Orthogonal plating for complex olecranon fractures: retrospective case series with patient-reported outcomes.

INTRODUCTION: Treatment for complex olecranon fractures with metaphyseal comminution can be challenging. To improve reduction maneuvers and augment stability, we apply a small medial and/or lateral locking compression plate (LCP) prior to placing a posterior contoured 3.5 mm-2.7 mm LCP. The aim is to describe our technique and outcomes of this "orthogonal" plating technique. MATERIAL AND METHODS: 26 patients were treated with orthogonal plating. Clinical outcome variables were available for all patients at a median of 27 months (IQR 6-54), and patient-reported outcomes (Q-DASH and MEPS) for 23 patients at 38 months (IQR 18-71). RESULTS: All fractures healed at a median of 2.0 months (IQR 1.5-3.8). The median elbow flexion was 120°, extension-deficit 15°, pronation 88°, and supination 85°. The median Q-DASH was 9 (IQR 0-22) and the median MEPS was 90 (IQR 80-100). Hardware was electively removed in seven patients. One patient had a late superficial infection that resolved with hardware removal and antibiotics, and one patient had two consecutive re-fractures after two hardware removals; and healed after the second revision surgery. CONCLUSION: Orthogonal plating with a posterior LCP and a small medial and/or lateral LCP is a safe technique that leads to excellent healing rates, and good clinical and patient-reported outcomes.

Surprise positive culture rate in the treatment of presumed aseptic long-bone nonunion: a systematic review with meta-analysis of 2397 patients.

INTRODUCTION: In pre-operatively presumed aseptic nonunions, the definitive diagnosis of infection relies on intraoperative cultures. Our primary objective was to determine (1) the rate of surprise positive intraoperative cultures in presumed aseptic long-bone nonunion (surprise positive culture nonunion), and (2) the rate of surprise positive cultures that represent infection vs. contamination. Secondary objectives were to determine the healing and secondary surgery rates and to identify cultured micro-organisms. MATERIALS AND METHODS: We performed a systematic literature search of PubMed, Embase and Cochrane Libraries from 1980 until December 2021. We included studies reporting on ≥ 10 adult patients with a presumed aseptic long-bone nonunion, treated with a single-stage surgical protocol, of which intraoperative cultures were reported. We performed a meta-analysis for: (1) the rates of surprise positive culture nonunion, surprise infected nonunion, and contaminated culture nonunion, and (2) healing and (3) secondary surgery rates for each culture result. Risk of bias was assessed using the QUADAS-2 tool. RESULTS: 21 studies with 2,397 patients with a presumed aseptic nonunion were included. The rate of surprise positive culture nonunion was 16% (95%CI: 10-22%), of surprise infected nonunion 10% (95%CI: 5-16%), and of contaminated culture nonunion 3% (95%CI: 1-5%). The secondary surgery rate for surprise positive culture nonunion was 22% (95%CI: 9-38%), for surprise infected nonunion 14% (95%CI 6-22%), for contaminated culture nonunion 4% (95%CI: 0-19%), and for negative culture nonunion 6% (95CI: 1-13%). The final healing rate was 98% to 100% for all culture results. Coagulase-negative staphylococci accounted for 59% of cultured micro-organisms. CONCLUSION: These results suggest that surprise positive cultures play a role in the clinical course of a nonunion and that culturing is important in determining the etiology of nonunion, even if the pre-operative suspicion for infection is low. High healing rates can be achieved in presumed aseptic nonunions, regardless of the definitive intraoperative culture result.

Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions.

