and frequently unicortical central region. A 4.5 mm iliac wing lag screw will not breach the cortex if it remains within 20 mm or 14 mm distal to the cranial aspect of the iliac crest in males and females, respectively. Not only is the gluteal pillar smaller than previously thought, in 41% of males and 73% of females, it is not be large enough for 5 mm implants. Conclusion This study quantitatively assesses the dimensions of the IOTC, the iliac crest osseous corridor, and the gluteal pillar. Overall, our findings provide improved understanding of the limits for implant use in the iliac wing as well as better appreciation of the complex osteology of the ilium. This will help surgeons to identify safe areas for implant placement and avoid inadvertent cortical penetration.

Tension band wiring (TBW) is the most widely accepted method for patella fracture fixation. The purpose of our study was to compare the biomechanical efficacy of a novel cable construct to TBW for the fixation of transverse patella fractures. The tensioned cable construct was hypothesized to have less fracture gapping after cyclic flexion–extension loading and greater ultimate load to failure as compared to TBW. Transverse patellar osteotomies (AO/OTA 34C1.1) were performed on nine pairs of fresh-frozen human cadaveric whole legs (mean age 82.2 years, range 71–101). Treatment with TBW or tensioned cable construct was randomized within each specimen pair. Fracture site displacement was measured after 5000 flexion–extension cycles from 0° to 90° at 0.5 Hz. In load to failure testing, the knee was fixed at 45° of flexion and the quadriceps tendon was pulled proximally at 0.5 mm/sec until patella fixation failure. Comparisons were made using paired t-tests with alpha values of 0.05. Eight paired specimens completed the cyclic loading. The tensioned cable construct had significantly less fracture gapping than TBW (2.9 vs 10.9 mm; p = 0.020). Seven paired limbs underwent load to failure testing, which revealed no significant difference between the tensioned cable construct and TBW (1551.6 N vs 1664.0 N; p = 0.26). In this study of transverse patella fracture fixation, a tensioned cable construct demonstrated significantly less fracture gapping compared to TBW in response to cyclic loading with no significant difference in load at failure.

Objective: To investigate the degree of error due to parallax during intraoperative rotational imaging involving the distal femur. Methods: Twelve, fresh-frozen, lower-extremity cadaveric specimens were studied. The limbs were positioned supine and rotated until the posterior femoral condyles were superimposed using a C-arm. The C-arm was then repositioned to place the femoral condyles at the anterior and posterior margins of the image intensifier. The rotation necessary to resuperimpose the femoral condyles due to parallax was recorded. A second C-arm was then used from the contralateral side to simulate the rotational imaging technique to determine the magnitude and directionality of combined parallax. Results: All 12 specimens demonstrated parallax, resulting in rotational discrepancies. Compared with central field of view alignment, the mean rotational discrepancy was 5.6 and 5.5 degrees for anterior and posterior positions, respectively. Contralateral imaging resulted in an additive effect with rotational differences of 9.0 and 12.6 degrees for bilateral anterior and posterior positions, respectively. Conclusions: Parallax causes rotational discrepancies with fluoroscopic imaging of the distal femur when the posterior femoral condyles are off-center in the imaging field of view. If femoral condyles are not centered when obtaining intraoperative rotational imaging of the uninjured and injured femurs, parallax can result in potentially clinically significant rotational deformity even if the femurs seem perfectly matched at the conclusion of surgery. We recommend perfectly centering of the posterior femoral condyles in the imaging field of view when obtaining lateral images of the distal femur to prevent this potentially overlooked contribution to malrotation.

PURPOSE:This study aimed to determine if standardized updates at specific perioperative events affect anxiety and satisfaction of the family members and if the length of surgical procedure affects the satisfaction with updates. METHODS:This study was a randomized control trial. In the control group, surgeons communicated with the family only once near the completion of the procedure. In the intervention group, families received electronic updates at 3 significant perioperative events during the procedure. A postoperative survey rating family member satisfaction and anxiety levels, using a Likert scale of 0-5, was administered. RESULTS:Mean level of overall satisfaction did not differ between groups (intervention: 4.68 ± 0.69 [95% CI: 4.50, 4.87]; control: 4.61 ± 0.78 [95% CI: 4.40, 4.82]; P=0.69). Mean anxiety levels were lower in the intervention group (2.48 ± 1.43 [2.10, 2.86]) than in the control group (3.12 ± 1.32 [2.77, 3.47]; P=0.01). Mean satisfaction with perioperative updates was higher in the intervention (4.48 ± 0.83 [4.26, 4.70]) versus control group (3.16 ± 1.89 [2.67, 3.65]; P=0.0001). For all subjects, there was positive correlation between procedure time and anxiety (Spearman's rho: 0.34; P=0.0002) and negative correlation between procedure time and overall satisfaction (Spearman's rho: -0.23; P=0.01). CONCLUSIONS:Anxiety and satisfaction with perioperative updates were significantly improved by additional perioperative updates. These findings indicate that updating families during significant standardized strategic perioperative events can reduce the anxiety of loved ones and are preferred by most families.

