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Background: Triplane ankle fractures are complex transitional fractures that often necessitate surgical treatment. Axial fracture lines determine optimal screw trajectories for fixation. The purpose of our study was to identify fracture patterns in triplane fractures by illustrating fracture lines in the axial plane of the distal tibial metaphysis and epiphysis.Methods: We retrospectively reviewed records of children presenting with ankle fractures at 1 center from January 2007 through June 2017. Thirty-three cases of triplane fractures with available computed tomographic (CT) scans were identified. Fractures in the axial plane of the metaphysis were identified 10 mm proximal to the physis, and fractures in the epiphysis were identified midway between the physis and distal tibial articular surface. Fracture lines were drawn and were superimposed on unfractured bone templates to generate fracture maps, and heat maps were then created to show areas of high and low fracture densities.Results: In the metaphysis, the most common fracture pattern was medial-lateral lines in the posterior metaphysis. This metaphyseal pattern was consistent across 2, 3, 4, and 5-part fractures. There were clear zones of rare fracture involvement in the anterior and anterolateral metaphysis. In the epiphysis, anterior-to-posterior fracture lines were common in the anterior epiphysis. All cases had an epiphyseal fracture exit through the anterior epiphysis. Fracture extension into the posteromedial epiphysis was a feature of all fracture classes.Conclusions: Fracture mapping of triplane fractures suggests consistent axial fracture patterns in the metaphysis and epiphysis with additional class-dependent fractures in the epiphysis. This study provides visual guidelines to assist surgeons in understanding the axial fracture patterns of individual triplane fractures for surgical planning. [ABSTRACT FROM AUTHOR]

Background: We are not aware of any previous investigation assessing a national cohort of patients enrolled in a fracture liaison service (FLS) program in an open health-care system to ascertain prevalent practice patterns. The objective of this investigation was to determine, in a geographically diverse group of centers in a single FLS program, the percentage of patients for whom anti-osteoporosis treatment was recommended or started as well as to identify associations between patient and fracture variables and the likelihood of treatment being recommended.Methods: The study utilized the Own the Bone program registry, which included 32,671 unique patient records with the required data. The primary outcome measure was whether a recommendation to start anti-osteoporosis treatment was made to the patient at the time of program enrollment. The associations between patient and fracture variables and the likelihood of having treatment recommended were calculated.Results: Anti-osteoporosis treatment was recommended to 72.8% of patients and was initiated for 12.1%. A sedentary lifestyle and a parent who had sustained a hip fracture increased the likelihood of a treatment recommendation by 10% and 12%, respectively. While patients with a spinal fracture were 11% more likely to have received a treatment recommendation, those with a hip fracture were 2% less likely to have received such a recommendation. Age was not strongly associated with the likelihood of receiving a treatment recommendation but was associated with the initiation of treatment.Conclusions: Practitioners at sites in the Own the Bone program recommend anti-osteoporosis treatment, at the time of initial evaluation, to about three-quarters of patients who present with a fragility fracture. This is a very strong improvement over previously reported national data. The findings that a hip fracture had the lowest association and age had very little association with the likelihood of recommending treatment were unexpected and perhaps deserve further investigation.Clinical Relevance: FLS programs and sites as well as all those who manage patients with a fragility fracture can utilize the information derived from this study to improve practice patterns for the care of these patients. [ABSTRACT FROM AUTHOR]

Background: Hoffa fractures, coronal-plane fractures involving the distal femoral condyles, are unstable, intra-articular fractures. The aim of this study was to define the location and frequency of fracture lines and comminution zones in Hoffa fractures using computed tomography (CT) mapping in both 2-dimensional and 3-dimensional contexts.Methods: Seventy-five Hoffa fractures (OTA/AO types 33B3.2 and 33B3.3) were retrospectively reviewed. The directions of fracture lines were characterized in the axial and sagittal CT planes. CT images for all fractures were superimposed on one another and oriented to fit a standard template. Mapping of fracture lines and comminution zones in both the axial and sagittal planes was performed. A 3-dimensional map was created by reducing reconstructed fracture fragments to fit to a model of the distal aspect of the femur.Results: This study included 1 bicondylar and 74 unicondylar (26 medial and 48 lateral) Hoffa fractures. Comminuted fractures accounted for 35.5% of all fractures and 44.9% of lateral fractures. Axial fracture mapping demonstrated that fracture lines were concentrated in the middle-third area of the lateral condyle but were less concentrated and with greater variation in the medial condyle. The mean angle of fracture lines with respect to the posterior condylar axis was 34.4° and 29.0° in the lateral and medial femoral condyles, respectively. Sagittal fracture mapping also demonstrated that fracture lines were concentrated in the middle third of the lateral condyle but were less concentrated in the medial condyle. The mean angle of fracture lines with respect to the posterior cortex of the distal femoral shaft was 23.1° and 19.3° in the lateral and medial condyles, respectively. Three-dimensional mapping demonstrated comminution zones commonly occurring in the weight-bearing zone of the lateral condylar articular surface.Conclusions: Hoffa fractures occurred more frequently in the lateral femoral condyle. In the axial plane, fractures commonly extended from anterolateral to posteromedial in the lateral condyle and from anteromedial to posterolateral in the medial femoral condyle. In the sagittal plane, fractures traversed from anteroinferior to posterosuperior. Articular comminution was more commonly seen in lateral condylar fractures and concentrated in the weight-bearing zone of the articular surface.Clinical Relevance: Research in this area is imperative for optimal preoperative planning, such as for the selection of surgical approach and fixation constructs. Our findings lend insight into fracture morphology, which can assist with fracture classification and the design of biomechanical studies, ultimately aiding in treatment. [ABSTRACT FROM AUTHOR]

Background: Pantalar dislocations without associated talar fracture are rare and have high risks of complications, including infection, osteonecrosis, and posttraumatic osteoarthrosis. Limited information on later function exists. This study evaluated complications and outcomes following pantalar dislocation without talar fracture.Methods: Nineteen patients were identified with open (n = 14) or closed (n = 5) pantalar dislocations without talar fracture. Ten male and 9 female patients with a mean age of 39.6 years (range, 19 to 68 years) were included. Open injuries underwent surgical debridement. Sixteen patients had open reduction, and 2 had closed reduction. Fixation was achieved with Kirschner wires (n = 4), external fixation (n = 9), or both (n = 3). Two patients did not have fixation. Another patient had primary transtibial amputation due to nonreconstructible foot trauma. Charts and radiographs were reviewed to identify infection, osteonecrosis, and posttraumatic arthrosis. Data on pain, medications, range of motion, and secondary procedures were collected. After a minimum of 1 year, Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) surveys were administered.Results: The mean clinical follow-up was 45.1 months. Two patients had superficial wound-healing problems with prolonged drainage, which healed with dressing changes and oral antibiotics, and 1 patient developed cellulitis 4 months after injury, which resolved with intravenous antibiotics. No deep wound infections occurred. Fourteen (88%) of the 16 patients with a minimum of 11 months of radiographic follow-up developed osteonecrosis, 2 with collapse of the talar dome, and 7 (44%) developed arthrosis of ≥1 peritalar articulation. Outcome surveys were obtained for 11 (58%) of the 19 patients, at a mean of 5.2 years after injury. The mean MFA score was 30.3, and the mean FFI score was 25.3. Six of 10 survey respondents had returned to employment, but 88% (14 of 16) of the patients with radiographic and clinical follow-up reported at least mild pain and 75% (12 of 16) were taking analgesics.Conclusions: Urgent surgical debridement of open injuries and reimplantation of the talus after pantalar dislocation was not associated with deep infection. Osteonecrosis occurred in the majority of patients, but collapse was uncommon. Persistent pain and functional limitations are frequent after pantalar dislocation, as reflected in extremity-specific and generalized functional outcome scores.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to determine if fracture reduction, fracture pattern, and patient-related factors influence clinical outcome after locked-plate fixation of displaced proximal humeral fractures.Methods: Ninety-eight patients (mean age, 61.1 ± 11.2 years) with a proximal humeral fracture involving the anatomical neck (type C according to the OTA/AO classification system) were included. Clinical outcome was determined by age and sex-adjusted Constant score (CS%) and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Fracture reduction was quantitatively determined by 3 parameters (head-shaft displacement, head-shaft alignment, and cranialization of the greater tuberosity), and patients were divided into groups according to anatomical reduction, acceptable reduction, or malreduction. Relative risk (RR) for complications, revision surgery, and inferior clinical outcome (CS of <50%) was determined according to the quality of fracture reduction and fracture pattern (disruption of the medial hinge; type-C3 fracture) and patient-related factors (age; comorbidities).Results: After a mean of 3.1 ± 1.5 years, the mean CS% and DASH score were 54.8% ± 28.0% and 31.9 ± 24.8, respectively. The complication rate was 32.7% (n = 32), and 27 patients (27.6%) required revision surgery. Anatomical or acceptable fracture reduction was achieved in 40 (40.8%) of the patients. This resulted in a significantly lower complication rate (20.0% compared with 41.4% among the patients with malreduction; p = 0.027), a trend of lower revision rate (20% compared with 32.8%; p = 0.165), and better clinical outcome (mean CS% of 65.4% ± 28.2% compared with 47.6% ± 25.7%; p = 0.002) without a higher risk for osteonecrosis of the humeral head (5% compared with 10.3%). Cranialization of the greater tuberosity of >5 mm (n = 25), head-shaft displacement of >5 mm (n = 50), and valgus head-shaft alignment (n = 12) all increased the RR for inferior clinical outcome by twofold to threefold. Conversely, a patient age of >65 years (n = 31) and an OTA/AO type-C3 fracture pattern (n = 38) were not significantly associated with complications and inferior clinical outcome (RR, 0.9 to 1.8).Conclusions: Anatomical fracture reduction with a locked plate significantly improved the clinical outcome of unstable and displaced proximal humeral fractures involving the anatomical neck.Level Of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article presents a summary of selected studies related to orthopaedic trauma published in 2015. These include a study on 235 consecutive patients treated with primary plate fixation for a substantially displaced mid-shaft clavicular fracture with shortening and/or deformity, a study on the treatment of acute type-3, 4 and 5 acromioclavicular (AC) joint separations and the multicenter Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial.

