Gravity Reduction View: A Radiographic Technique for the Evaluation and Management of Weber B Fibula Fractures.

BACKGROUND: While various radiographic parameters and application of manual/gravity stress have been proposed to elucidate instability for Weber B fibula fractures, the prognostic capability of these modalities remains unclear. Determination of anatomic positioning of the mortise is paramount. We propose a radiographic technique, the Gravity Reduction View (GRV), which helps elucidate non-anatomic positioning and reducibility of the mortise. METHODS: The patient is positioned lateral decubitus with the injured leg elevated on a holder with the fibula directed superiorly. The x-ray cassette is placed posterior to the heel, with the beam angled at 15° of internal rotation to obtain a mortise view. Our proposed treatment algorithm is based upon the measurement of the medial clear space (MCS) on the GRV versus the static mortise view (and in comparison to the superior clear space (SCS)) and is based on reducibility of the MCS. A retrospective review of patients evaluated utilizing the GRV was performed. RESULTS: 26 patients with Weber B fibula fractures were managed according to this treatment algorithm. Mean age was 50.57 years old (range:18-81, SD=19). 17 patients underwent operative treatment and 9 patients were initially treated nonoperatively. 2 patients demonstrated late displacement and were treated surgically. Using this algorithm, at a mean follow-up of 26 weeks, all patients had a final MCS that was less than the SCS (final mean MCS 2.86 mm vs. mean SCS of 3.32) indicating effectiveness of the treatment algorithm. CONCLUSIONS: The GRV is a radiographic view in which deltoid competency, reducibility and initial positioning of the mortise are assessed by comparing a static mortise view with the appearance of the mortise on the GRV. We have proposed a treatment algorithm based on the GRV that we found it useful in our patients in guiding treatment and achieving anatomic mortise alignment.

High Variability of Observed Weight Bearing During Standing Foot and Ankle Radiographs.

BACKGROUND: Weight-bearing radiographs are a critical component of evaluating foot and ankle pathology. An underlying assumption is that patients are placing 50% of their body weight on the affected foot during image acquisition. The accuracy of weight bearing during radiographs is unknown and, presumably, variable, which may result in uncertain ability of the resultant radiographs to appropriately portray the pathology of interest. METHODS: Fifty subjects were tested. The percentage body weight through the foot of interest was measured at the moment of radiographic image acquisition. The subject was then instructed to bear "half [their] weight" prior to the next radiograph. The percentage body weight was calculated and compared to ideal 50% weight bearing. RESULTS: The mean percentage body weight in trial 1 and 2 was 45.7% ± 3.2% ( P = .012 compared to the 50% mark) and 49.2% ± 2.4%, respectively ( P = .428 compared to 50%). The mean absolute difference in percentage weight bearing compared to 50% in trials 1 and 2 was 9.3% ± 2.3% and 5.8% ± 1.8%, respectively ( P = .005). For trial 1, 18/50 subjects were within the "ideal" (45%-55%) range for weight bearing compared to 32/50 on trial 2 ( P = .005). In trial 1, 24/50 subjects had "appropriate" (>45%) weight bearing compared to 39/50 on trial 2 ( P = .002). CONCLUSIONS: There was substantial variability in the weight applied during radiograph acquisition. This study raises questions regarding the assumptions, reliability, and interpretation when evaluating weight-bearing radiographs. LEVEL OF EVIDENCE: Level III, comparative study.

Determining Measurement Error for Bohler's Angle and the Effect of X-Ray Obliquity on Accuracy.

BACKGROUND: Bohler's angle (BA) is the most commonly utilized radiographic measurement in the study of calcaneus fractures and has been shown to be prognostic in nature. Therefore, it is critical that the measurement of BA be accurate as both therapeutic and prognostic information relies on it. Oblique lateral radiographs can be a cause of error in BA measurements. However, measurement error and the effects of X-ray beam obliquity on BA have not been established in the literature. The purpose of this study was to determine measurement error and understand the effects of X-ray beam's obliquity on the measurement of BA. METHODS: A cadaver specimen was imaged using a C-arm to obtain a perfect lateral radiograph of the ankle and slightly oblique lateral views in the anterior, posterior, cephalad, and caudad directions in 5° increments (21 images). Metallic beads were then placed on the anterior calcaneal process, posterior facet, and the superior aspect of the posterior tuberosity, and the same 21 images were then obtained. The metallic beads placed on the reference radiographs allowed the authors to accurately measure BA for each image and served as reference for the corresponding test radiographs. Thirty-four orthopaedic staff members participated in the study and used DICOM measurement tool to measure BA on each of the 21 test radiographs. The measurements were then compared to the measurements of BA from the reference radiographs to determine error in measurement. RESULTS: A total of 714 different measurements were obtained. Average measurement error was 6° (95% confidence interval = -4° to 15°). The difference between the observed BA measurements compared to the true BA measurements increased with increasing X-ray obliquity. CONCLUSIONS: Measurement error for BA is ±6° and increases most with cephalad oblique radiographs. Orthopaedic surgeons' ability to accurately measure BA significantly decreases with increasing obliquity of the lateral radiograph. LEVELS OF EVIDENCE: Level V: Cadaver bench study.

