High-energy Femoral Neck Fractures in Young Patients.

Femoral neck fractures in physiologically young patients typically occur from high-energy axial loading forces through the thigh with the hip in an abducted position. These fractures have a high rate of associated head, chest, abdominal, and musculoskeletal injuries. High-energy hip fractures differ from traditional geriatric hip fractures regarding incidence, mechanism, management algorithms, and complications. After adequate resuscitation, goals of treatment include anatomic reduction and stable fixation while maintaining vascularity of the femoral head, which can be achieved through a variety of different techniques. Prompt recognition and treatment of these fractures is crucial to achieve a successful outcome because these injuries are often associated with complications such as osteonecrosis, fixation failure, and nonunion.

Anatomic Analysis of a Percutaneous Fixation Technique for the Posterior Malleolus Using Posterior-to-Anterior-Directed Cannulated Screws: A Cadaveric Study and Technique Description.

BACKGROUND: Posterior malleolus fractures are traditionally managed with open reduction and internal fixation or percutaneous anterior-to-posterior screws. We present a third option using a percutaneous technique for the placement of posterior-to-anterior-directed screws. An anatomic safety analysis is done using cadaveric specimens. METHODS: Using 15 embalmed specimens (10 F and 5 M), a guidewire was placed using the described technique. The posterolateral ankle was dissected to evaluate for damage to vulnerable structures including the sural nerve, peroneal artery, and flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons. The distance from the sural nerve and peroneal artery was measured to the guidewire at its nearest point. The tendons were evaluated for traumatic piercings. RESULTS: The sural nerve had a mean distance to wire of 5.3 mm (range 0 to 12) and the peroneal artery had a mean distance to wire of 5.7 mm (range 2 to 13 mm) with no traumatic piercings of either structure. The flexor hallucis longus/flexor digitorum longus/peroneal/Achilles tendons had no traumatic piercings. CONCLUSION: This percutaneous technique provides a safe alternative to the standard open and traditional percutaneous techniques. It has limited application and is suitable for noncomminuted minimally displaced posterior malleolus fractures and those with fragile tissues where the morbidity of the soft tissue exposure outweighs the benefit of an open reduction.

Long-term Functional Outcomes of Nonoperatively Treated Highly Displaced Scapular Body and Neck Fractures.

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29-57 years) underwent follow-up for a mean of 54.1 months (range, 28.2-74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0-35), mean SF-36 score was 72.2 (range, 57.3-96.1), and mean ASES score was 85.9 (range, 46.7-100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177-e181.].

Evaluation of bacterial presence on lead X-ray aprons utilised in the operating room via IBIS and standard culture methods.

BACKGROUND: Despite precautions, surgical procedures carry risk of infection. Radiation-protective lead aprons worn by operating personnel are a potential source of bacterial contamination and have not been fully evaluated. AIM/OBJECTIVE: To evaluate lead aprons as a source of bacterial contamination, identify organisms most commonly found on this source, and devise a method with which to lower the risk of contamination. METHODS: In this basic science study, 20 randomly selected lead X-ray aprons were swabbed at three time points. The experimental treatment was with a hospital-grade disinfectant wipe. The samples were assessed for bacterial growth via traditional plating methods and mass spectrometry. Plates were graded on a scale of 0 to 4+ based on the number of quadrants with growth. Growth on one quadrant or more was considered contaminated. FINDINGS/RESULTS: Bacteria were initially detected via IBIS on a majority of the aprons (32/40), most commonly Staphylococcus epidermidis and Propionibacterium acnes. Virulent organisms cultured were Methicillin-resistant Staphylococcus epidermidis (MRSE), Neisseria, Streptococcus viridans and pseudomonas. MRSE were detected on 5/20 of the samples. Immediately after treatment, the majority of aprons showed less bacterial contamination (0/20 standard culture positive; 13/20 IBIS positive) with some recurrence at the 6-h time point (2/20 standard culture positive, 16/20 IBIS positive). All MRSE detected initially was eradicated. DISCUSSION: Lead X-ray aprons worn in the operating room harbour bacteria. Disinfecting before use may prevent the introduction of virulent organisms to patients. Our proposed method of sanitising with a disinfectant wipe is quick and effective.

Prevention of Osteoporosis in the Ovariectomized Rat by Oral Administration of a Nutraceutical Combination That Stimulates Nitric Oxide Production.

Osteoporosis represents an imbalance between bone formation and bone resorption. As a result of low estrogen levels, it is markedly prevalent during menopause, thus making such patients susceptible to fractures. Both bone formation and resorption are modulated by nitric oxide (NO). Currently, there are no risk-free pharmaceutical prevention therapies for osteoporosis. COMB-4, a nutraceutical combination of Paullinia cupana, Muira puama, ginger, and L-citrulline, known to activate the NO-cGMP pathway, was reported to accelerate fracture healing in the rat. To determine whether COMB-4 could be effective in preventing menopausal osteoporosis, it was compared to estradiol (E2) in an ovariectomized (OVX) rat osteoporosis model. Nine-month-old female Sprague Dawley rats were divided into SHAM, OVX, OVX+E2, and OVX+COMB-4. After 100 days of treatment, bone mineral density (BMD) and bone mineral content (BMC) were measured by DXA scan. TRAP staining was performed in the femur and lumbar vertebrae. TRACP 5b and osteocalcin levels were assayed in the serum. MC3T3-E1 cells were differentiated into osteoblasts and treated with COMB-4 for one week in order to evaluate calcium deposition by Alizarin staining, cGMP production by ELISA, and upregulation of the nitric oxide synthase (NOS) enzymes by RT-PCR. OVX resulted in a decrease in BMD, BMC, and serum osteocalcin and an increase in serum TRACP 5b. Except for an increase in BMC with COMB-4, both E2 and COMB-4 reverted all bone and serum markers, as well as the number of osteoclasts in the vertebrae, to SHAM levels. Incubation of MC3T3-E1 cells with COMB-4 demonstrated an increase in the three NOS isoforms, cGMP, and calcium deposition. COMB-4 increased BMD in OVX rats by inhibiting bone resorption and increasing calcium deposition presumably via activation of the NO-cGMP pathway. It remains to be determined whether COMB-4 could be a potential nutraceutical therapy for the prevention of premenopausal bone loss.

Technique Using Isoelastic Tension Band for Treatment of Olecranon Fractures.

The isoelastic ultrahigh-molecular-weight polyethylene tension band may be considered an alternative to stainless steel wire for tension band fixation of olecranon fractures. In this article, we present our technique using this isoelastic tension band and describe the outcomes of 7 patients who underwent open reduction and internal fixation of closed, displaced olecranon fractures with minimal or no articular surface comminution. We reviewed medical records and performed physical examinations and functional assessments. Anatomical reduction was maintained in all elbows through union. Physical examination measurements indicated nominal side-to-side differences in motion and strength. Mean Broberg and Morrey elbow score was good (92/100), and mean (SD) Disabilities of the Arm, Shoulder, and Hand score was 12.6 (17.2). One patient had a minor degree of hardware irritation at longest follow-up but did not request hardware removal. One patient underwent implant removal for a symptomatic implant 5 years after surgery. This easily reproducible technique yields excellent physical and functional outcomes.

Revision wrist arthroscopy after failed primary arthroscopic treatment.

UNLABELLED: Background The etiologies and outcomes of cases of failed therapeutic wrist arthroscopy have not been well-described to date. Purpose The purposes of this study were to identify common preventable patterns of failure in wrist arthroscopy and to report outcomes of a series of revision arthroscopy cases. Patients and Methods Retrospective review of 237 wrist arthroscopies revealed 21 patients with a prior arthroscopy for the same symptoms, of which 16 were assessed by questionnaires and physical exam for this study. Results Six of sixteen patients (38%) had unrecognized dynamic ulnar impaction after débridement of triangular fibrocartilage complex (TFCC) tears, which resolved with arthroscopic wafer resection. Five (31%) had persistent distal radioulnar joint (DRUJ) instability after initial treatment of TFCC tears, requiring arthroscopic repair at revision. Four (25%) experienced diffuse dorsal wrist pain initially diagnosed as TFCC tears, but dynamic scapholunate ligament injuries were found and addressed with radiofrequency (RF) shrinkage at reoperation. Two (13%) required further resection of the radial styloid, after initial débridement was insufficient to correct radioscaphoid impingement. At a mean of 4.8 years after repeat arthroscopy (range, 1.5-13.4 years), this cohort had significant improvements in pain and satisfaction with outcomes after revision arthroscopy. Conclusions The most common indications for repeat wrist arthroscopy were ligamentous instability (of the DRUJ or scapholunate ligament) and osteoarthritis (from dynamic ulnar impaction or radioscaphoid impingement). Although revision wrist arthroscopy may yield acceptable outcomes, careful assessment of stability and cartilage wear at index procedure is crucial. LEVEL OF EVIDENCE: Level IV Therapeutic.

Effect of white adipose tissue flap and insulin-like growth factor-1 on nerve regeneration in rats.

Adipose tissue-derived stem cells and insulin-like growth factor-1 (IGF-1) have shown potential to enhance peripheral nerve regeneration. The purpose of this study was to investigate the effect of an in vivo biologic scaffold, consisting of white adipose tissue flap (WATF) and/or IGF-1 on nerve regeneration in a crush injury model. Forty rats all underwent a sciatic nerve crush injury and then received: a pedicled WATF, a controlled local release of IGF-1, both treatments, or no treatment at the injury site. Outcomes were the normalized maximum isometric tetanic force (ITF) of the tibialis anterior muscle and histomorphometric measurements. At 4 weeks, groups with WATF had a statistically significant improvement in maximum ITF recovery, as compared to those without (P < 0.05), and there was an increase in myelin thickness and total axon count in the WATF-only group versus control (P < 0.01). Functional and histomorphometric data suggest that IGF-1 suppressed the effect of the WATF. Use of a pedicled WATF improved the functional and histomorphometrical results after axonotmesis in a rat model. IGF-1 does not appear to enhance nerve regeneration in this model. Utilizing the WATF may have a beneficial therapeutic role in peripheral nerve injuries.

A novel arthroscopic technique utilizing bone morphogenetic protein in the treatment of Kienböck disease.

Kienböck disease, first described in 1910, is osteonecrosis of the carpal lunate and has been associated with ulnar minus variance. Numerous joint leveling procedures have been developed for patients with ulnar-negative variance to decrease forces transmitted across the lunate. The basis of operative treatment is the presence or absence of advanced osteoarthritis associated with fragmentation of the carpal lunate and capitate descent. Bone morphogenetic proteins (BMPs) have been utilized successfully as adjunctive treatment in fracture healing and recently in the surgical treatment of a patient with Lichtman stage IIIA Kienböck disease. Arthroscopy is an available tool in assessing cartilage injury and coupled with the use of BMP may be of benefit in patients with ulnar-neutral or ulnar-negative wrists who have not progressed to severe arthritis and capitate descent. We report a novel arthroscopic technique in which a stage IIIA and IIIB carpal lunate osteonecrosis is treated by curettage and grafting with an admixture of autologous radial cancellous bone marrow graft and BMP-2.