Intact PCL is a potential predictor of ACL graft size in the skeletally immature knee and other anatomic considerations for ACL reconstruction.

PURPOSE: To develop a method for using an intact posterior cruciate ligament (PCL) as a predictor of anterior cruciate ligament (ACL) graft size and examine possible differences in tunnel length based on all-epiphyseal drilling method. METHODS: One hundred one patients 5-18 years of age with magnetic resonance imaging (MRI) of the knee at an outpatient pediatric orthopaedic clinic from 2008 to 2020 were included. ACL and PCL coronal, sagittal, and length measurements were made in all patients. Tunnel length measurements were made in patients with open physes. Statistical analyses were performed to evaluate potential associations in patient bony or ligamentous measurements. RESULTS: PCL sagittal width and PCL coronal width were statistically significant predictors of ACL sagittal width and ACL coronal width, respectively (p = 0.002, R = 0.304; p = 0.008, R = 0.264). The following equations were developed to calculate ACL coronal and sagittal width measurements from the corresponding measurement on an intact PCL; ACL Coronal Width (mm) = 6.23 + (0.16 x PCL Coronal Width); ACL Sagittal Width (mm) = 5.85 + (0.53 x PCL Sagittal Width). Mean tibial maximum oblique length (27.8 mm) was longer than mean tibial physeal sparing length (24.9 mm). Mean femoral maximum oblique length (36.9 mm) was comparable to mean femoral physeal sparing length (36.1 mm). Both were longer than mean femoral straight lateral length (32.7 mm). CONCLUSION: An intact PCL is a predictor of native ACL size. Tunnel length differs based on chosen drilling method in all-epiphyseal technique. LEVEL OF EVIDENCE: Diagnostic Level III.

Risk of Surgical Site Infections in OTA/AO Type C Tibial Plateau and Tibial Plafond Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVES: To analyze the current incidence of postoperative infection for OTA/AO type C fractures of the tibial plateau and tibial plafond. DATA SOURCES: Three medical databases: PubMed/MEDLINE, ScienceDirect, and the Cochrane Library, were used in our systematic literature search. Search results were restricted to articles transcribed in English/Spanish and publication date after January 1, 2000, to present day. STUDY SELECTION: Inclusion criteria were studies reporting postoperative infection data for OTA/AO type 41C, 43C, or equivalent fractures of skeletally mature individuals. A minimum of 6 total fractures of interest and a frequency of 75% overall were required. Studies reporting on pathologic fractures, stress fractures, or low-energy fracture types were excluded. DATA EXTRACTION: Two authors independently screened abstracts, evaluated full-text manuscripts, and extracted relevant data from included studies. Any instances of discrepancy were resolved within the study committee by consensus. DATA SYNTHESIS: Outcomes were expressed using direct proportions (PR) with a 95% confidence interval. The effects of comorbidities on infection rates were reported using odds ratios with a 95% confidence interval. All analyses used a DerSimonian-Laird estimate with a random-effects model based on heterogeneity. The presence of publication bias was evaluated using funnel plots and Egger's tests. CONCLUSIONS: Patients with these specific fractures develop infections at a notable frequency. The rates of deep infections were approximately 6% in tibial plateau fractures and 9% in tibial plafond fractures. These results may be useful as a reference for patient counseling and other future studies aimed at minimizing postoperative infection for these injuries. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Inequalities in Pediatric Fracture Care Timeline Based on Insurance Type.

INTRODUCTION: Socioeconomic and insurance status are often linked with limited access to health care. Despite several government-funded projects aimed at curtailing these barriers, pediatric orthopaedic patients continue to experience delays in receiving timely care for fracture treatments. This delay has been well-identified within the orthopaedic literature but, to our knowledge, has never been characterized based on timeline. Thus, the goal of this study is to evaluate the role of ethnicity, socioeconomic status, and insurance type on the timeline of pediatric patients to obtain orthopaedic care within our community. METHODS: Pediatric patients presenting to our clinic for the treatment of one of 21 most common fractures were included. Patient demographics and the timeline of patient care were collected by retrospective chart review. RESULTS: Government-funded insurance accounted for 60.6% of the 413 patients. These patients experienced significant (P < 0.001) delays in access to care when compared with commercial insurance patients; the time between injury and referral as well as the overall time from injury to orthopaedic evaluation was 2.8 and twofold greater at 4.4 days and 9.2 days, respectively. A strong correlation was established between income levels and insurance type. DISCUSSION: Pediatric patients with a lower socioeconomic status are more likely to rely on government-funded insurance and experience delays in fracture evaluation.

