Vascular injury risk stratification for lateral lumbar interbody fusion (LLIF) at L4-L5: a morphometric study using magnetic resonance imaging.

Background: Proper vascular injury risk stratification (VIRS) methods for L4-L5 lateral lumbar interbody fusion (LLIF) surgery have not been well-described. The objective of this study was to propose a novel VIRS method for L4-L5 LLIF surgery via the transpsoas approach. Methods: Axial magnetic resonance imaging (MRI) of adult patients were obtained and analyzed. The VIRS scores were assessed using anterior disc line to posterior vessel wall distance, the disc vessel angle (DVA), and the disc edge to vessel distance at the level of L4-L5 disc space. Results: Ninety-one consecutive adult patients were included in the study. The right common iliac vein (CIV) had a high risk of injury with both right- and left-sided approaches. The left CIV had a moderate risk with a left-sided approach when the iliocaval confluence was above the L4-L5 disc space but had a high risk when the confluence was at the L4-L5 disc space. The left CIV had a high risk with a right-sided approach when the confluence was above the L4-L5 disc space but had a moderate risk when the confluence was at the L4-L5 disc space. The inferior vena cava (IVC) had a high risk with both right- and left-sided approaches. The aorta had a moderate risk regardless of the right or left-sided approaches. The left common iliac artery (CIA) had a moderate risk with a right-sided approach and a low risk with a left-sided approach. The right CIA had a low risk with both right- and left-sided approaches. Conclusions: There are significant vascular anatomic variations at the L4-L5 disc level and a proper VIRS can be performed utilizing a combination of anterior disc line to posterior vessel wall distance, DVA, and disc edge to vessel distance, on the axial MRI.

Anterior Capsular Reconstruction with Dermal Allograft in Combination With Anatomic Glenohumeral Arthroplasty: A Case Report.

CASE: A 43-year-old man with chronic right shoulder pain and dysfunction due to recurrent anterior instability, irreparable subscapularis tear, and glenohumeral arthritis presented to our practice. After workup and counseling, he was treated with anatomic total shoulder arthroplasty augmented by anterior capsular reconstruction using human acellular dermal allograft. At 15 months postoperatively, his forward elevation, external rotation, and internal rotation were 160, 45, and T12, nearly equal to contralateral values. His glenohumeral joint remained reduced, and no complications were encountered. CONCLUSION: We report the first known anterior capsular reconstruction performed in combination with anatomic shoulder arthroplasty.

Early Return to Play With Thumb Spica Gauntlet Casting for Ulnar Collateral Ligament Injuries Complicated by Adjacent Joint Dislocations in Collegiate Football Linemen.

Background: Treatment of thumb ulnar collateral ligament (UCL) ruptures in elite athletes aims to restore thumb stability while minimizing lost playing time. Thus, surgical repair with early protected return to play in a thumb spica cast has been advocated. The purpose of this study was to document adjacent joint dislocations after primary surgical repair sustained during protected return to play with thumb spica casting in elite-level football players. Methods: Three Division I collegiate starting linemen sustaining adjacent joint dislocations in thumb spica casts following acute surgical repair of ipsilateral thumb UCL ruptures were retrospectively reviewed. Demographic data were recorded as well as the timeline for injury, treatment, and subsequent return to sport. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained at final follow-up. Results: The mean time from thumb UCL injury to surgical repair was 8.7 days, and the mean return to sport was 13.3 days from surgery. There were 4 simple dislocations including 3 proximal interphalangeal (PIP) joints and 1 elbow. Each PIP dislocation was close reduced and treated with buddy straps with immediate return to play. The elbow dislocation was close reduced and splinted with return to play 22 days after injury. The mean QuickDASH score was 2.3 at 12 month follow-up. Conclusions: This report highlights that while thumb spica casting protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints and therefore adjacent injury. Appropriate counseling of the risks and benefits of this treatment strategy is essential.

Impact of Septated First Dorsal Compartments on Symptomatic de Quervain Disease.