Background: Scaphoid fractures are common but may be missed on initial radiographs. Advanced imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) have improved diagnostic accuracy, but at an increased initial cost. The purpose of this study was to evaluate the cost-effectiveness of immediate advanced imaging for suspected occult scaphoid fractures.Methods: A decision analysis model was created to evaluate three diagnostic strategies for patients with concerning history and examination but negative radiographs: (1) empiric cast immobilization with orthopaedic follow-up and repeat radiography at two weeks post-injury, (2) immediate CT scanning, or (3) immediate MRI. Prevalence of occult scaphoid fracture, sensitivity and specificity of CT and MRI, and risks and outcomes of a missed fracture were derived from published clinical trials. Costs of imaging, lost worker productivity, and surgical costs of nonunion surgery were estimated on the basis of the literature.Results: Advanced imaging was dominant over empiric cast immobilization; advanced imaging had lower costs and its health outcomes were projected to be better than those of empiric cast immobilization. MRI was slightly more cost-effective than CT on the basis of the mean published diagnostic performance, but was highly sensitive to test performance characteristics. Advanced imaging would have to increase in cost to more than $2000 or decrease in sensitivity to <25% for CT or <32% for MRI for empiric cast immobilization to be cost-effective.Conclusions: Given its relatively low cost and high diagnostic accuracy, advanced imaging for suspected scaphoid fractures in the setting of negative radiographs represents a cost-effective strategy for reducing both costs and morbidity. The decision to use CT compared with MRI is a function of individual institutional costs and local test performance characteristics. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the efficacy of local wound cavity injections of aqueous aminoglycosides (gentamicin and tobramycin), in conjunction with systemic antibiotics, to lower the prevalence of infection in patients with open fractures.Methods: Three hundred and fifty-one open fractures were identified by Current Procedural Terminology codes 11011 and 11012. Data on patient demographic characteristics, injury characteristics, infection, and fracture union were obtained from the electronic medical records. Patients in the control group (183 fractures) received systemic antibiotics only. Patients in the intervention group (168 fractures) received, in addition to systemic antibiotics, a locally administered aminoglycoside (2 mg/mL) at the time of the index surgical procedure. At the discretion of the attending surgeon, some wounds also received postoperative irrigations of aqueous aminoglycoside (n = 34). For wounds that could not be closed and wounds that received postoperative irrigations, negative pressure dressings were used.Results: The deep and superficial infection rate in the control group was 19.7% (thirty-six of 183 fractures), but it was significantly lower (p = 0.010) in the intervention group at 9.5% (sixteen of 168 fractures). When comparing only the deep infections, the infection rate in the control group was 14.2% (twenty-six of 183 fractures) compared with 6.0% (ten of 168 fractures) in the intervention group (p = 0.011). After multivariate analysis to adjust for possible confounding factors, the administration of local antibiotics was found to be an independent predictor of lower infection rates in both deep and superficial infections (odds ratio, 2.6 [95% confidence interval, 1.2 to 5.6]; p = 0.015) and deep infections only (odds ratio, 3.0 [95% confidence interval, 1.1 to 8.5]; p = 0.034). The use of local antibiotics did not have an impact on nonunion rate (p = 0.881), with a type-I error rate of α = 0.05 and 0.8 power.Conclusions: This study suggests that local aqueous aminoglycoside administration as an adjunct to systemic antibiotics may be effective in lowering infection rates in open fractures; further research with higher-level research designs are needed. [ABSTRACT FROM AUTHOR]

Background: Clinical practice guidelines are being developed for a number of topics in medicine to decrease practice variability and to improve evidenced-based care. Within orthopaedic surgery, the American Academy of Orthopaedic Surgeons (AAOS) has a dedicated committee that produces these clinical practice guidelines on a variety of issues. One such issue was the treatment of pediatric diaphyseal femoral fractures, with the clinical practice guideline being published in 2009. We performed a retrospective review of the treatment of pediatric diaphyseal femoral fractures at a single institution from 2007 to 2012 to assess the clinical impact of this clinical practice guideline on the treatment of this condition.Methods: A retrospective review of all patients treated at a single pediatric hospital between 2007 and 2012 for a pediatric diaphyseal femoral fracture was conducted. The 2009 AAOS clinical practice guideline on the treatment of this condition was assessed and each patient record was analyzed to determine if the clinical practice guideline was followed, based on the age-specific recommendations. The percentage of treatment rendered adhering to the clinical practice guideline recommendations was compared in the pre-guideline group (prior to June 2009) and the post-guideline group (after June 2009).Results: A total of 361 patients were treated for a diaphyseal femoral fracture during this time frame and were included in this study. Overall, little change in treatment was found following the publication of this clinical practice guideline. The only significant change noted over this time period was a decrease (p = 0.03) in the percentage of patients between the ages of five and eleven years who were treated with flexible nails, at odds with this specific clinical practice guideline recommendation.Conclusions: We found little direct clinical impact of the recently published AAOS clinical practice guideline on the treatment of pediatric diaphyseal femoral fractures. This analysis suggests an important role for clinical assessment after guideline publication to identify areas of potentially important future clinical research and to assess the utility of this guideline. [ABSTRACT FROM AUTHOR]

Acetabular fractures increase the risk of posttraumatic arthritis and thus the risk of total hip arthroplasty (THA). We previously presented the ten-year results of THA performed for posttraumatic arthritis after an acetabular fracture; we now present the twenty-year outcomes. The original publication included sixty-six patients who underwent THA between 1970 and 1993 for posttraumatic arthritis after open reduction and internal fixation (ORIF) of an acetabular fracture. Clinical outcomes, implant survivorship, radiographic results, and complications were evaluated. A total of thirty-six patients had died. The mean Harris hip score was 80 at the latest follow-up. Nineteen acetabular and/or femoral components had been revised: eleven for aseptic loosening, seven for osteolysis, and one for instability. Twenty-year survivorship of the acetabular component was 71% free from revision for aseptic loosening and 57% free from revision for any reason. THA after ORIF of an acetabular fracture was associated with fair implant survivorship at twenty years after surgery. It is possible that newer implants with improved fixation surfaces and bearing materials may enhance long-term results, as the most common reasons for failure at twenty years were aseptic loosening and osteolysis. [ABSTRACT FROM AUTHOR]

Background: The efficacy of brace application for the treatment of osteoporotic compression fractures remains unclear. The purpose of this study was to compare the treatment outcomes in patients with osteoporotic compression fractures with regard to whether the patients had no braces, rigid braces, or soft braces. Methods: We randomly assigned sixty patients with acute one-level osteoporotic compression fractures within three days of injury to the no-brace, soft-brace, and rigid-brace groups through 1:1:1 allocation. The primary outcome was the baseline adjusted Oswestry Disability Index score at twelve weeks after compression fracture. The non-inferior margin of the Oswestry Disability Index was set at an average of 10 points. Results: The baseline adjusted Oswestry Disability Index score at twelve weeks after compression fracture in the nobrace group was not inferior to that in the soft-brace or rigid-brace groups. The mean adjusted Oswestry Disability Index score was 35.95 points (95% confidence interval, 25.42 to 46.47 points) in the no-brace group and 37.83 points (95% confidence interval, 26.77 to 48.90 points) in the soft-brace group, with a difference of 21.88 points (95% confidence interval, 27.02 to 9.38 points) between the groups. Similarly, the mean adjusted Oswestry Disability Index score was 35.95 points (95% confidence interval, 25.42 to 46.47 points) in the no-brace group and 33.54 points (95% confidence interval, 23.79 to 43.29 points) in the rigid-brace group, with a difference of 2.41 points (95% confidence interval, 27.86 to 9.27 points) between the groups. During the follow-up assessment period, there was no significant difference among the groups for the overall Oswestry Disability Index scores (p = 0.260), visual analog scale for pain scores for back pain (p = 0.292), and anterior body compression ratios (p = 0.237). However, the Oswestry Disability Index scores and the visual analog scale scores for back pain significantly improved with time after the fractures (p < 0.001), and the body compression ratios significantly decreased with time in all three groups (p < 0.001). Conclusions: The Oswestry Disability Index scores for the treatment of compression fractures without a brace were not inferior to those with soft or rigid braces. Moreover, the improvement in back pain and progression of anterior body compression were similar among the three groups. [ABSTRACT FROM AUTHOR]