Hypoalbuminemia and Obesity in Orthopaedic Trauma Patients: Body Mass Index a Significant Predictor of Surgical Site Complications.

The purpose of this investigation was to identify the prevalence of hypoalbuminemia and obesity in orthopaedic trauma patients with high-energy injuries and to investigate their impact on the incidence of surgical site complications. Patients 18 years of age and older undergoing intramedullary nail fixation of their femoral shaft fractures at a university-based level-1 trauma centre were assessed. Malnutrition was measured using serum markers (albumin <3.5 g/dL) as well as body mass index (BMI) as a marker of obesity (BMI > 30 kg/m2). The primary outcome measure was surgical wound complications. A total of 249 patients were included in this study. Ninety-eight patients (39.4%) presented with hypoalbuminaemia and 80 patients (32.1%) were obese. The overall incidence of wound complications in our study population was 9.65% (n = 25/259). A logistic regression model showed that non-obese patients (BMI < 30 kg/m2) were at significantly reduced risk for perioperative wound complications (Odds Ratio 0.400 [95% confidence interval 0.168, 0.954], p = 0.039). This study demonstrated a substantial prevalence of hypoalbuminemia and obesity among orthopaedic trauma patients with high-energy injuries. Obesity may increase the risk of surgical site complications. Future studies are required to further define malnutrition and its correlation with surgical site complications in orthopaedic trauma patients.

Fungal Infection following Total Elbow Arthroplasty.

A specific treatment protocol for managing fungal infections after total elbow arthroplasty (TEA) does not currently exist. The purpose of this report is to describe our experience and outline our treatment algorithm for a rare case of prosthetic joint infection (PJI) following a TEA. We present a case of a PJI due to Candida parapsilosis after TEA in a 57 year-old Caucasian woman with a history of hypertension, depression, and three previous surgical procedures to the affected limb. A fungal PJI by the organism C. parapsilosis following TEA has not been previously reported. Successful eradication of the fungal infection was achieved utilizing resection arthroplasty; placement of an amphotericin, vancomycin, and tobramycin-impregnated cement spacer; and 6 months of organism-specific antifungal medication. Although the patient was clinically ready for reimplantation, she passed away due to unrelated issues before reimplantation could be performed. While PJI is a devastating complication following TEA, a fungal infection is a rare complication that imposes difficult challenges to the treating surgeon. With our case report, we hope to contribute to the overall knowledge of fungal infections associated with TEA and describe our successful treatment of this complex case.

Early clinical and radiographic outcomes of a mini-fragment, low profile plating system in tibial plafond fractures.

OBJECTIVE: The Smith and Nephew mini-EVOS plating system is a mini-fragment, low profile, variable-angled plating system designed to obtain anatomic reduction while also minimizing soft tissue handling. However, literature has been limited in reporting the clinical and surgical outcomes of these specific plates. The goal of our study is to evaluate the safety and efficacy of the Smith and Nephew mini-EVOS plate in pilon fracture management, where significant high energy forces can result in severe fracture patterns and soft tissue injury. METHODS: Patients 18-65 years of age who underwent plate fixation of their tibial plafond fractures (OTA/AO) using the Smith and Nephew mini-EVOS plating system at our urban university-based level-1 trauma center were included in this retrospective investigation. A total of 37 patients (37 fractures) from January 2015 to March 2018 were included in this study. Primary outcome measure was mechanical hardware failure. Secondary outcome measures included nonunion, malunion, medical and surgical complications. RESULTS: The fractures were classified according to the OTA/AO classification as 43C1 (n = 15), 42C2 (n = 6), and 43C3 (n = 16). A mechanical failure was observed in three patients (8.1%). Six additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, one symptomatic hardware removal, and two soft tissue debridements. The mean follow-up was 298.9 days (range: 96-936). CONCLUSIONS: Early results of operative fixation of tibial plafond fractures using the Smith-Nephew mini-EVOS demonstrated low hardware failure and complication rates. This plating system is a safe and effective implant. LEVEL OF EVIDENCE: Therapeutic Level IV.

High-energy tibial pilon fractures: an instructional review.

