Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The management of infection following total ankle replacement: demographics and treatment.

BACKGROUND: Little has been published on the management of infected total ankle replacements. This study reviewed our experience with this difficult clinical problem. METHODS: From 2002 to 2011 we retrospectively evaluated patients requiring prosthesis removal for infection following primary or revision total ankle replacement. Infections were classified as acute postoperative, late chronic, or remote hematogenous. The demographics, treatment, and outcome of the infected replacements were evaluated. RESULTS: Of 613 replacements performed during this time period, 15 infections occurred at our institution and 4 from other institutions were treated. These 19 cases included 15 late chronic infections, 3 early postoperative infections, and 1 acute hematogenous infection. Fourteen of the infections occurred in a subset of 433 prostheses (3.2%) placed between 2002 and 2009 when we used an implant with a unique design that necessitated a tibiofibular syndesmosis fusion for the tibial component support (Agility, Depuy). One infection occurred out of 139 other prostheses (0.7%) between 2009 and 2011 when we switched to an anatomic design fixed bearing implant system. Prosthesis salvage was attempted in the 3 early postoperative and 1 acute hematogenous cases, however they all required subsequent removal of the prosthesis. Mean time to removal of the prosthesis after the index arthroplasty was 18 months. Mean follow-up was 19 months from the time of prosthesis removal. Three of the 19 patients underwent successful revision with replacement, 6 with arthrodesis, 7 with a permanent antibiotic spacer, and 3 patients required a transtibial amputation. CONCLUSION: Only a limited number of patients who develop a deep infection following primary or revision total ankle arthroplasty can expect to undergo successful joint-preserving revision ankle arthroplasty. LEVEL OF EVIDENCE: Level III, retrospective case series.

Initial fixation strength of transosseous-equivalent suture bridge rotator cuff repair is comparable with transosseous repair.

BACKGROUND: The outcome of rotator cuff repair correlates with tendon healing. Early studies of arthroscopic rotator cuff repair demonstrate lower healing rates than traditional open techniques. Transosseous-equivalent repair techniques (suture bridge) were developed to improve the initial fixation strength. PURPOSE: To compare the initial in vitro tensile fixation strength of a transosseous-equivalent suture bridge (TOE-SB) rotator cuff repair construct to a traditional transosseous (TO) suture construct. STUDY DESIGN: Controlled laboratory study. METHODS: Identical simulated rotator cuff tears were created on 8 matched pairs of humeri. Each matched pair underwent repair with 4 sutures using either the TOE-SB or TO technique. Initial fixation strength was tested in a custom testing jig. Each shoulder underwent 1000 cycles each of low and then high load testing. Gap displacement was measured at anterior and posterior sites of the repair with digital video tracking of paired reflective markers and recorded at predetermined cycle intervals. RESULTS: There were no statistically significant differences in gap formation at the repair sites under low or high load conditions between TOE-SB and TO techniques. The mean maximal gap formation of the repairs during low load testing in the TOE-SB and TO constructs was 0.93 ± 0.88 mm and 0.55 ± 0.22 mm, respectively (P = .505). The mean maximal gap formation during high load testing in the TOE-SB and TO constructs was 2.04 ± 1.10 mm and 2.28 ± 1.62 mm, respectively (P = .517). The most significant increase in gap distance occurred at the transition from low load to high load in both constructs. Most of the incremental displacement occurred within the first 100 cycles for both high and low load testing (P < .001). CONCLUSION: The arthroscopic TOE-SB technique is comparable in initial fixation strength to the traditional TO simple suture repair technique. CLINICAL RELEVANCE: Arthroscopic techniques can achieve initial fixation strength comparable with traditional TO techniques performed without suture anchors.

Surgical correction of midfoot arthritis with and without deformity.

The goals of midfoot reconstruction are to create a painless, functional, and plantigrade foot, which are generally accomplished with arthrodesis and realignment as indicated. The latter requires not only the correction of midfoot deformity when present, but also coexisting hindfoot and forefoot deformities. Once the initial decisions have been made regarding the need for realignment and which joints to include in the arthrodesis, the surgical plan needs to account for the approach, arthrodesis preparation, order of fixation, and choice of fixation.

Arthroscopic technique for medial epicondylitis: technique and safety analysis.

PURPOSE: The goals of this study are to report on a novel arthroscopic technique for the treatment of medial epicondylitis and to further describe the anatomic relations between the site of arthroscopic debridement and both the ulnar nerve and medial collateral ligament (MCL) complex. METHODS: Arthroscopic debridement of the medial epicondyle was performed on 8 fresh-frozen cadaveric specimens. Each specimen was dissected, and the shortest distance from the debridement site to both the ulnar nerve and MCL complex was measured with a 3-dimensional motion-tracking system. RESULTS: The mean distance between the debridement site and the ulnar nerve was 20.8 mm (range, 14.4 to 25.1 mm), and the mean distance between the medial debridement site and the origin of the anterior bundle of the MCL was 8.3 mm (range, 5.9 to 10.4 mm). CONCLUSIONS: Our results suggest that arthroscopic debridement of the medial epicondyle can be performed with low risk of injury to the ulnar nerve or MCL complex. CLINICAL RELEVANCE: This cadaveric study indicates a potential role for elbow arthroscopy in the surgical management of refractory medial epicondylitis.

General surgery residency program websites: usefulness and usability for resident applicants.

OBJECTIVE: To assess the content of general surgery residency program websites, the websites' potential as tools in resident recruitment, and their "usability." DESIGN: The homepages of general surgery residency programs were evaluated for accessibility, ease-of-use, adherence to established principles of website design, and content. Investigators completed a questionnaire on aspects of their online search, including number of mouse-clicks used, number of errors encountered, and number of returns to the residency homepage. SETTING: The World Wide Web listings on the Fellowship and Residency Electronic Interactive Database (FREIDA) of the American Medical Association (AMA). PARTICIPANTS: A total of 251 ACGME-accredited general surgery residency programs. RESULTS: One hundred sixty-seven programs (67%) provided a viable link to the program's website. Evaluators found an average of 5.9 of 16 content items; 2 (1.2%) websites provided as many as 12 content items. Five of the 16 content items (program description, conference schedules, listing of faculty, caseload, and salary) were found on more than half of the sites. An average of 24 mouse-clicks was required to complete the questionnaire for each site. Forty-six sites (28%) generated at least 1 error during our search. The residency homepage was revisited an average of 5 times during each search. On average, programs adhered to 6 of the 10 design principles; only 6 (3.6%) sites adhered to all 10 design principles. Two of the 10 design principles (use of familiar fonts, absence of frames) were adhered to in more than half of the sites. Our overall success rate when searching residency websites was 38%. CONCLUSIONS: General surgery residency programs do not use the World Wide Web optimally, particularly for users who are potential residency candidates. The usability of these websites could be increased by providing relevant content, making that content easier to find, and adhering to established web design principles.