OBJECTIVES:
To discover postoperative symptom differences between nerve-sparing and nerve-sacrificing techniques during ORIF of clavicle fractures.
METHODS:
Design:
Prospective, partially blinded randomized controlled trial.
Setting:
Single academic level I trauma center.
Patient Selection Criteria:
Patients with closed, isolated, displaced, midshaft clavicle fractures (OTA/AO 15-2A, -2B, -2C) underwent ORIF and were consented and randomized to a “nerve-sacrificing” or “nerve-sparing” group.
Outcome Measures and Comparisons:
Semmes-Weinstein monofilament used to test for sensation changes around the supraclavicular area, single assessment numerical evaluation scores, and symptom severity level providing patient self-reported changes, and patient morbidity questionnaires were issued at follow-up. One trained research fellow measured and mapped area of anesthesia. Outcomes between “nerve-sacrificing” and “nerve-sparing” groups were compared.
RESULTS:
In total, 21 patients (median age 41.5 years, 28.6% women) were randomized to “nerve-sacrificed” and 16 patients (median age 45.6 years, 18.8% women) to the “nerve-spared” group. There were no statistical differences in age or sex ratio (P = 0.304 and 0.702, respectively). Longitudinal models including an interaction between group and time showed cohort differences being driven by 12 weeks (49.3 (95% CLM 7.68–90.92)) and 24 weeks (23.92 (95% CLM 1.70–46.14)). Although point estimates for the spare group were still lower at 2 and 52 weeks, they were not significantly different between groups. Single assessment numerical evaluation scores and symptom severity level data showed improvements in both cohorts over time; however, there were no statistically significant differences between the groups (P = 0.176 and 0.155, respectively).
CONCLUSIONS:
Sparing the supraclavicular nerve during open reduction and internal fixation of clavicle fractures significantly decreased chest-wall area of anesthesia at 12 and 24 weeks postoperatively. However, nerve sparing did not provide clinically significant differences in other symptoms compared with sacrificing the nerve.
LEVEL OF EVIDENCE:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To describe outcomes after operative repair of clavicle nonunions and identify risk factors for recalcitrant nonunion.
METHODS:
Design:
Retrospective cohort study.
Setting:
Two academic Level 1 trauma centers.
Patient Selection Criteria:
Included were adults who underwent repair of a clavicle fracture (AO/OTA 15) nonunion from January 2004 to 2024.
Outcome Measures and Comparisons:
The primary outcome was recalcitrant nonunion, defined as nonunion requiring additional revision surgery after nonunion repair or absence of healing at final follow-up. Univariate and multivariable logistic regression was performed to determine associations between patient, nonunion, and treatment characteristics (fixation construct and position, use of bone graft, substitutes or compression) with recalcitrant nonunion. The secondary outcome was reoperation for complications other than recalcitrant nonunion.
RESULTS:
One hundred twenty-five patients were included [mean age 44 years (range 18–82 years), 55% male]. The median follow-up was 16 months and 82% of acute fractures were treated nonoperatively. No patients presented with confirmatory criteria of fracture-related infection. Twenty-four patients (19%) developed recalcitrant nonunion, with 17 undergoing revision. Body mass index [BMI; 5-point increase, odds ratio (OR) 3.38, P 0.05). Twenty-five patients (20%) underwent reoperations for complications other than recalcitrant nonunion.
CONCLUSIONS:
Operative repair for clavicle nonunion failed in 1 in 5 patients. Higher BMI, smoking, longer nonunion duration, older age, and non-diaphyseal nonunion locations were associated with increased risk of failure. No treatment characteristics were associated with failure. Surgeons may target modifiable risk factors, such as smoking and BMI, to achieve more reliable healing rates.
LEVEL OF EVIDENCE:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To determine the association between the timing of antibiotic delivery in the emergency department and deep surgical site infection in Gustilo–Anderson (GA) type III open tibia fractures.
METHODS:
Design:
Retrospective cohort study.
Setting:
Single level I trauma center.
Patient Selection Criteria:
Patients aged ≥18 years with a GA type III open tibia fracture (OTA/AO 41, 42, or 43) from 2016 to 2021 were included.
Outcome Measures and Comparisons:
The outcome was deep surgical site infection requiring irrigation and debridement. The effect of time of delivery of antibiotics was compared in 3 analyses: as a continuous variable, before versus after 60 minutes, and before versus after 180 minutes. The study analysis accounted for known confounders for infection, including Injury Severity Score, GA classification, and wound contamination.
