Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF). We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate. We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6–40 months). All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients. The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Background: We have recently developed a subcutaneous anterior pelvic fixation technique (INFIX). This internal fixator permits patients to sit, roll over in bed and lie on their sides without the cumbersome external appliances or their complications. The purpose of this study was to evaluate the biomechanical stability of this novel supraacetabular pedicle screw internal fixation construct (INFIX) and compare it to standard internal fixation and external fixation techniques in a single stance pelvic fracture model. Methods: Nine synthetic pelves with a simulated anterior posterior compression type III injury were placed into three groups (External Fixator, INFIX and Internal Fixation). Displacement, total axial stiffness, and the stiffness at the pubic symphysis and SI joint were calculated. Displacement and stiffness were compared by ANOVA with a Bonferroni adjustment for multiple comparisons Results: The mean displacement at the pubic symphysis was 20, 9 and 0.8 mm for external fixation, INFIX and internal fixation, respectively. Plate fixation was significantly stiffer than the INFIX and external Fixator (P = 0.01) at the symphysis pubis. The INFIX device was significantly stiffer than external fixation (P = 0.017) at the symphysis pubis. There was no significant difference in SI joint displacement between any of the groups. Conclusions: Anterior plate fixation is stiffer than both the INFIX and external fixation in single stance pelvic fracture model. The INFIX was stiffer than external fixation for both overall axial stiffness, and stiffness at the pubic symphysis. Combined with the presumed benefit of minimizing the complications associated with external fixation, the INFIX may be a more preferable option for temporary anterior pelvic fixation in situations where external fixation may have otherwise been used.

Background and Objectives: Tibial malunions are defined as tibial fractures that have healed in a clinically unacceptable position, resulting in deformity such as shortening, lengthening, abnormal rotation, or angulation. These deformities can have adverse effects on patients, such as pain and gait disturbance, as well as long term development of post-traumatic arthritis. This paper seeks to highlight some of the options for surgical management of malunions and detail the strategies and approaches used to manage these complicated cases. Materials and Methods: An exhaustive search was conducted on PubMed using the key search terms “Tibial” OR “Tibia” AND “Malunion” to be included in the title. Exclusions to the search included any article with patients aged < 18 years, any nonhuman subjects, and any article not published or translated into English. Results: A systematic review of the literature revealed 26 articles encompassing 242 patients who had undergone surgical correction for tibia malunion. A total of 19 patients suffered from complications. Methods of treatment included osteotomies, with plate and screws, external fixator, angled blade plate, intramedullary nails, Ilizarov fixator, Taylor Spatial Frame, Precise nail, and total knee arthroplasty. Restoring alignment and the articular surface led to overwhelmingly positive patient outcomes. Conclusions: Tibial malunions take many forms, and as such, there are many approaches to correcting deformities. The literature supports the following radiological parameters to diagnose tibial malunion: 5–10 degrees angulation, 1–2 cm shortening, 10–15 degrees internal rotation, and 10–20 degrees external rotation. Surgical plans should be customized to each individual patient, as there are many approaches to tibial malunion that have been shown to be successful in delivering excellent clinical outcomes.

Objective: To describe our experience using the anterior internal pelvic fixator (INFIX) for treating pelvic ring injuries.Design: Case Series.Setting: Level 1 Trauma Center.Patients: Eighty-three patients with pelvic ring injuries were treated with INFIX. Follow-up average was 35 months (range 12–80.33).Intervention: Surgical treatment of pelvic ring injuries included reduction, appropriate posterior fixation, and INFIX placement.Outcome Measurements: Reduction using the pelvic deformity index and pubic symphysis widening, Majeed functional scores, complications; infection, implant failure, heterotopic ossification (HO), nerve injury, and pain.Results: All patients healed in an appropriate time frame (full weight bearing 12 weeks postoperation). The average pelvic deformity index reduction (injury = 0.0420 ± 0.0412, latest FU = 0.0254 ± 0.0243) was 39.58%. The average reduction of pubic symphysis injuries was 56.92%. The average Majeed score of patients at latest follow-up was 78.77 (range 47–100). Complications were 3 infections, 1 case of implant failure, 2 cases implantation too deep, 7 cases of lateral femoral cutaneous nerve irritation, and 3 cases of pain associated with the device. HO was seen in >50% of the patients, correlated with increased age (P< 0.007), injury severity score (P< 0.05) but only 1 case was symptomatic.Conclusions: The pelvic injuries had good functional and radiological outcomes with INFIX and the appropriate posterior fixation. The downside is removal requiring a second anesthetic, there is a learning curve, HO often occurs, the lateral femoral cutaneous nerve may get irritated which often resolves once the implants are removed. Surgery-specific implants need to be developed.Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Knee dislocations from minor trauma have been reported sparsely in the literature. The consensus is that these injuries tend not to be associated with neurovascular compromise. Purpose: To present a series of atraumatic knee dislocations in obese and morbidly obese patients and to compare operative versus conservative treatment. Study Design: Case series; Level of evidence, 4. Methods: This study included 19 patients (21 knees) who presented with knee dislocation from a low-velocity or ultra low–velocity incident. Charts, radiographs, and magnetic resonance images (MRIs) were reviewed, and patients were reviewed based on their latest follow-up. We included patients in our database from 2001 to 2011 and compared knees of patients who had ligament repair or reconstruction (9 total knees) verses nonoperative treatment (12 total knees). Range of motion, activity levels, and knee laxity information were collected as outcome measures to compare operative and nonoperative results. Results: The mean age at presentation was 30.3 years (range, 15-74 years), with 5 men and 14 women. The average body mass index (BMI) was 41.4 kg/m² (range, 30-64.4 kg/m²), with an average follow-up of 31 months (range, 12-72 months). Five patients (27%) had a popliteal artery injury, and 7 (44.4%) had a peroneal nerve injury at presentation. Four had a vascular repair, 1 had an amputation, and 3 of 7 patients had return of peroneal nerve. Ligament reconstruction was performed on 9 individuals. The average operating time for ligament reconstruction was 183% of that with injury-matched normal-weight patients. Eight operative patients who complied with therapy had an average range of motion of 91.4° (range, 60°-110°). The nonoperative patients had an average range of motion of 60.45° (range, 0°-120°). Two of these patients later required a total knee arthroplasty (3 total knee arthroplasties overall). Conclusion: Knee dislocations from minor falls occur in obese patients and are often accompanied by neurovascular complications. While surgical reconstruction is more time consuming and more difficult than that in normal-weight individuals, it may be preferable to nonoperative treatment.