High-energy tibial pilon fractures continue to represent a significant challenge to the treating orthopaedic surgeon. Pre-operative evaluation includes a careful clinical assessment of the associated soft tissue injury, which frequently dictates surgical management. Staged surgical reconstruction remains the standard treatment protocol at most trauma centres. This includes application of a temporary spanning external fixator for approximately one to four weeks, followed by open reduction and internal fixation once the surrounding soft tissues are amendable. Despite careful soft tissue management protocols, the risk of wound complications continues to be relatively high compared to other orthopaedic trauma procedures. The functional long-term outcomes of these injuries remain limited, and recent data has emphasised that the majority of patients do not regain their pre-operative work status. In addition, the health-related quality of life scores fare poorly when compared to other orthopaedic and non-orthopaedic patient populations, and many patients develop post-traumatic arthritis within the tibiotalar joint. It has been shown that the quality of fracture reduction may significantly correlate with the long-term functional outcomes. While the orthopaedic community has come a long way with regard to safe management of high-energy tibial pilon fractures, the clinical outcomes continue to remain limited. In particular, the persistently high rates of wound complications and the limited functional long-term outcomes leave significant room for improvement. Future investigators may focus on further innovations to minimise the risk of wound complications. The surgical team may emphasise the quality of fracture reduction as an important treatment goal.

A new risk to the axillary nerve during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system.

BACKGROUND: Percutaneous aiming arms have been developed to minimize injury during placement of submuscular proximal humerus plates. The purpose of this study was to determine the risk of axillary nerve injury during percutaneous proximal humeral plate fixation using the Synthes PHILOS aiming system. METHODS: By use of 10 fresh-frozen cadavers (20 shoulders), a 3.5-mm locking compression proximal humeral plate was fixated percutaneously to the humerus through a lateral deltoid-splitting approach using the PHILOS aiming guide. Dissection of the axillary nerve was then carried out, and measurements of its relation to the screw holes in row A through row G of the plate were taken. The lateral acromion-to-axillary nerve distance was also measured. RESULTS: The axillary nerve traversed row D in every shoulder, whereas it crossed over row C in 11 shoulders and both holes in row E in 16 shoulders. The closest distance to the axillary nerve achieved was 4.5 mm, corresponding to the distal (left) screw in row B. A significant negative correlation was found for the distance from the nerve to the closest proximal and distal screws (row B and row G, respectively) in both right shoulders (ρ = -0.797; 95% confidence interval, -0.916 to -0.548) and left shoulders (ρ = -0.615; 95% confidence interval, -0.831 to -0.237). CONCLUSION: The axillary nerve traverses rows C, D, and E of the proximal humeral plate using the PHILOS aiming system. Importantly, our study is the first to demonstrate that the axillary nerve crosses over row C. Left-sided plate screws also came in closer proximity to the axillary nerve than right-sided plate screws.

Safety and efficacy of a two-screw cephalomedullary nail for intertrochanteric femur fracture fixation: a retrospective case series in 264 patients.

INTRODUCTION: Recent advances have led to the design of a new cephalomedullary nail, which aims to decrease the risk of failures in patients with intertrochanteric hip fractures by allowing for insertion of two interdigitating screws into the head segment. The goal of this study is to evaluate the safety and efficacy of this two-screw cephalomedullary nailing system. PATIENTS/PARTICIPANTS: Patients 18 years of age and older who underwent intramedullary nailing of their intertrochanteric femoral fracture using the InterTAN nailing system (Smith and Nephew, Memphis, TN) from 2012 to 2016 were included in this retrospective study which was performed at two urban certified level-1 trauma centers and one urban certified level-3 trauma center. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure and screw cutout. Secondary outcome measures included nonunion, malunion, medical and surgical complications. RESULTS: A total of 264 patients were included in this analysis. Two patients (0.75%) were found to have a screw cut out requiring revision surgery. Two other revision surgeries were performed for malrotation (n = 1) and malunion (n = 1). Other implant-related complications occurred in 19 cases (7.9%), which included broken distal screws (n = 9), distal screw loosening (n = 8), and loose lag screws (n = 2). There was a total of 10 (3.8%) surgical wound complications, including four deep and six superficial infections. DISCUSSION: This modified cephalomedullary nail is a reliable, safe, and effective implant for management of intertrochanteric hip fractures. Surgical treatment of patients with intertrochanteric hip fractures can be performed in a safe fashion using this implant.