RESULTS:
The study population included 191 patients with a mean age of 44 years (standard deviation [SD]: 17) and 153 men. The median time from arrival to the first antibiotic was 44 minutes (interquartile range: 21–147). Most patients (99.0%) received cephazolin as their initial antibiotic. The overall 90-day risk of deep surgical site infection requiring irrigation and debridement was 10.5%. The timing of antibiotic administration as a continuous variable was not associated with infection [adjusted odds ratio (aOR): 1.00, 95% confidence interval (CI), 0.99–1.00, P = 0.39]. Similarly, time to antibiotic administration was not associated with infection at thresholds of 1 hour (aOR: 1.02, 95% CI, 0.39–2.68, P = 0.96) or 3 hours (aOR: 1.08, 95% CI, 0.35–3.37, P = 0.89) in separate models.
CONCLUSIONS:
Early antibiotic administration was not associated with a reduced risk of deep surgical site infection in GA type III tibia fractures. These results suggest that the acute timing of antibiotics may not be as impactful to patients' risk of infection as once considered.
LEVEL OF EVIDENCE:
Therapeutic, level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To evaluate whether time to surgical debridement and medullary nailing of open tibial shaft fractures was predictive of infection.
METHODS:
Design:
Retrospective chart review.
Setting:
Single, academic, level-1 trauma center
Patient Selection Criteria:
All skeletally mature patients with open tibial shaft fractures (AO/OTA type 42) who presented to a level-1 trauma center between 2012 and 2024 with a minimum follow-up of 3-months were included. All patients underwent definitive treatment consisting of irrigation and debridement, followed by immediate intramedullary nailing during the same anesthetic. Patients with type IIIB fractures who did not receive soft tissue coverage within 7 days of presentation, and those with type IIIC fractures were excluded.
Outcome Measures and Comparisons:
The primary outcome measure was the incidence of deep infection necessitating a return to the operating room. Time to surgery was evaluated as a secondary outcome. Time intervals to surgical debridement were categorized as follows: 24 hours. Multivariate binary logistic regression analyses were performed to determine whether key factors, including age, diabetes, fracture type, smoking, ASA classification, and time to debridement at the previously categorized time points, were predictive of infection.
RESULTS:
A total of 393 patients (306 males) with a mean age of 38 years (range 15–87 years) were included. Of these, 24 patients (6%) had diabetes and 126 patients (32%) were smokers. There were 78 (20%) type I fractures, 170 (43%) type II fractures, and 144 (37%) type III fractures. Of the type III fractures, 99 (68%) were type IIIA while 45 (32%) were type IIIB. A total of 32 patients (8%) were treated within 6 hours, 111 patients (28%) between 6 and 12 hours, 131 patients (33%) between 12 and 18 hours, 69 patients (18%) between 18 and 24 hours, and 50 patients (13%) after 24 hours. A total of 46 infections (12.5%) were observed: 6 infections (13%) in type I fractures, 14 infections (20%) in type II fractures, 10 infections (22%) in type IIIA fractures, and 16 infections (35%) in type IIIB fractures. Time to surgery was not predictive of infection (p = 0.31). Logistic regression analysis showed that patients with a type IIIB fracture were 6.1 times more likely to develop an infection compared with other fracture types (OR = 6.147, 95% CI, 1.975–19.129, p = 0.002). Smokers were 2.8 times more likely to develop an infection (OR = 2.779, 95% CI, 1.357–5.691, P = 0.005). Age, time to debridement at the specified time points, diabetes, and ASA classification did not significantly predict infection (P = 0.32, 0.31, 0.27, and 0.50, respectively).
CONCLUSIONS:
Smoking and type IIIB fractures were identified as significant predictors of infection after immediate medullary nailing of open tibial shaft fractures, whereas time to debridement, within the categorized time points, was not found to be a significant factor.
LEVEL OF EVIDENCE:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To investigate the deep infection and reoperation rates associated with low-energy gunshot wound (LE-GSW) tibial shaft fractures and compare outcomes with fractures caused by blunt-force mechanisms and to analyze the microbial profile of infections in these cases.
METHODS:
Design:
Retrospective cohort study.
Setting:
Three Level 1 trauma centers in a large urban health system from 2014 to 2024.