Background: Antibiotic-impregnated cement-coated plates (ACPs) have been used successfully for temporary internal fixation between stages in the two-stage treatment of infected non-unions. We describe our approach of using an ACP in the staged treatment of a methicillin-resistant Staphylococcus aureus (MRSA)-infected distal femoral non-union below a total hip prosthesis. In addition, we present the results of an in vitro experiment to provide an in-depth insight into the capacity of ACPs in (i) treating residual biofilm and (ii) preventing bacterial recolonisation. Materials and methods: In the first stage, we used a titanium LISS plate coated with hand-mixed PALACOS with vancomycin (PAL-V) for temporary internal fixation combined with commercially prepared COPAL with gentamicin and vancomycin (COP-GV) to fill the segmental defect. In the second stage, the non-union was treated with double-plate fixation and bone grafting.A Kirby-Bauer agar disc diffusion assay was performed to determine the antimicrobial activity of both ACPs and a drug-release assay to measure antibiotic release over time. A biofilm killing assay was also carried out to determine if the antibiotic released was able to reduce or eradicate biofilm of the patient's MRSA strain. Results: At one-year follow-up, there was complete bone-bridging across the previous non-union. The patient was pain-free and ambulatory without need for further surgery. Both ACPs with COP-GV and PAL-V exerted an antimicrobial effect against the MRSA strain with peak concentrations of antibiotic released within the first 24 hours. Concentrations released from COP-GV in the first 24 hours in vitro caused a 7.7-fold log reduction of colony-forming units (CFU) in the biofilm. At day 50, both COP-GV and PAL-V still released concentrations of antibiotic above the respective minimal inhibitory concentrations (MIC), likely contributing to the positive clinical outcome. Conclusion: The use of an ACP provides stability and infection control in the clinical scenario of an infected non-union. This is confirmed in vitro where the release of antibiotics from ACPs is characterised by an early burst followed by a prolonged sustained release above the MIC until 50 days. The burst release from COP-GV reduces CFU in the biofilm and prevents early recolonisation through synergistic activity of the released vancomycin and gentamicin. Clinical significance: An antibiotic-impregnated cement-coated plate is a useful addition to the surgeon's armamentarium to provide temporary internal fixation without the disadvantages of external fixation and contribute to infection control in an infected non-union. How to cite this article: Wagner RK, Guarch-Pérez C, van Dam AP, et al. Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions. Strategies Trauma Limb Reconstr 2023;18(2):73-81.

[Non-union]. / Non-union.

A non-union is a fracture that fails to heal within the expected time frame and occurs in approximately 3 to 5% of all fractures. Non-union has a negative impact on mental and physical functioning and quality of life. The causes, clinical presentation and treatment for non-union differ strongly on a case-by-case basis. By presenting three cases we aim to give healthcare providers more insight into the clinical scenario of non-union. In addition, we elaborate on characteristics, etiology, diagnostics and treatment of non-union.

Blade Plate With Autogenous Bone Grafting to Salvage Peri Ankle Nonunions.

BACKGROUND: Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures. METHODS: This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS). RESULTS: We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P = .009), for the MCS 52 (IQR, 45-60, range 33-62, P = .701), and for the FAOS 73 (IQR, 48-83). CONCLUSION: In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores. LEVEL OF EVIDENCE: Level IV, therapeutic.

Risk Factors for Musculoskeletal Injury in CrossFit: A Systematic Review.

The objective of this systematic review was to identify potential risk factors for injury in CrossFit participants. Embase, Medline, Web of Science, Cochrane, CINAHL, Google Scholar, and SportDiscuss databases were all searched up to June 2021. Cohort studies that investigated risk factors for CrossFit injuries requiring medical attention or leading to time loss in sports were included. A best-evidence synthesis was performed combining all the outcomes from prospective cohort studies. From 9,452 publications identified, we included three prospective cohort studies from which two had a low risk of bias and one a high risk of bias. The studies examined 691 participants of whom 172 sustained an injury. There was limited evidence that switching between prescribed and scaled loads during training is associated with increased injury risk and that increased duration of participation is a protective factor for injury. This could mean that novice CrossFit athletes and those increasing their training load should have closer supervision by CrossFit coaches. These risk factors should be considered when developing preventive interventions.

Two-level fixation with headless compression screws for tibial plateau fractures.

PURPOSE: Reduction and fixation of tibial plateau fractures associated with small, "floating" intra-articular fragments proposes a challenge. We use fully threaded headless compression screws for (interfragmentary) fixation of such fragments before final plate fixation when standard fixation of intra-articular fragments with k-wires or lag screws is deemed insufficient. Our aim is to describe our technique and clinical experience of this two-level fixation. METHODS: Between 2006 and 2021, 29 patients with a comminuted tibial plateau fracture were treated with this two-level fixation in this retrospective case series. Clinical baseline and surgical variables were collected for all patients. Clinical outcome variables were available for 28 patients with a median follow-up of 16.5 months (IQR 5-24). Functional outcomes were measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported by 22 patients at a median of 5.2 years (IQR 3.5-9.8). RESULTS: Reduction was anatomic or good in 82% of cases, fair in 14%, and a malreduction in 4%. Arthrosis was graded as grade 0 in 25% of cases, 1 in 39%, 2 in 21%, and 3 in 14%. Flexion was 110 degrees (IQR 100-130). Five patients had an extension deficit of 5 to 10 degrees. Median KOOS for symptoms and stiffness was 69 points (IQR 45-78), for pain 71 (IQR 45-88), for ADL 85 (IQR 52-95), for sports 30 (IQR 11-55), and for quality of life 34 (IQR 19-56). CONCLUSION: The use of fully threaded headless compression screws is a simple and helpful addition in the treatment of comminuted tibial plateau fractures.