BACKGROUND: The authors conducted this study to determine whether septation of the first dorsal compartment is more prevalent in de Quervain tenosynovitis, and whether this contributes to failure of corticosteroid injection therapy. METHODS: A retrospective review of 79 consecutive patients (85 wrists) with symptomatic de Quervain tenosynovitis treated with surgical release was performed. The number of corticosteroid injections performed preoperatively and the presence of first dorsal compartment septation determined intraoperatively were recorded. Correlation between the number of steroid injections and the presence of septation was evaluated. In addition, 48 matched cadaver upper extremities (96 wrists) that had not previously undergone surgery for de Quervain disease were evaluated for the presence of first dorsal compartment septation. The prevalence of septation was compared between matched wrists and against the surgically treated clinical cohort. RESULTS: In the clinical cohort, 61.2 percent of wrists contained a septated first dorsal compartment. There was no correlation between the presence of a septated first dorsal compartment and the number of steroid injections before surgical release. In the cadaver portion of the study, 72.9 percent of wrists contained septa. There was no significant difference in the prevalence of septated first dorsal compartments between groups. CONCLUSIONS: In the present study, the majority of wrists contained a septated first dorsal compartment, with no difference in the prevalence of septa between surgically treated patients and a cadaver sample that had not undergone prior surgical release. Furthermore, there was no correlation between the presence of septa and the number of preoperative corticosteroid injections administered. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Suture Caliber and Looped Configurations on the Suture-Tendon Interface in Zone II Flexor Tendon Repair.

PURPOSE: To evaluate the impact of suture caliber and looped configurations on the integrity of 4-strand modified Kessler zone II flexor tendon repairs during progressive cyclic loading. METHODS: Seventy-two flexor digitorum profundus tendons from 18 fresh human cadaver hands were divided into 4 repair groups. Thirty-six matched tendons underwent repair using either a 4-0 looped or 4-0 single-stranded suture, and an additional 36 tendons underwent 3-0 looped or 3-0 single-stranded repairs. Repair strength was tested by progressive cyclic loading. The force generating 2-mm gap formation, ultimate failure, and the mechanism of failure were recorded for each test. The impact of looped versus single-stranded configurations and the effect of tendon cross-sectional area on repair integrity were analyzed for each suture caliber. RESULTS: There was no statistically significant difference between groups regarding the force to 2-mm gap formation or ultimate failure, and all values exceeded the minimum threshold of 27 N required to withstand an early active range of motion rehabilitation protocol. The use of a 3-0 caliber suture resulted in a significantly higher proportion of repairs failing by suture pullout through the tendon substance, including 63.5% of looped and 38.9% of single-stranded core sutures. By comparison, this occurred in 11.1% of 4-0 looped and 0% of 4-0 single-stranded sutures. Larger tendon cross-sectional areas were associated with more robust repairs, particularly in the 3-0 looped group. CONCLUSIONS: In a human cadaver flexor tendon repair model, there was no significant difference in the mean force to failure between all 4 flexor tendon repair constructs under progressive cyclic loading. However, the 3-0 caliber suture failed more frequently by suture pullout, particularly with the use of a looped suture. CLINICAL RELEVANCE: Four-strand flexor tendon repairs using a 3-0 caliber suture are more prone to early failure by suture pullout under progressive cyclic loading compared with a 4-0 caliber suture.

Radiologic Analysis of C2 to Predict Safe Placement of Pedicle Screws.

BACKGROUND: Preoperative assessment of C2 pedicle morphology is critical to safe pedicle screw placement. To avoid iatrogenic injury, complex digital templating software has been introduced; however, this technology may not be available in many centers. We report a technique for preoperative assessment of C2 pedicle screw placement safety based upon 2-dimensional sagittal computed tomography (CT) scan images and verify its utility in clinical practice. METHODS: A total of 46 consecutive patients underwent cervical spine CT scans between 2005 and 2011. The C2 pedicle morphology was assessed on sagittal CT imaging by 5 independent reviewers to determine the feasibility and risk associated with pedicle screw placement. Thirty consecutive patients underwent C2 pedicle screw placement and were followed clinically for a minimum of 2 years. The ability to place a screw was noted, and accuracy of screw placement was assessed postoperatively by CT scan. RESULTS: The CT scan analysis demonstrated that 11% (5/46) of patients had sufficient pedicle size bilaterally to allow safe placement of long pedicle screws with a low risk of vertebral artery injury, whereas 15% (7/46) were considered a high risk bilaterally. Screw placement was deemed low risk in 28%, moderate risk in 38%, and high risk in 34%. Excellent intraobserver reliability and good interobserver reliability was observed. Clinically, 18 of 20 (90%) low-risk and 21 of 24 (88%) moderate-risk pedicle screws were placed safely versus 5 of 16 (31%) high-risk pedicle screws (P < .001). CONCLUSIONS: Using the described technique for evaluating the C2 pedicle via sagittal CT scan images allows for safe and reliable pedicle screw placement without relying upon complex digital templating software, which may have limited availability. LEVEL OF EVIDENCE: II. CLINICAL RELEVANCE: This study aids in the surgical decision-making behind the placement of C2 pedicle screws using CT scans without reliance upon complex digital templating software.