Patient Selection Criteria:
Included were patients aged 16–65 years with tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) treated with intramedullary nails following LE-GSW or blunt-force mechanisms. Exclusions were pre-existing infections, high-velocity gunshot wounds, less than 6 weeks of follow-up, or delayed presentation (>24 hours).
Outcome Measures and Comparisons:
Primary outcomes included deep infection and unplanned reoperations. Patients were categorized into closed fractures, LE-GSWs, type I/II, and type III open fractures. Data between these categories were compared using chi-square, Fisher exact, and ANOVA with multivariable logistic regression.
RESULTS:
Included were 195 patients (mean age 37.6 years, range 17–65; M:F ratio 136:59). Fractures were closed (n = 68), type I/II (n = 55), type III (n = 37), and LE-GSWs (n = 35). LE-GSWs had significantly higher deep infection (34.3%) and reoperation rates (57.1%) than closed fractures (1.5% and 13.2%, respectively, P 
OBJECTIVES:
To determine the utility of sonication compared to traditional tissue culture in the setting of fracture-related infections (FRIs).
METHODS:
Design:
Retrospective cohort.
Setting:
One Level 1 Trauma Center.
Patient Selection Criteria:
Patients with prior fracture fixation that required a reoperation for suspected infection, nonunion, or hardware failure with available sonication data between 2018 and 2023 were included.
Outcome Measures and Comparisons:
The primary outcome was positivity of sonication compared to traditional tissue culture. FRIs were diagnosed based on clinical FRI diagnosis by the treating team in collaboration with infectious disease specialists. Secondary aims were to identify specificity and sensitivity of sonication and tissue culture and patient-specific factors associated with positive sonication in the setting of negative tissue culture.
RESULTS:
Of 79 patients identified, 67 met inclusion criteria. Mean age was 57 years (IQR: 43–72), and 50% were female. Most fractures were in the lower extremity (85%), and 73% were treated with plate fixation. Eighteen patients had positive tissue cultures, of which 15 were positive on sonication. Forty-nine patients had negative tissue cultures. Twenty-seven patients (40%) had positive sonication. Thirty cases were classified as FRI. Patients with positive sonication with negative tissue cultures were more likely male (66.6% vs. 32.4%, P = 0.048), older (65.5 vs. 55.7 years, P = 0.045), and had higher reoperation rates for suspected infection (50% vs. 13.5%, P = 0.0093) compared to negative sonication. Sonication demonstrated a higher sensitivity (80% vs. 56%) and lower specificity (92% vs. 97%) than tissue culture for FRI detection. The total sonication cost was $229 per patient compared to $122 for standard tissue cultures.
CONCLUSIONS:
Sonication demonstrated higher sensitivity for FRI detection compared to traditional tissue culture. Given its minimal additional cost and higher sensitivity, sonication is recommended as an adjunct diagnostic tool in reoperations for suspected orthopedic infections, hardware failure, and nonunion of unclear etiology.
LEVEL OF EVIDENCE:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To determine the incidence and risk factors for secondary arthrodesis (SA) and compare patients who underwent primary arthrodesis (PA) vs. SA after open reduction and internal fixation (ORIF) for Lisfranc injuries.
METHODS:
Design:
Retrospective cohort.
Setting:
Single tertiary level 1 trauma center
Patient Selection Criteria:
Adult patients treated surgically for Lisfranc injuries (AO/OTA 85.1A-C ± 85.2A-C, 85.3A-C; 87.1.1A-C-87.5.1A-C; 89B) between 2003 and 2023 were included.
Outcome Measures and Comparisons:
Patients who underwent index PA were compared with those who underwent index ORIF and subsequent SA. A composite primary outcome was used for comparison that included the development of adjacent midfoot arthrosis; midfoot collapse; or mal/nonunion rated satisfactory, suboptimal, poor, or severe; secondary outcomes were Patient Reported Outcome Measurement Information System measures of physical function (PF) and pain interference (PI). Descriptive and comparative statistics, multivariable analysis, and logistic regression were used to compare groups.
RESULTS:
Of 489 Lisfranc injuries (482 patients), index treatment for 98 (20%) was PA. Average age was 37.7 y (SD 15.6); mean follow-up was 2.3 y (SD 8.8). Fifty six percent of patients were men. There were 34 SAs (8.7% of index ORIF group). Patients who underwent SA were more likely to develop a poor (21.9% vs. 6.5% P = 0.021) or severe outcome (12.5% vs. 1.1%, P = 0.015) compared with those who underwent PA (OR 5.1, CI 1.4–18.5; OR 12.7, CI 1.1–12.8). Patients requiring SA also had significantly higher PI and significantly lower PF at final follow-up (P = 0.018, P 
OBJECTIVES:
To characterize the rate of failure and risk factors for treatment failure when operatively treating pertrochanteric and intertrochanteric femur nonunions.
METHODS:
Design:
Retrospective cohort study.
Setting:
One Level 1 North American trauma center.
Patient Selection Criteria:
Patients from 2008 to 2022 presenting with intertrochanteric or pertrochanteric (AO/OTA 31A1.2–31A3.3) nonunions that underwent nonunion repair.
Outcomes Measures and Comparisons:
The primary outcome measure was treatment failure, which was defined as conversion to arthroplasty for reasons other than progression of preexisting arthritis or persistent nonunion 1 year after nonunion repair. Patient demographics, caput-collum-diaphyseal (CCD) angle, the presence of medial bone loss, index implant selection, complications, use of bone graft, and presence of atypical femur fractures were examined for association with treatment failure.
RESULTS:
Sixty-three patients met inclusion criteria and had adequate follow-up to union or treatment failure (average 23.3 months, range 3–129). The mean age was 59 (range 24–93, SD 15.6), and 47.6% of patients were male. Forty-two patients (65.1%) were treated with an angled blade plate (ABP) and 19 (30.2%) with a cephalomedullary nail (CMN). The rate of failure was 26.5% (n = 17). In 23.8% of cases, autograft was used (n = 15), 11.1% a synthetic biologic (n = 7), 17.5% allograft (n = 11), and 11.1% with allograft and autograft (n = 7). A biologic augment was more frequently used in patients treated with an ABP versus CMN (71.4% vs. 42.1%, P = 0.02). Of the 42 patients managed with ABP, there were 14 treatment failures (33.3%), compared with 3 of 19 patients treated with CMN (15.8%, P = 0.15). Active tobacco use was associated with treatment failure; 7 of 14 patients went on to treatment failure compared with 10 of 49 without active tobacco use (50% vs. 20.4%, P = 0.03). In 14 cases (22.2%), there was medial bone loss noted at the time of revision. 50% of these cases (7/14) failed to unite compared with 20.4% (10/49) of patients without medial bone loss (P = 0.02).
CONCLUSIONS:
Despite variations in implant choice, use of biologic augments, and patient age, a failure rate of 26.5% was observed in patients undergoing pertrochanteric and intertrochanteric nonunion repair. Medial bone loss and tobacco use were each associated with a 50% rate of treatment failure, highlighting consideration of these factors preoperatively when considering undertaking nonunion repair.
Level of Evidence:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To determine the rate of and risk factors for reoperation to promote fracture union of periprosthetic distal femur fractures treated with lateral locked plating.
METHODS:
Design:
Retrospective cohort study.
Setting:
Two level 1 trauma centers.
Patient Selection Criteria:
Adult patients undergoing operative treatment for a periprosthetic distal femur fracture (AO/OTA 33A or 33C) between 2006 and 2023 with a minimum follow-up of 3 months.
Outcome Measures and Comparisons:
Reoperation to promote fracture union compared across patient, fracture, and treatment characteristics.
RESULTS:
Two hundred and eighteen patients [mean age 72 years (range: 52–84), 77% women] were included. There were 133 (61%) Su type 2 fractures, 10 (4.6%) open injuries, and 118 (54%) fractures with multifragmentary comminution of the metaphysis. Twenty (9.2%) patients required reoperation to promote fracture union, including 15 (6.9%) patients who presented with nonunion with implant failure. In multivariable logistic regression analysis, body mass index [5-point increase; OR: 1.37 (95% CI, 1.00–1.86), P = 0.047], multifragmentary metaphyseal comminution [OR: 5.17 (95% CI, 1.47–18.3), P = 0.011], and varus malalignment [OR: 5.88 (95% CI, 1.29–26.8), P = 0.023] were associated with increased odds of reoperation for nonunion, whereas the use of titanium plates was protective [OR: 0.21 (95% CI, 0.07–0.63), P = 0.005].
