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Introduction: Evaluation of suspected septic arthritis of the native adult knee is a common diagnostic dilemma. Pre-aspirate criteria predictive of septic arthritis do not exist for the adult knee and investigations of aspiration results (cell count, differential, gram stain and crystal analysis) have been limited to univariate analyses. Given numerous clinical variables inform the risk of septic arthritis, multivariable analysis that incorporates all clinically available information is critical to allowing accurate decision-making.Methods: We retrospectively identified 455 cases of potential septic arthritis of a native adult knee at a tertiary health system from 2012 to 2017, of which 281 underwent aspiration. We recorded demographics, comorbidities, history, exam, laboratory, and radiographic data. Among aspirated cases, we performed univariate analyses of all variables for association with septic arthritis followed by multivariable logistic regression analysis.Results: Septic arthritis was confirmed in 61 of 281 patients who underwent aspiration. Independent associations of risk for septic arthritis included synovial fluid WBC ≥ 30,000 (Odds Ratio 90.8, 95% Confidence Interval 26.6-310.1, p < 0.001), bacteria reported on synovial fluid gram stain (OR 21.5, 95% CI 3.9-119.2, p < 0.001), duration of pain >2 days (OR 6.9, 95% CI. 2.3-20.9, p < 0.001), history of septic arthritis at any joint (OR 5.0, 95% CI 1.1-23.4, p = 0.039), clinical effusion (OR 4.8, 95% CI 1.2-20.0, p = 0.030). Independent associations protective against septic arthritis included presence of synovial fluid crystals (OR 0.1, 95% CI 0.1-0.4, p < 0.001). The multivariable model was highly accurate in discriminating between septic and aseptic cases (AUC = 0.942). A web-based tool was created to aid clinical decision-making.Conclusion: When evaluating for septic arthritis of a native adult knee, several independent associations were identified for variables related and unrelated to joint aspiration. The associated multivariable model discriminated very well between patients with and without septic arthritis, outperforming previous univariate assessments. A web-based tool was created that estimates the probability of septic arthritis based on this model. This may aid decision-making in complex clinical scenarios. [ABSTRACT FROM AUTHOR]

Open fracture is a risk factor for nonunion of diaphyseal tibia fractures. Compared with closed injuries, there is a relative lack of scientific knowledge regarding the healing of open tibia fractures. The objective of this study was to investigate which patient, injury, and surgeon-related factors predict nonunion in open tibial shaft fractures. A cohort of 98 patients with 104 extra-articular open tibial shaft fractures (OTA/AO 41A2-3, 42A-C, and 43A) were treated surgically between 2007 and 2018 at a single level 1 trauma center and were retrospectively reviewed. Patients underwent irrigation and debridement followed by definitive intramedullary nailing or plate fixation. Patient, injury, and perioperative prognostic factors were analyzed as predictors of nonunion based on anteroposterior and lateral radiographs. The nonunion rate was 27.9% (n=29). There were 12 occurrences of deep infection (11.5%). The median follow-up was 14 months. High-energy mechanism of injury (hazard ratio [HR], 5.76), Gustilo-Anderson class IIIA injury (HR, 3.66), postoperative cortical continuity of 0% to 25% (HR, 2.90), early postoperative complication (HR, 4.20), and deep infection (HR, 2.25) were significant predictors of nonunion on univariable analysis (P<.05). On multivariable assessment, only high-energy mechanism of injury, Gustilo-Anderson class IIIA injury, and early postoperative complication reached significance as predictors of nonunion. These data also indicate that lack of cortical continuity is a significant univariable radiographic predictor of nonunion. This is potentially modifiable, may guide surgeons in selecting patients for early bone grafting procedures, and should be assessed carefully in this high-risk population. [Orthopedics. 2021;44(3):142-147.]. [ABSTRACT FROM AUTHOR]

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1-19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454-e459.]. [ABSTRACT FROM AUTHOR]