Background: The vast majority of displaced pediatric supracondylar humeral fractures can be treated successfully with closed reduction and percutaneous pinning. The need for open reduction is difficult to determine a priori and is typically due to the failure of closed reduction attempts or persistent limb ischemia. The aims of this study were to determine the prevalence of flexion-type supracondylar humeral fractures, the rate of open reduction for flexion-type fractures, and the predictive impact of ulnar nerve injury on the need for open reduction for flexion-type supracondylar humeral fractures.Methods: We developed a database of consecutive pediatric supracondylar humeral fractures treated operatively at a tertiary care pediatric trauma center from 2000 to 2015. Data recorded included age, mechanism of injury, fracture type (open or closed), fracture pattern (flexion-type or extension-type), concomitant skeletal injury, neurovascular injury, treatment, and surgeon. Radiographs of all flexion-type supracondylar humeral fractures were reviewed in order to confirm the classification of the injury pattern. The rate of open reduction for fractures with a flexion-type injury pattern and for such fractures with and without ulnar nerve injury at presentation was assessed.Results: Of 2,783 consecutive pediatric supracondylar humeral fractures treated by surgeons at our center, 95 (3.4%) were flexion-type fractures. Ulnar nerve injury was noted for 10 (10.5%) of the 95 flexion-type fractures. Open injuries were identified at presentation in 3 (3.2%) of the 95 cases. Among closed fractures, 21 (22.8%) of 92 flexion-type fractures required open reduction compared with 50 (1.9%) of 2,647 extension-type fractures (odds ratio [OR] = 15.4; 95% confidence interval [CI] = 8.8 to 27.0; p < 0.001). Among closed flexion-type fractures, open reduction was performed in 6 (60%) of 10 fractures with associated ulnar nerve injury and in 15 (18.3%) of 82 fractures without ulnar nerve injury (OR = 6.7; 95% CI = 1.7 to 26.7; p = 0.003).Conclusions: Among closed supracondylar humeral fractures, the flexion-type injury pattern was associated with a 15.4-fold increase in the odds of open reduction. The presence of an ulnar nerve injury at presentation resulted in an additional 6.7-fold higher risk of open reduction among flexion-type supracondylar humeral fractures. Patients and families should be counseled regarding the high rate of open reduction for flexion-type supracondylar humeral fractures, particularly those with an associated ulnar nerve injury.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: For more than thirty-five years, the sliding hip screw, an extramedullary implant, has been the standard treatment for the stabilization of intertrochanteric fractures. Over the last decade, intramedullary implants have replaced extramedullary implants as the most commonly used type of implant in the United States for the treatment of this condition, without strong evidence of superior outcomes. Methods: We conducted a retrospective cohort study with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients seventy years of age or older who had sustained an intertrochanteric fracture treated with extramedullary or intramedullary implant during 2009 to 2012 were identified. General surgical outcomes were compared between implant types, with adjustment for demographic data and comorbidities. Results: A total of 4432 patients were identified; 1612 (36.4%) were treated with an extramedullary implant, and 2820 (63.6%) with an intramedullary implant. The rates of the composite outcomes “serious adverse events” and “any adverse events” did not differ by implant type. The mean postoperative length of stay was shorter for patients treated with an intramedullary implant compared with those treated with an extramedullary implant (5.4 compared with 6.5 days; p < 0.001). Operation time, operating room time, and the rate of hospital readmission did not differ by implant type. Conclusions: These results reinforce the results of previous randomized trials, demonstrating little difference in rates of general surgical adverse events between implant types. The present study presents an important departure from previous trials in its finding that patients treated with intramedullary implants have, on average, a shorter postoperative length of stay (by 1.1 days). The finding may negate the perceived excess cost associated with intramedullary treatment. Limitations regarding the ACS NSQIP database include a lack of detail regarding fracture subtype, outcomes beyond thirty days, and orthopaedic-specific outcomes. [ABSTRACT FROM AUTHOR]

Background: It is unclear if pediatric patients with a supracondylar humeral fracture and isolated anterior interossous nerve injury require urgent treatment. Methods: A retrospective, multicenter study of 4409 patients with operatively treated supracondylar humeral fractures was conducted. Exclusion criteria were additional nerve injuries other than the anterior interosseous nerve, any sensory changes, pulselessness, ipsilateral forearm fractures, open fractures, less than two months of follow-up, or pathological fractures. Results: Thirty-five of 4409 patients met inclusion criteria. The average time to surgery was 14.6 hours (range, two to thirty-six hours). No patient developed compartment syndrome. There was no significant difference in time to return of anterior interosseous nerve function relative to the time to surgical reduction and fixation (p = 0.668). A complete return of anterior interosseous nerve function occurred in all patients with an average time of forty-nine days (range, two to 224 days). Ninety percent of patients recovered anterior interosseous nerve function by 149 days. Conclusions: To our knowledge, this is the largest series to date of supracondylar humeral fractures with anterior interosseous nerve injuries. There is no evidence that a supracondylar humeral fracture with an isolated anterior interosseous nerve injury requires urgent treatment. A delay in treatment up to twenty-four hours was not associated with an increased time of nerve recovery or other complications. This series excluded patients with sensory nerve injuries, pulselessness, and ipsilateral forearm fractures, which all may require urgent surgery. Barring other clinical indications for urgent treatment of a supracondylar humeral fracture, an isolated anterior interosseous nerve injury (no sensory changes) may not by itself be an indication for urgent surgery. The anterior interosseous nerve injuries in this series showed complete recovery at a mean time of forty-nine days. [ABSTRACT FROM AUTHOR]

Background: There are relatively few studies in the literature that specifically evaluate accelerated rehabilitation protocols for distal radial fractures treated with open reduction and internal fixation (ORIF). The purpose of this study was to compare the early postoperative outcomes (at zero to twelve weeks postoperatively) of patients enrolled in an accelerated rehabilitation protocol with those of patients enrolled in a standard rehabilitation protocol following ORIF for a distal radial fracture. We hypothesized that patients with accelerated rehabilitation after volar ORIF for a distal radial fracture would have an earlier return to function compared with patients who followed a standard protocol. Methods: From November 2007 to November 2010, eighty-one patients with an unstable distal radial fracture were prospectively randomized to follow either an accelerated or a standard rehabilitation protocol after undergoing ORIF with a volar plate for a distal radial fracture. Both groups began with gentle active range of motion at three to five days postoperatively. At two weeks, the accelerated group initiated wrist/forearm passive range of motion and strengthening exercises, whereas the standard group initiated passive range of motion and strengthening at six weeks postoperatively. Patients were assessed at three to five days, two weeks, three weeks, four weeks, six weeks, eight weeks, twelve weeks, and six months postoperatively. Outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) scores (primary outcome) and measurements of wrist flexion/extension, supination, pronation, grip strength, and palmar pinch. Results: The patients in the accelerated group had better mobility, strength, and DASH scores at the early postoperative time points (zero to eight weeks postoperatively) compared with the patients in the standard rehabilitation group. The difference between the groups was both clinically relevant and statistically significant. Conclusions: Patients who follow an accelerated rehabilitation protocol that emphasizes motion immediately postoperatively and initiates strengthening at two weeks after volar ORIF of a distal radial fracture have an earlier return to function than patients who follow a more standard rehabilitation protocol. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to report complication and reoperation rates following non-arthroplasty fixation of shoulder fractures determined on the basis of observational, population-based data from all inpatient admissions in California over an eleven-year period. Methods: Records from all inpatient hospital discharges and subsequent readmissions related to operative non-arthroplasty treatment of proximal humeral fractures were obtained for patients in California from December 1994 through December 2005. These admissions were evaluated to identify patient and hospital characteristics associated with short and intermediateterm complications (within and after ninety days, respectively) as well as reoperation rates. Procedures performed included open reduction and internal fixation in 9254 patients, closed reduction and internal fixation in 1903 patients, and internal fixation without reduction in 302 patients. Results: The short-term complications included mortality in 401 patients (3.5%), which was associated with a higher Charlson comorbidity index (odds ratio [OR] = 1.5, p < 0.001) and male sex (OR = 1.7, p < 0.001); and pulmonary embolism in sixty patients (0.5%), which was associated with male sex (OR = 2.2, p = 0.007) and patient age of seventy-five years or older (OR = 3.6, p = 0.001). Intermediate-term reoperations included conversion to hemiarthroplasty in 174 patients (1.5%); and conversion to total shoulder arthroplasty in eight patients (0.07%), which was associated with an age of fifty to sixty-four years (hazard ratio = 2.8, p = 0.007). Overall, an age of sixty-five years or older, male sex, residence in an area with an income in the lowest two quintiles, and the presence of preexisting comorbidities were associated with elevated risks of short-term complications but not of intermediate-term conversion to arthroplasty. The ninety-day revision rate was 5.3%. Conclusions: Surgical fixation of proximal humeral fractures has a low complication and mortality profile. The data provided in this study can serve in counseling patients about risks associated with operative fixation of displaced proximal humeral fractures. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article discusses the impact of global total joint replacement (TJR) registry. An overview on the essential of several levels of data including patient, surgeon, and hospital identifiers to monitor the revision rates after TJR, is provided. Also emphasized is the aim to TJR to collect all TJR procedures maintained by the national orthopaedic society and financed by the government.

Background: Currently, most hospitals in the United States are obliged to report infections that occur following total joint arthroplasty to the Centers for Disease Control and Prevention through the National Healthcare Safety Network surveillance. The objective of this study was to identify the risk factors of surgical site infections that were reported to the Centers for Disease Control and Prevention from a single institution. Methods: For this study, 6111 primary and revision total joint arthroplasties performed from April 2010 to June 2012 were identified. Surgical site infection cases captured by infection surveillance staff on the basis of the Centers for Disease Control and Prevention definition were identified. Surgical site infection cases with index surgery performed at another institution were excluded. All cases were followed up for one year for development of surgical site infection. The model for predictors of surgical site infection was created by logistic regression and was validated by bootstrap resampling. Results: Of all performed total joint arthroplasties, surgical site infection developed in eighty cases (1.31% [95% confidence interval, 1.02% to 1.59%]). The highest rate of surgical site infection was observed in revision total knee arthroplasty (4.57% [95% confidence interval, 2.31% to 6.83%]) followed by revision total hip arthroplasty (1.94% [95% confidence interval, 0.75% to 3.13%]). Among the variables examined, the predictive factors of surgical site infection were higher Charlson Comorbidity Index (odds ratio for a Charlson Comorbidity Index of ⩾2, 2.29 [95% confidence interval, 1.32 to 3.94] and odds ratio for a Charlson Comorbidity Index of 1, 2.09 [95% confidence interval, 1.06 to 4.10]), male sex (odds ratio, 1.79 [95% confidence interval, 1.11 to 2.89]), and revision total knee arthroplasty (odds ratio, 3.13 [95% confidence interval, 1.17 to 8.34]), and a higher level of preoperative hemoglobin (odds ratio, 0.85 per point [95% confidence interval, 0.73 to 0.98 per point]) was protective against surgical site infection. The C-statistic of the model was 0.709 without correction and 0.678 after bootstrap correction, indicating that the model has fair predictive power. Conclusions: Low preoperative hemoglobin level is one of the risk factors for surgical site infection and preoperative correction of hemoglobin may reduce the likelihood of postoperative surgical site infection. [ABSTRACT FROM AUTHOR]