CONCLUSIONS:
In this study of 218 patients undergoing lateral locked plating for a periprosthetic distal femur fracture, 9 out of 10 patients did not undergo reoperation to promote fracture union. Factors associated with reoperation included increased body mass index, the presence of multifragmentary metaphyseal comminution, and varus malalignment with a lateral distal femoral angle of ≥84 degrees. The use of titanium plates was associated with decreased odds of reoperation although this finding should be interpreted in the context of varying plate designs and configurations. These results may help delineate indications for the selection of specific fixation constructs when treating periprosthetic distal femur fractures.
LEVEL OF EVIDENCE:
Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To compare Healthy Days At Home (HDAH90) within 90 days of hospital discharge after single implant (SI) or dual implant (DI) fixation in geriatric distal femur fractures.
METHODS:
Design:
Retrospective review.
Setting:
Three level I trauma centers.
Patient Selection Criteria:
Geriatric (age ≥60 years) patients with distal femur fracture (OTA/AO 33 A, C) operatively treated with SI [lateral plate or retrograde intramedullary nail (IMN)] or DI (2 plates or plate and IMN) between January 2018 and January 2024 were included.
Outcome Measures and Comparisons:
The primary outcome was HDAH90, which was calculated from date of surgery to 90 days follow-up and accounted for days after mortality, skilled nursing facilities (SNF), readmissions, and secondary surgeries. HDAH90, days at SNF, 90-day readmission, 90-day mortality, return to baseline ambulatory status at 180 days, and length of hospitalization were compared between patients with SI or DI. A binary logistic multivariate regression was used to compare outcomes while controlling for age, sex, dependence on assistive device, periprosthetic fracture, and postoperative weight-bearing status.
Results:
The 229 patients with SI were 2 years younger than the 70 patients with DI (73 vs. 75 years, P = 0.03). The DI cohort had more female patients (82.9% vs. 70.7%, P = 0.044), and more periprosthetic fractures (55.7% vs. 35.4%, P = 0.002). There was no other demographic, fracture characteristic, or preoperative ambulatory differences between groups (P > 0.05). After regression analysis, patients with DI had greater HDAH90 (55 vs. 45, P = 0.024) and fewer days at SNF (22 vs. 32, P = 0.026) than patients with SI. There were no differences in 90-day readmission (DI odds 1.36, P = 0.353), 90-day mortality (DI odds 0.94 P = 0.935), return to baseline ambulatory status at 180 days (DI 1.64, P = 0.433), and length of hospitalization (DI 10 days vs. SI 9 days, P = 0.579).
Conclusions:
Geriatric patients treated with dual implants for distal femur fractures experienced an additional 10 Healthy Days at Home90 as compared with those treated with single implants. Given that a 10-day difference is clinically significant in geriatric fractures for Healthy Days at Home90, using dual implant constructs may represent an improvement in care for patients with distal femur.
LEVEL OF EVIDENCE:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To describe outcomes in patients with periprosthetic distal femur fractures who underwent retrograde intramedullary nailing (rIMN), including subsequent revision total knee arthroplasty (TKA) and subjective and/or objective evidence of flexion instability (FI). The hypothesis of this study is FI can occur following rIMN in cruciate-retaining TKA, possibly due to iatrogenic posterior cruciate ligament damage.
METHODS:
Design:
Retrospective review.
Setting:
Single academic Level-I trauma center.
Patient Selection Criteria:
All patients who sustained a periprosthetic distal femur fractures, AO/OTA 33A, between 2008 and 2022 who were treated with a rIMN by a trauma fellowship–trained orthopedic surgeon with >3-month follow-up were included. Patients with re for instability. There were 16 complications (20.5%) requiring return to the OR. The median time to return to OR was 204.5 days (interquartile range of 135–390.25 days). The most common indication was irritable hardware (n = 4, 5.5%) and nonunion (n = 4, 5.5%), followed by primary instability (n = 3, 4.1%). All 3 nonunions underwent revision open reduction internal fixation. Five patients (6.8%) reported symptoms, and 7 (9.6%) had positive physical examination findings suggestive of FI. There were 22 patients (30.1%) with radiographic posterior tibial translation.
CONCLUSIONS:
This retrospective review suggests that FI secondary to damage of the PCL is a potential complication following retrograde intramedullary of periprosthetic distal femur fractures.
LEVEL OF EVIDENCE:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To identify practices for treating interprosthetic femur fractures (IFFs) and determine factors that positively affect patient outcomes.
METHODS:
.
Design:
Retrospective cohort study.
Setting:
Fifteen trauma centers in the United States.