Background. A 72-year-old man with a history of delayed presentation for severe right lower extremity burns underwent through- knee amputation complicated by periprosthetic distal femur osteomyelitis. Subsequent transfemoral amputation was complicated by Stage IVB Cierny-Mader osteomyelitis despite appropriate medical and surgical treatment. Methods. Due to the presence of threatened proximal femur intramedullary nail from prior intertrochanteric femur fracture, inability to further shorten femur, and lack of local soft-tissue options, we performed soft tissue reconstruction with free gracilis flap. The free gracilis flap was pulled proximally through the femoral canal to obliterate intramedullary dead space and provide distal femoral stump coverage. Results. The stump was fully healed upon 6-month follow-up with computerized tomography demonstrating continued presence of gracilis flap within the femoral canal and no evidence of osteomyelitis. At 1-year follow-up, the patient was ambulatory using a prosthetic without recurrence of osteomyelitis. Conclusions. Previous descriptions of intramedullary free muscle flaps for the treatment of osteomyelitis are limited in number, with its function being limited to dead-space obliteration. This report presents intramedullary free gracilis flap to be a viable option in above-knee amputees for combined dead space obliteration and stump resurfacing in the context of recurrent osteomyelitis. [ABSTRACT FROM AUTHOR]

Although operative treatment of displaced, intra-articular fractures of the calcaneus in adults is generally accepted as standard practice, operative treatment for the same fractures in the skeletally immature remains controversial, potentially because the outcome for fracture types (intra- vs. extra-articular) and severity (displaced vs. nondisplaced) have been confounded in studies of children. We review herein the results of 21 displaced, intra-articular fractures in 18 skeletally immature patients, who were treated with open reduction and internal fixation using a standard surgical approach and protocol developed for adults. The average pre-operative Böhler's angle on the injured side was -5° (range: -35 - +35) compared to 31° (range: +22 - +47) on the uninjured side, indicating substantial displacement. There were no post-operative infections or wound healing problems, and all but one patient was followed to union (average follow- up: 1.5 years; range: 0.30-4.3 years). Maintenance of reduction was confirmed on follow-up radiographs with an average Böhler's angle of 31° (range: +22 - +49). We demonstrate that results for operative fixation of displaced, intra-articular calcaneal fractures in the skeletally immature are comparable to those in adults when the treatment protocol is the same. [ABSTRACT FROM AUTHOR]

The article presents a study that described a percutaneous technique to reduce and stabilize the peroneal tendons in their appropriate position posterior to the fibula. According to the article, operative treatment of peroneal tendon dislocation may be deferred until the soft tissue envelope has recovered adequately, which postpones the patient's participation in physical therapy as well as their overall recovery. In the technique described, the patient is positioned either laterally or supine with a bump under the affected hip.

Background: Treatment for proximal humerus fractures remains controversial. Studies of open reduction and internal fixation (ORIF) rarely account for reduction quality, while surgeon experience and sagittal plane reduction remain unstudied. In a retrospective case series analysis of AO/OTA C-type proximal humerus fractures treated with ORIF using a locking plate, we hypothesized that reduction quality would be associated with outcome, and reductions would improve with experience.Methods: We retrospectively identified 41 3- and 4-part proximal humerus fractures treated with ORIF by a single orthopaedic traumatologist. Two blinded traumatologists assessed injury and post-operative radiographs for medial calcar disruption and five measures of deformity. Major complications and functional outcome were assessed.Results: Outcome by ASES score was similar to previous reports (mean 73.6, std dev 22.5). Eleven of 35 patients (31.4%) with greater than six months follow-up experienced a complication. Post-reduction sagittal HSa<25° (RR = =9.44, p = =0.024) and medial calcar disruption (RR = =3.82, p = =0.009) were associated with complications. Post-reduction coronal and sagittal HSa improved with experience (p < 0.001 and p = =0.032, respectively) as did the likelihood of overall anatomic reduction (p = =0.006). ROC analysis found a threshold for superior reduction quality after 23 cases (AUC = =0.873, p < 0.001).Conclusion: Sagittal reduction quality and medial calcar disruption were associated with complications. Additionally, reduction quality improved with experience. Future studies of proximal humerus ORIF should include multiplanar assessments of reduction while accounting for surgeon experience. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine the validity and inter-rater reliability of radiographic assessment of sagittal deformity of femoral neck fractures., Design: This is a retrospective cohort study., Setting: Level 1 trauma center., Patients/participants: Thirty-one patients 65 years or older who sustained low-energy, Garden type I/II femoral neck fractures imaged with biplanar radiographs and either computed tomography or magnetic resonance imaging were included., Main Outcome Measurements: Preoperative sagittal tilt was measured on lateral radiographs and compared with the tilt identified on advanced imaging. Fractures were defined as "high-risk" if posterior tilt was ≥20 degrees or anterior tilt was >10 degrees., Results: Of 31 Garden type I/II femoral neck fractures, advanced imaging identified 10 high-risk fractures including 8 (25.8%) with posterior tilt ≥20 degrees and 2 (6.5%) with anterior tilt >10 degrees. Overall, there was no significant difference between sagittal tilt measured using lateral radiographs and advanced imaging ( P = 0.84), and the 3 raters had good agreement between their measurements of sagittal tilt on lateral radiographs (interclass correlation coefficient 0.79, 95% confidence interval [0.65, 0.88], P < 0.01). However, for high-risk fractures, radiographic measurements from lateral radiographs alone resulted in greater variability and underestimation of tilt by 5.2 degrees (95% confidence interval [-18.68, 8.28]) when compared with computed tomography/magnetic resonance imaging. Owing to this underestimation of sagittal tilt, the raters misclassified high-risk fractures as "low-risk" in most cases (averaging 6.3 of 10, 63%, range 6 - 7) when using lateral radiographs while low-risk fractures were rarely misclassified as high-risk (averaging 1.7 of 21, 7.9%, range 1 - 3, P = 0.01)., Conclusions: Lateral radiographs frequently lead surgeons to misclassify high-risk sagittal tilt of low-energy femoral neck fractures as low-risk. Further research is necessary to improve the assessment of sagittal plane deformity for these injuries., Level of Evidence: Level IV diagnostic study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Previous retrospective research found that the presence or absence of bridging callus within 4 months postoperatively discriminated accurately between eventual union and nonunion of fractures of the tibial shaft. However, there remains no consensus regarding early prognostication of long bone nonunion. We prospectively assessed the accuracy and reliability of the presence of any bridging callus within 4 months in a cohort that was expanded to include both tibial and femoral shaft fractures., Methods: We identified 194 consecutive fractures of the shaft of the tibia (OTA/AO type 42-A, B, or C) and femur (OTA/AO type 32-A, B, or C) that were treated with intramedullary nailing. Exclusions for inadequate follow-up (55), extended delay prior to nailing (10), and skeletal immaturity (3) resulted in a study population of 126 fractures (56 tibiae and 70 femora) in 115 patients. Digital radiographs made between 3 and 4 months postoperatively were independently assessed by 3 orthopaedic traumatologists. The accuracy of assessment of the presence of any bridging callus, bicortical bridging, and tricortical bridging to predict union or nonunion was assessed with chi-square analysis and by interobserver reliability (kappa statistic)., Results: The nonunion rate was 4% (5 of 126 fractures). The presence of any bridging callus by 4 months accurately predicted union (121 of 122 fractures) and its absence predicted nonunion (4 of 4 fractures). There was 1 incorrect prediction of union for a fracture that failed to unite (p < 0.001). Bicortical or greater bridging predicted union when present (116 of 116 fractures) and nonunion when absent (5 of 10 fractures), incorrectly predicting that 5 healing fractures would go on to nonunion (p < 0.001). Tricortical or greater bridging predicted union when present (103 of 103 fractures) and nonunion when absent (5 of 23 fractures), incorrectly predicting that 18 healing fractures would go on to nonunion (p < 0.001). Interobserver reliability was calculated for any bridging (kappa value, 0.91), bicortical bridging (kappa value, 0.79), tricortical bridging (kappa value, 0.71), and the exact number of cortices bridged (kappa value, 0.67)., Conclusions: The presence of any bridging callus within 4 months accurately predicts the final healing outcome for tibial and femoral shaft fractures treated with intramedullary nailing. This criterion is simple and reliable, and only standard radiographs are needed to make the determination. Basing the prognosis on the bridging of additional cortices risks overestimation of the nonunion rate and is associated with relatively poor reliability.

Objectives: To determine the accuracy of a technique for intraoperative assessment of syndesmotic reduction in ankle fractures., Design: Prospective, case series., Setting: University hospital., Patients/participants: Eighteen consecutive patients with suspected syndesmotic injuries were enrolled between 2007 and 2009. The diagnosis of syndesmotic injury was based on static ankle radiographs. The study group consisted of 12 male and 6 female patients with an average age of 32 years (range 19-56 years)., Intervention: All patients had mortise and talar dome lateral fluoroscopic images obtained of the uninjured ankle in the operating room. The injured ankle underwent operative reduction and provisional fixation using the uninjured ankle radiographs as a template for comparison. An intraoperative computed tomography (CT) scan was obtained to verify the syndesmotic reduction before syndesmotic fixation. If the reduction was not anatomic, the reduction was revised using fluoroscopy and the CT repeated., Main Outcome Measurements: Accuracy of syndesmotic reduction performed using fluoroscopy and confirmed by intraoperative CT scan., Results: Using the technique described, intraoperative CT confirmed anatomic reduction initially in 17 of the 18 fractures. The 1 case where CT did change the course of treatment, revision of fibular fracture reduction resulted in an anatomic reduction of the syndesmosis on repeat CT., Conclusions: Accurate evaluation of the syndesmotic reduction can be determined intraoperatively using comparison mortise and talar dome lateral fluoroscopic images. Direct visualization of the syndesmosis or CT may not be necessary to achieve an accurate reduction in these injuries.

Background: A model was developed to predict changes in pelvic volume associated with increasing pubic diastasis in unstable pelvic fractures., Methods: Intact and postfracture pelvic volumes were calculated in 10 cadavers using computerized axial tomography (CT). The true pelvis was assumed to be either a sphere, a cylinder, or a hemi-elliptical sphere. Using the appropriate equations for calculating the volume of each of these shapes, pelvic volume was predicted and then compared with the measured values., Results: The observed volume changes associated with increasing pubic diastasis were much smaller than previously reported. The mean difference between the measured and predicted volume was 20.0 +/- 9.9% for the sphere, 10.7 +/- 6.5% for the cylinder, and 4.5 +/- 5.9% for the hemi-elliptical sphere. The differences between these means were statistically significant (p < 0.001)., Conclusions: This data suggests that the hemi-elliptical sphere best describes the geometric shape of the true pelvis and better predicts quantitative changes in pelvic volume relative to an increasing pubic diastasis as the radius has little effect on the change in volume. Due to the small changes in volume observed with increasing diastasis, factors other than the absolute change in volume must account for the clinically observed effects of emergent pelvic stabilization.

A subtrochanteric femur fracture after cannulated screw fixation of a femoral neck fracture is a devastating complication. We hypothesized that an apex-distal screw orientation would tolerate higher loads to subtrochanteric fracture. Human cadaveric femora were instrumented with three cannulated screws in either an apex-distal or an apex-proximal configuration. Specimens were loaded along the mechanical axis to failure creating a subtrochanteric femur fracture. Ultimate load to failure and the effect of bone density on load to failure were compared between groups. There was a greater load to failure in the apex-distal group compared with the apex-proximal group. The mean force to fracture in the apex-distal group (11,330 N; standard deviation = 3151 N) was greater than the mean force to fracture in the apex-proximal group (7795 N; standard deviation = 3194 N). Previous investigations have shown improved femoral neck fixation with an apex-distal configuration, but none has examined the relationship between screw orientation and subtrochanteric fractures. Our observations support the use of an apex-distal configuration for cannulated screw fixation of femoral neck fractures.