Treatment of Proximal Fifth Metatarsal Fractures and Refractures With Plantar Plating in Elite Athletes.

BACKGROUND:: Fractures of the proximal fifth metatarsal are relatively common foot injuries in elite athletes. Acute fixation with intramedullary screws is the most common operative treatment. However, the rate of nonunion and refracture after this procedure remains a concern. The purpose of this study was to determine rates of clinical and radiographic fracture healing, return to sport, and patient-reported clinical outcomes of elite athletes with proximal fifth metatarsal fracture or refracture treated with plantar plating. METHODS:: An institutional review board-approved retrospective single-surgeon case series investigation assessed athletes (competing at college, Olympic, or professional levels) with proximal fifth metatarsal fracture or refracture, treated with open reduction internal fixation and calcaneal autogenous bone grafting using a plantar plate with a minimum 2-year follow-up. Demographic data, radiographic evaluation, and the time until return to unrestricted sporting competition were collected and analyzed. Means with standard deviations were calculated for continuous data, and frequencies of categorical data were calculated in percentages. RESULTS:: Four refractures and 4 primary fractures were treated in 8 male athletes with a mean age of 21.9 ± 1.9 years at a mean follow-up of 3.2 ± 0.4 years. Two patients experienced temporary neuropraxia of the sural nerve that resolved within 6 weeks. There were no incisional complications, delayed unions or nonunions, refractures, hardware loosening, or complaints of hardware prominence. Clinically asymptomatic radiographic union was observed in 100% of the athletes at 6.5 ± 1.1 weeks and full release given at 12.3 ± 1.9 weeks. All athletes returned to sport at the same level of competition. CONCLUSION:: With minimum 2-year follow-up, plantar plating of proximal fifth metatarsal fractures was an effective and safe technique that was used in both primary and revision settings. LEVEL OF EVIDENCE:: Level IV, case series.

Correlation of the Lateral Wrist Radiograph to Ulnar Variance: A Cadaveric Study.

PURPOSE: Both positive and negative ulnar variance have been implicated in a variety of wrist disorders. Surgery aims to correct the variance in these pathologic conditions. This necessitates accurate and reproducible measuring tools; however, the most accurate radiographic measurement technique remains unclear. The purposes of this study were to evaluate 3 methods for determining ulnar variance and to compare each with direct anatomic measurement in a cadaver model. METHODS: We fixed 10 fresh above-elbow cadaver specimens in neutral rotation and obtained standardized fluoroscopic posteroanterior and lateral wrist images. A dorsal approach was performed and two independent investigators directly measured ulnar variance using digital calipers with the cartilage both intact and denuded. Ulnar variance was measured radiographically using the lateral, perpendicular, and central reference point methods. The reliability of each set of measurements (within a 1-mm cutoff) was assessed by the intraclass coefficient; agreement between radiographic and direct measurements was evaluated by the Bland-Altman method. RESULTS: Each method of determining ulnar variance demonstrated near perfect agreement by the intraclass coefficient. The lateral radiograph method correlated highly with the directly measured ulnar variance with the cartilage denuded with an average measurement difference of 0.06 mm. No radiographic measurement technique demonstrated consistent agreement within 1 mm of the measured ulnar variance with the cartilage intact. CONCLUSIONS: Ulnar variance measured by the lateral wrist radiograph technique correlates highly with the directly measured osseous ulnar variance. The remaining measurement techniques did not correlate reliably to within 1 mm of the directly measured ulnar variance with 95% confidence. No method was able to account accurately for the articular cartilage thicknesses at the lunate facet of the radius or the distal ulnar head, which we found to vary in an unpredictable manner. Whereas the lateral radiograph has been shown to allow for more reliable standardization of wrist position compared with the posteroanterior view, this study also highlights the inherent limitations of using static radiographic images in evaluating ulnar variance. CLINICAL RELEVANCE: The results of the current study demonstrate the utility of the lateral wrist radiograph for assessing bony ulnar variance.

Patient Factors Associated With Methicillin-Resistant Staphylococcus aureus Septic Arthritis in Children.

Staphylococcus aureus is the most common causative organism in pediatric septic arthritis, with methicillin-resistant Staphylococcus aureus (MRSA) being responsible for a significant portion of these infections. Early identification and initiation of proper treatment may improve outcomes by minimizing potential morbidity. The purpose of this study was to identify variables obtained on initial patient presentation associated with MRSA septic arthritis. Sixteen factors were retrospectively evaluated in 109 consecutive pediatric patients diagnosed with culture-confirmed septic arthritis. Graphical and logistical regression analyses were employed to determine factors independently predictive of MRSA septic arthritis. Twenty-seven (25%) patients had MRSA and 82 (75%) had non-MRSA septic arthritis. C-reactive protein of 13.7 mg/L or greater, duration of symptoms of 4 days or more, heart rate of 126 beats per minute or greater, and absolute neutrophil count of 8.72×103 cells/µL or greater were associated with MRSA septic arthritis. Ultimately, 98% of patients with 1 or no risk factors had non-MRSA and 96% of patients with MRSA septic arthritis had 2 or more positive risk factors. Elevated C-reactive protein, duration of symptoms, heart rate, and absolute neutrophil count are predictive of MRSA infection in the setting of pediatric septic arthritis and can be obtained on initial evaluation. In patients for whom there is concern for MRSA infection, this may guide more expedient treatment, such as early initiation of contact precautions and appropriate antibiotic therapy before culture results become available. [Orthopedics. 2018; 41(2):e277-e282.].

A novel muscle-sparing high thoracotomy for upper thoracic spine resection and reconstruction.

PURPOSE: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions. METHODS: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement. RESULTS: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively. CONCLUSIONS: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components.

Sterile Abscess with Subsequent Iatrogenic Draining Sinus Tract Formation 3 Years After FiberWire and ENDOBUTTON Distal Biceps Brachii Tendon Repair: A Case Report.

CASE: We report a case of a sterile abscess with subsequent sinus tract formation mimicking infection 3 years after uncomplicated distal biceps brachii tendon repair with FiberWire suture in a 42-year-old man. The preoperative workup for infection was unremarkable. Intraoperative culture specimens confirmed the absence of infection. Excision of the sinus tract and FiberWire-ENDOBUTTON construct was curative. At the 1-year follow-up, there had been no recurrence of symptoms. CONCLUSION: Foreign-body inflammatory reactions should be considered in the differential diagnosis of patients with apparent infection with a history of FiberWire suture fixation and negative serologic workup.

Do Skin Lacerations Imply Tissue Transfer From Surgeon to Patient During Arthroscopic Knot Tying?

PURPOSE: To use simulated arthroscopic knot tying to assess (1) whether epithelial cells from the surgeon's hands were transmitted to the suture and (2) whether the number of knots tied or the presence of glove tears would correlate with the number of cells transmitted. METHODS: Knots were tied in a simulated arthroscopic environment using a nonabsorbable No. 2 suture over a metal hook. The surgeon was double gloved for each knot tied. For each "anchor," a surgeon's knot was tied, followed by 3 reversed half-hitches on alternating posts. Multiple skin lacerations were sustained by the surgeon during each knot-tying session. Gloves were collected after tying 2, 4, or 6 anchors. Gloves were tested for perforation by (1) electroconductivity and (2) saline solution load testing. Cytopathologic ThinPrep analysis was applied and allowed for the number of epithelial cells found on each suture (within 10 high-powered fields) to be counted. Statistical analysis included analysis of variance and logistic regression. RESULTS: There was no significant difference in the number of epithelial cells identified in any of the groups compared with the negative control groups (P > .05) or with each other (P > .05). Glove tears were present in 3.3% of gloves (50% in inner and 50% in outer gloves) and 1.7% of gloves (50% in inner and 50% in outer gloves) by electroconductivity and saline solution load testing, respectively. There was no significant association between glove tears and the number of epithelial cells found on the suture (P > .05). CONCLUSIONS: Epithelial cells were transmitted to the suture during simulated arthroscopic knot tying. However, despite multiple skin lacerations produced during knot-tying sessions, the number of cells transmitted was not significantly different when compared with the negative controls. The number of cells transmitted did not correlate with the number of knots tied and/or the presence of glove tears. CLINICAL RELEVANCE: Skin lacerations on the surgeon's fingers are often noted after arthroscopic knot tying. However, despite these skin lacerations, no skin tissue is transferred across the surgical gloves to the suture itself.

Osteochondral Allograft Donor-Host Matching by the Femoral Condyle Radius of Curvature.

BACKGROUND: Conventional osteochondral allograft (OCA) matching, requiring orthotopic, size-matched condyles, and narrow surgical time windows often prohibit timely transplantation. HYPOTHESIS: The femoral condyle radius of curvature (RoC) is an appropriate, isolated criterion for donor-host matching in fresh OCAs, potentially enhancing matching efficiency when compared with conventional matching techniques. STUDY DESIGN: Descriptive laboratory study. METHODS: In part 1 of this study, 3-dimensional digital reconstructions of 14 randomly selected, cadaveric distal femoral hemicondyles were performed. Each condyle was divided into anterior, middle, and posterior zones. A virtual best-fit grid was applied to each, and each zone's sagittal- and coronal-plane RoCs were determined. Seven nonorthotopic OCA transplantations were performed based on RoC matching with 1-mm tolerance, and the preoperative and postoperative surface geometry were quantified to assess the accuracy of articular surface restoration. Of note, each donor-host pair did not match by the conventional method. In part 2 of this study, 12 cadaveric distal femora were categorized by size and digitized in the aforementioned manner. Simulated circular defects measuring 20, 25, and 30 mm in diameter were introduced into each zone. OCA matches were determined based on donor and host RoCs, and the total number of potential matches (of 71 total comparisons) was recorded as a percentage for each simulated defect. Finally, the results of RoC matching were compared with the conventional method for simulated defects in all zones of both the medial and lateral femoral condyles. RESULTS: Part 1: The mean surface deviation after OCA transplantation was -0.09 mm, with a mean maximum protrusion at any point of 0.59 mm. Part 2: Using the RoC, 20-mm defects had a 100% chance of being matched. Defects of 25 and 30 mm had a 91% and 64% chance of being matched, respectively. Compared with the conventional method, the RoC method yielded a 3.2-fold greater match rate for lesions of the medial and lateral femoral condyles ( P = .02). CONCLUSION: This investigation shows that femoral condyle RoCs in the sagittal and coronal planes may be useful, alternative matching criteria, expanding on current standards. CLINICAL RELEVANCE: These matching criteria may increase the number of available matches, reduce wait times for patients, and reduce the number of wasted grafts.

Eighty-six Percent Failure Rate of a Modular-Neck Femoral Stem Design at 3 to 5 Years: Lessons Learned.

BACKGROUND: While innovation drives advancement, it is not immune to failure. Previously, we reported a corrosion-related revision rate of 28% (23 of 81 total hip arthroplasties) among patients who received the Rejuvenate modular-neck stem implant with short-term follow-up. Because we observed a dramatic interval failure rate after our initial report, we undertook this study. METHODS: We prospectively followed a cohort of patients who had undergone implantation of the Rejuvenate modular-neck stem, as previously reported. At a minimum of 3 years of follow-up (range, 3.0 to 5.5 years), 73 hips in 63 patients (90% of the original group) were available for analysis. The mean serum cobalt and chromium ion levels were obtained preoperatively and postoperatively. Elevated serum cobalt ion levels (>4 µg/L), pain, or abnormal magnetic resonance imaging (MRI) findings were indications for revision surgery. Patient factors and serum metal ion levels were correlated to revision surgery. Additionally, post-revision serum cobalt and chromium ion level trends were assessed. RESULTS: An 86% clinical failure rate (63 of the 73 hips) was observed at a mean follow-up of 4.2 ± 0.6 years (range, 3.0 to 5.5 years); 57 (78%) of the hips underwent revision at a mean of 3.2 ± 1.0 years (range, 1.0 to 5.5 years), and 6 (8%) of the hips were scheduled for revision. Patients who underwent revision surgery were younger and had greater serum metal ion levels and greater pain compared with patients who did not undergo revision. An elevated serum cobalt ion level was the most important independent factor associated with revision surgery. Cobalt ion levels decreased sharply after revision; however, some patients demonstrated persistent elevation with more gradual decline. CONCLUSIONS: Emphasizing the reporting of positive results may leave orthopaedic surgeons reticent to publicize negative results; however, the high failure rate of this implant design within 5 years prompted this report. We believe that patients and orthopaedic surgeons should be made aware of this implant's clinical problems and patients should be followed closely. Expedient revision is necessary when failure is identified, to minimize potentially severe tissue damage and metal toxicity. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does the combination of erythropoietin and tapered oral corticosteroids improve recovery following iatrogenic nerve injury?