Patient Selection Criteria:
Patients aged 50–90 years who underwent operative fixation of an AO/OTA 32 A-B-C type IFF fracture from 2011 to 2021 were included. Patients who underwent revision arthroplasty at the time of fixation or were nonambulatory were excluded.
Outcome Measures and Comparisons:
The primary outcome was union rate. Secondary outcomes included postoperative complications, revision surgery, mortality, and change in ambulation status. Univariate analyses using chi-square tests, Fisher exact tests, and analysis of variance were performed to detect associations between demographic, injury, and surgical characteristics with postoperative outcomes.
RESULTS:
One hundred thirty-nine patients were included, with 110 (79%) women and median age 78 [range, 57–90]. Distal one-third fractures were most common, 68% (N = 95). One hundred eighteen (85%) patients were treated with a lateral plate, 8% (N = 11) were treated with nail–plate combination and 7% (N = 10) were treated with dual plates. The median time to full-weight bearing was 2.5 months. Dual plate combination was associated with the fastest time to full-weight bearing (P = 0.048) at 2 weeks. In total, 61% (n = 85) of patients returned to baseline ambulation status (100% [11] IMN–plate, 60% [71] lateral plate, and 25% [3] dual plate) with patients treated with nail–plate had higher rates of return to baseline function (P = 0.009). The overall mortality rate was 13% and associated with greater than 1 comorbidity (P = 0.022).
CONCLUSIONS:
A spanning lateral plate was the most common fixation of IFF. Patients with dual fixation were more likely to return to baseline ambulatory status, particularly those with intramedullary nail–plate combination. The mortality rate at 1 year was 11% and comorbidity burden was associated with higher risk of mortality.
LEVEL OF EVIDENCE:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. 
OBJECTIVES:
To evaluate the diagnostic accuracy of imaging modalities and outcomes of treatment strategies for Morel-Lavallée lesions (MLLs) and provide evidence-based recommendations for optimal management.
METHODS:
Design:
Systematic review conducted according to PRISMA guidelines.
Setting:
MEDLINE, Embase, and Emcare databases were searched through September 2024.
Patient Selection Criteria:
Included studies were observational or randomized controlled trials reporting on diagnostic accuracy or treatment outcomes for Morel-Lavallée lesions.
Outcome Measures and Comparisons:
Diagnostic modalities, lesion characteristics, treatment modalities, recurrence rates, and complications were compared using descriptive statistics.
RESULTS:
Twenty-nine studies (928 patients, 964 lesions) were included. MLLs most frequently occurred in the thigh (26.5%), greater trochanter (24.9%), and lumbar region (20.3%). Among smaller lesions (100 cm3), percutaneous management was associated with the highest recurrence rate (15%) compared with other treatment approaches. Operative treatment of large lesions had a 50% recurrence rate in 1 study, while sclerodesis achieved the lowest rate (4.8%) for lesions averaging 387 cm3, however, this finding is based on a limited number of cases (21 lesions). MRI was the most common single imaging modality reported (n = 162 lesions, 19.5%), favored for its superior soft-tissue characterization. Ultrasound was used in 121 lesions (14.6%) as an accessible initial assessment tool, while computed tomography, often performed incidentally during trauma evaluation, diagnosed 339 lesions (40.9%).
CONCLUSIONS:
MRI was the most used single modality for diagnosing MLLs. Small, acute lesions were effectively managed nonoperatively. Large lesions (>100 cm3) often required operative management. Sclerodesis seems promising with the lowest recurrence (4.8%), but further studies are needed. Standardized treatment protocols may help improve outcomes and reduce recurrence.
LEVEL OF EVIDENCE:
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. 
Summary:
Pelvic ring injuries involving the posterior ring frequently require complex surgical solutions—particularly Tile C injuries. Despite various techniques available, there is no consensus gold standard for achieving stable fixation, particularly in complex injury patterns with lumbopelvic dissociation, severe posterior comminution, and/or severe sacral dysmorphism, or injuries requiring an open approach for reduction. Although biomechanical data demonstrate significant promise to percutaneous posterior pelvic plating, there is a paucity of literature examining its clinical application. This study introduces percutaneous posterior ilioiliac pelvic plating as a useful surgical technique for unstable posterior pelvic ring fractures including a case series of 11 patients treated with this technique, focusing on fixation stability, complication rates, and neurologic status. Incorporating this series with the existing literature, percutaneous posterior pelvic plating is presented as a viable, effective option for managing these complex injuries. 
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