Culture-Negative Infection After Operative Fixation of Fractures.

OBJECTIVES: (1) Compare the outcomes of patients with orthopaedic trauma with culture-negative infection with those with pathogens identified; (2) identify the incidence of culture-negative infection and describe the common characteristics. DESIGN: Retrospective study. SETTING: Two level 1 trauma centers. PATIENTS: A total of 391 patients 16 years of age or older who underwent irrigation and debridement for surgical site infection after having undergone fracture fixation were included. INTERVENTION: Patients underwent irrigation and debridement with cultures, and antibiotic therapy was initiated. MAIN OUTCOME MEASUREMENT: Treatment failure due to unsuccessful eradication of infection and time to union. RESULTS: We found 9% incidence of culture-negative infection. Approximately one-third of patients in both groups went on to have treatment failure (25% of pathogen-specific infections, 38% of culture-negative infections, P = 0.15), and there was no difference between the 2 groups with regard to time to union (22 vs. 24 weeks, P = 0.55). More than one-third of patients required subsequent reconstructive procedure and 5% of patients in each group required amputation to control their infection. There was no difference between the groups with respect to the use of antibiotics before intervention and culture. CONCLUSION: This study confirms the devastating effect that postoperative infections can have and suggests that, with clinical sign of infection, negative cultures do not portend a better prognosis. These entities should be treated in a similar manner to infections with positive cultures. Furthermore, we believe that future studies should not strictly rely on the presence of positive intraoperative cultures. Consensus as to what constitutes a clinical infection, in the absence of positive cultures, is needed. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopically Assisted Versus Standard Open Reduction and Internal Fixation Techniques for the Acute Ankle Fracture.

BACKGROUND: Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures. METHODS: A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications. RESULTS: A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures. CONCLUSIONS: Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients. LEVEL OF EVIDENCE: Level II, systematic review.

Nontuberculous Mycobacterial Osteomyelitis of the Thumb: Successful Treatment with Serial Debridement, Antimicrobial Therapy, External Fixation, and Interphalangeal Arthrodesis: A Case Report.

CASE: We present the case of a fifty-seven-year-old woman treated for persistent inflammation of her thumb initially thought to be due to tuberculous osteomyelitis but which ultimately proved to be due to infection caused by a novel nontuberculous mycobacterial species. The establishment of this diagnosis and her treatment are described. CONCLUSION: Indolent hand infections caused by atypical mycobacterial species may occur even in immunocompetent hosts, and their diagnosis remains challenging and often elusive. Surgeons should have a low threshold of suspicion for nontuberculous mycobacteria in cases refractory to treatment by standard protocols. The miniature external fixator provides stability and allows for soft-tissue healing in the setting of hand infections.

Peroneal tendon displacement accompanying intra-articular calcaneal fractures.

BACKGROUND: Peroneal tendon displacement (subluxation or dislocation) accompanying an intra-articular calcaneal fracture is often undetected and under-treated. The goals of this study were to determine (1) the prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures, (2) the association of tendon displacement with fracture classifications, (3) the association of tendon displacement with heel width, and (4) the rate of missed diagnosis of the tendon displacement on radiographs and computed tomography (CT) scans and the resulting treatment rate. METHODS: A retrospective radiographic review of all calcaneal fractures presenting at three institutions from June 30, 2006, to June 30, 2011, was performed. CT imaging of 421 intra-articular calcaneal fractures involving the posterior facet was available for review. The prevalence of peroneal tendon displacement was noted and its associations with fracture classification and heel width were evaluated. RESULTS: Peroneal tendon displacement was identified in 118 (28.0%) of the 421 calcaneal fracture cases. The presence of tendon displacement was significantly associated with joint-depression fractures compared with tongue-type fractures (p < 0.001). Only twelve (10.2%) of the 118 cases of peroneal tendon displacement had been identified in the radiology reports. Although sixty-five (55.1%) of the fractures with tendon displacement had been treated with internal fixation, the tendon displacement was treated surgically in only seven (10.8%) of these cases. CONCLUSIONS: Analysis of CT images showed a 28% prevalence of peroneal tendon displacement accompanying intra-articular calcaneal fractures. Surgeons and radiologists are encouraged to consider this association.

The role of extracellular signal-related kinase during abdominal aortic aneurysm formation.