INTRODUCTION: The reported prognosis for recovery after peripheral nerve injury is remarkably poor. Deficits may persist for years, resulting in significant functional disability. Both corticosteroids and Erythropoietin have been investigated as neuroprotective agents; however, their efficacy in total hip and knee arthroplasty is not known. The purpose of this study was to evaluate the effect of systemically-administered Erythropoietin and tapered oral corticosteroids on the recovery of postoperative nerve palsies in the setting of total hip and knee arthroplasty. METHODS: Eleven patients sustaining postoperative peripheral nerve injuries after total hip or knee arthroplasty were treated acutely with Erythropoietin and tapered oral steroids. Motor and sensory function was assessed clinically pre- and postoperatively until complete motor recovery or for a minimum of 1 year. RESULTS: Motor loss was complete in seven (64%) patients and partial in four (36%). Seven (64%) patients' symptoms affected the common peroneal nerve distribution and four (36%) had concomitant tibial nerve involvement. Eight (73%) patients experienced full motor recovery at an average of 39 days (range: 3-133 days), and three (27%) had near-complete motor recovery. At final follow up, no patient required assistive devices for ambulation. CONCLUSIONS: Administration of Erythropoietin coupled with oral tapered steroids for patients sustaining iatrogenic nerve injuries in total hip and knee arthroplasty demonstrated faster and more complete recovery of motor and sensory function compared to previous reports in the literature. This study highlights the importance of further investigation to define the role of each in the setting of acute postoperative nerve palsies. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures.

Tibialis posterior tendon rupture in the setting of pronation-type ankle fractures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a medial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accordance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated ruptures. [Orthopedics.2016; 39(5):e970-e975.].

A Cadaver Investigation of Screw Purchase With 2 Retrograde Techniques for Capitolunate Arthrodesis.

PURPOSE: To examine the hypothesis that the amount of bone purchase within the lunate is greater when using a technique for intermetacarpal retrograde screw placement across the capitolunate joint than when using a dorsal capitate technique. METHODS: Seven fresh cadaver limbs were dissected. We exposed the carpus and scaphoidectomy and performed selective capitolunate decortication. We compared the technique of dorsal capitate placement of headless compression screws with intermetacarpal placement by measuring the depth of purchase in the lunate. RESULTS: Drill hole depths in the lunate were greater using the intermetacarpal technique versus the dorsal capitate technique; the average depth was 9.0 and 6.4 mm, respectively. The calculated number of threads was also greater with the intermetacarpal technique than with the dorsal capitate technique (15 vs 9 threads, respectively). CONCLUSIONS: The intermetacarpal technique for retrograde headless compression screw placement in a capitolunate arthrodesis provided a greater depth of purchase in the lunate portion of the construct. It also afforded more ease of placement than previously described antegrade techniques without the risk of hardware migration into the radiocarpal joint. CLINICAL RELEVANCE: The knowledge gained from this study may help guide surgeons to choose a technique for retrograde placement of headless compression screws in capitolunate arthrodesis to gain better purchase within the lunate.

Predicting the Presence of Adjacent Infections in Septic Arthritis in Children.

BACKGROUND: The gold standard for treatment of septic arthritis is urgent surgical debridement. Preoperative magnetic resonance imaging (MRI) may identify osteomyelitis, subperiosteal abscesses, and intramuscular abscesses, which frequently occur with septic arthritis. If these adjacent infections are not recognized, initial treatment may be inadequate. The purpose of this study is to develop a prediction algorithm to distinguish septic arthritis with adjacent infections from isolated septic arthritis to determine which patients should undergo preoperative MRI. METHODS: An IRB-approved retrospective review of 87 children treated for septic arthritis was performed. All patients underwent MRI. Sixteen variables (age, sex, temperature, WBC, CRP, ESR, ANC, hematocrit, platelet count, heart rate, systolic blood pressure, diastolic blood pressure, symptom duration, weight-bearing status, prior antibiotic therapy, and prior hospitalization) from admission were reviewed. Graphical and logistical regression analysis was used to determine variables independently predictive of adjacent infection. Optimal cutoff values were determined for each variable and a prediction algorithm was created. Finally, the model was applied to our patient database and each patient with isolated septic arthritis or adjacent infection was stratified based upon the number of positive predictive factors. RESULTS: A total of 36 (41%) patients had isolated septic arthritis and 51 (59%) had septic arthritis with adjacent foci. Five variables (age above 3.6 y, CRP>13.8 mg/L, duration of symptoms >3 d, platelets <314×10 cells/µL, and ANC>8.6×10 cells/µL) were found to be predictive of adjacent infection and were included in the algorithm. Patients with ≥3 risk factors were classified as high risk for septic arthritis with adjacent infection (sensitivity: 90%, specificity: 67%, positive predictive value: 80%, negative predictive value: 83%). CONCLUSIONS: Age, CRP, duration of symptoms, platelet count, and ANC were predictive of adjacent infections. Patients who met ≥3 criteria are at high risk for adjacent infection and may benefit from preoperative MRI. LEVEL OF EVIDENCE: Level III­retrospective comparative study.

National Trends in Operative Treatment of Pediatric Fractures in the Ambulatory Setting.

This study evaluated the expanding role of freestanding ambulatory surgery centers in pediatric fracture care based on the only national ambulatory surgery database within the United States. Released by the Centers for Disease Control and Prevention in 1996 and again in 2006, these reports were used to estimate the volume of outpatient pediatric operative fracture care in the United States over a decade, based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedure codes. Particular attention focused on the prevalence of open vs closed vs percutaneous fixation. The estimated number of pediatric patients who presented to outpatient facilities and required operative fracture care between 1996 and 2006 increased by 88%, from 74,577 ± 4663 to 140,152 ± 9138. During this time, the use of outpatient surgical services for pediatric fractures increased threefold, from 10% ± 1% in 1996 to 32% ± 2% in 2006. An even greater preference for freestanding ambulatory surgery centers was observed during this same time by a factor of 7, from 3% ± 1% to 21% ± 4%. Additionally, a trend toward higher volumes of open and percutaneous fixation in freestanding ambulatory surgery centers and not in hospital-associated outpatient centers was observed. This study showed the expanding role of freestanding ambulatory surgery centers in the surgical treatment of pediatric fractures based on data from the only national ambulatory surgery database in the United States. The proportion of open and percutaneous treatment vs closed reduction of fractures in these facilities also greatly increased. Further study is needed to evaluate clinical outcomes and determine which fractures are most appropriately treated in the ambulatory vs hospital setting.

Results of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions.

OBJECTIVES: To evaluate the radiographic and clinical outcomes of a systematic approach to exchange nailing for the treatment of aseptic femoral nonunions previously treated with an intramedullary nail. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Fifty aseptic femoral nonunions in 49 patients who presented with an intramedullary nail in situ an average of 25 months after the initial fracture nailing were evaluated. INTERVENTION: Our systematic approach includes inserting an exchange nail at least 2 mm larger in diameter than the in situ nail, using a different manufacturer's nail, static interlocking, correction of any metabolic and endocrine abnormalities, and secondary nail dynamization in cases showing slow progression toward healing. MAIN OUTCOMES MEASUREMENTS: The outcome measures were radiographic and clinical evidence of nonunion healing and time to union. RESULTS: All 50 femoral nonunions (100%) healed after this systematic approach to exchange nailing. The average time to achieve union was 7 months (range, 3-26 months). CONCLUSIONS: Utilization of this systematic approach of exchange nailing for the treatment of aseptic femoral nonunions resulted in a 100% healing rate. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.