Background: Non-weight-bearing decreases the femoral head deformity but increases bone resorption without increasing bone formation in an experimental animal model of Legg-Calvé-Perthes disease. We sought to determine if local administration of bone morphogenetic protein (BMP)-2 with or without bisphosphonate can increase the bone formation during the non-weight-bearing treatment in the large animal model of Legg-Calvé-Perthes disease. Methods: Eighteen piglets were surgically induced with femoral head ischemia. Immediately following the surgery, all animals received an above-the-knee amputation to enforce local non-weight-bearing (NWB). One to two weeks later, six animals received local BMP-2 to the necrotic head (BMP group), six received local BMP-2 and ibandronate (BMP1IB group), and the remaining six received no treatment (NWB group). All animals were killed at eight weeks after the induction of ischemia. Radiographic, microcomputed tomography (micro-CT), and histomorphometric assessments were performed. Results: Radiographic assessment showed that the femoral heads in the NWB, BMP, and BMP1IB groups had a decrease of 20%, 14%, and 10%, respectively, in their mean epiphyseal quotient in comparison with the normal control group. Micro-CT analyses showed significantly higher femoral head bone volume in the BMP1IB group than in the BMP group (p = 0.02) and the NWB group (p < 0.001). BMP1IB and BMP groups had a significantly higher trabecular number (p < 0.01) and lower trabecular separation (p < 0.02) than the NWB group. In addition, the osteoclast number per bone surface was significantly lower in the BMP1IB group compared with the NWB group. Calcein labeling showed significantly higher bone formation in the BMP and BMP1IB groups than in the NWB group (p < 0.05). Heterotopic ossification was found in the capsule of four hips in the BMP1IB group but not in the BMP group. Conclusions: Administration of BMP-2 with bisphosphonate best decreased bone resorption and increased new bone formation during non-weight-bearing treatment of ischemic osteonecrosis in a pig model, but heterotopic ossification is a concern. Clinical Relevance: This preclinical study provides new evidence that BMP-2 with bisphosphonate can effectively prevent the extreme bone loss associated with the non-weight-bearing treatment and increase new bone formation in the femoral head in this animal model of ischemic osteonecrosis. [ABSTRACT FROM AUTHOR]

Background: Dynamic rehabilitation has been suggested to be an important part of nonoperative treatment of acute Achilles tendon rupture that results in functional outcome and rerupture rates comparable with those of operative treatment. However, the optimal role of weight-bearing during early rehabilitation remains unclear. The purpose of this study was to compare immediate weight-bearing with non-weight-bearing in a nonoperative dynamic treatment protocol for Achilles tendon rupture. Methods: The study was conducted as a blinded, randomized, controlled, parallel superiority trial. Patients eighteen to sixty years of age were eligible for inclusion. Both groups were treated nonoperatively with controlled early motion. The intervention group was allowed full weight-bearing from day one, and the control group was non-weight-bearing for six weeks. The primary outcome was the Achilles tendon Total Rupture Score (ATRS) after one year. Secondary outcomes included heelrise work, health-related quality of life, and the rerupture rate. Outcome assessors were blinded to the intervention. Results: Thirty patients were randomized to each group; twenty-nine in the weight-bearing group and twenty-seven in the control group were analyzed. The only significant difference between the groups was better health-related quality of life in the weight-bearing group at twelve months (p = 0.009). The mean ATRS at twelve months was 73 in the weight-bearing group and 74 in the control group (p = 0.81). At twelve months, the total heel-rise work performed by the injured limb relative to that by the uninjured limb was 53% in the weight-bearing group and 58% in the control group (p = 0.37). There were three reruptures in the weight-bearing group and two in the control group (p = 1.0). Conclusions: The ATRS and heel-rise work results did not differ significantly between the groups. The rerupture rate was 9% overall, and both groups had substantial functional deficits in the injured limb compared with the uninjured limb. Immediate weight-bearing can be recommended as an option in the nonoperative treatment of Achilles tendon rupture. [ABSTRACT FROM AUTHOR]

Background: Restoration of shoulder function is a primary goal when treating patients with traumatic brachial plexus injury. A concomitant rotator cuff tear may alter the treatment approach and prognosis for these individuals. The purpose of this study was to define the prevalence of rotator cuff tears in patients with traumatic brachial plexus injuries. Methods: This is a retrospective review of 280 adult patients with traumatic brachial plexus injury treated at a single institution over a twelve-year period. An upper-extremity magnetic resonance imaging (MRI) scan was acquired for all patients as part of the initial evaluation for posttraumatic brachial plexus injury. The radiographic and clinical data on these patients were reviewed to document partial or full-thickness rotator cuff tears, mechanism and location of the brachial plexus injury, and age. Results: Twenty-three patients (8.2%) had a full-thickness rotator cuff tear: one patient had tears involving three tendons, eight patients had tears involving two tendons, twelve patients had a single-tendon tear, one patient had a single-tendon tear in each shoulder, and one patient had a single-tendon tear in one shoulder and a two-tendon tear in the other. Twenty-one tears involved the supraspinatus, eight involved the infraspinatus, and seven involved the subscapularis. Thirteen patients underwent surgical repair of the rotator cuff. The average age of the patients in this cohort was 33.4 years, and older age was associated with an increased risk of full-thickness rotator cuff tears (odds ratio [OR], 1.06 per year). Patients with infraclavicular brachial plexus injury had a significantly higher rate of full-thickness rotator cuff tears. Conclusions: Concomitant rotator cuff tears are present in approximately one in ten patients with traumatic brachial plexus injury. These injuries may contribute to shoulder dysfunction; therefore, evaluation of the rotator cuff with imaging studies is appropriate when formulating treatment strategies. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: When a surgeon uses a percutaneous volar approach to treat scaphoid waist fractures, central screw placement is complicated by the shape of the scaphoid and by obstruction by the trapezium. In this study, we used radiographs and biomechanical tests to compare the standard volar percutaneous approach with the transtrapezial approach, with regard to central screw placement at the distal pole of the scaphoid. Methods: Fourteen matched pairs of cadaveric wrists were randomly assigned to two treatment groups. Under fluoroscopic control, a guidewire was drilled into the scaphoid, either through a transtrapezial approach or through a standard volar approach that avoided the trapezium. Guidewire position was measured in the coronal and sagittal planes. A transverse osteotomy was performed along the scaphoid waist, and this was followed by the insertion of the longest possible cannulated headless bone screw. Each specimen was placed into a fixture with a pneumatically driven plunger resting on the surface of the distal pole. Load was applied by using a load-controlled test protocol in a hydraulic testing machine. Results: All guidewires were inside the central one-third of the proximal pole. The guidewire positions at the distal pole differed significantly between the transtrapezial and standard volar approach groups (p < 0.001). The load to 2 mm of displacement and the load to failure averaged, respectively, 324.4 N (standard error of the mean [SEM] = 73.5 N) and 386.4 N (SEM = 65.6 N) for the transtrapezial approach group compared with 125.7 N (SEM = 22.6 N) (p = 0.002) and 191.4 N (SEM = 36.30 N) (p = 0.005) for the standard volar approach group. Conclusions: The data suggest that, in a cadaveric osteotomy-simulated scaphoid waist fracture model, the transtrapezial approach reliably achieves central positioning of a screw in the proximal and distal poles. This position offers a biomechanical advantage compared with central placement in only the proximal pole. [ABSTRACT FROM AUTHOR]

Background: The Lauge-Hansen classification system does not provide sufficient data related to syndesmotic injuries in supination-external rotation (SER)-type ankle fractures. The aim of the present study was to investigate factors helpful for the preoperative detection of syndesmotic injuries in SER-type ankle fractures using radiographs and computed tomography (CT). Methods: A cohort of 191 consecutive patients (104 male and eighty-seven female patients with a mean age [and standard deviation] of 50.7 ± 16.4 years) with SER-type ankle fractures who had undergone operative treatment were included. Preoperative ankle radiographs and CT imaging scans were made for all patients, and clinical data, including age, sex, and mechanism of injury (high or low-energy trauma), were collected. Patients were divided into two groups: the stable syndesmotic group and the unstable syndesmotic group, with a positive intraoperative lateral stress test leading to syndesmotic screw fixation. Fracture height, fracture length, medial joint space, extent of fracture, and bone attenuation were measured on radiographs and CT images and were compared between the groups. Binary logistic regression analysis was performed to identify the factors that significantly contributed to unstable syndesmotic injuries. Receiver operating characteristic curves were calculated, and cutoff values were suggested to predict unstable syndesmotic injuries on preoperative imaging measurements. Results: Of the 191 patents with a SER-type ankle fracture, thirty-eight (19.9%) had a concurrent unstable syndesmotic injury. Age, sex, mechanism of injury, fracture height, medial joint space, and bone attenuation were significantly different between the two groups. In the binary logistic analysis, fracture height, medial joint space, and bone attenuation were found to be significant factors contributing to unstable syndesmotic injuries. The cutoff values for predicting unstable syndesmotic injuries were a fracture height of >3 mm and a medial joint space of >4.9 mm on CT scans, and a fracture height of >7 mm and medial joint space of >4.5 mm on radiographs. Conclusions: Fracture height, medial joint space, and bone attenuation were useful factors for the preoperative detection of unstable syndesmotic injuries in SER-type ankle fractures. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: We previously demonstrated, in a rat anterior cruciate ligament (ACL) graft reconstruction model, that the delayed application of low-magnitude-strain loading resulted in improved tendon-to-bone healing compared with that observed after immediate loading and after prolonged immobilization. The purpose of this study was to determine the effect of higher levels of strain loading on tendon-to-bone healing. Methods: ACL reconstruction was carried out in a rat model in three randomly assigned groups: high-strain daily loading beginning on either (1) postoperative day one (immediate-loading group; n = 7) or (2) postoperative day four (delayedloading group; n = 11) or (3) after prolonged immobilization (immobilized group; n = 8). Animals were killed two weeks after surgery and micro-computed tomography (micro-CT) and biomechanical testing of the bone-tendon-bone complex were carried out. Results: The delayed-loading group had greater tissue mineral density than either the immediate-loading or immobilized group (mean [and standard deviation], 813.0 ± 24.9mg/mL compared with 778.4 ± 32.6 mg/mL and 784.9 ± 26.4 mg/mL, respectively; p < 0.05). There was a trend toward greater bone volume per total volume fraction in both the immobilized and the delayed-loading group compared with the immediate-loading group (0.24 ± 0.03 and 0.23 ± 0.06 compared with 0.20 ± 0.05; p = 0.06). Trabecular thickness was greater in the immobilized group compared with the immediate-loading group (106.5 ± 23.0 mmcompared with 72.6 ± 10.6 mm; p < 0.01). There were no significant differences in failure load or stiffness between the immobilized group and either high-strain cyclic-loading group. Conclusions: Immediate application of high-strain loading appears to have a detrimental effect on healing in this rat model. Any beneficial effects of delayed loading on the healing tendon-bone interface (after a brief period of immobilization) may be offset by the detrimental effects of excessive strain levels or by the detrimental effects of stress deprivation on the graft. Clinical Relevance: The timing and magnitude of mechanical load on a healing rat ACL reconstruction graft may have important implications for postoperative rehabilitation. Avoidance of exercises that cause high graft strain in the early postoperative period may lead to improved tendon-to-bone healing in humans. [ABSTRACT FROM AUTHOR]

Background: Smoking has been suggested to increase the rate of perioperative complications including soft-tissue complications, to decrease the rate of fracture union, and to prolong healing time. The purpose of our study was to systematically evaluate and analyze the literature regarding the relationship between smoking and healing following operative treatment of long-bone fractures. Methods: We searched the MEDLINE, Embase, and Cochrane databases by pairing the search terms ''smoking,'' ''tobacco,'' and ''nicotine'' with the terms ''fracture,'' ''nonunion,'' delayed union,'' and ''healing.'' Articles and citations were evaluated for relevance. Inclusion and exclusion criteria were established to maintain data quality for analysis. Relevant information was independently extracted and compared to ensure agreement. The methodological quality of the studies was determined. A random-effects model was used. The adjusted odds ratios (ORs) and frequency-weighted means for the primary and secondary outcome measures were calculated. Results: Our initial search identified 7110 articles. Of the 237 articles that underwent further evaluation of the abstract, nineteen (seven prospective and twelve retrospective cohort studies) were included. The adjusted OR of nonunion in the smoking group compared with the nonsmoking group was 2.32 (95% confidence interval [CI], 1.76 to 3.06; p < 0.001). An increased nonunion rate was observed in smokers with a tibial fracture (OR, 2.16; 95% CI, 1.55 to 3.01; p < 0.001) and those with an open fracture (OR, 1.95; 95% CI, 1.3 to 2.9; p < 0.001). For all fractures, the mean healing time was longer for smokers (30.2 weeks; 95% CI, 22.7 to 37.7 weeks) than for nonsmokers (24.1 weeks; 95% CI, 17.3 to 30.9 weeks) (p = 0.18). Trends toward more superficial and deep infections of postoperative or traumatic wounds in smokers were noted; however, the differences in superficial and deep infection rates were not significant (p = 0.13 and p = 0.33, respectively). Conclusions: Smoking significantly increased the risk of nonunion of fractures overall, tibial fractures, and open fractures. Nonsignificant trends toward increased time to union in all fractures and toward increased postoperative rates of superficial and deep infections were noted in smokers compared with nonsmokers. [ABSTRACT FROM AUTHOR]

A review of the article "Augmentation of Tendon-to-Bone Healing" by Kivanc Atesok and colleagues, which appeared in "The Journal of Bone and Joint Surgery" on March 19, 2014, is presented.

Background: The crista supinatoris is the insertion site of the lateral collateral ligament complex on the proximal part of the ulna. The purpose of this study was to report the presentation, management, and outcomes of patients with crista supinatoris fractures. Methods: Twelve patients with fractures of the crista supinatoris were assessed clinically and radiographically and with validated outcomes at a mean of thirty-nine months after injury. Outcome measures included the Patient-Rated Elbow Evaluation (PREE), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons elbow (ASES-e) score, and strength measured with a dynamometer. Results: No crista supinatoris fracture occurred in isolation. Other associated injuries included radial head fracture in ten patients (83%), a radial neck fracture in one patient, and a capitellar fracture in one. At the time of presentation, all crista factures were difficult to identify on standard radiographs, but oblique radiographs and/or computed tomography (CT) allowed definitive fracture identification. Four patients were managed nonoperatively, and eight patients were managed surgically, with the indication for surgery being the associated injuries, not specifically the presence of a crista fracture. At the time of surgery, posterolateral rotatory elbow instability, if present, was due to the crista fracture. At the time of follow-up, all elbows were clinically stable and had radiographic concentric reductions. Elbow flexion and extension were a mean (and standard deviation) of 136° ± 6° and 5° ± 8°, respectively. The mean PREE score was 15 ± 20, and the mean DASH was 13.5 ± 18. Conclusions: Crista supinatoris fractures are difficult to identify on standard elbow radiographs. Fracture management is based on an assessment of elbow stability and on appropriate treatment of the associated injuries. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article discusses the risks of acromioclavicular joint injuries which are among the most common shoulder girdle injuries in athletes. It states that acromioclavicular is connected to the glenohumeral joint which involves the raised incidence of superior labrum anterior posterior (SLAP) tears. It also mentions that acromioclavicular's anteroposterior stability is consulted by the capsule and acromioclavicular ligaments wherein superior ligaments are the strongest.

Background: The aim of this study was to document both the short and the long-term outcomes following primary nonoperative management of isolated displaced fractures of the olecranon. Methods: We identified, from our prospective trauma database, all patients who had been managed nonoperatively for a displaced olecranon fracture over a thirteen-year period. Inclusion criteria included all isolated fractures of the olecranon with >2-mm displacement of the articular surface. The primary short-term outcome measure was the Broberg and Morrey Elbow Score. The primary long-term outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Results: There were forty-three patients with a mean age of seventy-six years (range, forty to ninety-eight years) in the study cohort. A low-energy fall from a standing height accounted for 84% of all injuries, and one or more comorbidities were documented in thirty-eight patients (88%). At a mean of four months (range, 1.5 to ten months) following injury, the mean Broberg and Morrey score was 83 points (range, 48 to 100 points), with 72% of the patients having an excellent or good short-term outcome. No patient underwent surgery for a symptomatic nonunion. At a mean of six years (range, two to fifteen years) postinjury, the mean DASH score was 2.9 points (range, 0 to 33.9 points) and the mean Oxford Elbow Score was 47 points (range, 42 to 48 points); 91% (twenty-one) of twenty-three patients available for follow-up expressed satisfaction with the result of the procedure. Conclusions: We found satisfactory short-term and long-term outcomes following the nonoperative management of isolated displaced olecranon fractures in older, lower-demand patients. [ABSTRACT FROM AUTHOR]

Background: Pubic symphysiotomy is a rarely performed procedure in which the pubic symphysis is divided to facilitate vaginal delivery in cases of obstructed labor. Recently, many obstetricians have shown renewed interest in this procedure. The purpose of this paper is to report the long-term radiographic findings for patients who had undergone pubic symphysiotomy compared with the radiographic appearance of a group of age-matched and parity-matched controls. Methods: This was a retrospective case-control study. Twenty-five women who had previously undergone pubic symphysiotomy for childbirth were compared with twenty-five age-matched and parity-matched controls. The radiographic parameters recorded included pubic symphysis width, pubic symphysis translation, grade of sacroiliac joint osteoarthritis, and presence of parasymphyseal degeneration. Results: The mean time to follow-up after symphysiotomy was 41.6 years (range, twenty-two to fifty-five years). The symphysiotomy group had a significantly higher proportion of patients (80%) with high-grade sacroiliac joint osteoarthritis (Grade 3 or 4 according to the Kellgren and Lawrence osteoarthritis scoring system) than the control group (16%) (p < 0.001). Within the symphysiotomy group, patients with high-grade sacroiliac joint osteoarthritis tended to be older, have a longer time to follow-up, and have a larger pubic symphysis width. The control group had a higher prevalence of parasymphyseal degeneration than did the symphysiotomy group (p = 0.011). Conclusions: Late-onset sacroiliac joint osteoarthritis secondary to pelvic instability was a major finding in this study and, to our knowledge, has not been discussed previously in the literature regarding pubic symphysiotomy. [ABSTRACT FROM AUTHOR]

Background: Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Methods: Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (k) measure. Results: Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from "slight" to "fair." A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (k = 0.35 compared with 0.30, p < 0.001) and on the AO classification (k = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Conclusions: Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D ratherthan 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Stress fractures represent a fatigue failure of bone, occurring with a spectrum of severity of structural injury, and healing potential varies by location. There is no comprehensive classification system for stress fractures incorporating both clinical and radiographic characteristics of the injury that is applicable to all bones. We introduce a system that is reproducible, generalizable, easy to use, and clinically relevant, with three descriptors: fracture grade, fracture location, and imaging modality. Methods: After a review of current classification systems, a five-tier system was proposed to determine fracture grade: Grade I indicated asymptomatic stress reaction on imaging, Grade II indicated pain with no fracture line, Grade III indicated non-displaced fracture, Grade IV indicated displaced fracture, and Grade V indicated nonunion. Example cases of each grade with clinical vignettes and images were prepared to test the interobserver and intraobserver reliability of the system by the test and retest evaluation among fifteen clinicians. A questionnaire and recall test assessed the ease of use, clinical applicability, and recall accuracy. Results: Test and retest analysis showed thatthe system had almost perfect agreement in intraobserver reliability with a kappa value of 0.81. The overall intraobserver reliability showed almost perfect agreement with a kappa value of 0.81. Almost perfect agreement with a kappa value of 0.83 was also produced when these responses were compared with our assessment. The overall interobserver reliability had substantial agreement with a kappa value of 0.78. The reliability of the group compared with that of the answer key was almost perfect with a kappa value of 0.83. The recall test showed an overall accuracy of 97.3%. Of the fifteen evaluators who completed questionnaires, fourteen (93.3%) said that the system would be easily remembered, would facilitate communication among colleagues, and would be useful in clinical practice. Conclusions: The proposed stress fracture classification system is clinically relevant, easily applied, and generalizable, and has excellent interobserver and intraobserver reliability. [ABSTRACT FROM AUTHOR]

Background: Loss of bone mineral mass, muscle atrophy, and functional limitations are predictable consequences of immobilization and subsequent weight-bearing restriction due to leg or ankle fractures. The aim of this study was to prospectively determine whether decreased bone mineral mass following lower-limb fractures recovers at follow-up durations of six and eighteen months in adolescents. Methods: In the present study, we included fifty adolescents who underwent cast immobilization for a leg or ankle fracture. Dual x-ray absorptiometry scans of four different sites (total hip, femoral neck, entire lower limb, and calcaneus) were performed at the time of the fracture, at cast removal, and at follow-ups of six and eighteen months. Patients with fractures were paired with healthy controls according to sex, age, and ethnicity. Dual x-ray absorptiometry values were compared between groups and between injured and non-injured legs in adolescents with fractures. Results: Among those with fractures, lower-limb bone mineral variables were significantly lower at the injured side compared with the non-injured side at cast removal, with differences ranging from 6.2% to 31.7% (p < 0.0001). Similarly, injured adolescents had significantly lower bone mineral values at the level of the injured lower limb compared with healthy controls (p <0.0001). At the six-month follow-up, there were still significant residual differences between injured and non- injured legs in adolescents with fractures (p < 0.0001). However, a significant residual difference between healthy controls and injured adolescents was present only for femoral neck bone mineral density (p = 0.011). At the eighteen- month follow-up, no significant difference was observed at any lower-limb site. Conclusions: Bone mineral loss following a fracture of the lower limb in adolescents is highly significant and affects the lower limb both proximal to and distal to the fracture site. In contrast to observations in adults, a rapid bone mass reversal occurs with full bone recovery by eighteen months. Level of Evidence: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The sustentacular fragment in displaced intra-articular calcaneal fractures has historically been portrayed as a "constant fragment," bound to the talus by the interosseous and deltoid ligament complex. Operative treatment typically occurs through a lateral approach, with the remaining calcaneus being reconstructed back to the sustentaculum. We hypothesized that the sustentacular fragment in displaced intra-articular calcaneal fractures does not maintain its relationship to the talus. The purpose of this study was to characterize the frequency, magnitude, and mode of displacement of the sustentacular fragment. Methods: Computed tomographic (CT) scans of eighty-eight patients with 100 displaced intra-articular calcaneal fractures admitted to our level-I trauma center over a five-year period were retrospectively reviewed. Basic patient demo- graphics and mechanisms of injury were recorded. CT scans were graded according to the Sanders classification, and associated injuries were noted. Angulation and translation of the sustentacular fragment as well as gapping and intra-articular fractures of the middle facet were examined. Angulation exceeding 100 and translation of more than 3 mm were considered diagnostic of displacement. Results: Overall, the sustentacular fragment was displaced in forty-two of the 100 fractures. Twenty-five of one hundred calcanei had sustentacular fragment angulation of >10°, twenty-four had sustentacular translation >3 mm, twenty had fracture diastasis of the middle facet, and twenty-one had a displaced intra-articular fracture of the calcaneal middle facet. Fractures involving greater than 50% of the posterior facet (consistent with Sanders Type-B and Type-C fracture lines) demonstrated a significant increase in relative risk of angulation and translation of the sustentacular fragment as well as gapping and intra-articular fractures of the middle facet. Three-part or four-part fractures also showed a significant association with overall displacement of the sustentaculum. Conclusions: This study is the first to our knowledge to quantify in a detailed manner the displacement of the sustentacular fragment as occurring with calcaneal fractures. This displacement disproves the "constant" theory of the sustentacular fragment, and it may alter the quality of the fracture reduction and affect patient outcome. An alternative surgical approach may be indicated for the treatment of certain calcaneal fracture patterns with sustentacular displacement. Level of Evidence: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: There have been few scientific studies that have examined usage of human growth hormone to accelerate recovery from injury. The hypothesis of this study was that human growth hormone would accelerate tendon-to-bone healing compared with control animals treated with placebo in a rat model of acute rotator cuff injury repair. Methods: Seventy-two rats underwent repair of acute rotator cuff injuries and were randomized into the following post operative dosing regimens: placebo, and human growth hormone at 0.1, 1, 2, 5, and 10 mg/kg/day, administered sub-cutaneously once per day for fourteen days (Protocol 1). An additional twenty-four rats were randomized to receive either (1) placebo or (2) human growth hormone at 5 mg/kg, administered subcutaneously twice per day for seven days preoperative and twenty-eight days postoperatively (Protocol 2). All rats were killed twenty-eight days postoperatively. Mechanical testing was performed. Ultimate stress, ultimate force, stiffness, energy to failure, and ultimate distension were determined. Results: For Protocol 1, analysis of variance testing showed no significant difference between the groups with regard to ultimate stress, ultimate force, stiffness, energy to failure, or ultimate distension. In Protocol 2, ultimate force to failure was significantly worse in the human growth hormone group compared with the placebo group (21.1 ± 5.85 versus 26.3 ± 5.47 N; p = 0.035). Failure was more likely to occur through the bone than the tendon-bone interface in the human growth hormone group compared with the placebo group (p - 0.001). No significant difference was found for ultimate stress, ultimate force, stiffness, energy to failure, or ultimate distension between the groups in Protocol 2. Conclusions: In this rat model of acute tendon-bone injury repair, daily subcutaneous postoperative human growth hormone treatment for fourteen days failed to demonstrate a significant difference in any biomechanical parameter compared with placebo. Furthermore, subcutaneous administration of 5 mg/kg of human growth hormone twice daily from seven days preoperatively until twenty-eight days postoperatively demonstrated lower loads to ultimate failure and a higher risk of bone fracture failure compared with pfacebo. Clinical Relevance: This study suggests that human growth hormone treatment does not identifiably accelerate the strength of tendon-to-bone healing from acute injury and may have negative biomechanical consequences. [ABSTRACT FROM AUTHOR]

Background: Systemic administration of sclerostin neutralizing antibody has led to increased bone formation in animal models of osteoporosis. The purpose of this study was to determine if systemic administration of sclerostin neutralizing antibody could increase the healing response in a critical-sized femoral defect in rats. Methods: Critical-sized femoral defects were created in Lewis rats, and the rats were randomized into four groups. The sclerostin antibody (Scl-Ab) treatment groups included the continuous Scl-Ab group (twenty-one animals), the early Scl-Ab group (fifteen animals), and the delayed Scl-Ab group (fifteen animals), which received sclerostin antibody (25 mg/kg) twice weekly for weeks 0 through 12; weeks 0 through 2; and weeks 2 through 4; respectively. Twenty-one animals in the control group received vehicle from weeks 0 through 12. In a subsequent study, bone turnover markers were measured at zero, two, six, and twelve weeks after surgery in rats receiving vehicle or sclerostin neutralizing antibody for twelve weeks (fifteen rats per group). The quality of bone formed was evaluated with radiographs, microcomputed tomography, biomechanical testing, and histologic and histomorphometric analysis. Results: In the primary study, four of fifteen defects in the continuous (zero to twelve-week) Scl-Ab group, three of fifteen defects in the early (zero to two-week) Scl-Ab group, and four of fifteen defects in the delayed (two to four-week) Scl-Ab group healed at twelve weeks, while none of the defects healed in the control group. In both studies, treatment with sclerostin antibody for twelve weeks demonstrated a significant increase in new bone formation (p < 0.05) compared with the control group. The three treatment groups did not differ significantly with respect to the healing rates and the quality of new bone formed in the defect. The serum markers of bone formation were significantly elevated in the animals in the continuous Scl-Ab group (p < 0.05) compared with the controls. Conclusions: Administration of sclerostin neutralizing antibody led to increased bone formation, resulting in complete healing of femoral defects in a small subset of rats, with a majority of the animals not healing the defect by twelve weeks. Clinical Relevance: Sclerostin neutralizing antibody is a systemically delivered agent that exerts an anabolic effect during fracture repair and has the potential to be used as an adjuvant to enhance bone-healing in difficult bone-repair scenarios. [ABSTRACT FROM AUTHOR]

Background: Displaced patellar fractures are commonly stabilized with a modified anterior tension-band construct. The goal of the current study was to compare the incidence of complications after tension-band fixation of the patella with Kirschner wires as compared with cannulated screws. Methods: We performed a retrospective cohort study of consecutive, surgically treated patellar fractures. Patients were divided into two cohorts: fractures fixed with use of Kirschner wires and fractures fixed with use of cannulated screws. The primary outcome measure was early loss of fixation that necessitated revision surgery. Secondary outcomes included early postoperative infection and the need for implant removal. Results: Four hundred and forty-eight patellar fractures were studied. Kirschner wires were used for fixation in 315(70%), and cannulated screws were used for fixation in 133(30%). The incidence of fixation failure was 3.5% in the Kirschner-wire group and 7.5% in the screw group (p = 0.065). A postoperative infection occurred in 4.4% of patients in the Kirschner-wire group and 1.5% of patients in the screw group (p = 0.17). One hundred sixteen (37%) patients in the Kirschner-wire group and 30 (23%) in the screw group underwent elective implant removal (p = 0.003). After adjusting for confounding variables, a trend toward increased incidence of fixation failure with screws as compared with Kirschner wires was present (p = 0.083). Patients treated with Kirschner wires were twice as likely to undergo implant removal compared with those treated with screws (p = 0.002). Conclusions: Serious complications are uncommon following treatment of patellar fractures with a modified tension- band technique, with use of either Kirschner wires or cannulated screws. In both groups the rate of fixation failure was low, as was the rate of postoperative infection. Symptomatic implants, the most common complication observed, were twice as frequent in patients treated with Kirschner wires. Level of Evidence: Therapeutic Level lll. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Inducement of foreign-body granulation tissue is a relatively novel therapeutic modality in bone repair. A two-stage bone reconstruction method, known as the Masquelet technique, combines inducement of a granulation tissue membrane and subsequent bone autografting as a biphasic technique allowing reconstruction of large bone defects. In light of their already well-characterized osteogenesis-improving capabilities in animals, we performed this translational study to investigate these membranes in patients. Methods: Fourteen patients with complicated fractures and bone defects were randomly selected for this study. Biopsy samples of foreign-body-induced membranes were collected at different time points during scheduled surgical procedures. The membranes were co-cultured with mesenchymal stromal cells, and differentiation into the osteoblastic lineage was assessed by measuring alkaline phosphatase activity, aminoterminal propeptide of type-I procollagen (PINP) production, and Ca2+ concentration. Histological characteristics were evaluated with image analysis. Quantitative reverse transcription polymerase chain reaction was used to measure vascular endothelial growth factor (VEGF), interleukin-6 (IL-6), and type-I collagen (Col-1) expression. Results: The induced membranes were characterized histologically by maturating vascularized fibrous tissue. The vascularization was greatest in one-month-old samples and decreased to <60% in three-month-old samples. One-month- old membrane samples had the highest expression of VEGF, IL-6, and Col-1, whereas two-month-old membranes ex- pressed <40% of the levels of the one-month-old membranes. Specific alkaline phosphatase activity, PINP production, and Ca2+ concentration were increased in co-cultures when a membrane sample was present. In cultures of one-month-old membranes, PINP production was more than two times and Ca2+ deposition was four times higher than that in cultures of two-month-old membranes. Conclusions: The induced membranes have osteogenesis-improving capabilities. These capabilities, however, appear to decrease over time. We speculate that the optimal time for performing second-stage surgery may be within a month after implantation of foreign material. Clinical Relevance: The two-stage bone reconstruction method is an easily adaptable technique for repair of large bone defects. Further understanding of membrane biology and maturation in humans can help to optimize current procedures and improve their overall success rate. [ABSTRACT FROM AUTHOR]