Commentary Open fractures can result in substantial physical, emotional, and financial hardships. One estimate of this burden was performed by the Lower Extremity Assessment Project (LEAP) group, who studied patients with severe leg trauma, including individuals with Gustilo type-III open fractures. They found that at 2 years following injury, 19% of patients undergoing limb salvage required an additional surgical procedure1, 39% of patients reported moderate to severe psychological distress2, and the direct total cost of treatment was $81,3163. Thus, it is of the utmost importance to utilize the highest level of evidence when performing open fracture care in order to improve outcomes. Unfortunately, one of the most often debated surgeon-controlled variables—time to surgical debridement—is still unresolved and there is no consensus about whether “early” surgical care is superior. The study by Foote et al. performed the most comprehensive investigation to date. They included 84 studies involving 18,239 patients with an open fracture to identify whether a relationship between infection and time to surgical debridement exists. The authors should be commended for their effort to find all available patients and corresponding data. They not only contacted authors of prior studies to gain additional unpublished data, but also searched conference abstracts, scoured “gray literature” sources, and contacted several authors in the field to inquire about any forthcoming manuscripts. Because of the heterogeneity of the data, they performed numerous different analyses that all had a similar conclusion: earlier surgical debridement was associated with reduced infection risk. Their largest patient cohort analysis was a generic “early” versus “late” open fracture debridement comparison of all Gustilo types and body locations, as no uniform definition of early and late cutoff times existed among the included studies. They also performed subgroup analyses of all open tibial fractures and Gustilo type-IIIB tibial fractures using a 12-hour cutoff point to define early versus late debridement. Finally, they evaluated all Gustilo type-III open fractures in a time-gradient manner, comparing debridement performed before or after 6, 12, and 24 hours. Earlier surgical debridement was consistently superior in all analyses. These findings challenge some of the more recent smaller meta-analyses that have found no relationship between time to surgical debridement and infection4,5. Like all meta-analyses, the quality of the result is only as good as the studies that are included. Some of the studies, especially older publications, lacked important details that are absolutely essential, such as the type of antibiotic administered and time to antibiotic administration. Additionally, the starting point for the time to surgical debridement (i.e., injury versus hospital admission) varied between studies or was not reported. Furthermore, factors such as the time to definitive skin closure, degree of associated injuries, and other potentially confounding variables were often unknown. Finally, their primary outcome measure of deep infection was not well defined in a majority of studies. Ideally, future publications will include more complete information regarding any complications, especially superficial and deep infection, nonunion, and revision surgery for any reason within 2 years of injury. Such data, in addition to patient-reported outcomes, would provide a more thorough picture of the true relationship between time to surgery and outcomes. Given the results of this study and others, I believe that surgical debridement up to 24 hours from injury is still justifiable for less severe open fractures without obvious contamination and with timely antibiotic administration. This delay can be justified when the operating room is unavailable or the time of day results in less experienced staffing and limited resource availability. However, for more severe Gustilo type-III injuries, the results of the current study suggest that earlier debridement, especially before 12 hours from injury, should be the goal. Ultimately, the authors appropriately call for future studies to thoroughly document and present their data so that a higher-quality meta-analysis can be performed. Only then could we hope to more definitively answer the question regarding time to surgical debridement for all open fracture types.

Introduction The supraacetabular (SA) corridor extends from the anterior inferior iliac spine to the posterior ilium and can safely accommodate implants to stabilize pelvic and acetabular fractures. However, quantitative analysis of its dimensions and characteristics have not been thoroughly described. This study seeks to define the dimensions, common constriction points, and any alternative trajectories that would maximize the corridor diameter. Methods Computed tomography of 100 male and 100 female hemipelves without osseous trauma were evaluated. The corridor boundaries were determined through manual best-fit analysis. The largest intercortical cylinder within the pathway was created and measured. Alternative trajectories were tested within the SA boundaries to identify another orientation that maximized the diameter of the intercortical cylinder. Results The traditional SA corridor had a mean diameter of 8.3 mm in men and 6.2 mm in women. This difference in diameter is due to a more S-shaped ilium in women. A larger alternative SA corridor was found that had a less limited path through the ilium and measured 11.3 mm in men and 9.9 mm in women. These dimensions are significantly different compared to those of the traditional SA corridor in both men and women. Conclusions In men, the SA corridor allows for the safe passage of most hardware used in pelvic and acetabular fractures. However, in women, the SA corridor is restricted by a more S-shaped ilium. An alternative trajectory was found that has a significantly larger mean diameter in both sexes. Ultimately, the trajectory of hardware will be dictated by the clinical scenario. When large implants are needed, especially in women, we recommend considering the alternative SA corridor.