The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members.

Study Design Survey study. Objective To determine the global perspective on controversial aspects of sacral fracture classifications. Methods While developing the AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey asked four yes-or-no questions to help determine the best way to handle controversial aspects of sacral fractures in future classifications. Chi-square tests were initially used to compare surgeons\u27 answers to the four key questions of the survey, and then the data was modeled through multivariable logistic regression analysis. Results A total of 474 surgeons answered all questions in the survey. Overall 86.9% of respondents felt that the proposed hierarchical nature of injuries was appropriate, and 77.8% of respondents agreed that that the risk of neurologic injury is highest in a vertical fracture through the foramen. Almost 80% of respondents felt that the separation of injuries based on the integrity of L5-S1 facet was appropriate, and 83.8% of surgeons agreed that a nondisplaced sacral U fracture is a clinically relevant entity. Conclusion This study determines the global perspective on controversial areas in the injury patterns of sacral fractures and demonstrates that the development of a comprehensive and universally accepted sacral classification is possible

Sacral Fractures and Associated Injuries.

STUDY DESIGN: Literature review. OBJECTIVE: The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome. METHODS: A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures. RESULTS: Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration. CONCLUSIONS: Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management

Biomechanical Evaluation of Anterior Cruciate Ligament Femoral Fixation Techniques

Background: A number of different femoral anterior cruciate ligament fixation techniques are currently in use. Slippage of the graft caused by excessive early loading or aggressive rehabilitation may negate benefits of surgery and result in a knee with undesirable laxity. Hypothesis: Anterior cruciate ligament femoral graft slippage varies by fixation technique and amount of cyclic loading. Study Design: Controlled laboratory study. Methods: Graft slippage in 5 different soft tissue anterior cruciate ligament femoral fixation techniques (Bio-TransFix cross-pin technique, Stratis ST cross-pin technique, Bilok ST transverse femoral screw, Delta tapered bio-interference screw, and single-loop TensionLok) was compared by cyclic loading of double-bundle grafts in porcine femurs. Graft slippage was measured using a differential variable reluctance transducer. Results: The Bio-TransFix had significantly less (P = .002) total graft slippage (1.14 +/- 0.43 mm) compared to the Delta (3.74 +/- 3.25 mm), Bilok ST (3.92 +/- 2.28 mm), and TensionLok (5.09 +/- 1.12 mm) but not the Stratis ST (1.92 +/- 1.55 mm). All techniques showed the greatest amount of dynamic excursion (P < .001), slippage (P < .001), and percentage of total slippage (mean 68%, P < .001) during the first 100 cycles of loading. The TensionLok had the greatest amount of dynamic excursion during the first 100 cycles (4.15 +/- 1.00 mm) followed by the Bilok ST (3.37 +/- 2.07 mm), Delta (1.76 +/- 0.93 mm), and Stratis ST (1.75 +/- 0.96 mm); the Bio-TransFix demonstrated the least (1.26 +/- 0.48 mm). There was no statistical difference in failure load between repair techniques (P = .103). Conclusion: Graft slippage was statistically different between anterior cruciate ligament femoral fixation techniques for static and dynamic loading. All techniques exhibited the greatest amount of slippage during the first 100 cycles of loading. The differential variable reluctance transducer permitted evaluation of dynamic graft-construct-bone displacement during experimental loading, simulating the loading experienced during early rehabilitation. Clinical Relevance: The optimal method of graft fixation for anterior cruciate ligament reconstruction remains unknown. In the current study, cross-pin constructs appeared to be superior to certain other available fixation systems

Concomitant Upper Extremity Fracture Worsens Outcomes in Elderly Patients With Hip Fracture

Background: Elderly patients with low-energy hip fractures have high rates of morbidity and mortality, but it is not well known how often concurrent upper extremity fractures occur and how this impacts outcomes. We used the National Trauma Databank (NTDB), the largest aggregation of US trauma registry data available, to determine whether patients with concurrent upper extremity and hip fractures have worse outcomes than patients with hip fractures alone. Methods: We accessed the NTDB to identify patients aged 65 to 100 who sustained a hip fracture. The cohort was then narrowed to include only patients who sustained their injury in a fall and had an injury severity score indicating hip fracture as the most severe injury. We then analyzed this group to assess the impact of a simultaneous upper extremity fracture on length of stay, in-hospital mortality, and discharge disposition. Results: From 2007 to 2014, a total of 231,299 patients aged 65 to 100 were identified as having a hip fracture. The narrowed cohort with fall as the mechanism and hip fracture as the most severe injury included 193,862 patients. Of these, 12,618 patients sustained a concomitant upper extremity fracture (6.5%). Compared to isolated hip fractures, patients with a concomitant upper extremity fracture had higher odds of death in the hospital (odds ratio [OR] = 1.3; 95% confidence interval = 1.2-1.4), were less likely to be discharged to home as compared to a skilled facility (OR = 0.73; 95% confidence interval = 0.68-0.78), and had a significantly longer average length of stay (7.1 vs 6.4 days, P < .001). Conclusions: We found a 6.5% prevalence of concomitant upper extremity fractures in patients aged 65 to 100 with a hip fracture sustained after a fall where the hip fracture was the most severe injury. These patients had a higher risk of in-hospital mortality, were less likely to be discharged to home, and had longer average length of stay