BACKGROUND: It is hypothesized that activation of extracellular signal-related kinase (ERK) is critical in activating matrix metalloproteinases (MMPs) during abdominal aortic aneurysm (AAA) formation. STUDY DESIGN: C57BL/6 male mice underwent either elastase or heat-inactivated elastase aortic perfusion (n = 9 per group). Mouse aortic smooth muscle cells were transfected with ERK-1 and 2 siRNA along with or without elastase treatment. Mouse and human aortic tissue were analyzed by Western blots, zymograms, and immunohistochemistry, and statistical analysis was done using Graphpad and Image J softwares. RESULTS: Western blot and immunohistochemistry documented increased phospho-mitogen-activated protein kinase kinase-1/2 (pMEK-1/2; 153%, p = 0.270 by Western) and pERK (171%, p = 0.004 by Western blot) in the elastase perfused aortas. Male ERK-1(-/-) mice underwent elastase perfusion, and aortic diameter was determined at day 14. ERK-1(-/-) mice failed to develop AAA, and histologic analysis depicted intact collagen and elastin fibers in the aortas. Zymography of aortas of elastase-treated ERK-1(-/-) mice showed lower levels of proMMP2 (p < 0.005) and active MMP2 (p < 0.0001), as well as proMMP9 (p = 0.037) compared with C57BL/6 mice. siRNA transfection of ERK-1 and -2 significantly reduced formation of pro- and active MMP2 (p < 0.01 for both isoforms) in aortic smooth muscle cells treated with elastase in vitro. Human AAA tissue had significantly elevated levels of pMEK-1/2 (150%, p = 0.014) and pERK (159%, p = 0.013) compared with control tissues. CONCLUSIONS: The MAPK (mitogen-activated protein kinase)/ERK pathway is an important modulator of MMPs during AAA formation. Targeting the ERK pathway by reagents that inhibit either the expression or phosphorylation of ERK isoforms could be a potential therapy to prevent AAA formation.

Gender-dependent differential phosphorylation in the ERK signaling pathway is associated with increased MMP2 activity in rat aortic smooth muscle cells.

BACKGROUND: The present experiments were conducted to explore the role of mitogen-activated protein kinase (MAPK) pathways, potential upstream regulators of MMPs, in abdominal aortic aneurysms (AAAs). METHODS: Rat aortic smooth muscle cells (RASMCs) from males and females were treated with media containing interleukin (IL)-1beta (2 ng/mL), a concentration known to be present in AAAs. Levels of both total and phosphorylated (activated) extracellular signal-regulated kinase (ERK), c-Jun amino terminal kinase/stress-activated protein kinase (JNK/SAPK), and p38 were examined by Western blotting at various time intervals up to 60 min. Similar experiments were conducted following exposure of RASMCs to elastase (6 U/mL), a concentration known to induce AAA formation in rodents. Finally, media was assayed for MMP activity by zymography. RESULTS: Total ERK (t-ERK) was consistently no different in females compared with males prior to or following IL-1beta exposure. In contrast, levels of phosphorylated ERK (p-ERK) were significantly higher in males than females throughout the postexposure period (P < 0.0001). Levels of t-p38, p-p38, and t-JNK were not altered in a gender-dependent manner. The lack of p-JNK levels detected in both male and female RASMCs did not allow for conclusions to be drawn regarding gender disparities in this pathway. Results were similar following RASMC elastase exposure, although t-ERK levels were consistently higher in females than males (P < 0.0001). Pro-MMP2 levels were significantly higher (P = 0.0035) in males than females at each time point following elastase exposure. CONCLUSIONS: These data provide evidence implicating alterations in p-ERK signaling via the up-regulation of MMPs as a potential explanation for gender-related discrepancies in AAA formation.

Effects of smoking on survival for patients with end-stage liver disease.

BACKGROUND: Smokers with chronic liver disease can become eligible for transplantation, but some insurers refuse reimbursement pending smoking cessation. STUDY DESIGN: Our hypothesis is that liver transplantation candidates and recipients who smoke have inferior survival compared with nonsmokers. Using a retrospective cohort study design, three Cox proportional hazards models were constructed to determine covariate-adjusted mortality from transplantation evaluation and transplantation based on smoking status at evaluation, transplantation, and posttransplantation followup. RESULTS: From 1999 to 2007, 2,260 patients were evaluated. Seven hundred sixty were active smokers, and 1,500 were nonsmokers. Smokers at evaluation were younger (49.3 versus 51.7 years), were more likely to be men (65.9% versus 58.7%), have hepatitis C (54.2% versus 30.1%), have a lower Model for End-Stage Liver Disease score (10.5 versus 12.3), and less likely to receive transplant (12.2% versus 18.6%) (all p < 0.05). The postevaluation multivariate model indicated that substance use, higher Model for End-Stage Liver Disease score, hepatitis C, and older age increased mortality risk (all p < 0.05), and liver transplantation (hazards ratio = 0.986; 95% CI, 0.977 to 0.994) was associated with lower mortality. Smoking was not associated with increased mortality risk at any time point in those evaluated or receiving transplants. CONCLUSIONS: Providers should continue encouraging potential liver transplantation candidates to stop smoking, but insurer-driven mandated smoking cessation might not improve survival.