Background: Intracapsular femoral neck fractures are associated with high rates of nonunion. We aimed to identify risk factors for nonunion in patients with both displaced and nondisplaced intracapsular femoral neck fractures treated with three 7-mm parallel cannulated screws, placed in either a triangle or an inverted triangle configuration, using failure of fixation as the primary outcome. Methods: Clinical and radiographic data for patients with intracapsular femoral neck fractures treated with either triangle fixation (one proximal screw and two distal screws) or inverted triangle fixation (two proximal screws and one distal screw), between January 1, 2000, and July 30, 2009, were analyzed. Results: A total of 202 patients, seventy-six men and 126 women with an average age (and standard deviation) of 64.53 ± 15.81 years (range, nineteen to ninety-three years), were included in the analysis. Union occurred in 158 patients, and nonunion occurred in forty-four. There were no differences between the union and nonunion groups with respect to age, sex, fracture side, fracture angle, fracture level, or estimated bone density. There were significant differences in fracture type, fixation configuration, reduction quality, and screw-tip subchondral purchase between patients with and without union. The estimated odds ratio for fracture nonunion was 2.93 (95% confidence interval [CI], 1.08, 7.96) in subjects with displaced fractures compared with those without displaced fractures (p = 0.035), 18.92 (95% CI, 1.91, 187.09) in subjects with borderline and unacceptable reduction compared with those with anatomic reduction (p = 0.012), and 2.92 (95% CI, 1.27, 6.69) for internal fixation with a triangle configuration compared with fixation with an inverted triangle configuration (p = 0.010). Conclusions: Screw fixation with a triangle configuration, a displaced fracture, and poor reduction are risk factors for nonunion in intracapsular femoral neck fractures treated with fixation with multiple screws. [ABSTRACT FROM AUTHOR]

Background: Tibial malrotation is a complication that is seen in approximately 30% of patients following locked intramedullary nailing. In this cohort study, we evaluated the hypothesis that tibial malrotation would lead to impaired functional outcomes. Methods: Patients with a unilateral tibial shaft fracture who were managed with intramedullary nailing between 2003 and 2007 were identified with use of ICD-10 (International Classification of Diseases, 10th Revision) codes. After institutional review board approval and written informed consent had been obtained, specific assessment of eligible patients was achieved with use of computed tomography, functional measures (Lower Extremity Functional Scale, Olerud-Molander Score, six-minute walk test), and physical examination. Measures were compared between patients with and without tibial malrotation (defined as tibial rotation of ⩾10°) on imaging studies. Results: Of the 288 patients who were identified, 100 were eligible for the study and seventy consented to participate. The mean duration of follow-up (and standard deviation) for these seventy patients was 58 ± 11 months. Twenty-nine patients (41%) had tibial malrotation. Lower Extremity Functional Scale scores were similar between the groups with and without malrotation (mean, 70.8 ± 8.6 points compared with 72.6 ± 8.7 points; p = 0.41). The results for the other functional tests were also similar. Conclusions: Despite high rates of tibial malrotation following locked intramedullary nailing of isolated tibial diaphyseal fractures, this finding does not have a significant intermediate-term functional impact. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Fractures are an important public health problem affecting patients of all ages. Although most fractures heal quickly, some heal poorly and some do not heal at all. To achieve an optimal healing outcome, the standard of care for most fractures consists of reduction followed by immobilization, with a myriad of options regarding the approach to fracture-healing. Currently, biopharmaceutical companies are sponsoring research with regard to products that aim to enhance or accelerate fracture-healing; however, as there are no approved and marketed systemic therapies for fracture-healing, the development and commercialization process for such products will require close collaboration between industry, academia, and regulators to determine how to bring these products to market in the most efficient manner. The following manuscript provides a brief overview of the regulatory process in the United States for systemic therapies in fracture-healing and discusses key issues that may arise in connection with the regulatory approval of these novel investigational treatments. [ABSTRACT FROM AUTHOR]

Background: Existing guidelines recommend emergency surgical debridement of open fractures within six hours after injury. The aim of this study was to systematically review the association between time to operative debridement of open fractures and infection. Methods: Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual searches of bibliographies were performed. Randomized controlled trials and cohort studies (retrospective and prospective) eval-uating the association between time to operative debridement and infection after open fractures were included. De-scriptive and quantitative data were extracted. A meta-analysis of patient cohorts who underwent early or delayed debridement was performed with use of a random effects model. Results: The initial search identified 885 references. Of the 173 articles inspected further on the basis of the title, sixteen (six prospective and ten retrospective cohort studies with a total of 3539 open fractures) were included. No significant difference in the infection rate was detected between open fractures debrided early or late according to any of the time thresholds used in the included studies. Sensitivity analyses demonstrated no difference in infection rate between early and late debridement in subgroups defined according to the Gustilo-Anderson classification, level of evidence, depth of infection, or anatomic location. Conclusions: The data did not indicate an association between delayed debridement and higher infection rates when all infections were considered, when only deep infections were considered, or when only more severe open fracture injuries were considered. On the basis of this analysis, the historical "six-hour rule" has little support in the available literature. It is important to realize that additional carefully conducted studies are needed and that elective delay of treatment of patients with open fractures is not recommended. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Traditionally, distal radial fractures with marked displacement and angulation have been treated with closed or open reduction techniques. Reduction maneuvers generally require analgesia and sedation, which increase hospital time, cost, patient risk, and the surgeon's time. In our study, a treatment protocol for pediatric distal radial fractures was used in which the fracture was left shortened in an overriding position and g cast was applied without an attempt at anatomic fracture reduction. Methods: Consecutive patients three to ten years of age presenting between 2004 and 2009 with a closed overriding fracture of the distal radial metaphysis were followed prospectively. Our protocol consisted of no analgesia, no sedation, and a short arm fiberglass cast gently molded to correct only angulation. Patients were followed for at least one year. All parents or guardians were given a questionnaire assessing their satisfaction with the treatment. Financial analysis was performed with use of Current Procedural Terminology codes and the average total cost of care. Results: Fifty-one children with an average age of 6.9 years were included in the study. Initial radial shortening averaged 5.0 mm. Initial sagittal and coronal angulation averaged 4.0° and 3.2° respectively. The average duration of casting was forty-two days. Residual sagittal and coronal angulation at the time of final follow-up averaged 2.2° and 0.8° respectively. All fifty-one patients achieved clinical and radiographic union with a full range of wrist motion. All parents and guardians answered the questionnaire and were satisfied with the treatment. Cost analysis demonstrated that closed reduction with the patient under conscious sedation or general anesthesia is nearly five to six times more expensive than the treatment used in this study. Adding percutaneous pin fixation increases costs nearly ninefold. Conclusions: This treatment protocol presents an alternative approach to overriding distal radial fractures in children and provides the orthopaedic surgeon a simple, effective, and cost and time-efficient method of treatment. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) injury and reconstruction in the skeletally immature patient are becoming more common. The purpose of this study was to develop a reproducible anatomic ACL reconstruction technique, based on intra-articular and extra-articular landmarks, that reliably produces a femoral tunnel of adequate length and diameter while avoiding the distal femoral physis. Methods: Magnetic resonance images (MRIs) of one hundred and eighty-eight children (age range, six to seventeen years) were evaluated. Two extra-articular landmarks, the femoral insertion of the popliteus tendon and the lateral femoral epicondyle, and one intra-articular landmark, the central portion of the femoral footprint of the ACL, were identified. Computer software was used to plot these landmarks in all three planes and to draw lines representing two potential femoral tunnels. The first line connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, and the second connected the center of the ACL femoral footprint with the lateral femoral epicondyle. The length of each tunnel, the shortest distance from the center of each tunnel to the distal femoral physis, and the height of the lateral femoral condyle from the physis to the chondral surface and to the base of the cartilage cap were calculated. A three- dimensional MRI reconstruction was used to confirm that placement of a femoral tunnel with use of the chosen landmarks would avoid the distal femoral physis. Results: The mean distance from the center of the preferred ACL tunnel, which connected the center of the ACL femoral footprint with the insertion of the popliteus tendon, to the distal femoral physis was 12 mm, independent of sex (p = 0.94) or age, and the shortest distance was 8 mm. The length of this proposed tunnel averaged 30.1 mm in the boys and 27.4 mm in the girls (p < 0.001), and it averaged 25.4 mm at an age of six years and 29.7 mm at an age of seventeen years. The mean distance from the center of the alternative tunnel, which connected the center of the ACL femoral footprint with the lateral epicondyle, to the distal femoral physis was 8.8 mm in the boys and 8.9 mm in the girls (p = 0.55). The mean length of this alternative tunnel was 34.3 mm in the boys and 31.6 mm in the girls (p < 0.001). Conclusions: Drilling from the center of the ACL femoral footprint to the insertion of the popliteus tendon would have resulted in a mean tunnel length of 27 to 30 mm, and it would have allowed the safe placement of a femoral tunnel at least 7 mm in diameter in a patient six to seventeen years old. The center of the ACL femoral footprint and the popliteus insertion are easily identifiable landmarks and will allow safe, reproducible, anatomic ACL reconstruction in the skeletally immature patient. [ABSTRACT FROM AUTHOR]

The purpose of the present study was to analyze the longer-term results for a previously reported cohort of patients with cementless acetabular fixation and to compare the results with those for historical controls with cement fixation and a comparable follow-up period. One hundred and twenty consecutive nonselected total hip arthroplasties were performed in 108 patients with use of a cementless acetabular component. This series was evaluated at a minimum of twenty years of follow-up and was compared with 330 consecutive hip arthroplasties that had been performed by the same surgeon with use of cemented acetabular components and had been followed for a comparable period of time. Thirty-nine patients (forty-two hips) in the cementless fixation group were living at twenty years of follow-up. In the group of 120 hips with cementless acetabular fixation, twenty-two hips (18.3%) were revised during the follow-up period, but only one hip (0.8%) was revised because of loosening of the acetabular component, with no additional cup loosening since the previous report at thirteen to fifteen years of follow-up. In the group with cemented acetabular fixation with comparable follow-up, thirty-two hips (10%) were revised overall and eighteen hips (6%) were revised because of acetabular loosening. An additional twenty-five hips (8%) had acetabular cups that were loose on radiographs but had not undergone revision. At a minimum of twenty years of follow-up, cementless acetabular components provided superior long-term fixation compared with cemented components but the overall rates of acetabular revision for mechanical reasons were comparable. [ABSTRACT FROM AUTHOR]

Background: The purpose of the present retrospective study was to evaluate the influence of posterolateral corner reconstruction on anterior cruciate ligament (ACL) reconstruction in terms of anterior laxity and clinical outcomes. We hypothesized that the effects of combined ACL and posterolateral corner reconstruction would be less satisfactory than those of isolated ACL reconstruction in terms of anterior laxity and clinical outcomes. Methods: We retrospectively studied sixty-nine patients who underwent ACL reconstruction from February 2001 to December 2005. Forty-six patients underwent isolated ACL reconstruction (Group I), and twenty-three patients underwent combined ACL and posterolateral corner reconstruction (Group II). Clinical outcomes were determined from data obtained before surgery and at the time of the twenty-four-month follow-up examination. Results: Postoperatively, the mean side-to-side difference (and standard deviation) in anterior tibial translation, measured with a KT2000 arthrometer, was greater for Group I (2.2±1.0 mm) than for Group II (1.6±0.8 mm) (p = 0.031). Seven knees (15.2%) in Group I and two knees (8.7%) in Group II had grade-1 anterior translation. The mean Lysholm score was 93.2 in Group I and 90.1 in Group II (p = 0.392). Thirty-eight knees (82.6%) in Group I and twenty knees (87.0%) in Group II were classified as normal or nearly normal according to the International Knee Documentation Committee scoring system (p = 0.882). Conclusions: On the basis of the evaluation of ligamentous laxity with use of the KT2000 arthrometer, we observed that combined ACL and posterolateral corner reconstruction allows less anterior translation than isolated ACL reconstruction. However, we could not identify significant differences between the two groups in terms of functional outcomes. [ABSTRACT FROM AUTHOR]

Background: There is minimal published information regarding the epidemiology of simple elbow dislocations. The purpose of this study was to report the estimated incidence of elbow dislocations in the United States, with use of the National Electronic Injury Surveillance System (NEISS) database. Methods: The NEISS database includes 102 hospitals representing a random sampling of all patients presenting to U.S. emergency departments. The database was queried for elbow dislocation events. NEISS data for 2002 through 2006 were used for raw data and weighted injury counts, Incidence rates with 95% confidence intervals (95% Cl) were calculated by age group and sex, with use of U.S. census data. Results: One thousand and sixty-six elbow dislocations were identified, representing a weighted estimate of 36,751 acute dislocations nationwide. A calculated incidence of 5.21 dislocations per 100,000 person-years (95% CI, 4.74 to 5.68) was noted. The highest incidence of elbow dislocations (43.5%) occurred in those who were ten to nineteen years old (6.87 per 100,000 person-years; 95% Cl, 5.97 to 7.76). The incidence rate ratio for the comparison of dislocations in males with those in females was 1.02 (5.26 per 100,000 for males and 5.16 per 100,000 for females). In patients ten years or older, 474 injuries (44.5% of total dislocations) were sustained in sports. Males dislocated elbows in football, wrestling, and basketball. Females sustained elbow dislocations most frequently in gymnastics and skating activities. Conclusions: The estimated incidence of elbow dislocations in the U.S. population is 5.21 per 100,000 person-years, with use of a national database. Adolescent males are at highest risk for dislocation. Nearly half of acute elbow dislocations occurred in sports, with males at highest risk with football, and females at risk with gymnastics and skating activities. [ABSTRACT FROM AUTHOR]

Background: Loosening of the glenoid component continues to be the foremost cause of medium and long-term failure of shoulder replacements. The purpose of this study was to evaluate the clinical and radiographic results of a minimally cemented all-polyethylene pegged glenoid component designed for biologic fixation. Methods: Forty-four shoulders in forty-one patients with a mean age of sixty-six years underwent total shoulder arthroplasty with a pegged bone-ingrowth glenoid component. Outcome data included the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and visual analog scales. A detailed radiographic analysis was performed by two board-certified musculoskeletal radiologists who were blinded to clinical and patient-reported outcomes. The radiographs were evaluated with regard to the presence of radiolucent lines at the bone-cement interface, implant seating, and the radiodensity between the flanges of the central peg. Results: The mean duration of clinical follow-up was four years and the mean duration of radiographic follow-up was three years. Twenty shoulders had perfect seating and radiolucency grades, thirty had increased radiodensity between the flanges of the central peg, and three demonstrated osteolysis. Radiodensity about the uncemented central peg at the time of the latest follow-up was positively associated with perfect seating and radiolucency grades on the initial postoperative radiographs (p = 0.03, Fisher exact test). The Simple Shoulder Test score, the American Shoulder and Elbow Surgeons score, and all visual analog scale scores had improved significantly (p < 0.01) at the time of the latest follow-up. Conclusions: Total shoulder arthroplasty with a minimally cemented, all-polyethylene, pegged glenoid implant can yield stable and durable fixation at short to medium-term follow-up (mean, four years). [ABSTRACT FROM AUTHOR]

Background: Although the collateral and accessory collateral ligaments of the metacarpophalangeal joint contribute to the stability of this joint, the functional role of the various portions of these ligaments during flexion is unclear. We investigated changes in the three-dimensional shape and length of the collateral and accessory collateral ligaments during tiexion to determine how each portion stabilized the metacarpophalangeal joint. Methods: Twelve fingers from three embalmed cadavers were examined. The origin and the insertion point of the dorsal, middle, and volar portions of the radial and the ulnar collateral ligament and of the radial and the ulnar accessory collateral ligament were precisely identified. Microcomputed tomograms were obtained at 100 intervals during passive flexiori from OD to 80~. We created three-dimensional models of the metacarpal, the proximal phalange, and the paths of the twelve ligament portions. Finally, we calculated the change in the shape and length of the path of each ligament portion during flexion. Results: The region of contact between each collateral ligament and the lateral edge of the metacarpal gradually lengthened during flexion of the joint, and the ligament gradually stretched to pass around the convex radial or ulnar surface of the metacarpal head. In contrast, each accessory collateral ligament curved around the volar tubercle of the metacarpal head at all fiexion angles. The length of the volar portion of each collateral ligament and the length of the dorsal and middle portions of each accessory collateral ligament underwent little change during flexion. However, the lengths of the dorsal and middle portions of each collateral ligament increased significantly during flexion, and the length of the volar portion of each accessory collateral ligament decreased significantly. Conclusions: The collateral and accessory collateral ligaments can each be functionally divided into three portions- dorsal, middle, and volar. The volar portion of each collateral ligament and the dorsal and middle portions of each accessory collateral ligament are nearly isometric, the dorsal and middle portions of each collateral ligament become taut only in flexion. and the volar portion of each accessory collateral ligament becomes taut only in extension. [ABSTRACT FROM AUTHOR]

Background: Alcohol is a known modulator of the immune system and host-defense response. Alcohol abuse is common in trauma patients, although the influence of alcohol intoxication on the inflammatory response following major orthopaedic injury remains unknown. The aim of this investigation was to examine the influence of binge alcohol exposure on biomarkers of the systemic inflammatory response following bilateral traumatic femoral fracture in a rodent model. Methods: Ninety-two Sprague-Dawley rats were administered intraperitoneal injections of either saline solution or alcohol for three days. These animals then underwent a sham procedure or bilateral femoral intramedullary pinning and mid-diaphyseal closed fracture via blunt guillotine. The animals were killed at specific time points after the injury. Serum and lung tissue were collected, and twenty-five inflammatory markers were analyzed by immunoassay. Histological sections of lung tissue were evaluated by a board-certified pathologist. Results: Bilateral femoral fracture significantly (p <0.05) increased multiple serum biomarkers of inflammation. Binge alcohol treatment prior to injury significantly suppressed the increase in serum levels of interleukin (IL)-6, white blood cells, lL-2, IL-b, and C-reactive protein after the fracture. However, alcohol-treated animals were found to have increased pulmonary levels of lL-6, IL-1β, IL-2, and macrophage inflammatory protein-1⍺ following bilateral femoral fracture. in addition, lung tissue harvested following alcohol treatment and injury demonstrated increased pathologic changes, including parenchymal, alveolar, and peribronchial leukocyte infiltration and significantly elevated pulmonary wet-to-dry ratio, indicative of pulmonary edema. Conclusions: Our results indicate that acute alcohol intake prior to bilateral femoral fracture with fixation in rats modulates the inflammatory response after injury in a tissue-dependent manner. Although serum biomarkers of inflammation were suppressed in alcohol-treated animals following injury, several measures of pulmonary inflammation including cytokine levels, histological changes, and findings of pulmonary edema were significantly increased following fracture with the presence of alcohol. Clinical Relevance: These findings indicate that alcohol modulates the inflammatory response after a major orthopaedic injury and that analysis of serum markers of inflammation after trauma may not represent the pulmonary inflammatory status in acutely intoxicated patients. [ABSTRACT FROM AUTHOR]