Discrepancies and rates of publication in orthopaedic sports medicine abstracts

Background: Presentations of clinically relevant data at AOSSM national meetings are presented yearly and may influence clinical decision making. Hypothesis: The incidence of presentations that do not subsequently get published is high, and the numbers of major and minor inconsistencies, once published, are also high. Study Design: Systematic review. Methods: A database was created of all abstracts presented at AOSSM meetings from 1999 to 2001 from official program books. To assess whether each abstract had been followed by publication in a peer-reviewed journal, a PubMed search was conducted to include a 5-year follow-up for each conference. Minor inconsistencies included differences in title, authors, presentation of all outcomes, and authors' interpretation of data. Major inconsistencies included discrepancies in study objective and/or hypothesis, study design, primary and secondary outcome measures, sample size, statistical analysis, results, and standard deviations/confidence intervals. Results: Overall, 98 of the 165 abstracts presented at AOSSM national meetings from 1999 to 2001 were published in a peer-reviewed journal within 5 years, a publication rate of 59.4%. The median time to publication for all articles was 21 (range, 1-60) months. The majority of articles (61) were published in the American Journal of Sports Medicine (62.2%). The median number of major and minor inconsistencies from abstract to publication was 1 (range, 0-5) and 1 (range, 0-4), respectively. Sixty-two of the 98 published abstracts (63%) had at least 1 major inconsistency, while 79 (81%) had at least 1 minor inconsistency. In 5 manuscripts (5%), the authors' interpretation of the data had changed, and in 2 (2%), the change essentially invalidated the abstract. Conclusion: A large number of scientific presentations do not get published in a peer-reviewed journal. In addition, those published have a significant number of changes that, in a small percentage of cases, alter the validity of the original presentation. Clinical Relevance: Orthopaedic surgeons and other attendees as well as nonattendees who reference conference abstracts need to exercise good judgment when considering the implications of oral presentations of unpublished materials. When reviewing meeting presentation abstracts, readers should remember that the material being presented is often not in its definitive or ultimate form

Streamlining Trauma Research Evaluation With Advanced Measurement (STREAM) Study: Implementation of the PROMIS Toolbox Within an Orthopaedic Trauma Clinical Trials Consortium

Level of evidencePrognostic Level II

Validation of the AO Spine Sacral Classification System: Reliability Among Surgeons Worldwide.

OBJECTIVES: To 1) demonstrate that the AO Spine Sacral Classification System can be reliably applied by general orthopaedic surgeons, as well as subspecialists, universally around the world, and 2) delineate those injury subtypes which are most difficult to classify reliably in order to refine the classification before evaluating clinical outcomes. DESIGN: Agreement Study. SETTING: All level trauma centers, worldwide. PARTICIPANTS: One hundred seventy-two members of the AO Trauma and AO Spine community. INTERVENTION: The AO Sacral Classification System was applied by each surgeon to 26 cases in two independent assessments performed 3 weeks apart. MAIN OUTCOME MEASUREMENTS: Inter-observer reliability and intra-observer reproducibility. RESULTS: A total of 8,097 case assessments were performed. The Kappa coefficient for inter-observer agreement for all cases was 0.72/0.75 (Assessment 1/Assessment 2), representing substantial reliability. When comparing classification grading (A/B/C) regardless of subtype, the Kappa coefficient was 0.84/0.85 corresponding to excellent reliability. The Kappa coefficients for inter-observer reliability were 0.95/0.93 for type A fractures, 0.78/0.79 for type B fractures, and 0.80/0.83 for type C fractures. The overall Kappa statistic for intra-observer reliability was 0.82 (range 0.18-1.00), representing excellent reproducibility. When only evaluating morphology type (A/B/C), the average Kappa value was 0.87 (range 0.18-1.00) representing excellent reproducibility. CONCLUSION: The AO Spine Sacral Classification System is universally reliable among general orthopaedic surgeons and subspecialists worldwide, with substantial inter-observer and excellent intra-observer reliability. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence